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

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 metaanalysis 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%, I 2 = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I 2 = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I 2 = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I 2 = 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.

Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery

“…Graciloplasty is a technique that can be utilized to treat complex perianal fistulae [ 23 ]. Nevertheless, a well-perfused gracilis flap is of utmost importance for the success of this technique.…”

Treatment of Rectovaginal Fistula

“…After harvesting the gracilis muscle from the leg as a proximal pedicle, the gracilis muscle is used as an interposition graft between the rectum and vagina, following direct closure of the corresponding fistula orifices [1,10]. This procedure is usually preceded by a diverting stoma [28,88]. Gracilis muscle flap has been used for refractory, recurrent RVFs, especially secondary to Crohn's disease and post-pelvic surgery [11,73,[88][89][90][91][92].…”

“…This procedure is usually preceded by a diverting stoma [28,88]. Gracilis muscle flap has been used for refractory, recurrent RVFs, especially secondary to Crohn's disease and post-pelvic surgery [11,73,[88][89][90][91][92]. A success rate of 33%-100% has been reported in the review of 17 studies, including 106 patients at a median follow-up of 21 months [92].…”

The gracilis muscle: A versatile muscle for the colorectal surgeon

“…Another promising and documented indication for the gracilis muscle is the repair of complex perineal fistulas [10][11][12]. A metaanalysis of 25 studies, spanning a 20-year period, reported a pooled rate of success of the gracilis interposition procedure of 79.4% while the pooled rates of short-term complications and 30-day reoperation were 25.7% and 3.6%, respectively [13]. Half of the fistulas were rectovaginal and one-third were rectourethral, both types constitute a unique management challenge.…”