Treatment of complex anal and rectovaginal fistulas using the endorectal mucosal flap technique

BACKGROUND: Aim of the study is to evaluate the advantages of the surgical technique for the treatment of complex anal and rectovaginal fistulas by means of an endorectal mucosal flap and the removal of the fistular tract. The surgical removal of a fistular tract can lead to incontinence troubles, mostly for high complex transsphincteric fistulas. The endorectal mucosal flap technique involves the meticulous care of the sphincterial structures and of the mucosa of the anal canal, and is, in personal opinion, the best technique for the treatment of such fistulas. METHODS: The procedure used involves: meticulous study of the anatomic characteristics of the fistula; excision of the secondary opening up to the sphincters level with an elliptic excision of the skin by avoiding keyhole deformities; excision of the primary opening from inside the anal canal, with the interruption of the muscular fibers and their reconstruction; the preparation of an endorectal mucosal flap that is transposed to cover the primary opening of the fistula. 21 patients were treated with this technique, 17 were complex anal fistulas, two were associated to Crohn's disease, and of two rectovaginal fistulas, one was found in a patient with Crohn's disease. RESULTS: Recurrences were found in five patients (24%), after a median follow-up of 20 months. The delay of fistular healing, over a month, was found in 50% of the cases. No patient had continence troubles. CONCLUSIONS: The mucosal flap technique is a simple procedure, adequate in preserving the sphincteric function and in preventing deformities of the anal canal. However, it has not demonstrated clear benefits in terms of recurrences compared to other techniques, but it is highly considered for the treatment of complex anal fistulas, in terms of continence and for the earlier and better healing of the wounds and for the better tolerance of the patient.