Short note Extrasphincteric rectal fistulas treated successfully by Soave’s procedure despite marked local sepsis C. A. Maxwell-Armstrong and R. K. S. Phillips Department of Surgery, St Mark’s Hospital, Watford Road, Harrow, London HA1 3UJ, UK Correspondence to: Professor R. K. S. Phillips (e-mail: marie.gun@cancer.org.uk) Paper accepted 2 September 2002 Published online in Wiley InterScience (www.bjs.co.uk) DOI: 10.1002/bjs.4039 Introduction Soave 1 described a coloanal pull-through procedure to treat Hirschsprung’s disease, an operation similar to that described by Parks 2 to treat benign rectal conditions in adults and subsequently applied to colorectal anastomotic strictures 3 , even in the presence of advanced sepsis 4 . The advantage is to allow preservation of intestinal continuity, without risking a hazardous dissection in the presence of an ‘unfriendly’ pelvis. Extrasphincteric fistulas may originate from a seg- ment of sigmoid diverticular disease, or from terminal ileal–sigmoid Crohn’s disease, when abdominal resection of the affected part can be quite easy. However, if the fistula arises from the rectum itself, and especially when associated sepsis is marked, surgical management can be extremely challenging. This report describes three patients in whom a Soave endorectal pull-through procedure was used to treat such fistulas and a fourth patient who had a multiply recurrent anastomotic to vaginal fistula following anterior resection. Patients and methods Four patients were referred for definitive management of a fistula. The aetiology was considered to be a bone perforation in two patients, Crohn’s disease in the third and following anterior resection for cancer in the fourth. There were two men and two women with a mean age of 34·5 years. They each underwent a Soave procedure, as described below. Abdominal dissection proceeds to the point of maximum difficulty. Rather than persisting in the (usually distorted) conventional anatomical plane, risking organ injury or severe presacral haemorrhage, the surgeon transects the bowel at the point of maximum difficulty and delivers the proximal end into the wound. Attention is turned Blind end of old fistula occluded by colonic pull-through Rectal tube denuded of mucosa Mucosectomy ends here at point of anastomosis Fig. 1 Transanal endoanal coloanal hand-sewn anastomosis to the distal remnant. If it is strictured at any point, then forced dilatation with Hagar dilators is performed (through either the abdomen or the anal canal), sometimes aided by judicious longitudinal full-thickness cuts in the bowel tube (usually placed posteriorly) so as to splay the bowel remnant open for mucosectomy. Mucosectomy from above and below completes the preparation. This is technically challenging and may be as long as 10 cm, as in one patient in the present series. As much as possible should be performed by the abdominal operator. Transanal endoanal coloanal hand-sewn anastomosis is performed (Fig. 1). It is usually not possible or wise to form a colonic pouch – not possible because the rectal wall sleeve is usually too narrow to accommodate a pouch, and not wise because a straight coloanal anastomosis results in a suture line well away from the site of the fistula, whereas the apex of a colonic pouch may abut the original fistula and promote refistulation. All patients were defunctioned. Results There was no death, evidence of fistula recurrence or stenosis at a mean follow-up of 22·8 (range 9 – 60) months. Functional results, although not formally assessed, were clinically satisfactory. Discussion Coloanal sleeve anastomosis is a useful strategy in clinically difficult circumstances. In general, operative danger and difficulty are at the circumferential margins where ureter, blood vessels, vagina and prostate can all be damaged Copyright  2003 British Journal of Surgery Society Ltd British Journal of Surgery 2003; 90: 237–238 Published by John Wiley & Sons Ltd