Use of the Martius advancement flap for low rectovaginal fistulas

Abstract

Aim The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short‐ and long‐term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues. Method Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien–Dindo classification. Quality of life (SF‐12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre‐ and postoperatively. Results The mean follow‐up was 42 ± 29 months (range 3–101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45–70 min), and the median hospital stay was 3.5 days (range 3–5 days). No major complications occurred. Pre‐ and postoperative CCIS did not differ [1 (range 0–3.5)]. The postoperative SF‐12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001). Conclusion The Martius procedure should be considered as the first‐line method of treatment in carefully selected cases of LRVF.

Minimally invasive endoscopic repair of rectovaginal fistula

“…Fecal diversion was chosen as part of surgical treatment in some patients. Psychological components regarded as important as the success rate were rarely reported[ 19 , 37 ], with improved sexual function after repair mentioned in only one paper.…”

“…On the other hand, in terms of the precise anatomical relationship of the fistula defect and the surrounding tissue, the lack of consensus on classification of RVFs makes it difficult to compare different surgical techniques. It is therefore proposed that further revisions are needed to guide the choice of newly developed treatment approaches[ 19 ]. Additionally, some authors claimed that a precise preoperative anatomical relationship assessment allowed better classification of fistulas and comparisons among different techniques[ 14 ].…”

“…Transrectal advancement flap is more commonly adopted compared to the transvaginal approach, and the repair is performed from the high pressure of the rectum side, and has an actual success rate of 50%-70%[ 1 , 4 ]. Even though some studies have recommended transrectal advancement flap as the first-line treatment for low RVFs, it is not as effective as expected if the periorificial tissue is chronically inflamed, or when the fistula is large in diameter and causes anal stenosis[ 19 ]. Reconstruction by Martius flap, gracilis muscle flap or bulbocavernosus muscle transposition can be used to introduce healthy vascularized tissues, which has achieved a certain effect for recurrent, Crohn’s-disease-related and radiation-related RVFs, with reported overall success rates ranging from 25% to 100%[ 20 , 21 ].…”

Colgajo de Martius como tratamiento de una fístula rectovaginal recidivada. Revisión de la técnica quirúrgica a propósito de un caso clínico.

“…Pitel et al 14 , en una serie de 20 pacientes seguidos entre los años 2000 a 2010, dentro de los cuales un 40% era portadores de enfermedades inflamatorias intestinales, un 25% iatrogénica y 20% asociada a trauma obstétrico, concluyó un porcentaje de curación global de un 60%, el cual era mayor en pacientes con una FRV de origen iatrogénico o de causa obstétrica, en desmedro de los portadores de enfermedades inflamatorias. Series de casos pequeñas y casos clínicos muestran un porcentaje de éxito superior al 50%, otros, con tasas de éxito del 91,3% la recomiendan como primera opción al tratamiento de FRV seleccionadas 15 . Es así como este procedimiento ofrece una alternativa quirúrgica válida con escasa morbilidad, dentro de las que destaca infección de herida operatoria, dolor perineal, seromas y recidiva de la fístula, la que se espera en alrededor de un 40% 10 .…”

Martius flap and sphincteroplasty as treatment for recurrent anovaginal fistula associated with anal incontinence–a video vignette

“…The ends of the sphincter were dissected and the sphincteroplasty was completed. A Martius flap [1,2] was interposed between the vagina and the anal canal, including the skin of the outer labia in order to reconstruct the posterior vaginal wall. One year following the surgery, and after closure of the colostomy, the patient has no fistula recurrence and maintains perfect anal continence.…”