The following is the summary of “Gracilis Flap Repair for Reoperative Rectovaginal Fistula” published in the January 2023 issue of Diseases of the Colon & Rectum by Hull, et al.

Recto-vaginal fistulas that recur despite surgical repair are notoriously challenging. Closing recurrent fistulas requires a more complex method including the placement of the gracilis muscle between the vagina and the anus. Researchers have used this technique for intractable fistulas, and investigators anticipated that a gracilis interposition would be an effective treatment for patients with intractable rectovaginal fistulas, independent of the cause. The aim of this study was to examine the success of gracilis interposition in the treatment of rectovaginal fistulas that had previously failed to heal.  With consent from an institutional review board, a retrospective review of all female patients aged 18 and above who were diagnosed with rectovaginal fistula and who underwent gracilis interposition for definitive fistula closure between January 2009 and August 2020 was conducted.

The research was carried out in the United States, specifically in a tertiary care center’s colorectal surgery division. All of the patients had been diagnosed with rectovaginal fistula and had had gracilis interposition for permanent closure. Patient characteristics, rectovaginal fistula etiology, history of surgical intervention, presence of intestinal diversion, surgical details, 30-day morbidity, recurrence of fistula, and time to recurrence were the primary outcome measures. Lack of symptoms after stoma closure, negative fistula detection on gastrograffin enema, and no visible internal opening during anesthesia-guided inspection were all considered indicators of successful fistula closure.  About  22 patients were included with a median age of 43 years (range, 19-64 years) and a median body mass index of 31 kg/m2 (range, 22–51). In most cases, 7 months passed between the first surgical effort to fix the problem and the gracilis operation (range, 3–17). 8  people had attempted repairs a total of 1 or 2 times, 19 had attempted repairs between 3 and 4 times, and 5 had attempted repairs more than 4 times. Rectal advancement flap (n=7), transperineal +/- Martius flap (n=4), episioproctomy (n=3), transvaginal repair (n=2), and other (n=6) were the most current surgical repair methods explored. Gracilis procedures in all cases included fecal diversion. 

A total of 32% (n=7) of graft/donor sites had infections 30 days after surgery. Fistula closure rate was 59% (n=13) with a median follow-up of 22 months (range, 2-62). All IBD patients who underwent Gracilis interposition experienced complete healing.  The study had certain restrictions because it was retrospective.  Re-operational rectovaginal fistula repair with Gracilis interposition is an effective surgical procedure. Infection at the graft or donor site is a real risk that patients need to be made aware of.