Gracilis Muscle Transposition for Complex Perineal Fistulas and Sinuses: A Systematic Literature Review of Surgical Outcomes

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.

Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature

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.

Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration

Background

Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration.

Methods

A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months.

Results

The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications.

Conclusions

A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.

Gracilis Muscle Interposition for Treatment of Complex Anal Fistula: Experience With 119 Consecutive Patients

BACKGROUND

Treatment of complex anal fistula is challenging, often mandating multiple procedures. The gracilis muscle has been used to treat perineal fistulas and to repair perineal defects.

OBJECTIVE

This study aims to report the results of gracilis muscle interposition for complex anal fistula, including prognostic factors for success.

DESIGN

This is a retrospective analysis of a prospective database for patients who underwent gracilis muscle interposition for complex anal fistula from 2000 to 2018.

SETTING

Patient demographics, operative data, and postoperative outcome were obtained from medical records. Office visits were used for follow-up.

PATIENTS

All patients who underwent gracilis muscle interposition for complex anal fistula were included. Patients who underwent gracilis muscle interposition for reasons other than complex anal fistula were excluded.

MAIN OUTCOME MEASURES

The primary outcome measured was the healing of complex anal fistula following gracilis muscle interposition and following additional procedures, when needed.

RESULTS

A total of 119 patients (60 men, 59 women; median age: 56 (21-85) years) were included. The initial success rate of gracilis muscle interposition was 42%; the final success rate if additional procedures were undertaken was 92%. Overall success rate was 32.2% in women and 51.6% in men. Univariate analysis revealed that sex (p = 0.0315) and bed rest >3 days (p = 0.0078) were significant poor prognostic factors for failure, whereas the multivariate logistic regression model showed that length of bed rest >3 days was a significant poor prognostic factor for failure. In the female subgroup, multivariate analysis showed that bed rest ≥3 days was a significant poor prognostic factor, whereas in the male population there was no significant prognostic factor.

LIMITATION

This study was limited by its retrospective nature and the heterogeneity of patients.

CONCLUSION

Although initial success is <50%, the ultimate success after gracilis muscle interposition and other subsequent procedures is >90%. Patients must be preoperatively counseled that additional procedures will probably be required to achieve successful fistula closure. Furthermore, prolonged bed rest should be avoided after gracilis muscle interposition. See Video Abstract at http://links.lww.com/DCR/B551.

INTERPOSICIN DEL MSCULO GRACILIS PARA EL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA EXPERIENCIA CON PACIENTES CONSECUTIVOS

ANTECEDENTES:El tratamiento de la fístula anal compleja es un desafío que a menudo requiere de múltiples procedimientos quirúrgicos. El músculo gracilis se ha utilizado para tratar fístulas y reparar defectos perineales.OBJETIVO:Informar los resultados de la interposición del músculo gracilis para la fístula anal compleja, incluyendo los factores pronósticos para un tratamiento exitoso.DISEÑO:Se efectuó un análisis retrospectivo obtenido de una base de datos prospectiva para pacientes sometidos a interposición del músculo gracilis por fístula anal compleja del 2000 al 2018.METODO:Los datos demográficos de los pacientes, la información del procedimiento quirúrgico y los resultados postoperatorios se obtuvieron de los expedientes clínicos; el seguimiento se llevó a cabo por medio de visitas al consultorio.PACIENTES:Se incluyeron todos los pacientes sometidos a interposición del músculo gracilis por fístula anal compleja; Se excluyeron los pacientes que se sometieron a interposición del músculo gracilis por motivos distintos a la fístula anal compleja.CRITERIOS DE EVALUACION DE LOS RESULTADOS:Curación de una fístula anal compleja después de la interposición del músculo gracilis y procedimientos adicionales, cuando fueron necesarios.RESULTADOS:Se estudiaron un total de 119 pacientes [60 hombres, 59 mujeres; con media de edad de 56 (21-85) años]. La tasa de éxito inicial de la interposición del músculo gracilis fue del 42%; La tasa de éxito final cuando realizaron procedimientos adicionales fue del 92%. La tasa de éxito global fue del 32,2% en mujeres y del 51,6% en hombres. El análisis univariado reveló que el género (p = 0,0315) y el reposo en cama > 3 días (p = 0,0078) en forma significativa fueron factores de pronóstico bajo para el fracaso, mientras que el modelo de regresión logística multivariable mostró que la duración del reposo en cama> 3 días fue un factor de pronóstico significativamente bajo para fracaso. En el subgrupo de mujeres, el análisis multivariado mostró que el reposo en cama ≥3 días fue un factor de pronóstico significativamente bajo, mientras que en la población masculina no hubo un factor pronóstico significativo.LIMITACIÓN:Carácter retrospectivo y heterogenicidad de los pacientes.CONCLUSIÓN:Aunque el éxito inicial es <50%, el éxito final después de la interposición del músculo gracilis y otros procedimientos posteriores es > 90%. Se debe aconsejar a los pacientes antes de la operación que probablemente se requieran procedimientos adicionales para lograr el cierre exitoso de la fístula. Además, debe evitarse el reposo prolongado en cama después de la interposición del músculo gracilis. Consulte Video Resumen en http://links.lww.com/DCR/B551.

Video-Endoscopic Mobilization of the Gracilis Muscle for Rectourinary Fistula Repair

INTRODUCTION

Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis.

METHOD

We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail.

RESULTS

Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60-145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula.

DISCUSSION

The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access.

CONCLUSION

Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.

Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period

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.

An Algorithmic Approach to Perineal Reconstruction

Perineal wounds are one of the more challenging plastic surgical defects to reconstruct. Resections in the perineum vary in size and are frequently complicated by radiation, chemotherapy, and contamination. Furthermore, the awkward location and potential need to maintain function of the anus, urethra, and vagina and to allow comfortable sitting all contribute to the complexity of these reconstructions. In light of this complex nature, many options are available for flap coverage. In this paper, we discuss the properties of perineal defects that make each option appropriate.

Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas

AIM

Successful treatment of complex rectovaginal fistulas (RVFs) continues to be a surgical challenge. Interposition of well-perfused tissue, such as gracilis muscle, is one treatment option. The aim of this study was to investigate the operative results, sexual function and quality of life after gracilis muscle transposition (GMT) in the authors' own group of patients.

METHOD

The study included 19 women with RVF (mean age 48 years). The postoperative outcome was evaluated by a questionnaire and clinical examination.

RESULTS

The postoperative follow-up period was 7 months to 3.5 years (mean 23 months). GMT led to primary healing of RVF in 10 (53%) patients. Recurrences were observed in nine (47%) patients with RVF, in four (44%) of whom healing was achieved as a result of further interventions. Following GMT, two complications (abscess formation) requiring revision occurred. Although 42% of the patients reported certain limitations following muscle removal, GMT is a procedure that has a positive influence on the healing rate (74%), quality of life, continence and patient satisfaction.

CONCLUSION

GMT is a procedure that allows healing in the majority of patients with RVFs, and it should be considered especially in patients with recurrent fistulas, in whom a correlation between decreasing healing rates and the number of previous operations has been demonstrated.

Surgical Management of Complex Enteric Fistulas in Crohn's Disease

Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.

Outcome of Modified Park's Technique for Treatment of Complex Anal Fistula

BACKGROUND

Treatment of complex anal fistula (CAF) can be associated with high rates of recurrence and fecal incontinence (FI). Park suggested drainage of the affected intersphincteric anal gland for treatment of cryptoglandular anal fistula; however, recurrence after this technique was high. We modified the original Park's technique by extending the internal sphincterotomy to ensure adequate drainage of the intersphincteric space. The aim of this study was to evaluate the incidence of recurrence and FI after modified Park's technique in treatment of CAF.

METHODS

Adult patients of both genders with CAF were evaluated before undergoing modified Park's technique with Wexner continence score, clinical examination, and endoanal ultrasonography or MRI. Postoperatively, patients were examined every 2 wk until complete wound healing. The continence state was evaluated with Wexner continence score, and quality of life was assessed before surgery and at 6 mo postoperatively by Short Form-36 questionnaire.

RESULTS

Thirty-two patients (27 male) of a mean age of 38 y were included. Median follow-up was 12 mo. Two patients (6.25%) experienced recurrence and 5 (15.6%) developed complications. One patient (3.1%) developed new-onset FI postoperatively. Twenty-eight (87.5%) patients were completely satisfied with the procedure. Quality of life showed significant improvement at 6 mo postoperatively.

CONCLUSIONS

The modified Park's technique is a promising procedure for the treatment of CAF with low recurrence and FI rates, and improved quality of life.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies-new patients, old problem?

PURPOSE

Radiation-induced rectovaginal fistula (RI-RVF) is a chronic and serious condition with a significant influence on quality of life. The aim of this study is to evaluate the results of surgical treatment of rectovaginal fistulas of patients previously undergoing radiotherapy.

METHODS

Fifty patients treated in the Gynaecological Radiotherapy Unit for gynaecologic malignancy and in the Department of General and Colorectal Surgery for RI-RVF between 2003 and 2013 were enrolled into a prospectively maintained database and underwent regular follow-up examinations in an outpatient clinic, during which surgical outcomes were assessed.

RESULTS

Median age was 60 years (range 40-84 years). Cervical cancer was the most common cause of radiotherapy. Median time of fistula development after radiotherapy was 20 months (range 5-240 months). In 48 (96%) patients, only faecal diversion could be performed, while two patients underwent rectal resection. The fistula healed in six patients. Factors that correlated with fistula healing were a distance from the anal verge above 7 cm (p = 0.007 OR 18 95%CI 2.2609-14.3062) and creation of loop ileostomy (p = 0.08 OR 17 95%CI 1.2818-23.9701), whereas a prolonged course of radiotherapy of more than 6 weeks (p = 0.047) correlated negatively. In multivariate analysis, only distance from the anal verge remained significant (p = 0.031 OR 2.35 95%CI 1.0422-5.2924).

CONCLUSIONS

The treatment of radiation-induced rectovaginal fistulas needs to be tailored individually to each patient. Faecal diversion remains the simplest and safest method of treating RI-RVF, especially in the group of patients who cannot undergo complicated surgical procedures, and offers acceptable quality of life.

Gracilis Muscle Interposition for Rectourethral Fistula After Laparoscopic Prostatectomy: A Prospective Evaluation and Long-term Follow-up

BACKGROUND

Postoperative rectourethral fistula after radical prostatectomy is an infrequent but very serious problem.

OBJECTIVE

We aimed to describe our experience with transperineal repair and unilateral gracilis muscle interposition in patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer.

DESIGN

This was a cohort study.

SETTINGS

All of the procedures were performed at the same hospital by the same multidisciplinary team made up of a senior colorectal surgeon and a senior urologist.

PATIENTS

Patients with postoperative rectourethral fistula after laparoscopic prostatectomy were included.

INTERVENTION

Transperineal fistula repair and gracilis muscle interposition were included.

MAIN OUTCOME MEASURES

Fistula healing rate was measured.

RESULTS

Nine patients with postoperative rectourethral fistula were treated between November 2009 and February 2016. Four of them had received other previous treatments without success, and 5 had previously been treated with this technique. Seven patients had a fecal diverting stoma. After a median follow-up of 54 months (range, 2-72), all of the fistulas had successfully healed, and, to date, the patients remain asymptomatic without urinary diversion. Fecal diversion was closed in all but 1 patient. No intraoperative or infectious complications were detected. With the results of our series, we present specific technical details of our technique and hope to provide additional evidence of the low morbidity profile and excellent healing rate of this treatment. Moreover, we note that, although small, this series corresponds with a homogeneous group of patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer.

LIMITATIONS

This is a small but very homogeneous group of patients.

CONCLUSIONS

Simple repair with perineal gracilis muscle interposition is a safe and effective technique for the treatment of postoperative rectourethral fistulas after nonradiated prostate cancer surgery.

Management of Complex Perineal Fistula Disease

Management of complex perineal fistulas such as high perianal, rectovaginal, pouch-vaginal, rectourethral, or pouch-urethral fistulas requires a systematic approach. The first step is to control any sepsis with drainage of abscess and/or seton placement. Patients with large, recurrent, irradiated fistulas benefit from stoma diversion. In patients with Crohn's disease, it is essential to induce remission prior to any repair. There are different approaches to repair complex fistulas, from local repairs to transperineal and transabdominal approaches. Simpler fistulas are amenable to local repair. More complex fistulas, such as those secondary to irradiation, require interposition of healthy, well-vascularized tissue. The most common flap used for this treatment is the gracilis muscle with good outcomes reported. Once healing is confirmed by imaging and endoscopy, the stoma is reversed.

Rectovaginal fistula repair using a gracilis muscle flap

INTRODUCTION AND HYPOTHESIS

This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.

METHODS

We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient's prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula.

CONCLUSION

Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.

Testicular Interposition Flap for Repair of Perineal Urinary Fistulae: A Novel Surgical Technique

Rectourinary fistulae and urinary-cutaneous fistulae are a rare yet devastating complication. Current options for tissue interposition include rectus, gracilis, or gluteal muscle, omentum, or intestine for use in coloanal pull-through procedures. In elderly patients, testicular interposition flaps may be an excellent tissue option to use when vitalized tissue is necessary to supplement fistula repair. Elderly patients frequently have increased spermatic cord length, potentially offering a longer flap reach than use of a muscle flap. Additionally, mobilizing one of the testicles and developing it through the external inguinal ring may be a less morbid and less costly procedure than harvesting and tunneling a muscle flap. Longer follow-up and further studies are needed to determine the outcomes of this novel technique.