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Luo MY, Chen WP, Chen HX, Yang XY, Wan XY, Xiao GZ, Zheng YH, Ren DL, Peng H, Lin HC. Stapled transperineal rectovaginal fistula repair for low- and mid-level rectovaginal fistulas: A comparison study with rectal mucosal advancement flap repair. Asian J Surg 2024; 47:1756-1762. [PMID: 38228457 DOI: 10.1016/j.asjsur.2023.12.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/15/2023] [Accepted: 12/29/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND As an innovative treatment, stapled transperineal rectovaginal fistula repair (STR) for rectovaginal fistula (RVF) has demonstrated effectiveness in preliminary reports. This study aims to compare STR with rectal mucosal advancement flap repair (RAF), a widely utilized surgical procedure, for the surgical outcome of the low- and mid-level RVF. METHODS In this retrospective cohort study, patients with low- and mid-level RVF who underwent STR or RAF were included from both the Sixth Affiliated Hospital of Sun Yat-sen University and Xi'an Daxing Hospital. Among the 99 total patients, 77 underwent STR and 22 underwent RAF. Patient demographics, operative data, and outcomes were collected and analyzed. Recurrence rate and associated risk factors were evaluated. RESULTS There were no statistically significant differences among patients in terms of clinical characteristics like age, BMI, aetiology, and fistula features. During the follow-up period of 20 months (interquartile range 3.0-41.8 months), a total of 28 patients relapsed, with a significantly lower recurrence rate in the STR group (20.8 %) than in the RAF group (54.6 %) (P = 0.005). In the multivariate Cox analysis, STR was an independent protective factor against recurrence (HR: 0.37, 95%CI: 0.17-0.79, P = 0.01). Logistic regression indicated that there was no statistically significant difference between these two procedures in terms of surgical complications (OR: 0.53, 95%CI: 0.19-1.48, P = 0.23). CONCLUSION For low- and mid-level RVF, STR may be an alternative option for treatment modality that offers a lower recurrence rate, without observed disadvantage in terms of surgical complication rates.
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Affiliation(s)
- Min-Yi Luo
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Wen-Ping Chen
- Department of Anorectal and Pelvic Floor Surgery, Xi'an Daxing Hospital, China
| | - Hua-Xian Chen
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Xiao-Yuan Yang
- Department of Anorectal and Pelvic Floor Surgery, Xi'an Daxing Hospital, China
| | - Xing-Yang Wan
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Guo-Zhong Xiao
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Yi-Hui Zheng
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Dong-Lin Ren
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Hui Peng
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China.
| | - Hong-Cheng Lin
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China.
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Yilmaz S, Maspero M, Isakov R, Wong J, Foley N, Spivak A, Hull TL. Gracilis muscle interposition for recurrent rectovaginal fistula. Tech Coloproctol 2023; 27:945-946. [PMID: 37354333 DOI: 10.1007/s10151-023-02835-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Affiliation(s)
- S Yilmaz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, 9500 Euclid Avenue, Desk A-30, Cleveland, OH, 44195, USA
| | - M Maspero
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, 9500 Euclid Avenue, Desk A-30, Cleveland, OH, 44195, USA
- Università degli Studi di Milano, Milan, Italy
| | - R Isakov
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - J Wong
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, 9500 Euclid Avenue, Desk A-30, Cleveland, OH, 44195, USA
| | - N Foley
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, 9500 Euclid Avenue, Desk A-30, Cleveland, OH, 44195, USA
| | - A Spivak
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, 9500 Euclid Avenue, Desk A-30, Cleveland, OH, 44195, USA
| | - T L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, 9500 Euclid Avenue, Desk A-30, Cleveland, OH, 44195, USA.
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Maspero M, Otero Piñeiro A, Steele SR, Hull TL. Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis. Dis Colon Rectum 2023; 66:631-645. [PMID: 36735766 DOI: 10.1097/dcr.0000000000002739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A rectovaginal fistula is a debilitating condition that often severely impacts quality of life. Despite many treatment options available, the best surgical treatment is far from being established, and many patients will undergo several procedures before fistula closure is achieved. Gracilis muscle interposition, which is the transposition of the gracilis muscle into the rectovaginal septum, is an option for complex and persistent fistulas, but literature on the subject is scarce, mainly consisting of small case series. OBJECTIVE This study aimed to assess the success rate of gracilis muscle interposition for the surgical treatment of rectovaginal fistula. DATA SOURCES MEDLINE, Embase, Cochrane Library, and Web of Science. STUDY SELECTION Studies comprising at least 5 patients who underwent gracilis muscle interposition for rectovaginal fistula were included. No date or language restrictions was applied. INTERVENTION Gracilis muscle interposition. MAIN OUTCOME MEASURES The primary outcome is the fistula closure rate (%). Other domains analyzed are stoma closure rate, postoperative complications, quality of life, fecal continence, and sexual function. RESULTS Twenty studies were included for a total of 384 patients. The pooled fistula closure rate for gracilis muscle interposition was 64% (95% CI, 53%-74%; range, 33%-100%). Risk factors for failure were smoking, underlying Crohn's disease, and more than 2 previous repairs, whereas stoma formation was associated with improved outcomes. Postoperative complications ranged from 0% to 37%, mostly related to surgical site occurrences at the harvest site and perineal area. No deaths occurred. Gracilis muscle interposition improved quality of life and fecal continence, but impairment of sexual function was common. LIMITATIONS Most of the included studies were small case series. CONCLUSIONS Gracilis muscle interposition is a safe and moderately effective treatment that could be taken into consideration as second- or third-line therapy for recurrent rectovaginal fistula. REGISTRATION NO CRD42022319621.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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Surgical treatment of deep-lying ano-/rectovaginal fistulas using a de-epithelialized “Singapore flap” (pudendal thigh flap). Eur Surg 2022. [DOI: 10.1007/s10353-022-00759-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Summary
Background
Rectovaginal fistulas represent 5% of all anorectal fistulas. For affected women, this pathology is associated with a reduction in quality of life (QoL) and self-esteem. Most commonly used methods of surgical closure have high recurrence rates or permanent perineal complaints, which in turn lead to negative effects on QoL and self-esteem. A fistula closure, using the “de-epithelialized Singapore flap” (SF), can be a good alternative therapy strategy.
Method
Our retrospective case series processes the long-term results of seven patients who were operated on for ano-/rectovaginal fistula using the SF. All patients underwent surgery at the University Hospital Graz, between May 2012 and July 2015. The data of the surgical follow-up examinations were collected and an additional telephone survey was carried out. The procedure is presented based on a structured description. All procedures were performed jointly by the Department of General Surgery and the Department of Plastic Surgery.
Results
The average age of the seven patients was 46.14 years (23–72 a). Five patients had a total of 12 previous operations with frustrating results. Of the seven patients treated, six had a permanent fistula closure (85.7%). The results of the telephone survey (n = 6) showed a high level of patient satisfaction (100%), and an improvement in QoL (83.3%), through our surgical method. In our cohort, neither urinary nor fecal incontinence occurred.
Conclusion
The treatment of an ano-/rectovaginal fistula using the “de-epithelialized pudendal thigh flap” (Singapore flap) is a promising treatment alternative. In particular, patients who have had previous proctological interventions show a benefit from this procedure.
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Zhou Q, Liu ZM, Chen HX, Ren DL, Lin HC. Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair. World J Gastroenterol 2021; 27:1451-1464. [PMID: 33911467 PMCID: PMC8047532 DOI: 10.3748/wjg.v27.i14.1451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/29/2021] [Accepted: 03/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Currently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, with a relatively low healing rate. Unclosed intermittent suture and poor suture materials may be the main reasons for this. AIM To evaluate the efficacy and safety of stapled transperineal repair in treating RVF. METHODS This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among the 82 total patients, 37 underwent repair with direct suturing and 45 underwent repair with stapling. Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were assessed. RESULTS The direct suture and stapled repair groups showed similar clinical characteristics for aetiology, surgical history, fistula features, and perioperative Wexner score. The stapled repair group did not show superior results over the suture repair group in regard to operative time, blood loss, and hospital stay. However, the stapled repair group showed better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (1/45 vs 17/37, P = 0.045), and lower recurrence rate (6/45 vs 17/37, P = 0.001). There was no protective effect from previous repair history, smaller diameter of fistula (< 0.5 cm), better control of defecation (Wexner < 10), or stapled repair. Direct suture repair and preoperative high Wexner score (> 10) were risk factors for fistula recurrence. Furthermore, stapled repair gave better efficacy in treating complex RVFs (i.e., multiple transperineal repair history, mid-level fistula position, and poor control of defecation). CONCLUSION Stapled transperineal repair is advantageous for management of RVF, providing a high primary healing rate and low recurrence rate.
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Affiliation(s)
- Qian Zhou
- Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Zhi-Min Liu
- Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Hua-Xian Chen
- Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Dong-Lin Ren
- Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Hong-Cheng Lin
- Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
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Abstract
Rectovaginal fistula (RVF), defined as any abnormal connection between the rectum and the vagina, is a complex and debilitating condition. RVF can occur for a variety of reasons, but frequently develops following obstetric injury. Patients with suspected RVF require thorough evaluation, including history and physical examination, imaging, and objective evaluation of the anal sphincter complex. Prior to attempting repair, sepsis must be controlled and the tract allowed to mature over a period of 3 to 6 months. All repair techniques involve reestablishing a healthy, well-vascularized rectovaginal septum, either through reconstruction with local tissue or tissue transfer via a pedicled flap. The selection of a specific repair technique is determined by the level of the fistula tract and the status of the anal sphincter. Despite best efforts, recurrence is common and should be discussed with patients prior to repair. As the ultimate goal of RVF repair is to minimize symptoms and maximize quality of life, patients should help to direct their own care based on the risks and benefits of available treatment options.
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Affiliation(s)
- Aaron J. Dawes
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Sahnan K, Adegbola S, Iqbal N, Twum-Barima C, Reza L, Lung P, Warusavitarne J, Hart A, Tozer P. Managing non-IBD fistulising disease. Frontline Gastroenterol 2020; 12:524-534. [PMID: 34712471 PMCID: PMC8515280 DOI: 10.1136/flgastro-2019-101234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kapil Sahnan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Samuel Adegbola
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Nusrat Iqbal
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Charlene Twum-Barima
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Lillian Reza
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Phillip Lung
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
- IBD Unit, St Mark's Hospital, Harrow, UK
| | - Phil Tozer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
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Egal A, Etienney I, Atienza P. Endorectal Advancement Flap With Muscular Plication in Anovaginal and Anterior Perineal Fistulas. Ann Coloproctol 2020; 37:141-145. [PMID: 32674556 PMCID: PMC8273710 DOI: 10.3393/ac.2020.04.10.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/10/2020] [Indexed: 01/09/2023] Open
Abstract
Purpose Endorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas. Methods This retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms. Results Thirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%). Conclusion This study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.
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Affiliation(s)
- Axel Egal
- Department of Proctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Isabelle Etienney
- Department of Proctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Patrick Atienza
- Department of Proctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
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Huang MJ, Ye DX, Lin Y, Lu XR, Lin HM, Chi P, Huang Y. A nomogram for predicting rectovaginal fistula after low anterior resection for rectal cancer. Surg Today 2020; 50:1206-1212. [PMID: 32656700 DOI: 10.1007/s00595-020-02049-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/06/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Rectovaginal fistula (RVF) is a complicated and troublesome complication of low anterior resection (LAR) for rectal cancer. We aimed to investigate the risk factors for post-LAR RVF and develop a predictive nomogram. METHODS We performed a retrospective analysis of 821 female patients with rectal cancer who underwent LAR between October 2010 and October 2018. Logistic regression was performed to identify risk factors. A nomogram was developed to predict RVF. RESULTS The incidence of post-LAR RVF was 3.4% (28/821). A multivariate analysis showed that the preoperative serum hemoglobin level (OR 2.449, 95% CI 1.144-5.239), the distance between the tumor and anal verge (OR 4.158, 95% CI 1.392-12.418), surgical procedure (OR 2.369, 95% CI 1.117-5.027), hysterectomy (OR 2.996, 95% CI 1.106-8.833), and bilateral oophorectomy (OR 5.823, 95% CI 1.639-20.689) were significantly associated with the development of RVF. A nomogram was developed, which showed a C-index of 0.824 (95% CI 0.730-0.918) and an adjusted C-index of 0.790. CONCLUSION This study identified the preoperative serum hemoglobin level, the distance between the tumor and the anal verge, the type of surgical procedure, hysterectomy, and bilateral oophorectomy as predictors of post-LAR RVF. A nomogram was successfully developed. It could aid in the prediction of RVF in patients undergoing LAR.
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Affiliation(s)
- Ming-Jin Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Dao-Xiong Ye
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Yu Lin
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Xing-Rong Lu
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Hui-Ming Lin
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China.
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, People's Republic of China.
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Ziouziou I, Ammouri S, Ouazni M, Sumba H, Koutani A, Iben Attya Andaloussi A. Recto-vaginal fistulas: A case series. Int J Surg Case Rep 2020; 72:147-152. [PMID: 32535530 PMCID: PMC7298318 DOI: 10.1016/j.ijscr.2020.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 01/13/2023] Open
Abstract
Falandry and Martius’ techniques were used firstly for vesico-vaginal fistulas with satisfying long-term functional results. The same techniques are feasible and safe for rectovaginal fistula repair. In this case series, patients had an improvement of their self-image and health-related quality of life. Temporary colostomy is recommended before this reconstructive surgery.
Introduction Rectovaginal fistula (RVF) is defined as an abnormal communication between the anterior wall of the rectum and the posterior wall of the vagina. Many surgical techniques have been described in the treatment of RVF. However, none has proved its superiority. The aim of the study was to evaluate the functional results of surgical treatment of RVF using Martius and Falandry techniques in order to assess the feasibility and the efficacy of these techniques which were first described for vesico-vaginal fistulas. Methods The study was a retrospective case series conducted in a single centre: Department of general surgery at Ibn Sina University Hospital in Rabat. We included patients with rectovaginal fistula consecutively recruited from 2011 to 2014. 10 patients developed RVF after surgery for rectal cancer (9 cases), uterine cancer (1 case). One patient had RVF for ano-rectal malformation. Colostomy was performed before the treatment of fistula in 9 cases (82 %). They underwent surgical treatment using Falandry (8 patients) and Martius techniques (3 patients) performed by an experienced urologist surgeon. Results No postoperative complications were recorded. Time to discharge was postoperative day 3–4. There was a complete disappearance of RVF in 8 patients (72.7 % of cases), relapse in 2 cases (18 %), and failure in one case (9%). The average follow-up was 12.6 +/-10 months. Functionally, no long-term cases of fecal incontinence or dyspareunia were noted. Conclusion The choice of surgical technique in the treatment of RVF remains difficult because of poor literature data and absence of consensus. RVF repair results either by Martius or Falandry techniques are encouraging with low morbidity.
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Affiliation(s)
- Imad Ziouziou
- Service d'urologie, CHU d'Agadir, Agadir, Morocco; Equipe de recherche en médecine translationnelle et épidémiologie, Laboratoire des sciences de la santé, Faculté de médecine et de pharmacie, Université Ibn Zohr, Agadir, Morocco.
| | - Safaa Ammouri
- Service de gynécologie-obstétrique et d'endoscopie gynécologique, Maternité Soussi, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
| | - Mohammed Ouazni
- Service de chirurgie viscérale, CHU d'Agadir, Faculté de médecine et de pharmacie, Université Ibn Zohr, Agadir, Morocco
| | - Harrison Sumba
- Service d'urologie B, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
| | - Abdellatif Koutani
- Service d'urologie B, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
| | - Ahmed Iben Attya Andaloussi
- Service d'urologie B, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
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Kumar S, Medappil N, Singh SK, Chandra A. Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition. Ann Coloproctol 2020; 36:58-61. [PMID: 32146790 PMCID: PMC7069671 DOI: 10.3393/ac.2018.08.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/21/2018] [Indexed: 11/30/2022] Open
Abstract
Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient’s neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark’s incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.
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Affiliation(s)
- Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Noushif Medappil
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Sunil Kumar Singh
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
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Weledji EP, Elong FA, Eyongeta DE. A Case of Low Rectovaginal Fistula of Obstetric Origin: Treatment by Fistulotomy and Reconstitution or Advancement Flap? Front Surg 2020; 7:2. [PMID: 32133369 PMCID: PMC7041408 DOI: 10.3389/fsurg.2020.00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/27/2020] [Indexed: 11/13/2022] Open
Abstract
Many small low rectovaginal fistulas represent incompletely healed (third degree) perineal lacerations i. e., involving the sphincters. An individualized, systematic approach to these fistulas based on their size, location, and etiology provides a more concise treatment plan. We report a case of a low rectovaginal fistula developed some years following forceps vaginal delivery. This was managed successfully by a fistulotomy in which the bridge of skin and scar tissue was divided, and the defect repaired as a classical third degree perineal laceration. On the background of coexisting or occult sphincter damage which usually follows obstetric trauma, a fistulotomy and immediate composite repair for small, low rectovaginal fistula may be advantageous and acceptable in a low resource setting where endoanal imaging and manometry are not available.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Felix Adolphe Elong
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Divine Enoru Eyongeta
- Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon
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DeLeon MF, Hull TL. Treatment Strategies in Crohn's-Associated Rectovaginal Fistula. Clin Colon Rectal Surg 2019; 32:261-267. [PMID: 31275072 DOI: 10.1055/s-0039-1683908] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rectovaginal fistula (RVF) is a rare, but dreaded complication of Crohn's disease (CD) that is exceedingly difficult to manage. Treatment algorithms range from observation and medical therapy to local surgical repair and proctectomy. The multitude of surgical options and lack of consensus between experts speak to the complexity and shortcomings encountered to correct this disease process surgically. The key to successful management of these fistulae therefore rests on a multidisciplinary approach between the patient, gastroenterologists, and surgeons, with open communication about expectations and goals of care. In this article, we review the management of CD-associated RVF with an emphasis on surgical technique.
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Affiliation(s)
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Lin HC, Huang L, Chen HX, Zhou Q, Ren DL. Stapled Transperineal Fistula Repair of Rectovaginal Fistula: A Preliminary Experience. Surg Innov 2018; 26:66-71. [PMID: 30196767 DOI: 10.1177/1553350618799452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE This study is designed to assess the safety, efficacy, and postoperative outcomes of stapled transperineal repair in management of rectovaginal fistula (RVF). METHODS A prospective database of patients with RVF undergoing stapled transperineal repair between May 2015 and December 2017 was established and studied retrospectively. RESULTS Seven consecutive RVF patients underwent stapled transperineal repair. The mean operative time was 119 ± 42 minutes. The estimated blood loss during operation was 24 ± 14 mL. Concomitant levatorplasty was performed with 4 patients and sphincteroplasty with 2 patients. Over a median follow-up of 6 months (range 3-33 months), no case was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (mean preoperative vs postoperative Wexner scores 3 [range 3-4] vs 1 [range 1-2], respectively; P = .01). CONCLUSIONS Stapled transperineal repair of RVF appears safe and effective. The initial results are encouraging, suggesting the need for a more formal prospective assessment of this technique as part of a randomized trial for the management of low- and mid-vaginal fistulas.
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Affiliation(s)
- Hong-Cheng Lin
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Liang Huang
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Hua-Xian Chen
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Qian Zhou
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Dong-Lin Ren
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
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16
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VanBuren WM, Lightner AL, Kim ST, Sheedy SP, Woolever MC, Menias CO, Fletcher JG. Imaging and Surgical Management of Anorectal Vaginal Fistulas. Radiographics 2018; 38:1385-1401. [DOI: 10.1148/rg.2018170167] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Wendaline M. VanBuren
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Amy L. Lightner
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Sarasa T. Kim
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Shannon P. Sheedy
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Madeline C. Woolever
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Christine O. Menias
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Joel G. Fletcher
- From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
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17
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Knuttinen MG, Yi J, Magtibay P, Miller CT, Alzubaidi S, Naidu S, Oklu R, Kriegshauser JS, Mar WA. Colorectal-Vaginal Fistulas: Imaging and Novel Interventional Treatment Modalities. J Clin Med 2018; 7:jcm7040087. [PMID: 29690541 PMCID: PMC5920461 DOI: 10.3390/jcm7040087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 11/16/2022] Open
Abstract
Colovaginal and/or rectovaginal fistulas cause significant and distressing symptoms, including vaginitis, passage of flatus/feces through the vagina, and painful skin excoriation. These fistulas can be a challenging condition to treat. Although most fistulas can be treated with surgical repair, for those patients who are not operative candidates, limited options remain. As minimally-invasive interventional techniques have evolved, the possibility of fistula occlusion has enriched the therapeutic armamentarium for the treatment of these complex patients. In order to offer optimal treatment options to these patients, it is important to understand the imaging and anatomical features which may appropriately guide the surgeon and/or interventional radiologist during pre-procedural planning.
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Affiliation(s)
| | - Johnny Yi
- Mayo Clinic Arizona; Phoenix, AZ 85054 USA.
| | | | | | | | | | - Rahmi Oklu
- Mayo Clinic Arizona; Phoenix, AZ 85054 USA.
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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19
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20
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Lo TS, Huang YH, Dass AK, Karim N, Uy-Patrimonio MC. Rectovaginal fistula: Twenty years of rectovaginal repair. J Obstet Gynaecol Res 2016; 42:1361-1368. [DOI: 10.1111/jog.13066] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/03/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Tsia-Shu Lo
- Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital, Keelung, Medical Center; Keelung Taiwan
- Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital, Taipei, Medical Center; Taipei Taiwan
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- School of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Yu-Hsin Huang
- Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital, Taipei, Medical Center; Taipei Taiwan
| | - Anil Krishna Dass
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- Urogynaecology Unit, Department of Obstetrics and Gynaecology, Penang Hospital; Penang Malaysia
| | - Nazura Karim
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- Department of Obstetrics and Gynecology; Hospital Tuanku Jaafar; Negeri Sembilan Malaysia
| | - Ma. Clarissa Uy-Patrimonio
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- Department of Obstetrics and Gynecology; Dr Pablo O. Torre Memorial Hospital; Bacolod Philippines
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21
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Akiba RT, Rodrigues FG, da Silva G. Management of Complex Perineal Fistula Disease. Clin Colon Rectal Surg 2016; 29:92-100. [PMID: 27247533 DOI: 10.1055/s-0036-1580631] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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.
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Affiliation(s)
- Ricardo Tadayoshi Akiba
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, Florida
| | - Fabio Gontijo Rodrigues
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, Florida
| | - Giovanna da Silva
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, Florida
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22
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Sugrue J, Kaminski J, Patel S, Park J, Prasad L, Marecik S. Repair of a recurrent traumatic rectovaginal fistula using vaginal wall plication to reinforce a rectal wall advancement flap. J Vis Surg 2016; 2:65. [PMID: 29078493 DOI: 10.21037/jovs.2016.02.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/07/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Rectovaginal fistulas (RVF) can cause significant physical discomfort and psychological distress for patients and remain amongst the most challenging disorders for surgeons. METHODS A 28-year-old female with a history of a traumatic cloaca repaired 12 years prior was diagnosed with a recurrent RVF and underwent repair using a rectal wall advancement flap reinforced with posterior vaginal wall plication. This case is used to demonstrate surgical technique. The study adhered to the prescribed ethical guidelines. Informed consent was obtained from the patient to use the video recording of her operation for educational purposes. RESULTS The patient had an uneventful postoperative course. The fistula was fully healed without any signs or symptoms of recurrence at 8 weeks follow-up exam. Her protective ileostomy was successfully closed. CONCLUSIONS Transanal repair of a RVF through creation of a rectal advancement flap and plication of redundant vaginal wall can be used to treat appropriately selected patients with significant tissue defects.
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Affiliation(s)
- Jeremy Sugrue
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jan Kaminski
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Supriya Patel
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Division of Colon and Rectal Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - John Park
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Leela Prasad
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Slawomir Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Abstract
Rectovaginal fistulae are abnormal epithelialized connections between the rectum and vagina. Fistulae from the anorectal region to the posterior vagina are truly best characterized as anovaginal or very low rectovaginal fistulae. True rectovaginal fistulae are less common and result from inflammatory bowel disease, trauma, or iatrogenic injury. A very few patients are asymptomatic, but the symptoms of rectovaginal fistula are incredibly distressing and unacceptable. Diagnostic approach, timing, and choice of surgical intervention, including sphincteroplasty, gracilis flaps, Martius flaps, and special circumstances are discussed.
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Affiliation(s)
- Bidhan Das
- Division of Colon and Rectal Surgery, Department of Surgery, University of Texas-Houston, Houston, Texas
| | - Michael Snyder
- Department of Surgery, University of Texas-Houston, Houston, Texas
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Maeda K, Koide Y, Hanai T, Sato H, Masumori K, Matsuoka H, Katsuno H. The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula. Colorectal Dis 2015; 17:1002-6. [PMID: 25891199 DOI: 10.1111/codi.12977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023]
Abstract
AIM Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula. METHOD Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome. RESULTS Birth injury (n = 7), low anterior resection for rectal cancer (n = 3), pouch surgery for ulcerative colitis (n = 2) and a procedure for prolapse and haemorrhoids (n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure. CONCLUSION Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed.
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Affiliation(s)
- K Maeda
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Y Koide
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - T Hanai
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Sato
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - K Masumori
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Katsuno
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Presentation and management of rectovaginal fistulas after delivery. Int Urogynecol J 2015; 27:859-64. [PMID: 26476822 DOI: 10.1007/s00192-015-2860-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/22/2015] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Obstetric trauma leading to rectovaginal fistula (RVF) formation results from perineal laceration and/or from prolonged ischemia and necrosis following obstructed labor. Due to modern obstetric care fistulas are rare in industrialized countries. METHODS Patients undergoing surgery for a RVF between January 2005 and December 2014 at the Department of Obstetrics and Gynecology, Tuebingen, Germany, were identified and their records were reviewed retrospectively. RESULTS Of 48 patients, 13 developed RVF of obstetric etiology. Parity ranged from 2 to 4. RVF repair was performed in all patients using a transvaginal approach: fistula excision and multilayer closure (7 of 13) with Martius flap interposition (1 of 7) and sphincteroplasty (5 of 13). One RVF closed spontaneously. Due to significant destruction of the anal canal, large RVF and RVF recurrence, 4 of the 13 patients needed a temporary protective ileostomy. Fistula closure was achieved in 12 of 13 patients. CONCLUSION The choice of RVF repair should be tailored to the underlying pathology and type of repair done previously and the patient's wishes.
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27
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Kobayashi H, Sugihara K. Successful management of rectovaginal fistula treated by endorectal advancement flap: report of two cases and literature review. SPRINGERPLUS 2015; 4:21. [PMID: 25694858 PMCID: PMC4325007 DOI: 10.1186/s40064-015-0799-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/06/2015] [Indexed: 01/15/2023]
Abstract
Introduction Rectovaginal fistula (RVF) sometimes has a difficulty in treatment. This report describes two patients who suffered from RVF. Case descriptions One patient was a 76-year-old woman who had a RVF over 30 years after the 3rd childbirth. She underwent endorectal advancement flap (ERAF). She had a nighttime soiling after ERAF once a month, which disappeared one year after surgery. Second patient was a 23-year-old woman who had a RVF one month after the first childbirth. She underwent ERAF, and did not have any complications. Discussion and evaluation Both patients did not develop recurrence for four years. Quality of life after ERAF was satisfactory in both patients. ERAF is a safe procedure in terms of both short and long outcomes. We also present a review of the literature concerning ERAF for RVF. Conclusions ERAF can be a potential option as a treatment for RVF.
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Affiliation(s)
- Hirotoshi Kobayashi
- Center for Minimally Invasive Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519 Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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29
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de Weerd L, Weum S, Norderval S. Novel treatment for recalcitrant rectovaginal fistulas: fat injection. Int Urogynecol J 2014; 26:139-44. [PMID: 25199495 DOI: 10.1007/s00192-014-2497-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/24/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The treatment of recurrent rectovaginal fistula (RVF) is a challenge for the surgeon. Within plastic surgery fat harvesting and subsequent transplantation by injection is an established method for soft tissue augmentation. We hypothesized whether soft tissue augmentation by transperineal injection of autologous fat could stimulate fistula healing in women with recalcitrant RVF. MATERIALS AND METHODS Six patients with a recalcitrant RVF, 4 due to obstetric injury and 2 associated with Crohn's disease, were included in the pilot study. The fat graft from the lower abdomen was injected transperineally around the fistula tract. At the end of the injection procedure the fistula tract was transected transversely. RESULTS In 1 patient the fistula healed after a single treatment, while the other 5 required two treatments with a 6-week interval. In the patients with an RVF due to obstetric injury no recurrence occurred during follow-up, mean 41 months (range 4-53). In the 2 patients with Crohn's disease a new fistula developed after 23 and 25 months respectively. CONCLUSION We describe fat injection as a new and promising method for the treatment of a recalcitrant RVF where previous attempts had failed to heal the fistula. This method does not include wide dissection, thereby reducing the risk of injury to important neurovascular structures. The method is minimally invasive and causes minimal donor site morbidity. More advanced techniques can still be used in cases of recurrence.
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Affiliation(s)
- L de Weerd
- Department of Plastic Surgery and Hand Surgery, University Hospital North Norway, Tromsø, Norway,
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Pata G, Pasini M, Roncali S, Tognali D, Ragni F. Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition. Int J Surg Case Rep 2014; 5:527-31. [PMID: 25016079 PMCID: PMC4147571 DOI: 10.1016/j.ijscr.2014.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/03/2014] [Accepted: 04/10/2014] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures. PRESENTATION OF CASE We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient's quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures. DISCUSSION This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum. CONCLUSION In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.
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Affiliation(s)
- Giacomo Pata
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy.
| | - Mario Pasini
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy
| | - Stefano Roncali
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy
| | - Daniela Tognali
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, University of Brescia School of Medicine, Brescia, Italy
| | - Fulvio Ragni
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy
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Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M. German S3-Guideline: rectovaginal fistula. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2012; 10:Doc15. [PMID: 23255878 PMCID: PMC3525883 DOI: 10.3205/000166] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Indexed: 12/12/2022]
Abstract
Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. Methods: A systematic review of the literature was undertaken. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.
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Pescatori M. Rectovaginal Fistulae. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:85-97. [DOI: 10.1007/978-88-470-2077-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Kröpil F, Raffel AM, Schauer M, Rehders A, Eisenberger CF, Knoefel WT. Differentiated surgical treatment of rectovaginal fistulae. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc10. [PMID: 26504694 PMCID: PMC4582475 DOI: 10.3205/iprs000010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Rectovaginal fistulae (RVF) are a serious and debilitating problem for patients and a challenge for the treating surgeons. We present our experiences in the surgical treatment of these patients. METHODS Study population consisted of 22 consecutive patients (range 26-70 years) with RVF treated in our department between 2003 and 2009. 13 RVF were observed after colorectal or gynaecological surgery, 3 occurred after radiotherapy, 2 due to tumour infiltration, 4 because of local inflammation (3x diverticultis, 1x ulcus simplex recti). The RVF was classified in all patients before treatment as either 'low' or 'high'. RESULTS Local procedures (transvaginal excision, preanal repair) as initial treatment were performed in 9 patients with low fistula. In 13 cases with high fistula an abdominal approach was performed to close the fistula. A recurrence was observed in 8/22 cases (36%), which were treated by a gracilis flap (n=2), a bulbospongiosus composite (n=1), a second abdominal approach (n=4), and a re-local excision (n=1). Ultimatively, in 19 cases the defect healed but in 3 patients the RVF persisted. CONCLUSIONS Most important predictor of healing/failure is etiology followed by localization and recurrence of the RVF. Local (preanal, transvaginal) procedures are suitable for low RVF, whereas abdominal surgery is necessary in high RVF. In recurrent RVF, muscle flaps are promising procedures.
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Affiliation(s)
- Feride Kröpil
- Department of General Surgery, Heinrich-Heine-University Hospital Düsseldorf, Germany
| | - Andreas M Raffel
- Department of General Surgery, Heinrich-Heine-University Hospital Düsseldorf, Germany
| | - Matthias Schauer
- Department of General Surgery, Heinrich-Heine-University Hospital Düsseldorf, Germany
| | - Alexander Rehders
- Department of General Surgery, Heinrich-Heine-University Hospital Düsseldorf, Germany
| | - Claus F Eisenberger
- Department of General Surgery, Heinrich-Heine-University Hospital Düsseldorf, Germany
| | - Wolfram T Knoefel
- Department of General Surgery, Heinrich-Heine-University Hospital Düsseldorf, Germany
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Minimally invasive surgical technique in the management of perianal fistulas using the Surgisis® AFP material. POLISH JOURNAL OF SURGERY 2011; 83:392-402. [PMID: 22166669 DOI: 10.2478/v10035-011-0063-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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de Parades V, Dahmani Z, Blanchard P, Zeitoun JD, Sultan S, Atienza P. Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair. Colorectal Dis 2011; 13:921-5. [PMID: 20528893 DOI: 10.1111/j.1463-1318.2010.02338.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIM Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique. METHOD Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn's disease with proctitis, malignant or radiation-related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure-of-eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days. RESULTS Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28-78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn's disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow-up of 14 (2-67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre- and postoperatively were 1.3 (0-15) and 0.6 (0-6), respectively. CONCLUSION The success rate was promising with no deterioration of anal continence.
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Affiliation(s)
- V de Parades
- Proctologie médico-interventionnelle, Groupe hospitalier Diaconesses - Croix Saint Simon, Paris, France.
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Abstract
Rectovaginal fistulas are abnormal epithelial-lined connections between the rectum and vagina. They can be quite bothersome to both the patient and the surgeon due to their irritating and embarrassing symptoms and high failure rate after repair. An individualized, systematic approach to these fistulas based on their size, location, and etiology provides a more concise treatment plan. Treatment options of medical therapy, advancement flaps, plugs, fistula ligation, and tissue interposition are discussed.
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Pitel S, Lefevre JH, Parc Y, Chafai N, Shields C, Tiret E. Martius advancement flap for low rectovaginal fistula: short- and long-term results. Colorectal Dis 2011; 13:e112-5. [PMID: 21564462 DOI: 10.1111/j.1463-1318.2011.02544.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short- and long-term results of the Martius flap procedure. METHOD Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined. RESULTS Crohn's disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn's disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2-31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right-sided flap was associated with a higher success rate (P = 0.0442). CONCLUSION The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.
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Affiliation(s)
- S Pitel
- Department of General and Digestive Surgery, Hôpital Saint-Antoine, Assistance Publique Hopitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris VI, France
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Chern H, Varma MG. Rectovaginal and Rectourethral Fistulas. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum 2011; 54:54-9. [PMID: 21160314 DOI: 10.1097/01.dcr.0000388926.29548.36] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Closure of rectoanovaginal fistula from a cryptoglandular or obstetrical origin can be difficult. Multiple techniques exist and none are perfect. Although episioproctotomy offers the advantage of a simultaneous repair of the sphincter complex, it is a more extensive procedure. A rectal-advancement flap appears less traumatic and divides no perineal tissue or sphincter. The aim of this study was to evaluate the results of episioproctotomy and rectal-advancement flap on healing, postoperative continence, and sexual function. METHODS Data were retrospectively collected regarding 87 women with cryptoglandular or obstetrical rectoanovaginal fistula treated from June 1997 to 2009, who underwent episioproctotomy or rectal-advancement flap at the discretion of the treating surgeon. Healing, use of seton or stoma, number of previous procedures, smoking, age, body mass index, dyspareunia, SF-12 health survey, the IBD Quality of Life, and the Fecal Incontinence Quality of Life, and the Female Sexual Function Index were obtained from our database and via telephone interviews. The Fisher exact probability and χ tests were used. RESULTS The mean age of these 87 women was 42.8 ± 10.5 years. Mean follow-up was 49.2 ± 39.2 months. Fifty (57.5%) patients underwent episioproctotomy and 37 (42.5%) underwent rectal-advancement flap. Thirty-nine (78%) patients healed after episioproctotomy vs 23 (62.2%) patients after rectal-advancement flap (P = .1). Episioproctotomy was associated with significantly better fecal (P < .001) and sexual (P = .04) function. There was no significant difference in other studied variables between the 2 techniques. CONCLUSIONS Despite episioproctotomy being a more extensive procedure, healing rates were comparable between episioproctotomy and rectal-advancement flaps. In this select population, episioproctotomy may provide better continence and may confer better sexual function compared with rectal-advancement flap. In appropriate patients surgeons should not hesitate to perform episioproctotomy on cryptoglandular or obstetrical-associated rectoanovaginal fistula.
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Pescatori M. Fistole retto-vaginali. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:85-97. [DOI: 10.1007/978-88-470-2062-7_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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El-Gazzaz G, Hull TL, Mignanelli E, Hammel J, Gurland B, Zutshi M. Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function. J Gastrointest Surg 2010; 14:1758-63. [PMID: 20593308 DOI: 10.1007/s11605-010-1259-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
PURPOSE Rectovaginal fistula (RVF) repair can be challenging. Additionally, women may experience sexual dysfunction and psychosocial ramifications even after a successful repair. The aim of this study was to investigate variables looking for predictors of healing/failure and examine long-term quality-of-life (QOL) and sexual function in women with low RVF from obstetrical or cryptoglandular etiology METHODS From June 1997-2009, 268 women underwent RVF repair. Of those, 100 with obstetric or cryptoglandular etiology agreed to participate in this study. Healing, type of procedure, use of seton or stoma, number of previous procedures, smoking, age, body mass index (BMI), dyspareunia, QOL using SF-12, FIQL, IBS-QOL, and female sexual function index was obtained from our prospective database and telephone contact. Fisher's exact test, chi-square test, and multivariable-logistic-regression model were used to identify the variables associated with healing/failure. RESULTS Mean follow-up was 45.8 ± 39.2 months; mean age 42.8 ± 10.5 years; and BMI was 28.8 ± 7.6. Sixty (60%) fistulas were obstetric and 40 (40%) cryptoglandular and 68/100 patients (68%) healed. On multivariate analysis, treatment failure was related to a heavier BMI (p = 0.001) and number of repairs (p = 0.02). Looking at each type of repair, episioproctotomy had significant healing compared to the other choices (but was not significant on multivariate analysis). Forty-seven women were sexually active at follow-up and 12/47 (25.5%) reported dyspareunia. Fecal incontinence was reported preoperatively in 42 women, more often in those with obstetric-related RVF (76% vs. 24% p < 0.05). Healing was not affected by age, smoking, co-morbidities, preoperative seton, or stoma use. Fecal and sexual function and QOL were comparable between women with healed and unhealed RVF. CONCLUSION Patients with higher BMI and more repairs had a decreased healing rate following RVF repair. Despite surgical outcome, QOL and sexual function were surprisingly similar regardless of fistula healing.
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Affiliation(s)
- Galal El-Gazzaz
- Pelvic Floor Unit, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Evaluation and treatment of anal incontinence, constipation, and defecatory dysfunction. Obstet Gynecol Clin North Am 2010; 36:673-97. [PMID: 19932421 DOI: 10.1016/j.ogc.2009.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Posterior compartment disorders include anal incontinence, constipation, and defecatory dysfunction. These disorders cause considerable morbidity, and are typically underreported by patients and undertreated by providers. The purpose of this article is outline the approach to diagnosis and treatment of anal incontinence, constipation, and defecatory dysfunction with a brief description of the nature of the problem and approaches to evaluation and diagnosis, as well as medical and surgical management.
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Cui L, Chen D, Chen W, Jiang H. Interposition of vital bulbocavernosus graft in the treatment of both simple and recurrent rectovaginal fistulas. Int J Colorectal Dis 2009; 24:1255-9. [PMID: 19421760 DOI: 10.1007/s00384-009-0720-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2009] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of the study is to assess the efficacy of vital bulbocavernosus graft transposition in the treatment of rectovaginal fistula. MATERIALS AND METHODS From March 2003 to October 2007, nine consecutive patients diagnosed with rectovaginal fistula were refereed to our institute. All patients were treated using an interposing vital bulbocavernosus graft between rectum and vagina. RESULTS Median patient age was 33 years (range, 19-61) and seven of the nine patients had undergone between one and six fistula repair sessions prior to this grafting procedure. The etiology included congenital in three, surgery injury in four, obstetric in one, and radiation in one. No wound infections or abscesses occurred postoperatively, and the in-hospital mortality rate was zero. No recurrence was reported during the follow-up period and all patients had normal fecal continence. Only one patient had mild dyspareunia and no further surgical treatment needed. CONCLUSION Both simple and complex rectovaginal fistula can be reliably repaired using a bulbocavernosus graft.
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Affiliation(s)
- Long Cui
- Department of Colorectal Surgery, Shanghai XinHua Hospital Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai 200092, China.
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Schouten WR, Oom DMJ. Rectal sleeve advancement for the treatment of persistent rectovaginal fistulas. Tech Coloproctol 2009; 13:289-94. [DOI: 10.1007/s10151-009-0535-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 08/25/2009] [Indexed: 12/31/2022]
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Rahman MS, Al-Suleiman SA, El-Yahia AR, Rahman J. Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years' experience in a teaching hospital. J OBSTET GYNAECOL 2009; 23:607-10. [PMID: 14617459 DOI: 10.1080/01443610310001604349] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fifty-two women with a rectovaginal fistula were managed over a period of 15 years. All the fistulae were caused by obstetric injury commonly resulting from breakdown of the repair of complete perineal tears or from unrecognised injury during forceps or precipitate delivery. In five patients the fistula healed spontaneously within 12 weeks of the injury. Thirty-nine patients underwent transvaginal purse-string repair by standard technique and eight patients had perineoproctotomy and sphincteroplasty for large fistulae associated with anal incontinence. Surgical repair was successful in all the 47 patients including two patients who had previous failed repair elsewhere. The routine postoperative follow-up period of the patients ranged between 6 months and 8 years. There were no residual symptoms of anal sphincter weakness in the patients treated with transvaginal purse-string repair. Two of the patients who underwent perineoproctotomy and sphincteroplasty complained of varying degrees of postoperative incontinence of flatus that resolved by 8 weeks postoperation. In our experience the transvaginal purse-string method of repair for small, low rectovaginal fistulae proved highly satisfactory with 100% cure rate. Perineoproctotomy and sphincteroplasty for larger fistulae associated with anal incompetence was equally successful with minimal postoperative morbidity.
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Affiliation(s)
- M S Rahman
- Department of Obstetrics and Gynaecology, College of Medicine, King Faisal University, Dammam, Saudi Arabia.
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Garg P. To determine the efficacy of anal fistula plug in the treatment of high fistula-in-ano: an initial experience. Colorectal Dis 2009; 11:588-91. [PMID: 18637937 DOI: 10.1111/j.1463-1318.2008.01632.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to determine the efficacy of the anal fistula plug in the treatment of high fistula-in-ano. METHOD Twenty-three patients with high cryptoglandular fistula-in-ano were prospectively studied over 1 year. The number of tracks, number of previous procedures and co-morbid conditions that could potentially affect outcome were noted. A seton was used to guide the AFP into the fistula track which was anchored at the primary opening. RESULTS Two patients were lost to follow-up. Twenty-one patients (mean age was 49.8 years) were followed from 192 to 543 days (median = 292 days). Thirteen patients had single track, eight had multiple tracks and 14 had a recurrent fistula. Success, defined by closure of all fistula tracks occurred in 71.4% (15/21). The success rate was 84.6% in patients with a single fistula track (11/13) compared with 50% in patients with multiple tracks (4/8) (P = 0.14, Fisher's exact test). Recurrent [10/14 (71.4%)] vs nonrecurrent fistulae [5/7 (71.4%)] had no bearing on the outcome (P = 1.0). Two patients experienced healing despite extrusion of the plug in the early postoperative period. The procedure was safe and well tolerated. CONCLUSION The Surgisis AFP was successful in 71.4% of patients. Plug extrusion does not necessarily mean failure.
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Affiliation(s)
- P Garg
- Department of General Surgery, Fortis Super-Specialty Hospital, Mohali, Chandigarh, India.
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Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg 2008; 248:39-43. [PMID: 18580205 DOI: 10.1097/sla.0b013e31817d077d] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. MATERIAL AND METHODS A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). RESULTS Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. CONCLUSION The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.
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Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum 2008; 51:1084-8. [PMID: 18478298 DOI: 10.1007/s10350-008-9339-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Revised: 09/08/2007] [Accepted: 10/28/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to report the outcomes with the use of advancement flaps and bioprosthetic grafts for the management of rectovaginal fistulas. METHODS A retrospective analysis of prospectively collected data was performed for all patients treated with a rectovaginal fistula. RESULTS There were 44 patients in the advancement flap group. A mucosal flap repair was performed for 29 patients, and 15 patients had an anodermal flap repair. The mean follow-up was 10 (range, 6-22) months. There were 34 patients in the bioprosthetic repair group. A bioprosthetic interposition graft was used to repair the fistula in 27 patients with a mean follow-up of 12 (range, 6-22) months, and 7 patients had a bioprosthetic plug repair of their fistula with a mean follow-up of 6 (range, 3-12) months. The fistula recurred in 15 patients (34 percent) who were managed by a flap repair, 5 patients (19 percent) who were managed by a bioprosthetic sheet, and 1 patient (14 percent) who was treated with a bioprosthetic plug. CONCLUSIONS Use of bioprosthetics for the management of rectovaginal fistulas is a new technique, which, based on early experience, seems to yield results equal to advancement flap repair.
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Affiliation(s)
- C Neal Ellis
- Department of Surgery, University of South Alabama, Mobile, Alabama, USA.
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