Guideline proposal to reconstructive surgery for complex perineal sinus or rectal fistula

To evaluate a guideline approach of reconstructive surgery for complex perineal sinus or rectal fistula.

pre-, per-, and postoperative data of 28 patients undergoing transposition of rectus abdominis muscle (TRAM), gracilis muscle (GM), gluteal thigh flap (GTF), or omentoplasty (OP) for complex perineal sinus or rectal fistula were analyzed. A fistula higher than 10 cm and a sinus with a length of >10 cm were treated with TRAM or OP. If <8 cm, the first choice was GM or GTF. The operative team made choice between 8 and 10 cm. Vacuum assisted closure (VAC) therapy was used as adjunct therapy before and after muscle transposition in huge sinus. Success was defined as no residual or recurrent sinus or fistula within 6 months, postoperatively. Long-term complaints of perineum and muscle donor site were assessed.

Twenty-five out of 28 patients (90%) were treated according to the guideline. VAC therapy was done in six. Three patients died during mean follow up of 40 months (6-90). Initial success rate was 61% (17/28). After secondary surgery in seven, four (57%) were successful. Overall success rate, including VAC therapy, was 79% (22/28). Success was highest with GM and GTF and in small sinus or fistula.

A guideline approach to complex perineal sinus or fistula based on length or height of the sinus or rectal fistula, respectively, is successful in about 80% of cases. Large defects may best be downsized by VAC therapy, followed by muscle flap. Long-term complaints are acceptable.