Abstracts
1997 Digestive Disease Week

Long-term follow-up after transanal advancement flap for perianal fistulas in Crohn's disease.

F Makowiec, EC Jehle, HD Becker, M Starlinger. Department of Surgery, University of Tubingen, Germany.

Transanal advancement flap repair (TRAF) may be used to close transsphincteric (TS) or anovaginal (AV) fistulas in patients with Crohn's disease (CD) without active rectal disease. In a prospective study we assessed the outcome after 37 successful TRAFs (13 for AV, 24 for TS; mean follow-up 34.5 ± 16 months) and evaluated risk factors possibly influencing the postoperative recurrence of fistulas. METHODS: Thirty-seven of 42 (88%) TRAFs were primarily successful (healed for > 2 months). In 21 of 37 (57%) cases the TRAF was performed with a stoma followed by stoma closure in 15 patients a median of 7.3 months after TRAF. Four patients (11%) had ileal disease, all other (89%) had colonic or ileocolonic disease. CD of the rectum was documented in 16 patients (43%) but was inactive at the time of TRAF. Patients had regular postoperative follow-up examinations including endosonography, with prospective documentation. The recurrence rate was calculated using lifetable-analysis, the influence of independent risk factors on recurrence rate by Cox' regression analysis. RESULTS: Median hospital stay was 4 days. Complications other than primary failure of TRAF did not occur. Only one patient had a transitory mild incontinence. A recurrence occured in 16 patients (43%). The cumulative recurrence rate was 46% after 3 years and higher in patients with AV-fistula (p<0.03; relative risk compared with TS 3.6). Neither rectal disease (p=0.75) nor intestinal disease pattern (p=0.53) nor the presence of a stoma at the time of TRAF, independent of a later stoma closure (p=0.21), influenced the recurrence rate. A new fistula, independent of the operated one, occured in 11 patients (30%). New fistulas occured more frequently after stoma closure in patients with previous stoma (p<0.04). CONCLUSIONS: The TRAF is a safe technique to close anal fistulas in Crohn's disease with a high primary success rate. Within 3 years, however, half of the patients, especially those with anovaginal fistula will have a recurrence. A stoma did not influence the recurrence rate, probably due to inactive rectal disease at time of TRAF. After stoma closure new fistulas will develop due to the recurrent nature of perianal Crohn's disease.