Abstract
Management of complex perineal fistulas such as high perianal, rectovaginal, pouch-vaginal,
rectourethral, or pouch-urethral fistulas requires a systematic approach. The first
step is to control any sepsis with drainage of abscess and/or seton placement. Patients
with large, recurrent, irradiated fistulas benefit from stoma diversion. In patients
with Crohn's disease, it is essential to induce remission prior to any repair. There
are different approaches to repair complex fistulas, from local repairs to transperineal
and transabdominal approaches. Simpler fistulas are amenable to local repair. More
complex fistulas, such as those secondary to irradiation, require interposition of
healthy, well-vascularized tissue. The most common flap used for this treatment is
the gracilis muscle with good outcomes reported. Once healing is confirmed by imaging
and endoscopy, the stoma is reversed.
Keywords
perineal fistulas - perianal fistulas - rectovaginal fistulas - rectourethral fistulas
- complex fistulas
