Recurrent Rectovaginal Fistula Research Articles

Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis.

Rectovaginal fistulae (RVF) are notoriously challenging to treat. Martius flap (MF) is a technique employed to manage RVF, among various others, with none being universally successful. We aimed to assess the outcomes of RVF managed with MF interposition. A PRISMA-compliant meta-analysis searching for all studies specifically reporting on the outcomes of MF for RVF was performed. The primary objective was the mean success rate, whilst secondary objectives included complications and recurrence. The MedCalc software (version 20.118) was used to conduct proportional meta-analyses of data. Weighted mean values with 95% CI are presented and stratified according to aetiology where possible. Twelve non-randomized (11 retrospective, 1 prospective) studies, assessing 137 MF were included. The mean age of the study population was 42.4 (±15.7), years. There were 44 primary and 93 recurrent RVF. The weighted mean success rate for MF when performed for primary RVF was 91.4% (95% CI: 79.45-98.46; I2  = 32.1%; P = 0.183) and that for recurrent RVF was 77.5% (95% CI: 62.24-89.67; I2  = 58.1%; P = 0.008). The weighted mean complication rate was 29% (95% CI: 8.98-54.68; I2  = 85.4%; P < 0.0001) and the overall recurrence rate was 12.0% (95% CI: 5.03-21.93; I2  = 52.3%; P = 0.021). When purely radiotherapy-induced RVF were evaluated, the mean overall success rate was 94.6% (95% CI: 83.33-99.75; I2  = 0%; P = 0.350). MF interposition appears to be more effective for primary than recurrent RVF. However, the poor quality of the data limits definitive conclusions being drawn and demands further assessment with randomized studies.

Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Recurrent Rectovaginal Fistula.

Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Recurrent Rectovaginal Fistula.

Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas.

A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion. To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause. After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed. Colorectal surgery department at a tertiary center in the United States. Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included. Recurrence after the colonic pull-through procedure. There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months. Retrospective design. The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases. ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience.

Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.

What is the best surgical option after failure of graciloplasty in patients with recurrent rectovaginal fistula? A study of 19 consecutive patients.

Management of recurrent rectovaginal fistula (rRVF) remains challenging despite the good results of graciloplasty reported in the literature. However, little is known about how to avoid a permanent stoma if graciloplasty fails. The aim of our study was to report the management of rRVF after failure of graciloplasty. A retrospective study was performed on consecutive patients with rRVF after failure of graciloplasty treated at our institution in January 2005-December 2021. There were 19 patients, with a median age at graciloplasty of 39years (range 25-64years). Etiologies of RVF were Crohn's disease (CD) (n = 10), postoperative (n = 5), post-obstetrical (n = 3), and unknown (n = 1). After failure of graciloplasty, 45 new procedures were performed, all of them with a covering stoma: trans-anal repairs (n = 31), delayed colo-anal anastomosis (DCAA) (n = 4), biological mesh interposition (n = 3), second graciloplasty (n = 3), stoma only (n = 2) and redo ileal pouch-anal anastomosis (IPAA) (n = 2). One patient was not re-operated on and instead treated medically for CD. After a mean follow-up of 63 ± 49months, success (i.e., absence of stoma or RVF) was obtained in 11 patients (58%): 4/4 DCAA (100%), 5/31 after local repair (16%), 1 after stoma creation alone (50%) and 1 after redo IPAA (50%). Second graciloplasty and biologic mesh interposition all failed. All 8 patients with failed intervention had CD. In cases of rRVF after failed graciloplasty, reoperation is possible, although the chance of success is relatively low. The best results were obtained with DCAA. CD is a predictor of poor outcome.

Postoperative rectovaginal fistula: Can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases.

Management of rectovaginal fistula (RVF) remains a challenge, especially in cases of postoperative RVF as they are often large and surrounded by inflammatory and fibrotic tissue, making local repair difficult or even impossible. In this situation, colonic pull-through delayed coloanal anastomosis (DCAA) could be an interesting option. The aim of this study was to assess the results of DCAA for RVF observed after rectal surgery. All patients who underwent DCAA for RVF were reviewed. Success was defined as a patient without stoma and without any symptoms of recurrent RVF at the end of follow-up. From January 2010 to December 2020, 28 DCAA were performed for RVF after rectal surgery for rectal cancer (n=21) or endometriosis (n=7). Ten patients (36%) had at least one previous local procedure before DCAA. DCAA was associated with temporary ileostomy in 22/28 cases (79%). After a mean follow-up of 23 ± 23 (2-82) months, the success rate was 86% (24/28): three patients (11%) required a definitive stoma because of poor functional results (n=1), chronic pelvic sepsis with anastomotic leakage (n=1) or stoma reversal refused (n=1). Another patient (3%) presented with recurrence of RVF, 26months after DCAA. Although not significant, the success rate was higher in cases of DCAA with diverting stoma (20/22, 91%) than without (4/6, 67%) (p=0.191). In cases of postoperative RVF, DCAA is a safe option which can avoid definitive stoma in the great majority of the patients. Concomitant use of a temporary stoma appears to slightly increase the success rate.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases.

The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI). A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections. The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy. In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Fecal diversion in complex anal fistulas: Is there a way to avoid it?

Temporary fecal diversion by a diverting colostomy or ileostomy is occasionally performed for serious complex fistulas. The main indications are highly complex and extensive cryptoglandular anal fistula, anal fistula associated with severe anorectal Crohn’s disease, recurrent rectovaginal fistula, radiation-induced fistula and anal fistula with associated necrotizing fasciitis. The purpose of stoma formation is to divert the fecal stream away from the anorectum and the perianal region so as to control the infective process and prevent trauma to the operated repaired tissues. Once the fistula has healed, the diverting stoma is closed. However, two questions are relevant. First, is it certain that the same disease would not relapse (or the fistula would not recur) once the colostomy is closed? Second, is there a non-surgical method which can obviate the need for a diverting colostomy? An attempt is made to answer both these questions in this review.

Bartholin's gland abscess a rare cause of rectovaginal fistula: A case report and literature review.

IntroductionRectovaginal fistula (RVF) is an abnormal communication between the vagina and the rectum. RVFs caused by Bartholin's gland infection are very rare. We present the case of recurrent rectovaginal fistula complicating a bartholin's gland abcess successfully treated with a Martius flap. The aim of this work is to demonstrate the possibility of complication of bartholin's gland infection by a rectovaginal fistula and the efficacy of Martius flap procedure for recurrent RVF of the low third part of the vagina.ObservationIt is a 30-year-old woman admitted to our department for recurrent RVF due to an abscess of the Bartholin's glands. She was previously treated with a vaginal advancement flap which failed with persistence of the fistula and its symptoms. The patient underwent a RVF repair by Martius flap with complete healing of the fistula.DiscussionRectovaginal fistula is a complex pathology with psycho-social, individual, family, religious and ethno-environmental repercussions. Its main aetiologies are obstetric, rectal surgery. Several techniques including the vaginal or anal advancement flap and the Martius flap are used for the treatment of rectovaginal fistulas. For recurrent fistulas, the Martius flap seems to be the most indicated with better results.ConclusionRectovaginal fistula remain a challenge for surgeons and have major psycho-socio-economic repercussions for the patient. The complication of Bartholin's gland infection by rectovaginal fistula is rare. The Martius flap technique is the method of choice for recurrent rectovaginal fistulas of the lower third of the vagina or in association with other pathologies.

Rectovaginal fistula: Risk factors for failure after graciloplasty-A bicentric retrospective European study of 61 patients.

Graciloplasty (GP) is indicated in the case of recurrent rectovaginal fistula (RVF) after failure of previous local treatments. The aim of this study was to assess risk factors for GP failure performed for RVF. This is a retrospective study based on a prospective database on GP, coming from two expert centres. Sixty-one patients undergoing a first GP for RVF (n=51) or ileal-vaginal fistula after ileal pouch anal anastomosis (n=10), with a mean age of 42years (range 24-72), were analysed. After a mean follow-up of 56±48months (range 1-183), failure of GP (considered as persistent stoma and/or clinical RVF) was noted in 24/61 patients (39%). The failure rate was 43% (13/30) in the case of Crohn's disease, 38% (3/8) in the case of ileal-vaginal fistula after ileal pouch anal anastomosis for ulcerative colitis, 30% (3/10) in the case of obstetrical RVF, 33% (1/3) in the case of post radiotherapy RVF and 40% (4/10) for other causes (not significant). Two risk factors for failure of GP were found on univariate analysis: (1) absence of postoperative antibiotic prophylaxis-only 3/24 (13%) patients with failure of GP received postoperative antibiotic prophylaxis versus 18/37 (49%) patients with success of GP (P=0.0053); (2) postoperative perineal infection-11/23 (48%) with failure of GP developed postoperative perineal infection versus only 4/37 (10%) patients with success of GP (P=0.0021). Failure of GP for RVF is observed in approximately 40% of the patients whatever the aetiology of the fistula. A reduced failure rate was associated with systematic postoperative antibiotic prophylaxis.

Botulinum Toxin Injection for the Treatment of the Recurrent Rectovaginal Fistulas in Combination with Surgical Repair

Rectovaginal fistula is abnormal connections between the vagina and rectum. Via this connection, the passages of flatus or stool from rectum to vagina occur. Patient history and physical examination are usually enough to make diagnosis of fistula. Although there are so many defined surgical options including sphincteroplasty, advanced flap, muscle interposition, fibrin glue, plugs, and closure of fistulas remain a challenging condition with the high rate failure of surgical repair In this study, we aim to report the results of a new treatment approach with the injection of botulinum toxin into lateral internal sphincter on the management of rectovaginal fistula in conjunction with the surgical repair. Between 2013 and 2019, 8 patients with recurrent rectovaginal fistula underwent 10 surgical repairs in conjunction with 100 units botulinum toxin injection. Results of these patients were analyzed. We have treated 8 patients with recurrent rectovaginal fistula. The etiology of fistula in our patients included obstetrical trauna (3 patients), radiotherapy and rectal surgery (2 patients), vaginal reconstruction (2 patients) and Crohn’s disease (1 patient). The median number of their previous operations was 1.5 (range, 1–3). The sizes of fistulas range from 0.5 × 1 to 2 × 3 cm. In our surgical intervention, at the end, all of them were closed (100%) successfully. Botulinum toxin injection into lateral internal sphincter can be used successfully in combination with surgical intervention for the treatment of the rectovaginal fistulas.

Redo Repair of a Recurrent Rectovaginal Fistula With Rectal Advancement Flap

Redo Repair of a Recurrent Rectovaginal Fistula With Rectal Advancement Flap

An Ambiguous and Misleading Description.

Sir, We have read Dr. Khalil’s1 article published in 2016; we know it is about 4 years since its release, and we are deeply impressed by the satisfactory results of their procedure. However, herein, we have to point out an unclear claim of their study, which mentioned that their method is the first to repair recurrent rectovaginal fistula. To the best of our knowledge, similar procedures had already been described by Dr. Cardon2 in 1999 and later by Dr. Monstrey3 in 2001. The internal pudendal perforator thigh flap/Singapore flap/Lotus flap was first described by Wee and Joseph4 in 1989. Its versatility has been demonstrated in some fields but is not so commonly applied in rectovaginal fistula. In consideration of the authority and popularity of this journal, we would not expect researchers to cite an ambiguous view in the future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

P720 Recurrent rectovaginal fistula in patients with Crohn’s disease: How can we improve the success rate of graciloplasty? A bi-centric European study in 30 patients

Abstract Background Graciloplasty (GP) is indicated in case of recurrent rectovaginal fistula (RVF), even in patients with Crohn’s disease, after failure of previous local treatments. The aim of this study was to evaluate risk factors for GP failure performed for recurrent RVF in these patients. Methods We realised a retrospective study based on a prospective database of GP, realised in two Tertiary expert Centers in Italy (Bologna) and France (Clichy). Results Thirty-two patients undergoing 34 GP (2 patients have undergone 2 GP for failure of first GP): we excluded second GP and 2 patients without available follow-up: 30 patients undergoing a first GP for RVF (n = 29) or ileal-vaginal fistula after ileal-pouch-anal-anastomosis (IPAA) (n = 1) with a mean age of 41 ± 10 years (range, 25–64) were analysed. After a mean follow-up of 65 ± 52 months (2–183), a success of GP (considered as absence of diverting stoma and RVF healing) was noted in 17/30 patients (57%). We evaluated risk factors for failure of the procedure and we found only 2 risk factors on univariate analysis: (1) absence of a postoperative prophylactic antibiotherapy: only 2/13 (15%) patients with a GP failure had a postoperative antibiotic-prophylaxis vs. 9/15 (60%) patients with success of GP (p = 0.0238); (2) a postoperative perineal infection: 7/13 (54%) with a GP failure developed a postoperative perineal infection vs. 2/17 (12%) patients (p = 0.0196). Conclusion Graciloplasty for recurrent rectovaginal fistula in patients with Crohn’s disease is effective in 57% of patients. Our study underlines the possible benefit of a postoperative antibiotic-prophylaxis because it seems to increase significantly the success rate of the procedure.

Martius Labial Fat Pad Graft (use in RVF Repair)

Video Objective To demonstrate the utility of the Martius Labial Fat Pad Graft in pelvic fistula repair. Setting We present a minimally invasive surgical approach for a patient with recurrent rectovaginal fistula. Interventions An incision is made over the labium majus exposing the yellow fibrofatty graft. This graft is first retracted medially where a natural tissue plane facilitates dissection from the adjacent labium majus. It is then retracted laterally where a plane between it and the bulbocavernosus muscle is developed. To avoid devascularization of adjacent skin, a thin fatty layer is left attached at its undersurface. The division of the flap is begun in this case, at its anterior pedicle. It is important to develop a flap that easily covers the defect with a good degree of overlap. Once the flap has been sufficiently mobilized, a shellcross is used to create the subepithelial defect to enable passage of the flap through the levator plate. This defect is widened enough to prevent compression on the pedicled blood supply. After appropriate positioning, the flap is sewn into place by attaching it to the adjacent, underlying rectovaginal fascia with interrupted 2-0 Vicryl suture. It is important to note that no tensioning of the flap is required to approximate it to the adjacent tissue. The posterior vaginal wall is next closed over the graft in two layers followed by closure of the labial defect. Conclusion The Martius flap has multiple minimally invasive advantages in fistula repair to include low morbidity, lack of a cosmetic defect and the need for only a single surgical field. Its’ abundant blood supply promotes rapid neovascularization of the transplanted graft and lends itself well to a variety of surgical modifications that can be utilized in the repair of even the most difficult of fistulas.

2048 Colo -Anal Anastomosis: A Novel Idea for Treatment of Re-Re-Recurrent Rectovaginal Fistula

Video Objective Treatment of rectovaginal fistulas was always difficult; treating post radiation recurrent rectovaginal fistulas was challenging; Colo-Anal Anastomosis is a novel way of treating such fistulas. Setting 49yr/Female/P1L1 had undergone Total Abdominal Hysterectomy for AUB-E; was diagnosed with adenocarcinoma of endometrium stage II. Patient underwent BPLND + BSO 3 weeks later and then took 25# radiation for same. Patient developed radiation proctitis and Rectovaginal Fistula following Radiation Therapy. A diversion colostomy was done for same. Patients complaints persisted. Patient then underwent RVF closure with omental flap interposition. Despite the omental flap a distal loopogram was suggestive of leak of dye. Interventions Decision was taken to do a Laparoscopy with Colo Anal Anastomosis. Expected challenges were dense bowel adhesions; deficient anterior rectal wall; Non healing tissue. On Laparoscopy small bowel adhesiolysis was done. Colon was completely mobilized upto splenic flexure so as to obtain a tension free repair. Rectum transected proximal to fistula site. A tunnel was created in the distal rectum. Rectal Mucosa was excised so as to avoid mucus passage. Mobilized bowel was then pulled out through the tunnel. Colon was anastomsed to anal canal perineally by simple interrupted sutures. As anal sphincters were not dissected patient's anal tone was well maintained. Rectal drain was placed. Patient was gradually started on full diet by day 3; rectal drain was removed on day3 post op. Dye study done postoperatively showed no leak of dye. Conclusion Colo Anal Anastomosis is a unique way of treating fistulas not responding to routine RVF repair procedures.

Gracilis pull-through flap for the repair of a recalcitrant recto-vaginal fistula

Recto-vaginal fistulas are difficult to treat due to their high recurrence rate. Currently, no single surgical intervention is universally regarded as the best treatment option for rectovaginal fistulas. We present a case of recurrent recto-vaginal fistula surgically treated with a gracilis pull-through flap. The surgical goals in this patient were complete excision of the recto-vaginal fistula and introduction of fresh, vascularized muscle to seal the fistula. A defunctioning colostomy was performed 1 month prior to the present procedure. The gracilis muscle and tendon were mobilized, pulled through the freshened recto-vaginal fistula, passed through the anus, and anchored externally. Excess muscle and tendon were trimmed 1 week after the procedure. Follow-up at 4 weeks demonstrated complete mucosal coverage over an intact gracilis muscle, and no leakage. At 8 weeks post-procedure, the patient resumed sexual intercourse with no dyspareunia. At 6 months post-procedure, her stoma was closed. The patient reported transient fecal staining of her vagina after stoma reversal, which resolved with conservative treatment. The fistula had not recurred at 20 months post-procedure. The gracilis pull-through flap is a reliable technique for a scarred vagina with an attenuated rectovaginal septum. It can function as a well-vascularized tissue plug to promote healing.

13: Surgical management of recurrent rectovaginal fistula

13: Surgical management of recurrent rectovaginal fistula

Gracilis Muscle Flap for Recurrent Rectovaginal Fistula: a Case Report

Abstract We present the case of a 48-year-old patient with a recurrent rectovaginal fistula, who we treated surgically by transposing the gracilis muscle. The patient with a history of ulcerative colitis underwent colorectal resection with mechanical anastomosis and diverting ileostomy for rectal cancer. She was subsequently treated by radiation and chemotherapy. Six weeks later, the ileostomy was removed, but afterwards the patient developed a recto-vaginal fistula. A new diverting ileostomy was performed. After eight months, a transvaginal surgical procedure was performed, and the diverting ileostomy was closed after four months. Two years after the last surgery, the patient performed an MRI scan, which revealed the relapse of the rectovaginal fistula. This time the patient was reoperated using a flap of the gracilis muscle interposed between the rectum and the vagina, but the patient refused any diverting stoma. The rectovaginal fistula relapsed again after thirteen days. Fortunately, after six months of intensive systemic and local treatment with aminosalicilic-5-acid, the fistula closed by itself. Our conclusion is that with a well-managed medical treatment, the gracilis flap, because of its good vascular supply, could be successfully used to treat rectovaginal fistulas even in patients with ulcerative colitis who underwent rectal surgery and radiation therapy for cancer.

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.

The surgical management of rectovaginal fistulae associated with Crohn's disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn's-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn's disease patients and in a control group. All patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005-2016). The primary study outcome was the comparison of the success rate of GMT in Crohn's disease and control group patients. Twenty-one patients with a rectovaginal fistula due to Crohn's disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57months (p 0.34), the success rate of GMT was 75% in patients with Crohn's disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5months (1-12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1). GMT is associated with a high success rate, especially in Crohn's disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae.