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Yuan Y, Li S, Li F, Zhou Y, Qiang S, Che K, Wang K, Yang K, Li Q. Modified Internal Pudendal Artery Perforator Flap Interposition for Rectovaginal Fistula. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00164. [PMID: 38373234 DOI: 10.1097/spv.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
IMPORTANCE Rectovaginal fistula (RVF) is a challenging condition associated with recurrences and significant functional impairment. OBJECTIVES The internal pudendal artery perforator (IPAP) flap has become a viable option for reconstructing the vagina and perineal regions. This study aims to introduce a modified technique of IPAP flap interposition and evaluate its postoperative outcomes in the treatment of low RVF. STUDY DESIGN Sixteen patients with RVF who underwent modified IPAP flap interposition between 2016 and 2021 were retrospectively enrolled. Recurrence rate, the satisfaction of vulvar appearance (Visual Analog Scale), and quality of sexual life (Female Sexual Function Index score) were followed up and analyzed. RESULTS All patients presented with low fistula with a mean diameter of 8.3 mm. The mean width and length of the IPAP flaps were 3.8 and 6.2 cm, respectively. The mean follow-up period was 14.1 months. All patients achieved successful healing without recurrence. High satisfaction was reported for the cosmetic effect of the vulva with a mean Visual Analog Scale score of 8.4. The proportion of female sexual disorder exhibited a statistically significant reduction, decreasing from 100% preoperatively to 38% after surgery (P < 0.05). CONCLUSIONS The modified IPAP flap interposition is a reliable and safe option for repairing low RVF, with high success rates and minimal donor site morbidity. Moreover, this procedure provides a suitable volume flap and preserves the vaginal physiological environment, which benefits postoperative sexual function.
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Affiliation(s)
- Ye Yuan
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Senkai Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengyong Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhou
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuai Qiang
- Plastic Surgery Department, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kexin Che
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keke Wang
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Yang
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Maspero M, Otero Piñeiro A, Steele SR, Hull TL. Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis. Dis Colon Rectum 2023; 66:631-645. [PMID: 36735766 DOI: 10.1097/dcr.0000000000002739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Schoene MI, Schatz S, Brunner M, Fuerst A. Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases. Int J Colorectal Dis 2023; 38:16. [PMID: 36652018 PMCID: PMC9849283 DOI: 10.1007/s00384-022-04293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies. METHODS A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef's Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula. RESULTS A total of 60 patients (44 women, 16 men; mean age 50 years, range 24-82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1-15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1-187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1). CONCLUSION Based on the authors' experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.
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Affiliation(s)
- Milla Isabelle Schoene
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
- University of Regensburg, Regensburg, Germany
| | - Sabine Schatz
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Marion Brunner
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Alois Fuerst
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany.
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Garoufalia Z, Gefen R, Emile SH, Silva-Alvarenga E, Horesh N, Freund MR, Wexner SD. Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature. Colorectal Dis 2022; 25:549-561. [PMID: 36413086 DOI: 10.1111/codi.16427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/09/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
AIM Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF. METHOD PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data. RESULTS Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I2 = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I2 = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I2 = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I2 = 61%). CONCLUSION The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.
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Affiliation(s)
- Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.,Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.,Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Emanuela Silva-Alvarenga
- Cleveland Clinic Martin Health at Tradition Health Park Two, Cleveland Clinic Florida, Port St Lucie, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.,Department of Surgery and Transplantations, Sheba Medical Center, Sheba Tel Hashomer, Ramat Gan, Israel
| | - Michael R Freund
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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Meyer J, Ris F, Parkes M, Davies J. Rectovaginal Fistula in Crohn's Disease: When and How to Operate? Clin Colon Rectal Surg 2022; 35:10-20. [PMID: 35069026 PMCID: PMC8763467 DOI: 10.1055/s-0041-1740029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Rectovaginal fistula (RVF) occurring during the course of Crohn's disease (CD) constitutes a therapeutic challenge and is characterized by a high rate of recurrence. To optimize the outcome of CD-related RVF repair, the best conditions for correct healing should be obtained. Remission of CD should be achieved with no active proctitis, the perianal CD activity should be minimized, and local septic complications should be controlled. The objective of surgical repair is to close the fistula tract with minimal recurrence and functional disturbance. Several therapeutic strategies exist and the approach should be tailored to the anatomy of the RVF and the quality of the local supporting tissues. Herein, we review the medical and surgical management of CD-related RVF.
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Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland,Medical School, University of Geneva, Genève, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland,Medical School, University of Geneva, Genève, Switzerland
| | - Miles Parkes
- Division of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom,Address for correspondence Richard Justin Davies, MChir Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation TrustCambridge CB2 0QQUnited Kingdom
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Rektovaginale Fisteln. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00567-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Grott M, Rickert A, Hetjens S, Kienle P. Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period. Int J Colorectal Dis 2021; 36:569-580. [PMID: 33386945 DOI: 10.1007/s00384-020-03825-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Gracilis muscle transposition (GMT) is an established surgical technique in the treatment of anorectal fistulas and fistulas to the vagina and the urinary system when previous closure options have failed. There is little evidence on the success rate of this procedure in the long term. METHODS This is a follow-up study on all patients undergoing GMT over a 10-year period at a tertiary referral center for complex fistulas. Postoperative function and quality of life were evaluated by standardized questionnaires (Wexner score, Fecal Incontinence Quality of Life Score (FIQL), SF-12 and a brief questionnaire designed for this study). Sexual function was evaluated by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function. RESULTS Forty-seven gracilis muscle transpositions (GMT) in 46 patients were performed. Most treated patients had (neo-)-rectovaginal fistulas (n = 29). An overall fistula closure was achieved in 34 of 46 patients (74%): in 25 cases primarily by GMT (53%) and in nine patients with persistent or recurrent fistula by additional surgical procedures. A clinically apparent relapse occurred on average 276 days (median: 180 days) after GMT (mean follow-up 73.4 months). CONCLUSION GMT in our hands has a primary closure rate of 53%, and after further procedures, this rises to 74%. Fecal continence is impaired in patients having undergone GMT. The overall quality of life in patients after GMT is only slightly impaired, and sexual function is severely impaired in female patients.
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Affiliation(s)
- M Grott
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University, Röntgenstraße 1, 69126, Heidelberg, Germany
| | - A Rickert
- Department of Surgery, St. Josefskrankenhaus Heidelberg, Akademisches Lehrkrankenhaus der Medizinischen Fakultät Mannheim der Universität Heidelberg, Landhausstraße 25, 69115, Heidelberg, Germany
| | - S Hetjens
- Department for Medical Statistics and Biomathematics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Akademisches Lehrkrankenhaus der Universität Heidelberg, Heidelberg University, Bassermannstraße 1, 68165, Mannheim, Germany.
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