Surgical management of rectovaginal fistula

Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis

BACKGROUND

A rectovaginal fistula is a debilitating condition that often severely impacts quality of life. Despite many treatment options available, the best surgical treatment is far from being established, and many patients will undergo several procedures before fistula closure is achieved. Gracilis muscle interposition, which is the transposition of the gracilis muscle into the rectovaginal septum, is an option for complex and persistent fistulas, but literature on the subject is scarce, mainly consisting of small case series.

OBJECTIVE

This study aimed to assess the success rate of gracilis muscle interposition for the surgical treatment of rectovaginal fistula.

DATA SOURCES

MEDLINE, Embase, Cochrane Library, and Web of Science.

STUDY SELECTION

Studies comprising at least 5 patients who underwent gracilis muscle interposition for rectovaginal fistula were included. No date or language restrictions was applied.

INTERVENTION

Gracilis muscle interposition.

MAIN OUTCOME MEASURES

The primary outcome is the fistula closure rate (%). Other domains analyzed are stoma closure rate, postoperative complications, quality of life, fecal continence, and sexual function.

RESULTS

Twenty studies were included for a total of 384 patients. The pooled fistula closure rate for gracilis muscle interposition was 64% (95% CI, 53%-74%; range, 33%-100%). Risk factors for failure were smoking, underlying Crohn's disease, and more than 2 previous repairs, whereas stoma formation was associated with improved outcomes. Postoperative complications ranged from 0% to 37%, mostly related to surgical site occurrences at the harvest site and perineal area. No deaths occurred. Gracilis muscle interposition improved quality of life and fecal continence, but impairment of sexual function was common.

LIMITATIONS

Most of the included studies were small case series.

CONCLUSIONS

Gracilis muscle interposition is a safe and moderately effective treatment that could be taken into consideration as second- or third-line therapy for recurrent rectovaginal fistula.

REGISTRATION NO

CRD42022319621.

Clinical value of endoluminal ultrasonography in the diagnosis of rectovaginal fistula

Background

Rectovaginal fistula (RVF) refers to a pathological passage between the rectum and vagina, which is a public health challenge. This study was aimed to explore the clinical value of endoluminal biplane ultrasonography in the diagnosis of rectovaginal fistula (RVF).

Methods

Thirty inpatients and outpatients with suspected RVF from January 2006 to June 2013 were included in the study, among whom 28 underwent surgical repair. All 28 patients underwent preoperative endoluminal ultrasonography, and the obtained diagnostic results were compared with the corresponding surgical results.

Results

All of the internal openings located at the anal canal and rectum of the 28 patients and confirmed during surgery were revealed by preoperative endosonography, which showed a positive predictive value of 100 %. Regarding the 30 internal openings located in the vagina during surgery, the positive predictive value of preoperative endosonography was 93 %. The six cases of simple fistulas confirmed during surgery were revealed by endosonography; for the 22 cases of complex fistula confirmed during surgery, the positive predictive value of endosonography was 90 %. Surgery confirmed 14 cases of anal fistula and 14 cases of RVF, whereas preoperative endoluminal ultrasonography suggested 16 cases of anal fistula and 12 cases of RVF, resulting in positive predictive values of 92.3 and 93 %, respectively.

Conclusion

The use of endoluminal biplane ultrasonography in the diagnosis of RVF can accurately determine the internal openings in the rectum or vagina and can relatively accurately identify concomitant branches and abscesses located in the rectovaginal septum. Thus, it is a good imaging tool for examining internal and external anal sphincter injuries and provides useful information for preoperative preparation and postoperative evaluation.