Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases
Tóm tắt
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. 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. 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). 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.
Tài liệu tham khảo
Akiba RT, Rodrigues FG, da Silva G (2016) Management of complex perineal fistula disease. Clin Colon Rectal Surg 29(2):92–100. https://doi.org/10.1055/s-0036-1580631. (PMID:27247533; PMCID:PMC4882183)
Grott M, Rickert A, Hetjens S, Kienle P (2021) Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period. Int J Colorectal Dis 36(3):569–580. https://doi.org/10.1007/s00384-020-03825-2. (Epub 2021 Jan 2 PMID: 33386945)
Studniarek A, Abcarian A, Pan J, Wang H, Gantt G Jr, Abcarian H (2021) What is the best method of rectovaginal fistula repair? A 25-year single-center experience. Tech Coloproctol 25(9):1037–1044. https://doi.org/10.1007/s10151-021-02475-y. (Epub 2021 Jun 8 PMID: 34101044)
Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y (2015) Rectovaginal fistula: what is the optimal strategy?: an analysis of 79 patients undergoing 286 procedures. Ann Surg 262(5):855–860. https://doi.org/10.1097/SLA.0000000000001461. (PMID: 26583676)
Wang D, Chen J, Zhu L, Sang M, Yu F, Zhou Q (2018) Surgical repair of rectovaginal fistula using the modified Martius procedure: a step-by-step guide. J Minim Invasive Gynecol 25(4):573–575. https://doi.org/10.1016/j.jmig.2017.08.657. (Epub 2017 Sep 6. PMID: 28888700)
Devakumar H, Chandrasekaran N, Alas A, Martin L, Davila GW, Hurtado E (2017) Transvaginal repair of complex rectovaginal fistulas using the porcine urinary bladder matrix as an augmenting graft. Female Pelvic Med Reconstr Surg 23(3):e25–e28. https://doi.org/10.1097/SPV.0000000000000410. (PMID: 28277472)
Christoforidis D, Etzioni DA, Goldberg SM, Madoff RD, Mellgren A (2008) Treatment of complex anal fistulas with the collagen fistula plug. Dis Colon Rectum 51(10):1482–1487. https://doi.org/10.1007/s10350-008-9374-5. (Epub 2008 Jun 3 PMID: 18521674)
Hechenbleikner EM, Buckley JC, Wick EC (2013) Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes. Dis Colon Rectum 56(3):374–383. https://doi.org/10.1097/DCR.0b013e318274dc87. (PMID: 23392154)
Ommer A, Herold A, Berg E, Fürst A, Post S, Ruppert R, Schiedeck T, Schwandner O, Strittmatter B (2017) German S3 guidelines: anal abscess and fistula (second revised version). Langenbecks Arch Surg 402(2):191–201. https://doi.org/10.1007/s00423-017-1563-z. (Epub 2017 Mar 1 PMID: 28251361)
Maljaars LP, Nundwe W, Roovers JWR, Pope RJ (2022) Follow-up of obstetric fistula repair using Singapore fasciocutaneous flap and/or gracilis muscle flap. Neurourol Urodyn 41(1):246–254. https://doi.org/10.1002/nau.24805. (Epub 2021 Oct 4 PMID: 34605563)
Maeda Y, Heyckendorff-Diebold T, Tei TM, Lundby L, Buntzen S (2011) Gracilis muscle transposition for complex fistula and persistent nonhealing sinus in perianal Crohn’s disease. Inflamm Bowel Dis 17(2):583–589. https://doi.org/10.1002/ibd.21311. (PMID: 20848513)
Zmora O, Potenti FM, Wexner SD, Pikarsky AJ, Efron JE, Nogueras JJ, Pricolo VE, Weiss EG (2003) Gracilis muscle transposition for iatrogenic rectourethral fistula. Ann Surg 237(4):483–487. https://doi.org/10.1097/01.SLA.0000059970.82125.DB. (PMID:12677143; PMCID:PMC1514481)
Zmora O, Tulchinsky H, Gur E, Goldman G, Klausner JM, Rabau M (2006) Gracilis muscle transposition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 49(9):1316–1321. https://doi.org/10.1007/s10350-006-0585-3. (PMID: 16752191)
Wexner SD, Ruiz DE, Genua J, Nogueras JJ, Weiss EG, Zmora O (2008) Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg 248(1):39–43. https://doi.org/10.1097/SLA.0b013e31817d077d. (PMID: 18580205)
Fürst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, Agha A (2008) Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease. Int J Colorectal Dis 23(4):349–353. https://doi.org/10.1007/s00384-007-0413-9. (PMID: 18084771)
Ulrich D, Roos J, Jakse G, Pallua N (2009) Gracilis muscle interposition for the treatment of recto-urethral and rectovaginal fistulas: a retrospective analysis of 35 cases. J Plast Reconstr Aesthet Surg 62(3):352–356. https://doi.org/10.1016/j.bjps.2008.11.067. (Epub 2009 Jan 21 PMID: 19158006)
Lefèvre JH, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y (2009) Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis Colon Rectum 52(7):1290–1295. https://doi.org/10.1007/DCR.0b013e3181a74700. (PMID: 19571707)
Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD (2010) Are there predictors of outcome following rectovaginal fistula repair? Dis Colon Rectum 53(9):1240–1247. https://doi.org/10.1007/DCR.0b013e3181e536cb. (PMID: 20706066)
Nassar OA (2011) Primary repair of rectovaginal fistulas complicating pelvic surgery by gracilis myocutaneous flap. Gynecol Oncol 121(3):610–614. https://doi.org/10.1016/j.ygyno.2011.02.008. (Epub 2011 Apr 1 PMID: 21458039)
Chen XB, Wang YX, Jiang H, Liao DX, Yu JH, Luo CH (2013) Salvage irrigation-suction in gracilis muscle repair of complex rectovaginal and rectourethral fistulas. World J Gastroenterol 19(39):6625–6629. https://doi.org/10.3748/wjg.v19.i39.6625. (PMID:24151391; PMCID:PMC3801378)
Troja A, Käse P, El-Sourani N, Raab HR, Antolovic D (2013) Treatment of recurrent rectovaginal/pouch-vaginal fistulas by gracilis muscle transposition - a single center experience. J Visc Surg 150(6):379–382. https://doi.org/10.1016/j.jviscsurg.2013.08.002. (Epub 2013 Oct 18 PMID: 24144724)
Park SO, Hong KY, Park KJ, Chang H, Shin JY, Jeong SY (2017) Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up. Int J Colorectal Dis 32(7):1029–1032. https://doi.org/10.1007/s00384-017-2784-x. (Epub 2017 Feb 16 PMID: 28210852)
Rottoli M, Vallicelli C, Boschi L, Cipriani R, Poggioli G (2018) Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn’s disease a risk factor for failure? A prospective cohort study Updates Surg 70(4):485–490. https://doi.org/10.1007/s13304-018-0558-9. (Epub 2018 Jul 7 PMID: 29982963)
Kersting S, Athanasiadis CJ, Jung KP, Berg E (2019) Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas. Colorectal Dis 21(12):1429–1437. https://doi.org/10.1111/codi.14741. (Epub 2019 Jul 17 PMID: 31245912)
Korsun S, Liebig-Hoerl G, Fuerst A (2019) Gracilis muscle transposition for treatment of recurrent anovaginal, rectovaginal, rectourethral, and pouch-vaginal fistulas in patients with inflammatory bowel disease. Tech Coloproctol 23(1):43–52. https://doi.org/10.1007/s10151-018-1918-7. (Epub 2019 Jan 2. Erratum in: Tech Coloproctol. 2019 Jul 26; PMID: 30604248; PMCID: PMC6656797)
Yellinek S, Sousa CB, Gilshtein H, Strassmann V, da Silva G, Wexner SD (2021) Gracilis muscle interposition for treatment of complex anal fistula: experience with 119 consecutive patients. Dis Colon Rectum 64(7):881–887. https://doi.org/10.1097/DCR.0000000000001964. (PMID: 33833143)
Baeten CG, Uludag OO, Rongen MJ (2001) Dynamic graciloplasty for fecal incontinence. Microsurgery 21(6):230–234. https://doi.org/10.1002/micr.1045. (PMID: 11746553)
Fuerst A (2017) Gracilis transposition for repair of recurrent rec- tovaginal fistula. Coloproctology 39(2):84
Garlock JH (1928) The cure of an intractable vesicovaginal fistula by the use of pedicled muscle flap. Surgery Gynecol Obstet 47
Kocot A, Riedmiller H (2017) Fisteln des Urogenitaltraktes nach Strahlentherapie [Fistulas of the urogenital tract after radiotherapy]. Urologe A 56(3):329–335. https://doi.org/10.1007/s00120-017-0320-9. (German; PMID: 28127628)
Hanna JM, Peterson AC, Mantyh C (2014) Rectourethral fistulas in the cancer survivor. Curr Opin Urol 24(4):382–388. https://doi.org/10.1097/MOU.0000000000000073. (PMID: 24841377)
Chrouser KL, Leibovich BC, Sweat SD, Larson DW, Davis BJ, Tran NV, Zincke H, Blute ML (2005) Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol 173(6):1953–1957. https://doi.org/10.1097/01.ju.0000158041.77063.ff. (PMID: 15879789)
Lane BR, Stein DE, Remzi FH, Strong SA, Fazio VW, Angermeier KW (2006) Management of radiotherapy induced rectourethral fistula. J Urol 175(4):1382–1387. https://doi.org/10.1016/S0022-5347(05)00687-7. (discussion 1387–8; PMID: 16516003)
Matiwos B, Tesfaw G, Belete A, Angaw DA, Shumet S (2021) Quality of life and associated factors among women with obstetric fistula in Ethiopia. BMC Womens Health 21(1):321. https://doi.org/10.1186/s12905-021-01458-3. (PMID:34454486; PMCID:PMC8403383)
Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM (1998) Repair of simple rectovaginal fistulas. Influence of previous repairs. Dis Colon Rectum 31(9):676–678. https://doi.org/10.1007/BF02552581. (PMID: 3168676)
Park KM, Rosli YY, Simms A, Lentz R, Bharadia DR, Breyer B, Hoffman WY (2022) Preventing rectourethral fistula recurrence with gracilis flap. Ann Plast Surg. https://doi.org/10.1097/SAP.0000000000003085. (Epub ahead of print. PMID: 35180755)