Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials

Sameh Hany Emile; Zoe Garoufalia; Pauline Aeschbacher; Nir Horesh; Rachel Gefen; Steven D Wexner

doi:10.1016/j.surg.2023.04.004

Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials

Surgery. 2023 Aug;174(2):172-179. doi: 10.1016/j.surg.2023.04.004. Epub 2023 May 15.

Authors

Sameh Hany Emile¹, Zoe Garoufalia², Pauline Aeschbacher³, Nir Horesh⁴, Rachel Gefen⁵, Steven D Wexner⁶

Affiliations

¹ Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Egypt. Electronic address: https://twitter.com/dr_samehhany81.
² Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. Electronic address: https://twitter.com/ZGaroufalia.
³ Department of General Surgery and Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, FL. Electronic address: https://twitter.com/PaAeschbacher.
⁴ Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and transplantation, Sheba Medical Center, Ramat-Gan, Israel. Electronic address: https://twitter.com/nirhoresh.
⁵ Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Israel. Electronic address: https://twitter.com/RachellGefen.
⁶ Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. Electronic address: wexners@ccf.org.

PMID: 37198039
DOI: 10.1016/j.surg.2023.04.004

Abstract

Background: Rectal advancement flap and ligation of intersphincteric fistula tract are common procedures for treating complex anal fistula. The present meta-analysis aimed to compare the surgical outcomes of advancement flap and ligation of intersphincteric fistula tract.

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials comparing the ligation of intersphincteric fistula tract and advancement flap was conducted. PubMed, Scopus, and Web of Science were searched through January 2023. The risk of bias was assessed using the Risk of Bias 2 tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcomes were healing and recurrence of anal fistulas, and secondary outcomes were operative time, complications, fecal incontinence, and early pain.

Results: Three randomized clinical trials (193 patients, 74.6% male) were included. The median follow-up was 19.2 months. Two trials had a low risk of bias, and 1 had some risk of bias. The odds of healing (odds ratio: 1.363, 95% confidence interval: 0.373-4.972, P = .639), recurrence (odds ratio: 0.525, 95% confidence interval: 0.263-1.047, P = .067), and complications (odds ratio: 0.356, 95% confidence interval: 0.085-1.487, P = .157) were similar between the 2 procedures. Ligation of intersphincteric fistula tract was associated with a significantly shorter operation time (weighted mean difference: -4.876, 95% confidence interval: -7.988 to -1.764, P = .002) and less postoperative pain (weighted mean difference: -1.030, 95% confidence interval: -1.418 to -0.641, 0.198, P < .001, I² = 3.85%) than advancement flap. Ligation of intersphincteric fistula tract was associated with marginally lower odds of fecal incontinence than advancement flap (odds ratio: 0.27, 95% confidence interval: 0.069-1.06, P = .06).

Conclusion: Ligation of intersphincteric fistula tract and advancement flap had similar odds of healing, recurrence, and complications. The odds of fecal incontinence and extent of pain after ligation of intersphincteric fistula tract were lower than after advancement flap.

Publication types

Meta-Analysis
Review
Systematic Review

MeSH terms

Anal Canal / surgery
Fecal Incontinence* / epidemiology
Fecal Incontinence* / etiology
Female
Humans
Inflammation / complications
Ligation / adverse effects
Male
Neoplasm Recurrence, Local / complications
Pain, Postoperative / epidemiology
Pain, Postoperative / etiology
Randomized Controlled Trials as Topic
Rectal Fistula* / etiology
Rectal Fistula* / surgery
Recurrence
Treatment Outcome