Surgical strategy for complex perineal small bowel fistula after pelvic malignancy: An etiology-driven approach

doi:10.4240/wjgs.120918

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Surg. Aug 27, 2026; 18(8): 120918
Published online Aug 27, 2026. doi: 10.4240/wjgs.120918

Surgical strategy for complex perineal small bowel fistula after pelvic malignancy: An etiology-driven approach

Tian-Qi Wu, Jin-Fa Yang, Li He, Ren-Yuan Gao, Shi-Lin Wang, Bo-Ran Pang, Fang-Tao Wang, Lu Yin, Chun-Qiu Chen, Xiao-Cai Wu

Tian-Qi Wu, Jin-Fa Yang, Li He, Ren-Yuan Gao, Shi-Lin Wang, Bo-Ran Pang, Fang-Tao Wang, Lu Yin, Chun-Qiu Chen, Xiao-Cai Wu, Department of Difficult Abdominal Surgery, Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China

Jin-Fa Yang, Department of General Surgery, People’s Hospital, Lahu-Wa-Bulang-Dai Autonomous County of Shuangjiang, Lincang 677399, Yunnan Province, China

Co-first authors: Tian-Qi Wu and Jin-Fa Yang.

Co-corresponding authors: Chun-Qiu Chen and Xiao-Cai Wu.

Author contributions: Wu TQ and Yang JF are members of two distinct medical teams; their independent activities in the surgical treatment and management of all patients were critical to the collection of case data that formed the basis of this study and as such are designated as co-first authors; Wu TQ, Yang JF, He L, Gao RY, Wang SL, Pang BR, Wang FT, and Yin L, performed the data analyses and interpretation; Wu TQ, Yang JF, and Wu XC conceived and designed the study; Yang JF and Chen CQ provided critical revision of the subsequent versions of the article for important intellectual content; Chen CQ and Wu XC are the chief attending physicians of two distinct medical teams; both were responsible for leading the operation and Wu XC was also responsible for providing major funding for this research, and as such are designated as co-corresponding authors; Wu XC drafted the manuscript. All authors provided final approval of the article.

AI contribution statement: Gemini was used solely for linguistic refinement and formatting assistance in the Introduction and Discussion sections.

Supported by Excellent Young Physician Training Program of Shanghai Tenth People’s Hospital, No. 2018SYPDRC043; and National Natural Science Foundation of China, No. 82403215 and No. 82470555.

Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Shanghai Tenth People’s Hospital (Approval No. SHSY-LYZX-652).

Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymized clinical data that were obtained after each patient agreed to treatment by written consent.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: No additional data are available.

Corresponding author: Xiao-Cai Wu, MD, PhD, Department of Difficult Abdominal Surgery, Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, No. 301 Yanchang Middle Road, Jing’an District, Shanghai 200072, China. wuxiaocai@tongji.edu.cn

Received: March 13, 2026
Revised: June 18, 2026
Accepted: July 14, 2026
Published online: August 27, 2026
Processing time: 158 Days and 10 Hours

Abstract

BACKGROUND

Perineal small bowel fistula (PSF) is a highly debilitating complication of radical pelvic malignancy resections. It is typically driven by empty pelvis syndrome (EPS) and chronic adhesive disease. Current therapeutic guidelines lack standardization.

AIM

To evaluate an etiology-driven surgical algorithm, where procedures are chosen based on the underlying mechanism, aiming to improve closure rates.

METHODS

Retrospective cohort analysis was performed on 28 consecutive patients who underwent definitive repair for complex PSF. Patients were stratified into two surgical groups based on etiology: Group 1 (n = 15) underwent modified pelvic floor reconstruction for structural defects or EPS; group 2 (n = 13) underwent internal intestinal plication for extensive adhesions or tumor recurrence. Overall survival was calculated from the date of definitive surgery to the last follow-up or death.

RESULTS

The study cohort (mean age 56.6 years) included patients with rectal (35.7%), gynecological (35.7%), and various other pelvic malignancies. There were no significant baseline demographic differences between the groups. A significant correlation was observed between fistula etiology and surgical strategy (P = 0.02). While reconstruction was the exclusive surgical approach for patients with EPS (100%), plication was predominantly utilized for cases of tumor recurrence (66.7%). The overall fistula closure rate was 89.3% (25/28), showing no significant difference between group 1 (86.7%) and group 2 (92.3%; P = 1.0). However, group 2 experienced a significantly longer mean time to postoperative flatus (6.8 days vs 4.2 days; P = 0.002). The median follow-up time for the entire cohort was 34.5 months (range: 9.0-107.0 months). Overall survival was comparable across the two surgical groups (32.0 months vs 37.0 months; P = 0.66).

CONCLUSION

Managing complex PSFs requires a tailored approach. Employing an etiology-driven strategy, specifically pelvic floor reconstruction for structural voids (EPS) and internal intestinal plication for “frozen” adhesive conditions, achieves > 89% closure rates with acceptable morbidity.

Keywords: Perineal small bowel fistula; Empty pelvis syndrome; Radiation enteritis; Internal intestinal plication; Pelvic exenteration

Core Tip: This study evaluated an etiology-driven algorithm for repairing perineal small bowel fistulas. By customizing surgical interventions - such as pelvic floor reconstruction and intestinal plication - to the underlying mechanisms of the fistula, researchers achieve a successful closure rate of 89.3% in high-risk patients with a history of pelvic cancer.