International Journal of Colorectal Disease

, Volume 23, Issue 4, pp 349–353 | Cite as

Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease

  • Alois FürstEmail author
  • Christin Schmidbauer
  • Justyna Swol-Ben
  • Igors Iesalnieks
  • Oliver Schwandner
  • Ayman Agha
Original Article



Local surgical procedures in the presence of Crohn’s disease have a markedly reduced success rate, especially in the treatment of recurrent anovaginal and distant rectovaginal fistulas. In these patients, local surgery (e.g., flap closure) has unsatisfactory results if the anal canal is destroyed by ulceration and indurations or in patients with extensive defects of the perineum.

Materials and methods

Over a period of 6 years (2000 to 2006), 12 patients with recurrent rectovaginal fistulas were treated with graciloplasty. The age of the female patients ranged from 24 to 47 years, the mean age being 38 years. The presence of Crohn’s disease in all patients had a mean duration of 12 years. Corticosteroids, mesalazin, or azathioprin were administered preoperatively. All patients were diverted by a temporary ileostomy before graciloplasty.


Rectovaginal fistula was closed in 11 of 12 patients after graciloplasty with a mean follow-up of 3.4 years. One rerecurrence of a rectovaginal fistula was documented. One of 12 ileostomies was not closed due to persistence of the fistula tract. One patient had a pouch-anal and, additionally, a pouch-vaginal fistula. In this patient, the first transposition of the gracilis muscle was unsuccessful. After a few months, she underwent renewed graciloplasty. There was no recurrence of a fistula within the follow-up period. Reconstruction of the perineum constituted an additional positive effect of the graciloplasty. In one patient, the preexisting fecal incontinence persisted, even after secondary implantation of a pacemaker. Due to diarrhea and persistent fecal incontinence, the patient opted for a renewed ileostomy.


In our series, gracilis transposition in the treatment of recurrent anovaginal and rectovaginal fistulas in patients with Crohn’s disease has excellent short-term results. In addition, graciloplasty can reconstruct the perineal defect.


Graciloplasty Recurrent fistula Anovaginal Rectovaginal Crohn’s disease 


  1. 1.
    Athanasiadis S, Oladeinde I, Kuprian A, Keller B (1995) Endorectal advancement flap-plasty vs. transperineal closure in surgical treatment of rectovaginal fistulas. A prospective long-term study of 88 patients. Chirurg 66:493–502PubMedGoogle Scholar
  2. 2.
    Belt RL, Belt RL Jr (1969) Repair of anorectal vaginal fistula utilizing segmental advancement of the internal sphincter muscle. Dis Colon Rectum 12:99–104PubMedCrossRefGoogle Scholar
  3. 3.
    Byron RL, Ostergard DR (1969) Sartorius muscle interposition for the treatment of radiation-induced vaginal fistula. Am J Obstet Gynecol 104:104–107PubMedGoogle Scholar
  4. 4.
    Corman ML (1979) Management of fecal incontinence by gracilis muscle transposition. Dis Colon Rectum 22:290–292PubMedCrossRefGoogle Scholar
  5. 5.
    Greenwald JC, Hoexter B (1965) Repair of rectovaginal fistula. Surg Gynecol Obstet 120:1019–1030Google Scholar
  6. 6.
    Halverson AL, Hull TL, Fazio VW et al (2001) Repair of recurrent rectovaginal fistulas. Surgery 130:753–757 discussion 757–758PubMedCrossRefGoogle Scholar
  7. 7.
    Haray PN, Stiff G, Foster ME (1996) New option for recurrent rectovaginal fistulas. Dis Colon Rectum 39:463–464PubMedCrossRefGoogle Scholar
  8. 8.
    Hesterberg R, Schmidt WU, Müller F, Röhrer HD (1993) Treatment of anovaginal fistulas with an anocutaneous flap in patients with Crohn’s disease. Int J Colorectal Dis 8:51–54PubMedCrossRefGoogle Scholar
  9. 9.
    Joo JS, Weiss EG, Nogueras JJ, Wexner SD (1998) Endorectal advancement flap in perianal Crohn’s disease. Am Surgeon 64:147–150PubMedGoogle Scholar
  10. 10.
    Kodner IJ, Mazor A, Shemesh EI et al (1993) Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 114:682–689 discussion 689–690PubMedGoogle Scholar
  11. 11.
    Kohler L, Troidl H (2000) [Transposition of the gracilis muscle—an option in the surgical treatment of rectovaginal fistulae]. Chirurg 71:86–88PubMedCrossRefGoogle Scholar
  12. 12.
    Laird DR (1948) Procedures used in treatment of complicated fistulas. Am J Surg 76:701–708CrossRefGoogle Scholar
  13. 13.
    Lens J, Vink M (1979) Gracilis muscle transplant for delayed healing of the perineal wound. Arch Chir Neerl 31:231–235PubMedGoogle Scholar
  14. 14.
    MacRae HM, McLeod RS, Cohen Z, Stern H, Reznick R (1995) Treatment of rectovaginal fistulas that has failed previous repair attempts. Dis Colon Rectum 38:921–925PubMedCrossRefGoogle Scholar
  15. 15.
    Morrison JG, Gathright JB Jr, Ray JE et al (1989) Results of operation for rectovaginal fistula in Crohn’s disease. Dis Colon Rectum 32:497–499PubMedCrossRefGoogle Scholar
  16. 16.
    Penninckx F, Moneghini D, D’Hoore A et al (2001) Success and failure after repair of rectovaginal fistula in Crohn’s disease: analysis of prognostic factors. Colorectal Dis 3:406–411PubMedCrossRefGoogle Scholar
  17. 17.
    Perez F, Arroyo A, Serrano P, Candela F, Perez M-T, Calpena R (2006) Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistulo-in-ano. Int J Colorectal Dis 21:522–526PubMedCrossRefGoogle Scholar
  18. 18.
    Pye PK, Dada T, Duthie G, Phillips K (2004) Surgisis mesh: A novel approach to repair of a recurrent rectovaginal fistula. Dis Colon Rectum 47:1554–1556PubMedGoogle Scholar
  19. 19.
    Rius J, Nessim A, Nogueras JJ, Wexner SD (2000) Gracilis transposition in complicated perianal fistula and unhealed perineal wounds in Crohn’s disease. Eur J Surg 166:218–222PubMedCrossRefGoogle Scholar
  20. 20.
    Ryan JA Jr (1984) Gracilis muscle flap for the persistent perineal sinus of inflammatory bowel disease. Am J Surg 148:64–70PubMedCrossRefGoogle Scholar
  21. 21.
    Senatore PJ (1994) Anovaginal fistulae. Surg Clin North Am 74:1361–1375PubMedGoogle Scholar
  22. 22.
    Shelton AA, Welton ML (2006) Transperineal repair of persistent rectovaginal fistulas using an acellular cadaveric dermal graft (AlloDerm). Dis Colon Rectum 49:1454–1457PubMedCrossRefGoogle Scholar
  23. 23.
    Sher ME, Bauer JJ, Gelernt I (1991) Surgical repair of rectovaginal fistulas in patients with Crohn’s disease: transvaginal approach. Dis Colon Rectum 34:641–648PubMedCrossRefGoogle Scholar
  24. 24.
    Sonoda T, Hull T, Piedmonte MR, Fazio V (2002) Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 45:1622–1628PubMedCrossRefGoogle Scholar
  25. 25.
    Stern H, Gamliel Z, Ross T, Dreznik Z (1988) Rectovaginal fistula, initial experience. Can J Surg 31:359–362PubMedGoogle Scholar
  26. 26.
    Stirnemann H (1969) Treatment of recurrent recto-vaginal fistula by interposition of a glutaeus maximus muscle flap. Am J Proctol 20:52–54PubMedGoogle Scholar
  27. 27.
    Tsujinaka S, Ruiz D, Wexner SD, Baig MK, Sands DR, Weiss EG, Nogueras JJ, Efron JE, Vernava AM (2006) Surgical management of pouch-vaginal fistula after restorative proctocolectomy. J Am Coll Surg 202:912–918PubMedCrossRefGoogle Scholar
  28. 28.
    Uribe N, Millan M, Minguez M, Ballester C, Asencio F, Sanchiz V, Esclapez P, Castillo JR (2007) Clinical and manometric results of endorectal advancement flaps for complex anal fistula. Int J Colorectal Dis 22:259–264PubMedCrossRefGoogle Scholar
  29. 29.
    Watson SJ, Phillips RKS (1995) Non-inflammatory rectovaginal fistula. Br J Surg 82:1641–1643PubMedCrossRefGoogle Scholar
  30. 30.
    Wise WE Jr, Aguilar PS, Padmanabhan A et al (1991) Surgical treatment of low rectovaginal fistulas. Dis Colon Rectum 34:271–274PubMedCrossRefGoogle Scholar
  31. 31.
    Zmora O, Potenti FM, Wexner SD et al (2003) Gracilis muscle transposition for iatrogenic rectourethral fistula. Ann Surg 237:483–487PubMedCrossRefGoogle Scholar
  32. 32.
    Zmora O, Tulchinsky H, Gur E, Goldman G, Klausner JM, Rabau M (2006) Gracilis muscle transposition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 49:1316–1321PubMedCrossRefGoogle Scholar
  33. 33.
    Zuber JC, Glattli A, Tschopp H (1992) [Gracilis muscle repair in perineal and genital soft tissue problems]. Helv Chir Acta 58:883–887PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Alois Fürst
    • 1
    Email author
  • Christin Schmidbauer
    • 1
  • Justyna Swol-Ben
    • 2
  • Igors Iesalnieks
    • 2
  • Oliver Schwandner
    • 1
  • Ayman Agha
    • 2
  1. 1.Department of SurgeryCaritas-Clinic St. JosefRegensburgGermany
  2. 2.Department of SurgeryUniversity of RegensburgRegensburgGermany

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