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Review
. 2016 Jun;29(2):92-100.
doi: 10.1055/s-0036-1580631.

Management of Complex Perineal Fistula Disease

Ricardo Tadayoshi Akiba  1 , Fabio Gontijo Rodrigues  1 , Giovanna da Silva  1
Affiliations
Review

Management of Complex Perineal Fistula Disease

Ricardo Tadayoshi Akiba et al. Clin Colon Rectal Surg. 2016 Jun.

Abstract

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.

Keywords: complex fistulas; perianal fistulas; perineal fistulas; rectourethral fistulas; rectovaginal fistulas.

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Figures

Fig. 1
Fig. 1
Transanal circumferential mucosectomy is performed, removing the affected mucosa and submucosa. The dissection proceeds through the supralevator space until sufficient rectal mobilization is achieved. The ulcerated distal segment is resected and the fistula tract cored out. (Reprinted with permissionfrom Cleveland Clinic Center for Medical Art & Photography © 1999–2015. All Rights Reserved.)
Fig. 2
Fig. 2
A hand-sewn anastomosis of the healthy rectum and the neodentate line is performed. (Reprinted with permissionfrom Cleveland Clinic Center for Medical Art & Photography © 1999–2015. All Rights Reserved.)
Fig. 3
Fig. 3
A probe is placed through the fistula and a longitudinal incision is performed, dividing all the tissues overlying the probe. The rectovaginal fistula tract is debrided followed by dissection and identification of the muscular groups. (Reprinted with permissionfrom Cleveland Clinic Center for Medical Art & Photography © 1999–2015. All Rights Reserved.)
Fig. 4
Fig. 4
The rectal mucosa is closed and overlapping repair of the sphincteric muscle is performed. Finally the vaginal wall is closed. (Reprinted with permissionfromCleveland Clinic Center for Medical Art & Photography © 1999–2015. All Rights Reserved.)
Fig. 5
Fig. 5
Patient in Lloyd-Davies position: both extremities of the gracilis muscle are harvested. (With permission from Ruiz D, Bashankaev B, Speranza J, Wexner SD. Graciloplasty for rectourethral fistula, rectovaginal and rectovesical fistulas: technique overview, pitfalls, and complications. Tech Coloproctol 2008;12:227–282. © Springer 2008.)
Fig. 6
Fig. 6
The neurovascular bundle is identified using a neurostimulator. (With permission from Ruiz D, Bashankaev B, Speranza J, Wexner SD. Graciloplasty for rectourethral fistula, rectovaginal and rectovesical fistulas: technique overview, pitfalls, and complications. Tech Coloproctol 2008;12:227–282. © Springer 2008.)
Fig. 7
Fig. 7
The gracilis muscle is transposed through a subcutaneous tunnel from the proximal thigh incision to the perineal wound and anchored with sutures. (With permission from Ruiz D, Bashankaev B, Speranza J, Wexner SD. Graciloplasty for rectourethral fistula, rectovaginal and rectovesical fistulas: technique overview, pitfalls, and complications. Tech Coloproctol 2008;12:227–282. © Springer 2008.)
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