International Journal of Colorectal Disease

, Volume 23, Issue 11, pp 1023–1031 | Cite as

Continence disorders after anal surgery—a relevant problem?

  • A. OmmerEmail author
  • F. A. Wenger
  • T. Rolfs
  • M. K. Walz



Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure.


The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula.


Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0–50%, lateral sphincterotomy 0–45%, haemorrhoidal surgery 0–28%, lay open technique of anal fistula 0–64% and plastic repair of fistula 0–43%. Results vary considerably depending on what definition of “incontinence” was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum.


Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.


Anal surgery Anal fissure Anal fistula Haemorrhoids Faecal incontinence 


  1. 1.
    Lestar B, Penninckx F, Kerremans R (1989) The composition of anal basal pressure—an in vivo and in vitro study in man. Int J Colorect Dis 4:118–122CrossRefGoogle Scholar
  2. 2.
    Parks AG (1975) Royal society of medicine, section of proctology; meeting 27 November 1974. president's address. Anorectal incontinence. Proc R Soc Med 68:681–690PubMedGoogle Scholar
  3. 3.
    Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97PubMedCrossRefGoogle Scholar
  4. 4.
    Sultan AH, Michael CB, Kamm A, Hudson CN, Thomas JM, Bartram CI (1993) Anal-sphincter disruption during vaginal delivery. New Engl J Med 329:1905–1911PubMedCrossRefGoogle Scholar
  5. 5.
    Fitzpatrick M, Fynes M, Cassidy M, Behan M, O'Connell PR, O'Herlihy C (2000) Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury. Eur J Obstet Gynecol Reprod Biol 89:159–163PubMedCrossRefGoogle Scholar
  6. 6.
    Damon H, Bretones S, Henry L, Mellier G, Mion F (2005) Long-term consequences of first vaginal delivery-induced anal sphincter defect. Dis Colon Rectum 48:1772–1776PubMedCrossRefGoogle Scholar
  7. 7.
    van Tets WF, Kuijpers HC (1994) Continence disorders after anal fistulotomy. Dis Colon Rectum 37:1194–1197PubMedCrossRefGoogle Scholar
  8. 8.
    Ho YH, Seow-Choen F, Tsang C, Eu KW (2001) Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Br J Surg 88:1449–1455PubMedCrossRefGoogle Scholar
  9. 9.
    Ho YH, Tsang C, Tang CL, Nyam D, Eu KW, Seow-Choen F (2000) Anal sphincter injuries from stapling instruments introduced transanally: randomized, controlled study with endoanal ultrasound and anorectal manometry. Dis Colon Rectum 43:169–173PubMedCrossRefGoogle Scholar
  10. 10.
    Weyand G, Webels F, Celebi H, Ommer A, Kohaus H (2002) Anale Druckverhältnisse nach Staplerhämorrhoidektomie - Eine prospektive Analyse bei 33 Patienten. Zentralbl Chir 127:22–24PubMedCrossRefGoogle Scholar
  11. 11.
    Nelson RL (1999) Meta-analysis of operative techniques for fissure-in-ano. Dis Colon Rectum 42:1424–1428 discussion 1428–1431PubMedCrossRefGoogle Scholar
  12. 12.
    Stamatiadis A, Konstantinou E, Theodosopoulou E, Mamoura K (2002) Frequency of operative trauma to anal sphincters: evaluation with endoanal ultrasound. Gastroenterol Nurs 25:55–59PubMedCrossRefGoogle Scholar
  13. 13.
    Scholefield JH, Bock JU, Marla B, Richter HJ, Athanasiadis S, Prols M, Herold A (2003) A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures. Gut 52:264–269PubMedCrossRefGoogle Scholar
  14. 14.
    Utzig MJ, Kroesen AJ, Buhr HJ (2003) Concepts in pathogenesis and treatment of chronic anal fissure—a review of the literature. Am J Gastroenterol 98:968–974PubMedGoogle Scholar
  15. 15.
    Lund JN, Nystrom PO, Coremans G, Herold A, Karaitianos I, Spyrou M, Schouten WR, Sebastian AA, Pescatori M (2006) An evidence-based treatment algorithm for anal fissure. Tech Coloproctol 10:177–180PubMedCrossRefGoogle Scholar
  16. 16.
    Nash GF, Kapoor K, Saeb-Parsy K, Kunanadam T, Dawson PM (2006) The long-term results of diltiazem treatment for anal fissure. Int J Clin Pract 60:1411–1413PubMedCrossRefGoogle Scholar
  17. 17.
    Orsay C, Rakinic J, Perry WB, Hyman N, Buie D, Cataldo P, Newstead G, Dunn G, Rafferty J, Ellis CN, Shellito P, Gregorcyk S, Ternent C, Kilkenny J 3rd, Tjandra J, Ko C, Whiteford M, Nelson R (2004) Practice parameters for the management of anal fissures (revised). Dis Colon Rectum 47:2003–2007PubMedCrossRefGoogle Scholar
  18. 18.
    Khubchandani IT, Reed JF (1989) Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 76:431–434PubMedCrossRefGoogle Scholar
  19. 19.
    Garcia-Aguilar J, Belmonte Montes C, Perez JJ, Jensen L, Madoff RD, Wong WD (1998) Incontinence after lateral internal sphincterotomy: anatomic and functional evaluation. Dis Colon Rectum 41:423–427PubMedCrossRefGoogle Scholar
  20. 20.
    Hasse C, Brune M, Bachmann S, Lorenz W, Rothmund M, Sitter H (2004) Laterale, partielle Sphinkteromyotomie zur Therapie der chronischen Analfissur - Langzeitergebnisse einer epidemiologischen Kohortenstudie. Chirurg 75:160–167PubMedCrossRefGoogle Scholar
  21. 21.
    Meier zu Eissen J (2001) Chronische analfissur, therapie. Kongressbd Dtsch Ges Chir Kongr 118:654–656PubMedGoogle Scholar
  22. 22.
    Engel AF, Eijsbouts QA, Balk AG (2002) Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment. Br J Surg 89:79–83PubMedCrossRefGoogle Scholar
  23. 23.
    Lindsey I, Cunningham C, Jones OM, Francis C, Mortensen NJ (2004) Fissurectomy–botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure. Dis Colon Rectum 47:1947–1952PubMedCrossRefGoogle Scholar
  24. 24.
    Scholz T, Hetzer FH, Dindo D, Demartines N, Clavien PA, Hahnloser D (2007) Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures. Int J Colorectal Dis 22:1077–1081PubMedCrossRefGoogle Scholar
  25. 25.
    Baraza W, Boereboom C, Shorthouse A, Brown S (2008) The long-term efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females. Dis Colon Rectum 51:239–243PubMedCrossRefGoogle Scholar
  26. 26.
    Sileri P, Mele A, Stolfi VM, Grande M, Sica G, Gentileschi P, Di Carlo S, Gaspari AL (2007) Medical and surgical treatment of chronic anal fissure: a prospective study. J Gastrointest Surg 11:1541–1548PubMedCrossRefGoogle Scholar
  27. 27.
    Garcia-Granero E, Sanahuja A, Garcia-Armengol J, Jimenez E, Esclapez P, Minguez M, Espi A, Lopez F, Lledo S (1998) Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy. Dis Colon Rectum 41:598–601PubMedCrossRefGoogle Scholar
  28. 28.
    Herold A (2007) Therapie des Hämorrhoidalleidens. Coloproctology 29:157–169CrossRefGoogle Scholar
  29. 29.
    Athanasiadis S, Gandji D, Girona J (1986) Langzeitergebnisse nach submuköser Hämorrhoidektomie unter besonderer Berücksichtigung der Kontinenz. Phlebol u Proktol 15:119–121Google Scholar
  30. 30.
    Ebert KH, Meyer HJ (2002) Die Klammernahtresektion bei Hämorrhoiden - eine Bestandsaufnahme nach zweijähriger Anwendung. Vergleich der Ergebnisse mit der Technik nach Milligan-Morgan. Zentralbl Chir 127:9–14PubMedCrossRefGoogle Scholar
  31. 31.
    Ho YH, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL, Seow-Choen F (2000) Stapled hemorrhoidectomy—cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 43:1666–1675PubMedCrossRefGoogle Scholar
  32. 32.
    Kanellos I, Zacharakis E, Kanellos D, Pramateftakis MG, Tsachalis T, Betsis D (2006) Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids. Tech Coloproctol 10:47–49PubMedCrossRefGoogle Scholar
  33. 33.
    Felt-Bersma RJ, van Baren R, Koorevaar M, Strijers RL, Cuesta MA (1995) Unsuspected sphincter defects shown by anal endosonography after anorectal surgery. A prospective study. Dis Colon Rectum 38:249–253PubMedCrossRefGoogle Scholar
  34. 34.
    Abbasakoor F, Nelson M, Beynon J, Patel B, Carr ND (1998) Anal endosonography in patients with anorectal symptoms after haemorrhoidectomy. Br J Surg 85:1522–1524PubMedCrossRefGoogle Scholar
  35. 35.
    Köhler A, Athanasiadis S, Psarakis E (1997) Die Analfistel - Ein Plädoyer für die kontinente Fistulektomie. Coloproctology 19:186–203Google Scholar
  36. 36.
    Cavanaugh M, Hyman N, Osler T (2002) Fecal incontinence severity index after fistulotomy: a predictor of quality of life. Dis Colon Rectum 45:349–353PubMedCrossRefGoogle Scholar
  37. 37.
    Zimmerman DDE, Briel JW, Gosselink MP, Schouten WR (2001) Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 44:1474–1480PubMedCrossRefGoogle Scholar
  38. 38.
    Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD (1996) Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 39:723–729PubMedCrossRefGoogle Scholar
  39. 39.
    Belliveau P, Thomson JP, Parks AG (1983) Fistula-in-ano. A manometric study. Dis Colon Rectum 26:152–154PubMedCrossRefGoogle Scholar
  40. 40.
    Lunniss PJ, Kamm MA, Phillips RK (1994) Factors affecting continence after surgery for anal fistula. Br J Surg 81:1382–1385PubMedCrossRefGoogle Scholar
  41. 41.
    Gustafsson UM, Graf W (2002) Excision of anal fistula with closure of the internal opening: functional and manometric results. Dis Colon Rectum 45:1672–1678PubMedCrossRefGoogle Scholar
  42. 42.
    Aitola P, Hiltunen KM, Matikainen M (1999) Fibrin glue in perianal fistulas—a pilot study. Ann Chir Gynaecol 88:136–138PubMedGoogle Scholar
  43. 43.
    Cintron JR, Park JJ, Orsay CP, Pearl RK, Nelson RL, Sone JH, Song R, Abcarian H (2000) Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum 43:944–949 discussion 949–950PubMedCrossRefGoogle Scholar
  44. 44.
    Lindsey I, Smilgin-Humphreys MM, Cunningham C, Mortensen NJ, George BD (2002) A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum 45:1608–1615PubMedCrossRefGoogle Scholar
  45. 45.
    Swinscoe MT, Ventakasubramaniam AK, Jayne DG (2005) Fibrin glue for fistula-in-ano: the evidence reviewed. Tech Coloproctol 9:89–94PubMedCrossRefGoogle Scholar
  46. 46.
    Champagne BJ, O'Connor LM, Ferguson M, Orangio GR, Schertzer ME, Armstrong DN (2006) Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum 49:1817–1821PubMedCrossRefGoogle Scholar
  47. 47.
    Johnson EK, Gaw JU, Armstrong DN (2006) Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum 49:371–376PubMedCrossRefGoogle Scholar
  48. 48.
    Varma MG, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK, Beattie MS, Subak LL (2006) Fecal incontinence in females older than aged 40 years: who is at risk? Dis Colon Rectum 49:841–851PubMedCrossRefGoogle Scholar
  49. 49.
    Parks AG, Porter NH, Hardcastle J (1966) The syndrome of the descending perineum. Proc Roy Soc Med 59:477–482PubMedGoogle Scholar
  50. 50.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantois C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Fecal incontinence quality of life scale—quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43:9–17PubMedCrossRefGoogle Scholar
  51. 51.
    Garcia-Aguilar J, Davey CS, Le CT, Lowry AC, Rothenberger DA (2000) Patient satisfaction after surgical treatment for fistula-in-ano. Dis Colon Rectum 43:1206–1212PubMedCrossRefGoogle Scholar
  52. 52.
    Stelzner F, Dietl H, Hahne H (1956) Ergebnisse bei Radikaloperationen von 143 Analfisteln (Kritik der einzeitigen Sphinctertrennung bei ein- oder mehrzeitigen Fisteloperationen). Chirurg 27:158–162PubMedGoogle Scholar
  53. 53.
    Mylonakis E, Katsios C, Godevenos D, Nousias B, Kappas AM (2001) Quality of life of patients after surgical treatment of anal fistula; the role of anal manometry. Colorectal Dis 3:417–421PubMedCrossRefGoogle Scholar
  54. 54.
    Mentes BB, Tezcaner T, Yilmaz U, Leventoglu S, Oguz M (2006) Results of lateral internal sphincterotomy for chronic anal fissure with particular reference to quality of life. Dis Colon Rectum 49:1045–1051PubMedCrossRefGoogle Scholar
  55. 55.
    Herold A, Bruch HP (1996) Stufendiagnostik der anorektalen Inkontinenz. Zentralbl Chir 121:632–638PubMedGoogle Scholar
  56. 56.
    Ommer A, Köhler A, Athanasiadis S (1998) Funktionsdiagnostik des Anorektums und des Beckenbodens. Dtsch Med Wochenschr 123:537–544PubMedCrossRefGoogle Scholar
  57. 57.
    Blum AL, Akovbiantz A (1975) Postoperative Analinkontinenz. Internist 16:267–275PubMedGoogle Scholar
  58. 58.
    Terra MP, Dobben AC, Berghmans B, Deutekom M, Baeten CG, Janssen LW, Boeckxstaens GE, Engel AF, Felt-Bersma RJ, Slors JF, Gerhards MF, Bijnen AB, Everhardt E, Schouten WR, Bossuyt PM, Stoker J (2006) Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients. Dis Colon Rectum 49:1149–1159PubMedCrossRefGoogle Scholar
  59. 59.
    Morgan R, Patel B, Beynon J, Carr ND (1997) Surgical management of anorectal incontinence due to internal anal sphincter deficiency. Br J Surg 84:226–230PubMedCrossRefGoogle Scholar
  60. 60.
    Abou-Zeid AA (2000) Preliminary experience in management of fecal incontinence caused by internal anal sphincter injury. Dis Colon Rectum 43:198–202 discussion 202–204PubMedCrossRefGoogle Scholar
  61. 61.
    Leroi AM, Kamm MA, Weber J, Denis P, Hawley PR (1997) Internal anal sphincter repair. Int J Colorectal Dis 12:243–245PubMedCrossRefGoogle Scholar
  62. 62.
    Madiba TE, Moodley MM (2003) Anal sphincter reconstruction for incontinence due to non-obstetric sphincter damage. East Afr Med J 80:585–588PubMedGoogle Scholar
  63. 63.
    Kammerer-Doak DN, Dominguez C, Harner K, Dorin MH (1998) Surgical repair of fecal incontinence. Correlation of sonographic anal sphincter integrity with subjective cure. J Reprod Med 43:576–580PubMedGoogle Scholar
  64. 64.
    Nikiteas N, Korsgen S, Kumar D, Keighley MR (1996) Audit of sphincter repair. Factors associated with poor outcome. Dis Colon Rectum 39:1164–1170PubMedCrossRefGoogle Scholar
  65. 65.
    Herold A (2005) Spinkterrekonstruktion/Spinkterraffung. Coloproctology 27:383–386CrossRefGoogle Scholar
  66. 66.
    Ommer A (2006) Operativer schließmuskelersatz: dynamische grazilisplastik—artificial bowel sphincter—sakralnervenstimulation. Coloproctology 28:64–69CrossRefGoogle Scholar
  67. 67.
    Müller C, Belyaev O, Deska T, Chromik A, Weyhe D, Uhl W (2005) Fecal incontinence: an up-to-date critical overview of surgical treatment options. Langenbecks Arch Surg 390:544–552PubMedCrossRefGoogle Scholar
  68. 68.
    Holzer B, Rosen HR, Novi G, Ausch C, Holbling N, Schiessel R (2007) Sacral nerve stimulation for neurogenic faecal incontinence. Br J Surg 94:749–753PubMedCrossRefGoogle Scholar
  69. 69.
    Melenhorst J, Koch SM, Uludag O, van Gemert WG, Baeten CG (2007) Sacral neuromodulation in patients with faecal incontinence: results of the first 100 permanent implantations. Colorectal Dis 9:725–730PubMedCrossRefGoogle Scholar
  70. 70.
    Bachmann Nielsen M, Rasmussen OO, Pedersen JF, Christiansen J (1993) Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. Dis Colon Rectum 36:677–680CrossRefGoogle Scholar
  71. 71.
    Farouk R, Gunn J, Duthie GS (1998) Changing patterns of treatment for chronic anal fissure. Ann R Coll Surg Engl 80:194–196PubMedGoogle Scholar
  72. 72.
    Konsten J, Baeten CG (2000) Hemorrhoidectomy vs. Lord's method: 17-year follow-up of a prospective, randomized trial. Dis Colon Rectum 43:503–506PubMedCrossRefGoogle Scholar
  73. 73.
    Babor R, Keating JP, Isbister WH (2003) Long-term outcomes after anal dilatation for anal fissure. Coloproctology 25:135–141Google Scholar
  74. 74.
    Blessing H (1993) Spätergebnisse nach individueller lateraler Internus-Sphinkterotomie. Helv Chir Acta 59:603–607PubMedGoogle Scholar
  75. 75.
    Pfeifer J, Berger A, Uranus S (1994) Die chirurgische therapie der chronischen analfissur–beeinträchtigen proktologische zusatzoperationen die kontinenzleistung? Chirurg 65:630–633PubMedGoogle Scholar
  76. 76.
    Pernikoff BJ, Eisenstat TE, Rubin RJ, Oliver GC, Salvati EP (1994) Reappraisal of partial lateral internal sphincterotomy. Dis Colon Rectum 37:1291–1295PubMedCrossRefGoogle Scholar
  77. 77.
    Sharp FR (1996) Patient selection and treatment modalities for chronic anal fissure. Am J Surg 171:512–515PubMedCrossRefGoogle Scholar
  78. 78.
    Nyam DC, Pemberton JH (1999) Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 42:1306–1310PubMedCrossRefGoogle Scholar
  79. 79.
    Casillas S, Hull TL, Zutshi M, Trzcinski R, Bast JF, Xu M (2005) Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum 48:1193–1199PubMedCrossRefGoogle Scholar
  80. 80.
    Read MG, Read NW, Haynes WG, Donnelly TC, Johnson AG (1982) A prospective study of the effect of haemorrhoidectomy on sphincter function and faecal continence. Br J Surg 69:396–398PubMedCrossRefGoogle Scholar
  81. 81.
    McConnell JC, Khubchandani IT (1983) Long-term follow-up of closed hemorrhoidectomy. Dis Colon Rectum 26:797–799PubMedCrossRefGoogle Scholar
  82. 82.
    Kirsch JJ, Staude G, Herold A (2001) Hämorrhoidektomie nach Longo und Milligan-Morgan - Prospektive Vergleichsstudie mit 300 Patienten. Chirurg 72:180–185PubMedCrossRefGoogle Scholar
  83. 83.
    Johannsson HO, Graf W, Pahlman L (2002) Long-term results of haemorrhoidectomy. Eur J Surg 168:485–489PubMedCrossRefGoogle Scholar
  84. 84.
    Hetzer FH, Demartines N, Handschin AE, Clavien PA (2002) Stapled vs excision hemorrhoidectomy: long-term results of a prospective randomized trial. Arch Surg 137:337–340PubMedCrossRefGoogle Scholar
  85. 85.
    Beattie GC, Loudon MA (2001) Follow-up confirms sustained benefit of circumferential stapled anoplasty in the management of prolapsing haemorrhoids. Br J Surg 88:850–852PubMedCrossRefGoogle Scholar
  86. 86.
    Altomare DF, Rinaldi M, Sallustio PL, Martino P, De Fazio M, Memeo V (2001) Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity. Br J Surg 88:1487–1491PubMedCrossRefGoogle Scholar
  87. 87.
    Fantin AC, Hetzer FH, Christ AD, Fried M, Schwizer W (2002) Influence of stapler haemorrhoidectomy on anorectal function and on patients’ acceptance. Swiss Med Wkly 132:38–42PubMedGoogle Scholar
  88. 88.
    Jongen J, Bock JU, Peleikis HG, Eberstein A, Pfister K (2006) Complications and reoperations in stapled anopexy: learning by doing. Int J Colorectal Dis 21:166–171PubMedCrossRefGoogle Scholar
  89. 89.
    Kügler S (1966) Die Kontinenz nach Spaltung anorektaler Fisteln. Chirurg 37:64–66PubMedGoogle Scholar
  90. 90.
    Akovbiantz A, Arma S, Hegglin J (1968) Kontinenz nach Sphinkterspaltung bei Analfissuren und Analfisteln. Helv Chir Acta 35:260–265PubMedGoogle Scholar
  91. 91.
    Riedler L, Papp C, Autengruber M (1978) Chirurgische Spätergebnisse bei 107 Patienten mit anorektalen Fisteln. Leber Magen Darm 8:55–58PubMedGoogle Scholar
  92. 92.
    Saino P, Husa A (1985) A prospective manometric study of the effect of anal fistula surgery on anorectal function. Acta Chir Scand 151:279–288Google Scholar
  93. 93.
    Westerterp M, Volkers NA, Poolman RW, van Tets WF (2003) Anal fistulotomy between Skylla and Charybdis. Colorectal Dis 5:549–551PubMedCrossRefGoogle Scholar
  94. 94.
    Aguilar PS, Plasencia G, Hardy TG Jr, Hartmann RF, Stewart WR (1985) Mucosal advancement in the treatment of anal fistula. Dis Colon Rectum 28:496–498PubMedCrossRefGoogle Scholar
  95. 95.
    Abcarian H, Dodi G, Girona J, Kronborg O, Parnaud E, Thomson JP, Vaifai M, Goligher JC (1987) Fistula-in-ano. Int J Colorectal Dis 2:51–71PubMedCrossRefGoogle Scholar
  96. 96.
    Wedell J, Meier zu Eissen P, Banzhaf G, Kleine L (1987) Sliding flap advancement for the treatment of high level fistulae. Br J Surg 74:390–391PubMedCrossRefGoogle Scholar
  97. 97.
    Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH (1993) Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 114:682–689 discussion 689–690PubMedGoogle Scholar
  98. 98.
    Athanasiadis S, Köhler A, Nafe M (1994) Treatment of high anal fistulae by primary occlusion of the internal ostium, drainage of the intersphincteric space, and mucosal advancement flap. Int J Colorectal Dis 9:153–157PubMedCrossRefGoogle Scholar
  99. 99.
    Miller GV, Finan PJ (1998) Flap advancement and core fistulectomy for complex rectal fistula. Br J Surg 85:108–110PubMedCrossRefGoogle Scholar
  100. 100.
    Willis S, Rau M, Schumpelick V (2000) Chirurgische Therapie hoher anorectaler und rectovaginaler Fisteln mittels transanaler endorectaler Verschiebelappenplastik. Chirurg 71:836–840PubMedCrossRefGoogle Scholar
  101. 101.
    Ortiz H, Marzo J (2000) Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas. Br J Surg 87:1680–1683PubMedCrossRefGoogle Scholar
  102. 102.
    van der Hagen SJ, Baeten CG, Soeters PB, Beets-Tan RG, Russel MG, van Gemert WG (2005) Staged mucosal advancement flap for the treatment of complex anal fistulas: pretreatment with noncutting Setons and in case of recurrent multiple abscesses a diverting stoma. Colorectal Dis 7:513–518PubMedCrossRefGoogle Scholar
  103. 103.
    Perez F, Arroyo A, Serrano P, Candela F, Sanchez A, Calpena R (2005) Fistulotomy with primary sphincter reconstruction in the management of complex fistula-in-ano: prospective study of clinical and manometric results. J Am Coll Surg 200:897–903PubMedCrossRefGoogle Scholar
  104. 104.
    Uribe N, Millan M, Minguez M, Ballester C, Asencio F, Sanchiz V, Esclapez P, del Castillo JR (2007) Clinical and manometric results of endorectal advancement flaps for complex anal fistula. Int J Colorectal Dis 22:259–264PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • A. Ommer
    • 1
    Email author
  • F. A. Wenger
    • 1
  • T. Rolfs
    • 1
  • M. K. Walz
    • 1
  1. 1.Kliniken Essen-MitteClinic of Surgery and Center of Minimal Invasive SurgeryEssenGermany

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