Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

Background/Purpose

Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux.

Methods

A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patient's profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ² tests and t tests.

Results

Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open.

Conclusion

Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.     

Comparison of pharyngeal stenosis between hypopharyngeal patients undergoing primary versus salvage laryngopharyngectomy

Objective

To survey the risk factors of pharyngeal stenosis after laryngopharyngectomy in patients with advanced hypopharyngeal cancers.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Pharyngeal stenosis rates and risk factors were compared between two groups of laryngopharyngectomy patients: a group that underwent concurrent chemoradiation therapy followed by surgical salvage, and a surgery initiated group with adjuvant chemoradiation.

Results

Of 160 patients, 25 developed pharyngeal stenosis, which was diagnosed by barium esophagography with a pooling of barium contrast above the neopharyngeal inlet. These patients required nasogastric tube feeding or gastrostomy feeding because an oral liquid diet could not meet their nutritional needs. Primary closure and old age were risk factors for pharyngeal stenosis. Pharyngeal stenosis did not affect survival in patients with advanced hypopharyngeal cancer who underwent laryngopharyngectomy.

Conclusion

Primary closure reconstruction is discouraged in patients over the age of 65 years.     

Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer

Background

Multiple organ resection for locally advanced (assumed T4) gastric cancer is associated with high morbidity and mortality. Our aim was to evaluate the efficacy of these surgeries with regard to surgical morbidity, mortality, and survival.

Methods

Fifty-six patients underwent potentially radical gastrectomy combined with invaded organ resection. Early and late results of multiorgan resection and clinicopathologic factors influencing these results were evaluated.

Results

Forty patients (71.4%) received 1 additional organ resection and 16 patients (28.6%) received 2 or more additional organ resections. Postoperative morbidity and mortality was 37.5% and 12.5%, respectively. Resection of 2 or more additional organs increased postoperative morbidity and advanced age increased mortality. The 1- and 3-year survival rates were 53.3% and 28.1%, respectively. Advanced age, lymph node metastasis, and resection of more than 1 additional organ were significant prognostic factors for survival.

Conclusions

For patients with locally advanced gastric carcinoma, multiple organ resection is worthwhile with careful patient selection.     

Cancer-specific and other-cause mortality after radical prostatectomy versus observation in patients with prostate cancer: competing-risks analysis of a large North American population-based cohort

Background

Initial treatment options for low-risk clinically localized prostate cancer (PCa) include radical prostatectomy (RP) or observation.

Objective

To examine cancer-specific mortality (CSM) after accounting for other-cause mortality (OCM) in PCa patients treated with either RP or observation.

Design, setting, and participants

Using the Surveillance Epidemiology and End Results Medicare-linked database, a total of 44 694 patients ≥65 yr with localized (T1/2) PCa were identified (1992-2005).

Intervention

RP and observation.

Measurements

Propensity-score matching was used to adjust for potential selection biases associated with treatment type. The matched cohort was randomly divided into the development and validation sets. Competing-risks regression models were fitted and a competing-risks nomogram was developed and externally validated.

Results and limitations

Overall, 22 244 (49.8%) patients were treated with RP versus 22450 (50.2%) with observation. Propensity score-matched analyses derived 11 669 matched pairs. In the development cohort, the 10-yr CSM rate was 2.8% (2.3-3.5%) for RP versus 5.8% (5.0-6.6%) for observation (absolute risk reduction: 3.0%; relative risk reduction: 0.5%; p < 0.001). In multivariable analyses, the CSM hazard ratio for RP was 0.48 (0.38-0.59) relative to observation (p < 0.001). The competing-risks nomogram discrimination was 73% and 69% for prediction of CSM and OCM, respectively, in external validation. The nature of observational data may have introduced a selection bias.

Conclusions

On average RP reduces the risk of CSM by half in patients aged ≥65 yr, relative to observation. The individualized protective effect of RP relative to observation may be quantified with our nomogram.     

Long-term outcomes of portal Y-graft interposition for anomalous right portal veins in living donor liver transplantation

Background

Anomalous portal vein (PV) branching in living donor livers is not uncommon and usually leads to double PV orifices of the right lobe grafts. We have assessed the long-term outcomes of portal Y-graft interposition for adult living donor liver transplantation (LDLT).

Methods

We retrospectively assessed the outcomes of 79 right-lobe LDLTs using portal Y-graft interposition among the 2001 adult LDLTs performed at our institution from January 2002 to December 2010.

Results

Donor PV types were type III except for one case of type II. Sources of Y-grafts were recipient autologous PV in 76 LDLTs, fresh iliac vein allografts in two, and patch plasty using recipient greater saphenous vein in one. Detailed procedures included a portal Y-graft resection with Y-limbs, corner stay sutures, tying of suture materials under direct mechanical dilatation, and direct edge-to-edge anastomosis to the recipient remnant main PV. Early PV stenting was necessary in five patients (6.3%) due to stenosis or buckling deformity. During a mean follow-up of 42 months, all PVs remained patent until patient death or censoring. Overall 1-, 3-, and 5-year patient survival rates were 93.6%, 88.3%, and 85.5%, respectively. None of the 79 donors experienced major complications requiring reoperation or therapeutic intervention.

Conclusions

Due to their technical feasibility and excellent long-term outcome, portal Y-graft interposition should be considered a standard procedure for reconstruction of right-lobe grafts with double PV orifices.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Speech prognosis and need of pharyngeal flap for non syndromic vs syndromic Pierre Robin Sequence

Background

The aim of this retrospective study was to evaluate speech outcome and need of a pharyngeal flap in children born with nonsyndromic Pierre Robin Sequence (nsPRS) vs syndromic Pierre Robin Sequence (sPRS).

Methods

Pierre Robin Sequence was diagnosed when the triad microretrognathia, glossoptosis, and cleft palate were present. Children were classified at birth in 3 categories depending on respiratory and feeding problems. The Borel-Maisonny classification was used to score the velopharyngeal insufficiency.

Results

The study was based on 38 children followed from 1985 to 2006. For the 25 nsPRS, 9 (36%) pharyngeal flaps were performed with improvements of the phonatory score in the 3 categories. For the 13 sPRS, 3 (23%) pharyngeal flaps were performed with an improvement of the phonatory scores in the 3 children. There was no statistical difference between the nsPRS and sPRS groups (P = .3) even if we compared the children in the 3 categories (P = .2).

Conclusions

Children born with nsPRS did not have a better prognosis of speech outcome than children born with sPRS. Respiratory and feeding problems at birth did not seem to be correlated with speech outcome. This is important when informing parents on the prognosis of long-term therapy.     

Effects of rapid distraction rate on new bone formation during mandibular distraction osteogenesis in goats

Objective

Distraction osteogenesis typically requires a long treatment period, which can lead to bone and soft-tissue infection and considerable patient discomfort. Use of a rapid distraction rate in craniofacial distraction osteogenesis to shorten the distraction period is possible owing to the unique characteristics of craniofacial bones, including an abundant blood supply and rapid bone healing compared with long bones. The effects of using a rapid distraction rate in the treatment of craniofacial deformities are currently unclear, however. The objective of this study was to investigate the effects of a rapid distraction rate on new bone formation during mandibular distraction osteogenesis in goats.

Methods

Sixteen goats were randomly divided into four groups consisting of four goats each. In Groups A, B, and C, the right mandible of each goat was distracted at a rate of 0.8 mm/d, 1.6 mm/d, and 2.0 mm/d, respectively; Group D was the control group and did not undergo distraction. Six weeks after the conclusion of distraction, bone densitometry and three-point bending testing were performed in all groups.

Results

The mean bone density value of goats in Group A was significantly higher than those of all the other groups (p < 0.05), and the mean bone density value of goats in Group C was significantly lower than those of all the other groups (p < 0.05). The mean curve slope, peak stress, bending modulus, and energy to failure values of Groups A, B, and C were all significantly lower than those of the control group (p < 0.05). As the distraction rate increased, the curve slope and peak stress values gradually declined (p < 0.05).

Conclusions

Use of a rapid distraction rate in mandibular distraction osteogenesis may have detrimental effects on the quality of new bone, despite the abundant blood supply of craniofacial bones.     

Is there a role for aggressive use of fresh frozen plasma in massive transfusion of civilian trauma patients?

Background

Damage control resuscitation (DCR) with early plasma in combat casualties requiring massive transfusion (MT) decreases early deaths from bleeding.

Methods

To ascertain the potential role of early plasma DCR in civilian MT, we queried a prospective traumatic shock database of 383 civilians.

Results

Ninety-three (24%) of the traumatic shock civilians received a MT, of which 26 (28%) died early, predominantly from bleeding within 6 hours. Comparatively, this early MT death cohort arrived in more severe shock and were coagulopathic (mean INR 2.4). In the critical period of MT (ie, the first 3 hours), these patients received 20 U of packed red blood cells (PRBCs) but only 4 U of fresh frozen plasma (FFP). They remained severely acidotic and their coagulopathy worsened as they exsanquinated.

Conclusion

Civilians who arrived in traumatic shock, required a MT, and died early had worsening coagulopathy, which was not treated. DCR with FFP may have a role in civilian trauma.     

Prognostic significance of biochemical heterogeneity of catecholaminergic clones in neuroblastoma

Background/Purpose

Genetic heterogeneity of neuroblastic tumors leads to biochemical changes that manifest themselves in different symptoms and clinical courses, which may vary from spontaneous regression and remission to progression with fatal outcome.

Methods

To test the hypothesis that ratios of dopamine (DA) to noradrenaline and of DA to vanillylmandelic acid reflect the composition of adrenergic clones and tumor heterogeneity, we determined urinary DA/noradrenaline and DA/vanillylmandelic acid ratios that presumably reflect DA-β-hydroxylase (DBH) activity and the prognostic values thereof.

Results

Based on catecholamine metabolism, 4 model situations were defined: (a) complete block of DBH in all cells; (b) block of DBH in some cells; (c) a different enzymatic block; and (d) normal DBH activity in the population of tumor-forming cells. Normal DBH activity was encountered most frequently in children younger than 2 years and in tumors representing favorable prognostic stages (I, II, and IVS). Surviving children with stage IV neuroblastoma presented with tumors composed primarily of cells without the DBH block. Further stratification of 2 prognostically poor groups (stages IV and III + IV) was possible with respect to DBH activity.

Conclusions

Differential production of neurotransmitters in a population of tumor cells may be explained in terms of tumor heterogeneity.     

Post-appendectomy visits to the emergency department within the global period: a target for cost containment

Background

Postoperative visits to the emergency department (ED) instead of the surgeon's office consume enormous cost.

Hypothesis

Postoperative ED visits can be avoided.

Setting

Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine.

Patients

Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period.

Methods

Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson χ² test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospital's billing department.

Results

Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was $55,000 plus physician services.

Conclusions

ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access.     

Donor/recipient algorithm for management of the middle hepatic vein in right graft live donor liver transplantation

Background

The aim of this study was to delineate an algorithm for donor and recipient criteria and middle hepatic vein (MHV) management in right-graft live-donor liver transplantation (LDLT) on the basis of computerized 3-dimensional computed tomographic image analysis.

Methods

Data on 94 consecutive right-graft LDLTs were prospectively collected. Graft and remnant data for the first 23 cases were retrospectively evaluated by means of 3-dimensional computed tomographic reconstructions, and on the basis of that preliminary series, a graft selection algorithm using 3 parameters—hepatic vein dominance classification, graft and remnant graft volume/body weight ratios, and congestion volumes—was created. It was subsequently applied to the next 71 right-graft LDLTs.

Results

Fifty-nine right grafts contained the MHV. Four of the 12 grafts with no MHVs required MHV reconstructions. In 18 cases, small liver grafts were used. The postoperative function of liver grafts and remnants with versus without MHVs was not statistically different.

Conclusions

The proposed algorithm favored the inclusion of the MHV with the right grafts. It also allowed for the procurement of grafts that were potentially small for size without compromising donor or recipient safety.     

Is congenital lobar emphysema a surgical disease?

Background

The management of congenital lobar emphysema has traditionally been surgical. Because of increased use of imaging, this lesion is frequently found in asymptomatic and mildly symptomatic children, prompting us to adopt a more conservative approach to these children.

Methods

All children with congenital lobar emphysema presenting between 1995 and 2002 were included. Medical records, imaging files, and pathology reports were reviewed.

Results

Twenty children (0-17 years) were identified. Eight were diagnosed antenatally. Fourteen were managed without surgery. Of the 11 symptomatic children, 6 showed spontaneous improvement.

Conclusions

The favorable outcome of both asymptomatic and mildly symptomatic children suggests that a nonoperative approach should be considered in these patients.     

Augmentation mentoplasty with osteocartilaginous nasal graft

Objective

Augmentation mentoplasty is a common procedure, applied especially in conjunction with rhinoplasty. Although various materials have been used, autogenous nasal hump tissue has not been studied in a big series of patients. The main objective of this study was to evaluate the use of autogenous nasal hump in chin augmentation.

Study Design

Case series with chart review.

Setting

University hospital.

Subjects and Methods

The osteocartilaginous mentoplasty procedure was performed in 124 patients along with rhinoplasty in a series of 218 patients who had undergone combined rhinoplasty and mentoplasty with various techniques. The median follow-up was 58 months (range, 12-120 months) over a 10-year period. The procedure commenced under general anesthesia for all patients with large humps and poor chin projection. During the rhinoplasty procedure, the osteocartilaginous nasal hump was removed, tailored to achieve an anatomic mental form, and inserted into the mental pocket through a submental or an intraoral incision.

Results

Infection was detected in five patients, two of whom required graft removal. All other patients recovered normally along an almost painless process, without displacements or any other complaints.

Conclusion

Nasal hump in reduction rhinoplasty is a useful alternative for augmentation mentoplasty on patients with large humps and poor chin projection. It also avoids all the disadvantages of alloplastic materials and eases integration compared with other alternatives in selected cases.     

BK Virus Infection in Association With Posttransplant Urothelial Carcinoma

Objective

BK virus infection after transplantation is known to cause graft failure but the association with malignancies is controversial.

Methods

BK virus workup was performed for kidney recipients in our center under conditions of hematuria or acute deterioration of graft function. We reviewed the history and reported our treatment and the disease course of three patients with BK virus later diagnosed with urothelial carcinoma.

Results

All three patients received kidneys from China with immunosuppression using a calcineurin inhibitor and monoclonal antibodies. Synchronous bladder and upper-tract tumors were treated with surgery followed by intravesical chemotherapies. We tapered the immunosuppressants and changed to a sirolimus-based regimen. Intravesical chemotherapy and concurrent chemoradiotherapy were performed to prevent recurrence. All three patients now have functional grafts.

Conclusion

BK virus infection may lead to tumorigenesis. Besides decreasing immunosuppressants, we should be more alert to the detection of malignancies in BK virus-reactivated recipients. Early aggressive treatment may be curative, preserving functional grafts.     

The testicular regression syndrome--do remnants require routine excision?

Aim

Excision of testicular remnants is debatable in the scenario where hypoplastic vas and vessels can be seen entering a closed internal ring during laparoscopy for impalpable testes. We aimed to establish how frequently excised remnants have identifiable testicular tissue and, hence, malignant potential.

Methods

This study is a retrospective review of all excised testicular remnants in children with impalpable testis. Specimens that were excised for indications other than testicular regression syndrome were excluded. Pathology reports of excised specimens were reviewed, and the presence of multiple histologic features was noted. Histologic confirmation of testicular/paratesticular tissue required the presence of 1 or more of the following: seminiferous tubules, germ cells, Sertoli cells, Leydig cells, vas deferens, or epididymal structures. Malignancy potential was defined by the presence of germ cells or seminiferous tubules. All patients with seminiferous tubules were further examined by a single histopathologist.

Results

A total of 208 testicular remnants from 206 children were excised over the 11-year period (1999-2009). Histologic evidence confirmed excision of testicular/paratesticular tissue in 180 cases (87%). Seminiferous tubules were noted in 27 (15%), and germ cells were present in 19 (11%) cases.

Conclusion

Viable germ cells were found in 11% of examined remnants, which, in our opinion, justifies their removal.     

Haemostatic squeezing and purse-string sutures: optimising surgical techniques for early excision of critical infantile haemangiomas

Background/Purpose

Surgical excision of critical infantile haemangiomas (HMs) is usually delayed until intralesional blood flow spontaneously decreases, but fibrofatty tissue and exuberant skin invariably remain even after total involution.The aim of this study was to describe 2 surgical techniques used for early excision in 50 selected cases of HM defined critical in site or size.

Methods

Among a total of 952 patients affected by HM observed from 1999 to 2005, 50 children (5.2%) were submitted to early surgical removal of the tumour (age range, 6-24 months).In group 1, a technique of lenticular incision and linear closure was used in 34 patients using an original clamp for haemostasis during excision. In group 2, a modified round-block excision and purse-string closure technique was performed in 16 patients.

Results

Only 2 patients required transfusion to replace intraoperative blood losses. Infection, delayed wound healing, and cheloids occurred in 3 patients in group 2. Satisfactory cosmetic results have been observed in most cases in both groups at a follow-up ranging from 6 months to 6 years.

Conclusions

The range of indications for early surgical removal of critical HM might be enlarged to achieve earlier the better cosmetic results. A few surgical tricks can minimize intraoperative bleeding and optimise the surgical scar.     

Acellular porcine intestinal submucosa as fascial graft in an animal model: Applications for revision tympanoplasty

Objective

To demonstrate regeneration of muscle fascia appropriate for future harvest with the use of acellular porcine intestinal submucosa in a rat model.

Study Design

Animal cohort study.

Setting

Tertiary care academic medical center.

Subjects and Methods

Sixteen male Sprague-Dawley rats underwent excision of rectus abdominis muscle fascia. A sheet of acellular porcine intestinal submucosa was placed in the fascia harvest defect. Graft and underlying muscle were harvested at three-, six-, and nine-week intervals. Histologic examination, including immunohistology for anti-von Willebrand factor, was performed at each timepoint. Additional selected specimens were subjected to latex vascular perfusion casts to examine vessel growth patterns within the graft.

Results

Gross examination revealed a new tissue plane, indistinguishable from surrounding native fascia. Histology revealed an initial inflammatory response within the graft. Progressive influx of native tissue was noted over successive timepoints. Via collagen-specific staining, we noted progressive reorganization and maturation of the graft collagen matrix. At the final nine-week time point, a new loose connective tissue plane was reestablished between the graft and underlying muscle. Immunohistochemistry and latex perfusion both demonstrate an initial development of small capillaries that progresses over time to greater organization and arteriole formation.

Conclusion

Fascia regeneration may be possible with use of an acellular porcine intestinal submucosa graft in an animal model. Future studies may prove beneficial in restoring fascia in humans. Implications for potential advantages in tympanoplasty are discussed.     

Hematologic recovery in patients who are treated with autologous stem cells transplantation taken from bone marrow after granulocyte-colony-stimulating factor stimulation

Background

We sought to compare hematologic recovery between patients who did or did not receive granulocyte-colony-stimulating factor (G-CSF)-stimulated bone marrow (rich bone marrow [RBM]).

Materials and Methods

The study subjects were 20 patients whose bone marrow was taken without prior stimulation with G-CSF and 15 patients in whom bone marrow was taken after previous G-CSF mobilization. The bone marrow harvest took place on the fifth day after G-CSF initiation. The bone marrow aliquot was 20 mL/kg.

Results

The median value of nucleated cells obtained from patients without G-CSF preparation was 3.65 × 10⁸/kg. The median value of nucleated cells from RBM patients was 4.83 × 10⁸/kg. The median value of stem cells obtained from patients without G-CSF preparation was 0.96 × 10⁶/kg versus 1.9 × 10⁶/kg from RBM patients. The median time to recovery of the hematopoietic system based on an increase in PLT value >20 g/L was 12.6 days for RBM versus 18.8 days without G-CSF preparation. The median time to recovery of the hematopoietic system based on assessment of growth ANC>0.5 g/L was 13.0 days for RBM versus 17.8 days without G-CSF stimulation. Significantly higher values of nucleated cells and increased stem cells were observed among RBM patients compared with those whose bone marrow was harvested without any stimulation (P = .01). There was faster recovery of the hematopoietic system in cases where bone marrow was collected after G-CSF: PLT >20 g/L (P = .015) and ANC >0.5 g/L (P = .01). We also observed that the use of stimulated bone marrow shortened hospital stay after the administration of hematopoietic cells to 17.3 days compared with 23.1 days among patients receiving hematopoietic cells from nonstimulated bone marrow. The number of complications during transplantation was comparable in both cases, the most frequent ones being febrile neutropenia and grade III and IV mucositis.

Conclusion

RBM is a better method to obtain stem cells from bone marrow. Stimulated bone marrow shows faster engraftment compared with nonstimulated bone marrow helping patients who fail to generate are adequate number of stem cells from peripheral blood.     

Impacto de los colgajos transanales de avance en la continencia fecal

Objective

The aim of this study was the prospective evaluation of the functional results of a series endorectal advancement flaps in the treatment of complex anal fistulas.

Material and methods

A total of 90 patients were operated on for a complex anal fistula by means of fistulectomy and endorectal advancement flap. The functional results were evaluated using the Wexner continence scale and an anorectal manometry study before and after surgery.

Results

There were seven patients with fistula recurrence (7.7%) and the same surgical procedure was performed on five of them, resulting in healing in all cases. Significant reductions in maximum resting pressure (83.85±30.96 vs 46.51±18.67; p<0.001) and maximum squeeze pressure (220.97±100.21 vs 183.06±75.36; p<0.001) were seen 3 months after surgery. On the continence scale, 80% of patients had a normal continence with a value of 0 on thepostoperative Wexner scale, while 20% recorded changes in continence values, most of them lower than 3 points.

Conclusions

Endorectal advancement flap is an effective surgical procedure in complex anal fistulas treatment, with a low recurrence rate. Only 20% of the patients showed changes in the continence value.