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van Onkelen RS, Mitalas LE, Gosselink MP, van Belkum A, Laman JD, Schouten WR. Assessment of microbiota and peptidoglycan in perianal fistulas. Diagn Microbiol Infect Dis 2012; 75:50-4. [PMID: 23102557 DOI: 10.1016/j.diagmicrobio.2012.09.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/19/2012] [Accepted: 09/20/2012] [Indexed: 11/17/2022]
Abstract
Transanal advancement flap repair has been advocated as the treatment of choice for high transsphincteric perianal fistulas, but fails in 1 of every 3 patients. Persistence of the fistula after flap repair might be the result of ongoing disease in the remaining fistula tract. In 10 specimens of the distal part of the fistula, microbiota was assessed by means of conventional microbiological culture and 16S rRNA gene sequencing. Proinflammatory bacterial peptidoglycan and recognition proteins were assessed by immunohistochemistry. Bacterial species were bowel derived, skin derived, or a combination of both. No mycobacterium species were identified. 16S rRNA gene sequencing failed to identify bacteria in all but 1 specimen, most likely as a result of low numbers of organisms. Peptidoglycan was detected in 90% of the patients, and a host response to peptidoglycan in 60%. Therefore, we suggest that peptidoglycan might play a role in the ongoing inflammation in perianal fistulas.
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Affiliation(s)
- R S van Onkelen
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Mitalas LE, van Onkelen RS, Monkhorst K, Zimmerman DD, Gosselink MP, Schouten WR. Identification of epithelialization in high transsphincteric fistulas. Tech Coloproctol 2012; 16:113-7. [PMID: 22231563 PMCID: PMC3310980 DOI: 10.1007/s10151-011-0803-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 12/10/2011] [Indexed: 12/15/2022]
Abstract
Background At present, transanal advancement flap repair (TAFR) is the treatment of choice for transsphincteric fistulas passing through the upper and middle third of the external anal sphincter. It has been suggested that epithelialization of the fistula tract contributes to the failure of the treatment. The aim of this study was to assess the prevalence of epithelialization of the fistula tract and to study its effect on the outcome of TAFR and TAFR combined with ligation of the intersphincteric fistula tract (LIFT). Methods Forty-four patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Nine of these patients underwent a combined procedure of TAFR with LIFT. In all patients the fistula tract was excised from the external opening up to the outer border of the external anal sphincter. In patients undergoing TAFR combined with LIFT an additional central part of the intersphincteric fistula tract was excised. A total of 53 specimens were submitted. Histopathological examination of the specimens was carried out by a pathologist, blinded for clinical data. Results Epithelialization of the distal and intersphincteric fistula tract was observed in only 25 and 22% of fistulas, respectively. There was no difference in outcome between fistulas with or without epithelialization. Conclusions Epithelialization of high transsphincteric fistulas is rare and does not affect the outcome of TAFR and TAFR combined with LIFT.
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Affiliation(s)
- L E Mitalas
- Division of Colon and Rectal Surgery, Department of Surgery, Erasmus MC, University Medical Center, H 181,'s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Mitalas LE, Dwarkasing RS, Verhaaren R, Zimmerman DDE, Schouten WR. Is the outcome of transanal advancement flap repair affected by the complexity of high transsphincteric fistulas? Dis Colon Rectum 2011; 54:857-62. [PMID: 21654253 DOI: 10.1007/dcr.0b013e31820eee2e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transanal advancement flap repair for the treatment of high transsphincteric fistulas fails in 1 of every 3 patients. Until now no definite risk factors for failure have been identified. The question is whether the more complex fistulas, such as those with horseshoe extensions and associated abscesses, have a less favorable outcome. OBJECTIVE Aim of the present study was to indentify whether more complex fistulas have a less favorable outcome. DESIGN This study is a retrospective case series review. PATIENTS Between 1995 and 2007 a series of 162 patients underwent endoanal MR imaging before transanal advancement flap repair. Two investigators, without prior knowledge of the surgical findings, reviewed all MR images. RESULTS Lateral fistulas were identified in 5 patients. Because of the small number, these patients were excluded from further analysis. Posterior fistulas were identified in 119 patients (76%). These fistulas had 3 types of extensions: a direct course (36%), a classic horseshoe extension (23%), or an intersphincteric horseshoe extension (41%). The corresponding healing rates were 37%, 81%, and 73%. Anterior fistulas were observed in 23% of the patients. These fistulas had 2 types of extensions: a direct course (61%) or a classic horseshoe extension (39%). The corresponding healing rates were 60% and 52%. The healing rate of fistulas with a direct course was significantly lower than the healing rate of fistulas with a classic or intersphincteric horseshoe extension. Associated abscesses were found in 47% of the posterior fistulas and 5% of the anterior fistulas. Once adequately drained, these abscesses did not affect the outcome of transanal advancement flap repair. CONCLUSION The complexity of high transsphincteric fistulas does not affect the outcome of transanal advancement flap repair.
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Affiliation(s)
- Litza E Mitalas
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
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Mitalas LE, van Wijk JJ, Gosselink MP, Doornebosch P, Zimmerman DDE, Schouten WR. Seton drainage prior to transanal advancement flap repair: useful or not? Int J Colorectal Dis 2010; 25:1499-502. [PMID: 20645104 PMCID: PMC2974209 DOI: 10.1007/s00384-010-0993-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2010] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of high transsphincteric fistulas. Recent studies indicate that TAFR fails in one out of three patients. Until now, no definite predictive factor for failure has been identified. Although some authors have reported that preoperative seton drainage might improve the outcome of TAFR, this could not be confirmed by others. We conducted the present study to assess the influence of preoperative seton drainage on the outcome of TAFR in a relatively large series. METHODS Between December 1992 and June 2008, a consecutive series of 278 patients [M/F = 179:99, median age 46 years (range, 19-73 years)] with cryptoglandular, transsphincteric fistula, passing through the upper or middle third of the external anal sphincter underwent TAFR. Patients were recruited from the colorectal units of two university hospitals (Erasmus Medical Center, Rotterdam, n = 211; and Leiden University Medical Center, Leiden, n = 67). Baseline characteristics did not differ between the two clinics. Sixty-eight of these patients underwent preoperative seton drainage for at least 2 months and until the day of the flap repair. RESULTS Median healing time was 2.2 months. In patients without preoperative seton drainage, the healing rate was 63%, whereas the healing rate was 67% in patients who underwent preoperative seton drainage. This difference was not statistically significant. No differences in healing rates were found between the series from Leiden and Rotterdam. CONCLUSION Preoperative seton drainage does not improve the outcome of TAFR.
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Affiliation(s)
- Litza E. Mitalas
- Colorectal Research Group, Department of Surgery, Erasmus Medical Center, H 181 ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands ,Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan J. van Wijk
- Colorectal Research Group, Department of Surgery, Erasmus Medical Center, H 181 ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Martijn P. Gosselink
- Colorectal Research Group, Department of Surgery, Erasmus Medical Center, H 181 ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Pascal Doornebosch
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - David D. E. Zimmerman
- Colorectal Research Group, Department of Surgery, Erasmus Medical Center, H 181 ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - W. Rudolph Schouten
- Colorectal Research Group, Department of Surgery, Erasmus Medical Center, H 181 ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Mitalas LE, Gosselink MP, Oom DMJ, Zimmerman DDE, Schouten WR. Required length of follow-up after transanal advancement flap repair of high transsphincteric fistulas. Colorectal Dis 2009; 11:726-8. [PMID: 19708091 DOI: 10.1111/j.1463-1318.2008.01666.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Repair of high perianal fistulas presents a major surgical challenge. Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of these fistulas. Initially promising results have been reported. More recent studies indicate that TAFR fails in one out of three patients. The aim of the present study was to determine the appropriate length of follow-up needed to assess the healing rate after TAFR of high transsphincteric fistulas. METHOD Between 1992 and 2000 a consecutive series of 80 patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Medical records of all patients were studied. The initial healing rate and the median healing time were assessed. The initial outcome was successful in 54 patients. The medical records revealed that only one of these patients presented with a recurrent fistula after 28 months. The other 53 patients were sent a questionnaire in 2006 aimed to determine whether they had any complaints or signs of a recurrent fistula. RESULTS The initial healing rate was 68%. The median healing time was 3.6 months. The completed questionnaire was returned by 48 patients. None of these patients reported any complaints or signs of a recurrent fistula. Median duration of follow-up in these patients was 92 months. CONCLUSION At a median time interval of 3.6 months fistula healing was observed in 54 patients (68%). Only one patient (2%) encountered a recurrence. The length of follow-up can be restricted to the healing time.
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Affiliation(s)
- L E Mitalas
- Department of Surgery, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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Abstract
INTRODUCTION Transanal advancement flap repair provides a useful tool for the treatment of high transsphincteric fistulas. Recent studies indicate that transanal advancement flap repair fails in one of every three patients. Until now no definite risk factors for failure have been identified. A previous pilot study, conducted in our own institution, revealed a significant decrease in rectal mucosal blood flow after creation of the advancement flap. We postulated that impaired blood flow might result in breakdown of the distal part of the flap. This study was designed to evaluate the effect of rectal mucosal blood flow on the outcome of transanal advancement flap repair. METHODS Between August 2004 and June 2007 a series of 54 patients with a high transsphincteric fistula underwent transanal advancement flap repair. The present series comprised 34 males and 20 females. Median age at the time of repair was 45 (range, 25-68) years. Rectal mucosal blood flow was determined by laser Doppler flowmetry before and after creation of the flap. The flow was expressed in arbitrary units. RESULTS Transanal advancement flap repair was successful in 34 patients (63%). Median healing time was 2.2 months. Median mucosal blood flow before and after transanal advancement flap repair was 145 arbitrary units and 94 arbitrary units, respectively. This decrease was statistically significant. In a comparison of patients with and patients without a successful repair, no differences were found in mucosal blood flow before and after creation of the flap (146 vs. 138 arbitrary units and 83 vs. 104 arbitrary units). CONCLUSION Rectal mucosal blood flow does not affect the outcome of transanal advancement flap repair.
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Affiliation(s)
- Litza E Mitalas
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Zimmerman DDE, Mitalas LE, Schouten WR. Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin. Dis Colon Rectum 2009; 52:1196-7; author reply 1197. [PMID: 19581868 DOI: 10.1007/dcr.0b013e3181a51354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Mitalas LE, Gosselink MP, Oom DMJ, Zimmerman DDE, Schouten WR. Adverse effect of BioGlue on the outcome of transanal advancement flap repair. Dis Colon Rectum 2009; 52:754; author reply 755. [PMID: 19404091 DOI: 10.1007/dcr.0b013e3181a1aa46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mitalas LE, Gosselink MP, Zimmerman DDE, Schouten WR. Repeat transanal advancement flap repair: impact on the overall healing rate of high transsphincteric fistulas and on fecal continence. Dis Colon Rectum 2007; 50:1508-11. [PMID: 17701070 PMCID: PMC2039788 DOI: 10.1007/s10350-007-9015-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Transanal advancement flap repair (TAFR) has been advocated as the treatment of choice for transsphincteric fistulas passing through the upper or middle third of the external anal sphincter. It is not clear whether previous attempts at repair adversely affect the outcome of TAFR. The purpose of the present study was to evaluate the success rate of a repeat TAFR and to assess the impact of such a second procedure on the overall healing rate of high transsphincteric fistulas and on fecal continence. METHODS Between January 2001 and January 2005, a consecutive series of 87 patients (62 males; median age, 49 (range, 27-73) years) underwent TAFR. Median follow-up was 15 (range, 2-50) months. Patients in whom the initial operation failed were offered two further treatment options: a second flap repair or a long-term indwelling seton drainage. Twenty-six patients (male:female ratio, 5:2; median age, 51 (range, 31-72) years) preferred a repeat repair. Continence status was evaluated before and after the procedures by using the Rockwood Faecal Incontinence Severity Index (RFISI). RESULTS The healing rate after the first TAFR was 67 percent. Of the 29 patients in whom the initial procedure failed, 26 underwent a repeat TAFR. The healing rate after this second procedure was 69 percent, resulting in an overall success rate of 90 percent. Both before and after the first attempt of TAFR, the median RFISI was 7 (range, 0-34). In patients who underwent a second TAFR, the median RFISI before and after this procedure was 9 (range, 0-34) and 8 (range, 0-34), respectively. None of these changes were statistically significant. CONCLUSIONS Repeat TAFR increases the overall healing rate of high transsphincteric fistulas from 67 percent after one attempt to 90 percent after two attempts without a deteriorating effect on fecal continence.
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Affiliation(s)
- Litza E. Mitalas
- Colorectal Research Group Rotterdam, Department of Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Martijn P. Gosselink
- Colorectal Research Group Rotterdam, Department of Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - David D. E. Zimmerman
- Colorectal Research Group Rotterdam, Department of Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - W. Ruud Schouten
- Colorectal Research Group Rotterdam, Department of Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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Zimmerman DDE, Gosselink MP, Mitalas LE, Delemarre JBVM, Hop WJC, Briel JW, Schouten WR. Smoking impairs rectal mucosal bloodflow--a pilot study: possible implications for transanal advancement flap repair. Dis Colon Rectum 2005; 48:1228-32. [PMID: 15868234 DOI: 10.1007/s10350-004-0943-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Transanal advancement flap repair has been advocated as the treatment of choice for trans-sphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26-69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8-70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7-35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.
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Affiliation(s)
- David D E Zimmerman
- Colorectal Research Group of Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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