Jun 1, 1998 - George Pinedo MD. Clinical Assistant. Robin Phillips MS FRCS. Dean, Academic Institute. Department of Surgery, St Mark's Hospital, London.
Ann R Coll Surg Engl 1998; 80: 410-412
Labial fat pad grafts (modified Martius graft) in complex perianal fistulas George Pinedo MD
Robin Phillips MS FRCS
Clinical Assistant
Dean, Academic Institute
Department of Surgery, St Mark's Hospital, London
Key words: Anal fistula; Martius graft
Complex perianal fistulas may at times be very difficult to treat. New vascularised tissue can reach the perineum from leg muscles and the omentum. A less well-known source is the labial fat tissue (modified Martius graft) which has a robust posterolateral pedicle and which can be useful as an adjunctive technique for high anterior anal and rectovaginal fistulas. Between November 1993 and July 1997, eight women (age range 18-55 years) underwent modified Martius grafting, six of the eight having a rectovaginal fistula and two a high complex (suprasphincteric) perianal fistula. Anorectal advancement flaps were performed in five patients and three had a transperineal approach with simultaneous anterior sphincter repair because of concurrent anal incontinence. All patients had a defunctioning stoma. The fistula healed in six of the eight patients (75%) and recurred in two patients. The stoma has been closed in five of the eight patients (one patient's fistula has healed but her stoma cannot be closed because of anal incontinence). This is a useful technique when confronted with a difficult anterior fistula in women.
Eliminating the use of the bulbocavernosus muscle to develop the flap reduces morbidity and expedites operating time. In the last 20 years there have been few articles published using Martius grafts (2-6). What has been published has been mainly by gynaecologists, who have reported variable success rates for a range of different perineal fistulas of assorted aetiology. The aim of this paper is to present and describe this technique and show its results in eight women with complex perianal fistulas.
When confronted with a difficult perianal fistula, there are several available adjuvant techniques, of which one of the simplest but least well known is the Martius graft. In 1928, Henri Martius published the use of a bulbocavernosus muscle and labial fat pad graft for vesicovaginal fistulas (1). In 1990, Elkins et al. (2) showed after a superb anatomical description that the bulbocavernosus muscle itself did not need to be incorporated in the graft as the labial adipose tissue has a robust blood supply and is rich in fibres, giving the graft firmness and consistency.
Results
Correspondence to: Mr R K S Phillips, St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex HAl 3UJ
Patients and methods This was a retrospective study of eight women with recurrent perianal fistulas referred to St Mark's Hospital from November 1993 to July 1997. Only patients with non-irradiated perianal fistulas were included. All patients either had previous defunctioning stomas performed before referral or simultaneously during surgery. The eight patients had modified Martius graft developed as an adjuvant technique together with the primary operation (Fig. 1, Fig. 2).
The mean age was 36 years (range 18-55 years). Mean length of follow-up was 23 months (range 4-44 months). Six patients had rectovaginal fistulas and two patients had suprasphincteric fistulas. In five patients, an adjunctive anorectal advancement flap was performed with the primary surgery, and in three patients a transperineal approach, fistulectomy and simultaneous anterior sphincter repair was performed. The causes of fistulas were obstetric in four cases, cryptoglandular in two, Crohn's disease in one and coloanal vaginal anastomotic fistula in one (this patient had previously undergone intersphinc-
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healed fistul as 7%(TbeI.Thstm a oughithe th her somaee
Discussion Anastomotic
1 6/r(5% Sometimes when dealing with complex recurrent perineal fistula results can be poor, even with anorectal advancement flaps (7,8). There are several published adjuvant 0 Totals2/8 (25%)
techniques (use of omentum, ischiocavernosus muscle, gracilis muscle, gluteus muscle and bulbocavernosus muscle plus labial fat pad) that try to increase the success Table I. Results of modified Martius graft
Aetiology Graoht'
rate of any repair attempted in these difficult situations. When there has been radiotherapy or there is active inflammatory bowel disease, different strategies may be more appropriate, such as laparotomy plus coloanal anastomosis or conservative treatment, respectively. Nonetheless, when the fistula is caused by trauma (mainly obstetric' _r cryptoglandular, a simpler approach is still the first choice (transanal advancement flap, transperineal approach, transvaginal approach (9-13). If the fistula is recurrent, then there is a case for an adjunctive procedure as well. The association of these techniques with a modified Martius graft obliterates the space left after repair, avoids haematoma, improves blood supply and it incorporates two different synergistic methods of repair. Modified Martius grafting is a simple adjuvant technique, uses the same operative field and is a less extensive procedure than its alternatives.
Success
Failure
1
0
References 1 Martius H. Die operative Wiederhellstellung der volkonmmen fehlenden Harnrohare und des Schlessmuskels derselben. Zentralbi Gynakol 1928; 52: 480-86. 2 Elkins TE, DeLancey JOL, McGuire EJ. The use of modified Martius graft as an adjunctive technique in
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vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75: 727-32. 3 Margolis T, Elkins TE, Seffah, J, Oparo-Addo HS, Fort D. Full-thickness Martius grafts to preserve vaginal depth as an adjuvant in the repair of large obstetric fistulas. Obstet Gynecol 1994; 84: 148-52. 4 Aartsen EJ, Sindram IS. Repair of the radiation-induced rectovaginal fistulas without or with interposition of bulbocavernosus muscle (Martius procedure). Eur J Surg Oncol 1988; 14: 171-7. 5 White AJ, Buchsbaum HJ, Blythe JG, Lifshitz S. Use of the bulbocavernosus muscle (Martius procedure) for repair of radiation-induced rectovaginal fistulas. Obstet Gynecol 1982; 60: 114-18. 6 Boronow RC. Repair of the radiation-induced vaginal fistula utilizing the Martius technique. World J Surg 1986; 10: 23748. 7 MacRae HM, McLeod RS, Cohen Z, Stern H, Reznick R. Treatment of rectovaginal fistulas that have failed previous repair attempts. Dis Colon Rectum 1995; 38: 921-5.
8 Watson SJ, Phillips RKS. Non-inflammatory rectovaginal fistulas. Br J Surg 1995; 82: 1641-3. 9 Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal fistulas. Dis Colon Rectum 1988; 31: 676-8. 10 Aguilar PS, Plascencia G, Hardy TG, Hartmann RF, Stewart WRC. Mucosal advancement in the treatment of anal fistula. Dis Colon Rectum 1985; 28: 496-8. 11 Shemesh EI, Kodner IJ, Fry RD, Neutfeld DM. Endorectal sliding flap repair of complicated anterior anoperineal fistulas. Dis Colon Rectum 1988; 31: 22-4. 12 Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993; 114: 682-9. 13 Jones IT, Fazio VW, Jagelman DG. The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum. Dis Colon Rectum 1987; 30: 919-23.
Received 1 June 1998
