Obliteration of the fistulous tract with BioGlue® adversely affects the outcome of transanal advancement flap repair

Background: Transanal advancement flap repair (TAFR) is useful in the treatment of high transsphincteric fistulas. Initially, promising results were reported. More recent studies have indicated that TAFR fails in one out of three patients. In almost all of our patients with a failure, we have observed healing of the flap except at the site of the original internal opening. A possible explanation for this remarkable finding might be persistent inflammation in the fistulous tract, finding a way out through the original internal opening. The question is whether obliteration of the fistulous tract by local installation at a surgical adhesive, can prevent persistent inflammation to break through the original opening. The aim of this pilot study was to investigate whether concomitant instillation of BioGlue could improve the healing rate following TAFR for high transsphincteric fistulas. Methods: Between March 2006 and April 2006 a consecutive series of eight patients (four men, four women; median age 46 years) with a high transsphincteric fistula underwent TAFR after instillation of BioGlue in the fistulous tract. All patients were seen in the outpatient department for postoperative evaluation. Results: Fistula healing was observed in only one patient (12.5%). All other patients experienced one or more of the following complications: prolonged severe pain (n=5), discharge of great amounts of purulent liquid from the external opening (n=3) and abscess formation (n=2), necessitating incision and drainage. Because of this unexpected outcome we decided to terminate the study prematurely. Conclusions: Our findings indicate that obliteration of the fistulous tract with BioGlue adversely affects the outcome of TAFR for high transsphincteric fistulas.

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