[Endo-anal and transperineal continence preserving closure techniques in surgical treatment of Crohn fistulas. A prospective long-term study of 186 patients]. / Endoanale und transperineale kontinenzschonende Verschlusstechniken bei der chirurgischen Behandlung der Crohn-Fisteln: Eine prospektive Langzeitstudie bei 186 Patienten.

UNLABELLED: Our aim was to review the results and to investigate the prognosis in a prospective study of aggressive surgical treatment in 186 patients (59% women, 41% men, age 18 to 65 years) treated during the past 9 1/2 years by conventional laying open of the fistula (n = 71), endorectal advancement flap repair (n = 89) and by fistulectomy without internal sphincterotomy (n = 37). 54 (29%) patients had intersphincteric, 57 (30.5%) transsphincteric, 10 (5.5%) suprasphincteric, 37 (20%) low rectovaginal and 28 (15%) had complex fistulas without internal opening. Four sphincter saving techniques were performed by the high and fistulas (n = 89) with primary occlusion of the intraanal ostium and endorectal mucosal flap (n = 29), endorectal advancement flap (n = 41), anodermal flap (n = 8) and transperineal repair with levator interposition (n = 11). Postoperatively 18 cases (20.2%) of suture leakage occurred, 27% in the mucosal flap group, 17.6% in the advancement flap group, 12.5% in the anodermal group, and 27% in the transperineal group. A complete primary healing of perianal wounds was noted in 73% of the patients within 6 months. The presence of rectal disease (n = 77) did not adversely influence the rate and duration of healing. Persistent or recurrent fistula occurs in 29 patients (15.6%), 22% in the sphincter saving group, 4% in the intersphincteric group and 32% in the complex type of fistulas. Disturbance of continence was observed in 9 patients (4.8%). Postoperatively, there was no significant change in resting anal pressure and maximum voluntary conctraction pressure in any fistula group (n = 104). CONCLUSION: The presented clinical and functional long term results of patients with Crohn's fistulas underline the importance of experience in the treatment of perianal fistula disease. A successful treatment depends primarily on an aggressive therapeutic strategy and the appropriate method of operation.

[Endorectal advancement flap-plasty vs. transperineal closure in surgical treatment of rectovaginal fistulas. A prospective long-term study of 88 patients]. / Endorectale Verschiebelappenplastik vs. transperinealer Verschluss bei der chirurgischen Behandlung der rectovaginalen Fisteln. Eine prospektive Langzeitstudie bei 88 Patientinnen.

UNLABELLED: A prospective study was carried out on 88 patients with rectovaginal fistulae to evaluate the value of two sphincter-saving techniques: primary occlusion of the intraanal ostium and endorectal advancement flap (n = 37) or transperineal repair with levator interposition (n = 34). Causes were Crohn's disease 35, obstetric injury 31, proctological-gynecological operation 11, cryptoglandular 11. Perineal group: 11 patients underwent concomitant anterior sphincter plication. Crohn group (n = 35): endorectal advancement flap was performed in 8 patients only, and 10 with intra- or supraanal stenosis were treated by transperineal approach, 12 (34%) with extended perianal fistula complaints required primary proctectomy, and operative therapy was not possible in 5 with persistent rectal inflammation. No deaths occurred. Postoperatively 12 cases (17%) of suture leakage occurred (flap group (FG): 16.2%, transperineal group (TPG): 17.6%). Persistent or recurrent fistula occurred in 8 patients (11%), 5.4% FG, 17.6% TPG. Disturbance of continence was observed in one patient after endorectal approach. Postoperatively there were no significant changes in the resting anal pressure and maximum voluntary contraction pressure. A complete primary healing with no further recurrence (follow-up 3 months to 9.5 years) was noted in 78.4% FG and 64.7% TPG. One patient with postoperative incontinence after the endorectal flap, had undergone anterior levator plication with perineal body reconstruction. CONCLUSIONS: Endorectal advancement flap allows preservation of the sphincter and is an effective method for repair of rectovaginal fistulae. The endorectal advancement flap proved to result in a better primary healing rate with 85% than the mucosal advancement flap with 65%. Perineal procedures are indicated in selected patients with simultaneous sphincter plication and in Crohn's fistulae associated to intra- or supraanal stenosis.