Treatment of recurrent rectovaginal/pouch-vaginal fistulas by gracilis muscle transposition – a single center experience

Abstract

Rectovaginal fistulas constitute a serious burden for the affected patient and a major challenge for the attending surgeon. Definitive surgical treatment of the fistula depends on the size and location of the fistula, the underlying disease, and any previous therapies. In regards to complicated recurrent rectovaginal fistulas, transposition of the gracilis muscle is one of the well-established therapeutic options with a success rate of up to 70%. Between 01/2004 and 06/2010, ten patients diagnosed with a recurrent rectovaginal fistula were treated in the surgical department of Klinikum Oldenburg by gracilis muscle transposition; their data were collected and analyzed. Post-operative evaluation was performed using a standardized telephone interview. All patients had a protective stoma. The primary endpoint of assessment was the long-term healing of the fistula following stoma reversal, and the comparison between those who were treated successfully versus those who were not. Over a time span of 6years, ten women with a complicated rectovaginal fistula underwent fistula repair with the gracilis muscle transposition. Patient age ranged from 29 and 64years. There were five rectovaginal fistulas, four pouch-vaginal fistulas, and one anovaginal fistula. The underlying disease was rectal cancer in seven patients, Crohn's disease in one patient, previous complicated gynecologic surgery in one patient, and idiopathic anal fistula in one patient. All seven patients with rectal cancer underwent radiochemotherapy with 50.4Gy (n=6 neo-adjuvant, n=1 adjuvant). All ten patients had previously undergone repair by a different surgical approach while five presented with a second or third recurrence. Post-operative complications were noted in two patients (perineal wound defect, thigh hematoma). Follow-up of the patients ranged from 8 to 60months. Recurrent rectovaginal fistula occurred in four patients. Evaluation of the data failed to identify statistically significant criteria for treatment failure of rectovaginal fistula repair. Our results are similar to previous studies in this area. For the majority of the patients, the gracilis muscle transposition was a long-term effective treatment of recurrent rectovaginal fistulas, however recurrences were noted in 40% of cases. Predictive criteria for treatment failure could not be established.