Redo Gracilis Muscle Transposition for Recurrent Complex Pouch-Vaginal Fistula: A Feasible and Effective Pouch Salvage Surgical Procedure.

BACKGROUND. Pouch-vaginal fistulae (PVF) affect 4 to 16% of women after ileal-pouch-anal anastomosis (IPAA) and significantly impact the patients’quality of life. They indeed represent a challenge for the surgeon. A variety of surgical options have been described but the reported pouch failure rate varies between 20 and 30% after the development of a PVF. Gracilis muscle transposition (GMT) is often considered a last resort treatment after the failure of multiple previous attempts. CASE REPORT. A 45 years old women came to our tertiary IBD surgical department due to a recurrent PVF. She had already been treated elsewhere with multiple surgical repairs (mucosal advancement flaps, local injection of Adalimumab and redo-pouch). She had a severe pelvic sepsis and an IPAA stricture. Therefore, a pelvic surgical toilette, a diverting loop ileostomy and the dilatation of the anastomotic stricture were performed. After twelve months, a left GMT was fashioned. Unfortunately, three months after the procedure, a pouchoscopy and a contrast enema revealed an early recurrence of the fistula. After further six months, the patient was scheduled for a redo GMT as a rescue procedure of a pouch salvage strategy. After the transversal incision through the perineal body the pouch-vaginal fistulous track was identified and repaired. The left gracilis muscle was still in place, viable and well-vascularized. The right gracilis mucle was transposed to the perineum and secured to the apex of the dissection in the cavity between vagina and pouch, lying along the left muscle previously placed. After three months healing, of the PVF was assessed and confirmed with pouchoscopy. So, the patient was scheduled for closure of the ileostomy. Twelve months after reversal of fecal diversion, the successful healing is maintained. DISCUSSION. GMT is usually advocated as a last resort strategy for PVF before declaring a pouch failure. However, redo gracilis GMT is a faesible and effective pouch salvage procedure in a tertiary IBD surgical center.