Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt.
Gynecol Oncol. 2011 Jun 1;121(3):610-4. doi: 10.1016/j.ygyno.2011.02.008. Epub 2011 Apr 1.
Complex rectovaginal fistulas repair are extremely challenging. Various surgical options have been suggested; nevertheless, none had been universally accepted as the procedure of choice. This prospective study discusses a novel surgical technique using gracilis myocutaneous flap interposition.
Eleven patients had fistulas post-resection of pelvic malignancy (n=10) and rectal endometriosis (n=1). Primary treatment was pelvic resection; nevertheless, 6 cases had adjuvant chemo-irradiation, 2 cases had post-operative irradiation and 2 patients had chemotherapy only. Fistulas mean diameter was 2±0.24 cm (1-3) and 8 patients (72.7%) had their fistulas in the middle vaginal third. Repair was wide debridement of fistulas margins followed by gracilis myocutaneous flap interposition with synchronous diverting stomas. Success was defined as healing of fistula after stomal closure.
Five patients were repaired by single gracilis myocutaneous flaps, 2 cases by simple gracilis muscle and 4 cases by double gracilis myocutaneous flaps. Patients had a mean follow-up time of 34.8±5.03 months (12-67) and all patients had definitive healing of their fistulas (100%). Median time to stoma closure was 2 months (1-5). Four women (36.4%) had at least one early postoperative complications including temporary leak (n=3), vaginal sepsis (n=1), partial skin paddle necrosis (n=1) and donor limb deep venous thrombosis (n=1). Late morbidities were seen in 3 cases (27.3%) including vaginal stricture, anorectal anastomotic stricture and anastomotic tumor recurrence.
Rectovaginal septum repair requires adequate debridement of necrotic devascularized tissues, tissue transposition and reconstruction of vaginal wall. Gracilis myocutaneous flaps are ideal for this issue.
复杂的直肠阴道瘘修复极具挑战性。各种手术方法都有被提出，但没有一种方法被普遍接受为首选方法。本前瞻性研究讨论了一种使用股薄肌肌皮瓣间置的新手术技术。
11 例患者因盆腔恶性肿瘤（n=10）和直肠子宫内膜异位症（n=1）切除后出现瘘。初次治疗是盆腔切除术；然而，有 6 例患者接受了辅助化疗放疗，2 例患者接受了术后放疗，2 例患者仅接受了化疗。瘘的平均直径为 2±0.24cm（1-3），8 例患者（72.7%）的瘘位于阴道中段三分之一。修复方法是广泛清创瘘边缘，然后用股薄肌肌皮瓣间置，同时行转流造口。成功定义为造口关闭后瘘的愈合。
5 例患者采用单股薄肌肌皮瓣修复，2 例采用单纯股薄肌肌瓣修复，4 例采用双股薄肌肌皮瓣修复。患者平均随访时间为 34.8±5.03 个月（12-67），所有患者的瘘均完全愈合（100%）。造口关闭的中位时间为 2 个月（1-5）。4 名女性（36.4%）至少有 1 种术后早期并发症，包括暂时性漏液（n=3）、阴道脓肿（n=1）、部分皮瓣坏死（n=1）和供区肢体深静脉血栓形成（n=1）。3 例（27.3%）患者出现晚期并发症，包括阴道狭窄、直肠吻合口狭窄和吻合口肿瘤复发。
直肠阴道隔修复需要充分清创坏死无血管化组织、组织移位和阴道壁重建。股薄肌肌皮瓣是解决这个问题的理想选择。
