Effect of Tobacco Smoking on Advancement Flap Repair of Complex Anal Fistulas

PURPOSE: Options for the management of complex anal fistulas include fistulotomy, setons, fibrin sealant, and advancement flaps. This study was performed to evaluate our results with advancement flap repair of anal fistulas and to identify factors associated with failure. METHODS: A retrospective analysis was performed for all patients treated with an anal fistula between June 2000 and May 2003. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, smoking history, procedure performed, and fistula recurrence. RESULTS: There were 95 patients (43 males and 52 females) with a mean age of 42 years. Transsphincteric fistulas were present in 51 patients and 44 females had rectovaginal fistulas. A mucosal flap repair was performed for 68 patients and 27 patients had an anodermal flap repair. The median length of follow-up was ten months. The fistula recurred in 31 patients (32.6 percent). Subset analysis showed an association between a history of previous attempts at repair or tobacco smoking and an increased rate of fistula recurrence, but did not reveal any increased risk of recurrence for patients over age 40 years, for those with rectovaginal fistula, or for males. CONCLUSION: A history of previous attempts at repair of an anal fistula or tobacco smoking is associated with an increased risk of fistula recurrence; while age over 40 years, male gender, or a rectovaginal fistula are not.