Anal Fistula Clinical Trial
Official title:
Treatment of Anal Fistulas by Partial Rectal Wall Advancement Flap or Mucosal Advancement Flap: a Prospective Randomized Study
This study comprises a prospective study of 40 patients with transphincteric anal fistula. The patients were classified into two groups: Group I: Fistulectomy, closure of internal sphincter and rectal advancement flap includes mucosa, submucosa, and circular muscle layer sutured 1cm below the level of internal opening. Group II: The same as group one but the flap includes only mucosa and submucosa.
This study comprises a prospective study of 40 patients with transphincteric anal fistula.
They were referred to our colorectal surgery unit, Mansoura University Hospital during the
period from May 2005 to May 2008. Patients with acute sepsis, specific cause of fistula,
strictured anorectum, and any degree of incontinence were excluded from the study.
All patient were evaluated by digital examination, procto-sigmoidoscopy, fistulography and
MRI fistulography without contrast media, using a 1.5 Tesla super conducting magnet
(Magnetom Symphony MRease VA12 Siemens medical system), (either STIR or SPIR in addition to
T1 weighted or T2 weighted sequences). Axial, coronal and sometimes sagittal planes were
used. Preoperative assessment of anal sphincter dysfunction was done by conventional
manometry using a standard low compliance water perfusions system and eight-channels
catheters with pressure transducer connected to 5.5 mm manometric probe with spirally
located ports at 0.5cm interval, which measured along the length of the anal canal, as well
as inflatable rectal balloon. The protocol of performance is stationary pull through
technique with recording the functional length of the anal canal (FL), mean maximum resting
pressure in the anal canal (MRP), mean maximum squeeze pressure in the anal canal (MSP).
Pressure was recorded using a computerized recording device (MMS ;Holland) which included
menu-driven software to aid with data acquisition. Data were analyzed with the use of a
complied software package that automatically produced numeric reports and graphs.
The patients were then classified into 2 groups. After carefully explaining the purpose of
the study, an informed consent was taken from every patient. Group I: Fistulectomy, closure
of internal sphincter with loose vicryl 3(0) suture and rectal advancement flap (the length
5cm of the flap is twice its width) includes mucosa, submucosa, circular muscle layer
sutured 1cm below the level of internal opening. Group II: The same as group one but the
flap includes only mucosa and submucosa.
Surgical technique:
Fleet enema was used for preoperative bowel preparation in all cases. Operation was done
under general anesthesia in the lithotomy position. Prophylactic antibiotics were used with
ciprofloxacin 500 mg and metronidazole 500 mg preoperatively and twice daily for 5 days.
Examination under anaesthesia (EUA) was firstly performed and the extent of the disease was
established by cannulating the fistulas with probes and by laying open all primary tracts,
extensions, and abscesses. All the incisions and dissections were made by electrocautery.
The standard procedure was to perform core fistulectomy and traversing the external
sphincter until the internal sphincter was exposed the track was then transected. The
crypt-bearing tissue around the internal opening of the fistula is excised, if there is
difficulty in excising the main tract, the granulation tissue of the remaining tract is
scraped with a curette. Advancement flap was constructed in both group.
1. Group I: - The flap comprised mucosa, submucosa and circular muscle fibers. It is
raised from the dentate line and mobilized 4-6 cm cephaled and advanced to the new
dendentate line (1 cm below the dentate line) and sutured with absorbable sutures
(vicryl; ethicone 3/0). Also the defect is closed with absorbable sutures.
2. Group II: - The flap comprised mucosa, submucosa only.
Rectal pack was removed after 24 hours. The patients were allowed to drink freely for 5
days, then normal diet and laxatives. The external fistulectomy wound was dressed daily.
Histopatho;ogical examination of all excised fistulous tract was done.
1. Follow up of our patients had been done for about 12 months with clinical assessment of
the patients as regard. Incidence of any postoperative complications as bleeding, haematoma,
ecchymosis, and disruption. Incidence of any degree of postoperative incontinence according
to Cliveland clinic incontinence Score (Rockwood et al., 1999). Recurrence was defined as a
discharge or abscess arising in the same area or by obvious evidence of fistulation.
Postoperative assessment of physioanatomical changes in the anal sphincter using anal
manometry: 6 months post-operative after wound healing to measure MRP & MSP.
;
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Investigator), Primary Purpose: Treatment
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