Application of Advancement Flap After Loose Seton Placement: A Modified Two-Stage Surgical Repair of a Transsphincteric Anal Fistula

PURPOSE: A number of techniques have been described for the treatment of a transsphincteric anal fistula. In this report, we aimed to introduce a relatively new two-stage technique, application of advancement flap after loose seton placement, to present its technical aspects and to document our results. METHODS: Included in this retrospective study were 13 patients (10 males, 3 females) with a mean age of 42 years who underwent a two-stage seton and advancement flap surgery for transsphincteric anal fistula between June 2008 and June 2013. In the first stage, a loose seton was placed in the fistula tract, and in the second stage, which was performed three months later, the internal and external orifices were closed with advancement flaps. RESULTS: All the patients were discharged on the first postoperative day. The mean follow-up period was 34 months. Only one patient reported anal rigidity and intermittent pain, which was eventually resolved with conservative measures. The mean postoperative Wexner incontinence score was 1. No recurrence or complications were observed, and no further surgical intervention was required during follow-up. CONCLUSION: The two-stage seton and advancement flap technique is very efficient and seems to be a good alternative for the treatment of a transsphincteric anal fistula.

Stapled Mucosectomy: An Alternative Technique for the Removal of Retained Rectal Mucosa after Ileal Pouch-Anal Anastomosis

Restorative proctocolectomy (RPC), when performed with a stapled ileal pouch-anal anastomosis (IPAA), allows the retention of the rectal mucosa above the dentate line and can result in disease persistence or recurrence, as well as neoplastic lesions in patients with ulcerative colitis (UC). We report the case of a patient with chronic UC who underwent staple mucosectomy, which is an alternative technique that evolved from stapled hemorrhoidopexy, rather than more traditional procedures. The patient had undergone laparoscopic RPC with a stapled IPAA 2 cm above the dentate line and a temporary loop ileostomy. Because the histopathology showed low-grade dysplasia in the proximal rectum, stapled mucosectomy with a 33-mm circular stapler kit at the time of ileostomy closure was scheduled. Following the application of a purse-string suture 1 cm above the dentate line, the stapler was inserted with its anvil beyond the purse-string and was fired. The excised rectal tissue was checked to ensure that it was a complete cylindrical doughnut. Histopathology of the excised tissue showed chronic inflammation. There were no complications during a follow-up period of 5 months. Because it preserves the normal rectal mucosal architecture and avoids a complex mucosectomy surgery, stapled mucosectomy seems to be a technically feasible and clinically acceptable alternative to the removal of rectal mucosa retained after RPC.