Garoufalia Zoe, Gefen Rachel, Emile Sameh Hany, Silva-Alvarenga Emanuela, Horesh Nir, Freund Michael R, Wexner Steven D
Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.
Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel.
Colorectal Dis. 2023 Apr;25(4):549-561. doi: 10.1111/codi.16427. Epub 2022 Dec 7.
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.
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 meta-analysis of data.
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 = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I = 61%).
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.
复杂性会阴瘘（CPF）是结直肠手术中最具挑战性的问题之一。已采用多种手术方法治疗CPF，但无一堪称万能。我们的研究旨在评估股薄肌置入术后CPF患者的总体成功率和并发症发生率。
根据PRISMA 2020指南，系统检索PubMed、Scopus和谷歌学术数据库直至2022年1月。排除包括18岁以下儿童或患者少于10例的研究，以及综述、重复或动物研究、记录不佳（未报告成功率）的研究和非英文文献。使用用于高级荟萃分析的开源跨平台软件openMeta [Analyst]™ 12.11.14版和Cochrane系统评价员手册5.4®进行数据的荟萃分析。
共纳入2002年至2021年间发表的25项研究。这些研究包括658例患者（409例女性）。大多数患者患有直肠阴道瘘（50.7%）或直肠尿道瘘（33.7%）。CPF最常见的病因是盆腔手术（29.4%）和炎症性肠病（25.2%）。约18%的患者有放疗史。498例（75.7%）CPF患者在股薄肌置入术后实现完全愈合。股薄肌置入术的加权平均成功率为79.4%（95%CI 73.8%-85%，I² = 75.3%），加权平均短期并发症发生率为25.7%（95%CI 18.1%-33.2%，I² = 84.1%），30天再次手术的加权平均发生率为3.6%（95%CI 1.6%-5.6%，I² = 42%）。瘘复发的加权平均发生率为16.7%（95%CI 11%-22.3%，I² = 61%）。
股薄肌置入技术是CPF的一种可行治疗选择。外科医生应熟悉其适应证和技术，以便为患者提供该选择。鉴于该手术使用相对较少，推荐患者进行股薄肌成形术而非直接实施手术是一种可接受的选择。
