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Pastier C, Loriau J, Denost Q, O'Connell LV, Challine A, Collard MK, Debove C, Chafai N, Parc Y, Lefevre JH. Rectovaginal Fistula: What Is the Role of Martius Flap and Gracilis Muscle Interposition in the Therapeutic Strategy? Dis Colon Rectum 2024; 67:1056-1064. [PMID: 38653492 DOI: 10.1097/dcr.0000000000003148] [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: 04/25/2024]
Abstract
BACKGROUND Although numerous treatments exist for the management of rectovaginal fistula, none has demonstrated its superiority. The role of diverting stoma remains controversial. A few series include Martius flap in the armamentarium. OBJECTIVE Determine the role of gracilis muscle interposition and Martius flap in the surgical management of rectovaginal fistula. DESIGN Retrospective cohort study of a pooled prospectively maintained database from 3 centers. PATIENTS All consecutive eligible patients with rectovaginal fistula undergoing Martius flap and gracilis muscle interposition were included from 2001 to 2022. MAIN OUTCOME MEASURES Success was defined by the absence of stoma and rectovaginal fistula. RESULTS Sixty-two patients were included with 55 Martius flap and 24 gracilis muscle interposition performed after failures of 164 initial procedures. Total length of stay was longer for gracilis muscle interposition by 2 days ( p = 0.01) without a significant difference in severe morbidity (20% vs 12%, p = 0.53). Twenty-seven percent of the Martius flap interpositions were performed without a stoma, which did not have an impact on overall morbidity ( p = 0.763). Per patient immediate success rates were not significantly different between groups (35% vs 31%, p > 0.99). The success of gracilis muscle interposition after the failure of the Martius flap was not significantly different from an initial gracilis muscle interposition ( p > 0.99). After simple perineal procedures, the immediate success rate rose to 49.4% (49% vs 50%, p > 0.99). After a median follow-up of 23 months, no significant difference was detected in success rate between the 2 procedures (69% vs 69%, p > 0.99). Smoking was the only negative predictive factor ( p = 0.02). LIMITATIONS By its retrospective nature, this study is limited in its comparison. CONCLUSIONS This novel comparison between Martius flap and gracilis muscle interposition suggests that Martius flap presents several advantages, including shorter length of stay, similar morbidity, and similar success rate. Proximal diversion via a stoma for Martius flap does not appear mandatory. Gracilis muscle interposition could be reserved as a salvage procedure after Martius flap failure. See Video Abstract . FSTULA RECTOVAGINAL CUL ES EL ROL DEL COLGAJO DE MARTIUS Y LA INTERPOSICIN DEL MSCULO GRACILIS EN LA ESTRATEGIA TERAPUTICA ANTECEDENTES:Si bien existen numerosos tratamientos para el manejo de la fistula rectovaginal, ninguno ha demostrado su superioridad. El papel del estoma de derivación sigue siendo controvertido. Pocas series incluyen colgajo de Martius en el armamento.OBJETIVO:Determinar el rol de la interposición del músculo gracilis y del colgajo de Martius, en el manejo quirúrgico de la fístula rectovaginal.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente en 3 centros.AJUSTES/PACIENTES:Se incluyeron todos los pacientes elegibles consecutivos con fistula rectovaginal sometidos a colgajo de Martius y la interposición del músculo gracilis desde 2001 hasta 2022.RESULTADOS PRINCIPALES:El éxito se definió por la ausencia de estoma y fistula rectovaginal.RESULTADOS:Se incluyeron 62 pacientes con 55 colgajo de Martius y 24 con interposición del músculo gracilis realizados después de fracasos de 164 procedimientos iniciales. La duración total de la estancia hospitalaria fue dos días más larga para la interposición del músculo gracilis ( p = 0,01) sin una diferencia significativa en la morbilidad grave (20% frente a 12%, p = 0,53). El 27% de los colgajos de Martius se realizaron sin estoma, sin impacto en la morbilidad global ( p = 0,763). Las tasas de éxito inmediato por paciente no fueron significativamente diferentes entre los grupos (35% vs. 31%, p = 1,0). El éxito de la interposición del músculo gracilis después del fracaso del colgajo de Martius no fue significativamente diferente de una interposición del músculo gracilis inicial (p = 1,0). La tasa de éxito inmediato aumentó al 49,4% (49% frente a 50%, p = 1,0) después de procedimientos perineales simples. Después de una mediana de seguimiento de 23 meses, no se detectaron diferencias significativas en la tasa de éxito entre los dos procedimientos (69 % frente a 69 %, p = 1,0). El tabaquismo fue el único factor predictivo negativo ( p = 0,02).LIMITACIONES:Por su naturaleza retrospectiva, este estudio tiene limitaciones en su comparación.CONCLUSIÓN:Esta novedosa comparación entre colgajo de Martius y la interposición del músculo gracilis sugiere que el colgajo de Martius presenta varias ventajas, incluida una estancia prolongada más corta, una morbilidad similar y un éxito. La derivación proximal a través de un estoma para el colgajo de Martius no parece obligatoria. La interposición del músculo gracilis podría reservarse como procedimiento de rescate después de una falla de colgajo de Martius. (Traducción-Dr. Aurian Garcia Gonzalez ).
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Affiliation(s)
- Clément Pastier
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Jérôme Loriau
- Department of Visceral Surgery, Groupe Hospitalier Saint Joseph, Paris, France
| | - Quentin Denost
- Clinique Tivoli-Ducos, Bordeaux Colorectal Institute, Bordeaux, France
| | - Lauren V O'Connell
- Centre for Colorectal Disease, St. Vincent's University Hospital, Dublin, Ireland
| | - Alexandre Challine
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Maxime K Collard
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Clotilde Debove
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Najim Chafai
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Yann Parc
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
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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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Swindon D, Izwan S, Ng J, Chan E, Abbas N, Von Papen M, Sahebally SM. Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis. ANZ J Surg 2024. [PMID: 38475976 DOI: 10.1111/ans.18922] [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: 10/29/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Rectovaginal fistulae (RVF) are notoriously challenging to treat. Martius flap (MF) is a technique employed to manage RVF, among various others, with none being universally successful. We aimed to assess the outcomes of RVF managed with MF interposition. METHODS A PRISMA-compliant meta-analysis searching for all studies specifically reporting on the outcomes of MF for RVF was performed. The primary objective was the mean success rate, whilst secondary objectives included complications and recurrence. The MedCalc software (version 20.118) was used to conduct proportional meta-analyses of data. Weighted mean values with 95% CI are presented and stratified according to aetiology where possible. RESULTS Twelve non-randomized (11 retrospective, 1 prospective) studies, assessing 137 MF were included. The mean age of the study population was 42.4 (±15.7), years. There were 44 primary and 93 recurrent RVF. The weighted mean success rate for MF when performed for primary RVF was 91.4% (95% CI: 79.45-98.46; I2 = 32.1%; P = 0.183) and that for recurrent RVF was 77.5% (95% CI: 62.24-89.67; I2 = 58.1%; P = 0.008). The weighted mean complication rate was 29% (95% CI: 8.98-54.68; I2 = 85.4%; P < 0.0001) and the overall recurrence rate was 12.0% (95% CI: 5.03-21.93; I2 = 52.3%; P = 0.021). When purely radiotherapy-induced RVF were evaluated, the mean overall success rate was 94.6% (95% CI: 83.33-99.75; I2 = 0%; P = 0.350). CONCLUSIONS MF interposition appears to be more effective for primary than recurrent RVF. However, the poor quality of the data limits definitive conclusions being drawn and demands further assessment with randomized studies.
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Affiliation(s)
- Daisy Swindon
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Sara Izwan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Justin Ng
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Erick Chan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Naveed Abbas
- Department of Colorectal Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Michael Von Papen
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Shaheel Mohammad Sahebally
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Department of Colorectal Surgery, Tallaght University Hospital, Dublin, Ireland
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Otero-Piñeiro AM, Hull T, Holubar S, Pedersen KE, Aykun N, Obi M, Butler R, Steele SR, Lightner AL. Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn's Disease: Experience of a Tertiary Center. J Gastrointest Surg 2023; 27:2867-2875. [PMID: 37985619 DOI: 10.1007/s11605-023-05603-1] [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] [Received: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis. OBJECTIVE Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn's disease phenotype of the pouch. DESIGN Retrospective cohort study of a prospectively maintained, IRB-approved database. SETTINGS/PATIENTS Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn's-related perianal disease. INTERVENTIONS Two hundred thirty-one operations for perianal or anovaginal fistula(s). MAIN OUTCOME AND MEASURES Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure. RESULTS Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03-0.43, p = 0.001). Overall pouch failure rate was 12.1%. LIMITATIONS Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset. CONCLUSIONS Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Karina E Pedersen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nihal Aykun
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Megan Obi
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Robert Butler
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Strassmann V, Silva-Alvarenga E, Emile SH, Garoufalia Z, DaSilva G, Wexner SD. Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience. Am Surg 2023; 89:6366-6369. [PMID: 37216694 DOI: 10.1177/00031348231175481] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. METHODS A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. RESULTS Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. CONCLUSIONS Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.
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Affiliation(s)
- Victor Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Emanuela Silva-Alvarenga
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
- Cleveland Clinic Florida, Martin Health, Port St. Lucie, Florida
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Giovanna DaSilva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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Lavryk OA, Justiniano CF, Bandi B, Floruta C, Steele SR, Hull TL. Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas. Dis Colon Rectum 2023; 66:1539-1546. [PMID: 37379170 DOI: 10.1097/dcr.0000000000002920] [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: 06/30/2023]
Abstract
BACKGROUND A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion. OBJECTIVE To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause. DESIGN After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed. SETTING Colorectal surgery department at a tertiary center in the United States. PATIENTS Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included. MAIN OUTCOME MEASURES Recurrence after the colonic pull-through procedure. RESULTS There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months. LIMITATIONS Retrospective design. CONCLUSIONS The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases. EL PROCEDIMIENTO PULLTHROUGH DE TURNBULLCUTAIT ES UNA ALTERNATIVA A LA OSTOMA PERMANENTE EN PACIENTES CON FSTULAS PLVICAS COMPLEJAS ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).
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Affiliation(s)
- Olga A Lavryk
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Satora M, Żak K, Frankowska K, Misiek M, Tarkowski R, Bobiński M. Perioperative Factors Affecting the Healing of Rectovaginal Fistula. J Clin Med 2023; 12:6421. [PMID: 37835064 PMCID: PMC10573987 DOI: 10.3390/jcm12196421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
Rectovaginal fistula is rare, but a severe complication in gynecology, which despite the effort of clinicians is still not treated successfully in many cases. According to statistics, the healing rates of surgery in patients with RVF range from 20 to 100%. The treatment effectiveness depends on the etiology of fistula, the age of the patients, the presence of comorbidities, the type of surgery and many other factors. Considering the low efficiency of treatment and the high risk of recurrence, the question of possible methods to improve the results occurs. In our review, we analyzed both modifiable and non-modifiable factors which may influence the treatment, healing rate and future fate of the patients. Taking into account all analyzed risk factors, including age, comorbidities, smoking status, microbiology, medications, stoma and stool features, we are aware that rectovaginal fistula's treatment must be individualized and holistic. In cases of poorly healing RVF, the drainage of feces, the use of antibiotic prophylaxis or the implementation of estrogen therapy may be useful. Moreover, microbiome research in women with RVF and towards estrogen therapy should be performed in order to create treatment algorithms in women with fistulae. Those interventions, in our opinion, may significantly improve the outcome of the patients.
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Affiliation(s)
- Małgorzata Satora
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Marcin Misiek
- Department of Gynecology, Holy Cross Cancer Center, 25-734 Kielce, Poland;
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland;
| | - Marcin Bobiński
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland;
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8
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Sapci I, Zutshi M, Akeel N, Hull T. What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery? Colorectal Dis 2023; 25:1653-1657. [PMID: 37461257 DOI: 10.1111/codi.16660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 09/05/2022] [Accepted: 05/29/2023] [Indexed: 08/17/2023]
Abstract
AIM Rectovaginal fistulas in patients with Crohn's disease are challenging to manage, and surgical treatment remains the best option for achieving permanent closure of the fistula. Biologicals are now used routinely for patients with Crohn's disease. The aim of this study was to investigate the surgical procedures used by us to treat rectovaginal fistula in patients with Crohn's disease in the era of biologicals. METHOD Patients with Crohn's disease who underwent surgery for a rectovaginal fistula between 2010 and 2020 were included in this retrospective study and were identified from a prospectively maintained institutional database. Collected variables included demographics, perioperative and operative variables and data regarding medications used. Success of the procedure was defined as no symptoms at least 6 months after definitive repair and/or stoma closure. RESULTS Twenty patients (out of 80 referred for evaluation) underwent surgery with intent to close the fistula and had at least 6 months of follow-up. Mean age was 44 ± 12 years with a median follow-up duration of 33 months (range 6-130 months). Forty per cent of the patients had a history of at least two surgeries to close the fistula. The overall healing rate was 70% (14/20). The most performed procedure was a transanal rectal advancement flap (7/20), with a success rate of 85%. CONCLUSION Rectovaginal fistula in Crohn's disease is difficult to cure; according to our results almost half of these patients have multiple surgeries due to recurrence. Multiple procedures may be offered for this challenging problem in motivated patients. Perioperative diversion should be strongly considered.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Massarat Zutshi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nouf Akeel
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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9
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Muller O, Labiad C, Frontali A, Giacca M, Monsinjon M, Panis Y. What is the best surgical option after failure of graciloplasty in patients with recurrent rectovaginal fistula? A study of 19 consecutive patients. Tech Coloproctol 2023; 27:453-458. [PMID: 36574114 DOI: 10.1007/s10151-022-02742-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 12/06/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Management of recurrent rectovaginal fistula (rRVF) remains challenging despite the good results of graciloplasty reported in the literature. However, little is known about how to avoid a permanent stoma if graciloplasty fails. The aim of our study was to report the management of rRVF after failure of graciloplasty. METHODS A retrospective study was performed on consecutive patients with rRVF after failure of graciloplasty treated at our institution in January 2005-December 2021. RESULTS There were 19 patients, with a median age at graciloplasty of 39 years (range 25-64 years). Etiologies of RVF were Crohn's disease (CD) (n = 10), postoperative (n = 5), post-obstetrical (n = 3), and unknown (n = 1). After failure of graciloplasty, 45 new procedures were performed, all of them with a covering stoma: trans-anal repairs (n = 31), delayed colo-anal anastomosis (DCAA) (n = 4), biological mesh interposition (n = 3), second graciloplasty (n = 3), stoma only (n = 2) and redo ileal pouch-anal anastomosis (IPAA) (n = 2). One patient was not re-operated on and instead treated medically for CD. After a mean follow-up of 63 ± 49 months, success (i.e., absence of stoma or RVF) was obtained in 11 patients (58%): 4/4 DCAA (100%), 5/31 after local repair (16%), 1 after stoma creation alone (50%) and 1 after redo IPAA (50%). Second graciloplasty and biologic mesh interposition all failed. All 8 patients with failed intervention had CD. CONCLUSIONS In cases of rRVF after failed graciloplasty, reoperation is possible, although the chance of success is relatively low. The best results were obtained with DCAA. CD is a predictor of poor outcome.
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Affiliation(s)
- O Muller
- Department of Colorectal Surgery, Pôle des Maladies de l'appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - C Labiad
- Department of Colorectal Surgery, Pôle des Maladies de l'appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - A Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - M Giacca
- Department of Colorectal Surgery, Pôle des Maladies de l'appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - M Monsinjon
- Department of Colorectal Surgery, Pôle des Maladies de l'appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France.
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10
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Godoy-Brewer GM, Owodunni OP, Parian AM, Duraes LC, Selaru FM, Gearhart SL. Initial Clinical Outcomes Using Umbilical Cord-Derived Tissue Grafts to Repair Anovaginal Fistula. Dis Colon Rectum 2023; 66:299-305. [PMID: 35001050 DOI: 10.1097/dcr.0000000000002258] [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: 01/15/2023]
Abstract
BACKGROUND Perianal fistula is a debilitating disease and challenging condition to treat. Recently, the use of stem cells has been shown to improve healing of fistulas. OBJECTIVE The aim was to examine the use of an umbilical cord-derived stem cell graft in a pilot study as a novel scaffold/stem inlay implanted into fistula repairs for anovaginal fistula to examine healing rates. DESIGN This was a pilot study. SETTINGS This study took place in a colorectal surgery practice. PATIENTS Patients with anovaginal fistula consented to participate. Cryopreserved umbilical cord tissue graft with viable cells was incorporated as an inlay using a previously reported technique by the authors. Demographic data including history of previous repairs and IBD were included. All patients were followed for a minimum of 6 weeks. MAIN OUTCOME MEASURES The primary measures were safety and efficacy of novel stem cell graft in the treatment of anovaginal fistula. RESULTS From September 2017 to September 2019, 15 patients underwent anovaginal fistula repair. Three of these patients underwent a second repair, for a total of 18 repairs. No patient was intentionally diverted, but 3 patients presented for repair with a preexisting stoma. The majority of repairs were previous repair failures (12; 67%), and 7 repairs were performed on 5 patients with IBD. Median follow-up was 30 (6-104) weeks. The safety profile for cryopreserved umbilical cord tissue graft was excellent as no adverse events occurred. Overall complete healing rate was 39%, and 12 (67%) repairs resulted in improvement of symptoms. LIMITATIONS This was a small pilot study. CONCLUSIONS This is the largest series using cryopreserved umbilical cord graft for anovaginal fistula repair. The use of umbilical cord was safe and effective at closing defects. Randomized studies are necessary to determine added benefits over current standard of care. See Video Abstract at http://links.lww.com/DCR/B896 . RESULTADOS CLNICOS INICIALES DEL USO DE INJERTOS DE TEJIDO DERIVADO DE PLACENTA PARA REPARACIN DE FSTULAS ANOVAGINALES ANTECEDENTES:La fístula perianal es una enfermedad debilitante y una afección difícil de tratar. Recientemente, se ha demostrado que el uso de células madre mejora la curación de las fístulas.OBJETIVO:Deseamos examinar el uso de un injerto de células madre derivadas de cordón umbilical en un estudio piloto como una nueva matriz/injerto de células madre implantado en reparaciones de fístula para fístula anovaginal para examinar las tasas de curación.DISEÑO:Este fue un estudio piloto.ESCENARIO:Este estudio se llevó a cabo en una clínica de cirugía colorrectal.PACIENTES:Se obtuvo consentimiento informado de pacientes con fístula anovaginal. El injerto de tejido de cordón umbilical criopreservado con células viables se incorporó como incrustación utilizando una técnica previamente informada por los autores. Se incluyeron datos demográficos que incluían antecedentes de reparaciones previas y enfermedad inflamatoria intestinal. Todos los pacientes fueron seguidos durante un mínimo de 6 semanas.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas fueron la seguridad y la eficacia del nuevo injerto de células madre en el tratamiento de la fístula anovaginal.RESULTADOS:Desde 9/2017-9/2019, 15 pacientes fueron sometidas a reparación de fístula anovaginal. Tres de estos pacientes fueron sometidos a una segunda reparación, para un total de 18 reparaciones. Ningún paciente fue derivado intencionalmente mientras que 3 pacientes se presentaron para reparación con un estoma preexistente. La mayoría de las reparaciones fueron fallas de reparaciones previas (12, 67%) y se realizaron siete reparaciones en 5 pacientes con enfermedad inflamatoria intestinal (EII). La mediana de seguimiento fue de 30 semanas (6-104). El perfil de seguridad del injerto de tejido de cordón umbilical criopreservado fue excelente ya que no se produjeron efectos adversos. La tasa general de curación completa fue del 39% y 12 (67%) reparaciones dieron como resultado una mejoría de los síntomas.LIMITACIONES:Este fue un pequeño estudio piloto.CONCLUSIÓNES:Ésta es la serie más grande de utilización de injerto de cordón umbilical criopreservado para la reparación de una fístula anovaginal. La utilización del cordón umbilical resultó segura y eficaz para cerrar defectos. Se necesitan estudios aleatorizados para determinar los beneficios adicionales sobre el estándar de atención actual. Consulte Video Resumen en http://links.lww.com/DCR/B896 . (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Gala M Godoy-Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | | | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Leonardo C Duraes
- Division of Colorectal Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Florin M Selaru
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Susan L Gearhart
- Division of Colorectal Surgery, Johns Hopkins University, Baltimore, Maryland
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11
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Otero-Piñeiro AM, Falloon K, Philpott J, Lightner AL, Debernardo R, Steele SR, Hull T, Holubar SD. Entero-Gynecologic Fistula: A Rare Complication of Penetrating Crohn's Disease. J Gastrointest Surg 2023; 27:413-415. [PMID: 36279090 DOI: 10.1007/s11605-022-05487-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/17/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colon & Rectal Surgery, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - Katherine Falloon
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colon & Rectal Surgery, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | | | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA.
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12
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Schoene MI, Schatz S, Brunner M, Fuerst A. Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases. Int J Colorectal Dis 2023; 38:16. [PMID: 36652018 PMCID: PMC9849283 DOI: 10.1007/s00384-022-04293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies. METHODS A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef's Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula. RESULTS A total of 60 patients (44 women, 16 men; mean age 50 years, range 24-82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1-15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1-187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1). CONCLUSION Based on the authors' experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.
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Affiliation(s)
- Milla Isabelle Schoene
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
- University of Regensburg, Regensburg, Germany
| | - Sabine Schatz
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Marion Brunner
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Alois Fuerst
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany.
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13
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Garoufalia Z, Gefen R, Emile SH, Silva-Alvarenga E, Horesh N, Freund MR, Wexner SD. Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature. Colorectal Dis 2022; 25:549-561. [PMID: 36413086 DOI: 10.1111/codi.16427] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/09/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
AIM Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF. METHOD PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data. RESULTS Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I2 = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I2 = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I2 = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I2 = 61%). CONCLUSION The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.
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Affiliation(s)
- Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.,Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.,Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Emanuela Silva-Alvarenga
- Cleveland Clinic Martin Health at Tradition Health Park Two, Cleveland Clinic Florida, Port St Lucie, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA.,Department of Surgery and Transplantations, Sheba Medical Center, Sheba Tel Hashomer, Ramat Gan, Israel
| | - Michael R Freund
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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14
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Venara A, Trilling B, Ngoma M, Brochard C, Duchalais E, Siproudhis L, Faucheron J, de Parades V, Alves A, Cotte E, Ouaissi M, Bridoux V, Corbière L, Heraud J, Ortega‐Deballon P, Abo‐Alhassan F, Hamel J. Ano-rectovaginal fistula after obstetrical anal sphincter injury: Diverting stoma does not improve the surgical results. Colorectal Dis 2022; 24:1371-1378. [PMID: 35656842 PMCID: PMC9796529 DOI: 10.1111/codi.16211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/01/2023]
Abstract
AIM Ano-rectovaginal fistulas (ARVF) are challenging for the surgeon. Most of the series mix aetiologies, leading to confusion with respect to the conclusion. The aim of this study was to assess the factors associated with the success of ARVF management following obstetrical anal sphincter injury (OASIS). METHODS This retrospective multicentric study included all the patients undergoing surgery for ARVF identified by the hospital codes. Patients for whom the aetiology of ARVF was not OASIS were excluded. The major outcome measure was the success of the procedure. RESULTS Sixty patients with treated ARVF due to OASIS were identified. The success of overall management was 91.7%. Female patients underwent a mean of 2.5 (±1.7) procedures. A diverting stoma was formed in 29 patients (48.3%) of which 26 were closed at the end of the management period (89.7%). Of the 148 surgical procedures, only 55 were successful (37.2%). The order of the procedures (OR = 1.38; 95% CI: 0.75-2.51) or the diverting stoma (OR = 1.46; 95% CI: 0.31-6.91) were not significantly associated with the success of the surgery. However, Martius flap (OR = 4.13; 95% CI: 1.1-15.54) and Musset procedures (OR = 5.79; 95% CI: 1.77-18.87) produced better results than the endorectal advancement flap (ERAF). The other procedures did not show a significant correlation with management success. CONCLUSION A diverting stoma is not mandatory in the management of ARVF due to OASIS to improve the success of the surgical procedure. While the Martius flap procedure offers better results, the ERAF procedure may be preferred as a primary intervention in the absence of sphincter injury as it is less invasive. In cases of residual sphincter injury, the Musset procedure is most likely to be the best option.
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Affiliation(s)
- Aurélien Venara
- Department of Digestive SurgeryUniversity Hospital of AngersAngers Cedex 9France,CHU AngersUniversity of AngersAngersFrance,CHU AngersHIFIH, SFR ICATUniversity of AngersAngersFrance
| | - Bertrand Trilling
- TIMC‐IMAG Laboratory, National Centre for Scientific Research, Grenoble National Polytechnical Institute, Grenoble Alps University HospitalGrenoble Alps UniversityGrenobleFrance,Colorectal Surgery Unit, Visceral surgery and Acute Care surgery DepartmentGrenoble Alps University HospitalGrenobleFrance
| | - Marie Ngoma
- Institut Léopold Bellan, Groupe Hospitalier Paris Saint‐JosephService de Proctologie Médico‐ChirurgicaleParisFrance
| | - Charlène Brochard
- Unité D'explorations Fonctionnelles DigestivesCHU Rennes PontchaillouRennesFrance,Unité de Proctologie, Service des Maladies de l'appareil digestifCHU Rennes PontchaillouRennesFrance
| | - Emilie Duchalais
- Department of Digestive SurgeryUniversity Hospital of NantesNantesFrance
| | - Laurent Siproudhis
- Unité D'explorations Fonctionnelles DigestivesCHU Rennes PontchaillouRennesFrance,Unité de Proctologie, Service des Maladies de l'appareil digestifCHU Rennes PontchaillouRennesFrance
| | - Jean‐Luc Faucheron
- TIMC‐IMAG Laboratory, National Centre for Scientific Research, Grenoble National Polytechnical Institute, Grenoble Alps University HospitalGrenoble Alps UniversityGrenobleFrance,Colorectal Surgery Unit, Visceral surgery and Acute Care surgery DepartmentGrenoble Alps University HospitalGrenobleFrance
| | - Vincent de Parades
- Institut Léopold Bellan, Groupe Hospitalier Paris Saint‐JosephService de Proctologie Médico‐ChirurgicaleParisFrance
| | - Arnaud Alves
- Department of Digestive SurgeryUniversity Hospital of CaenCaen CedexFrance,UMR INSERM U1086 AnticipeCentre François BaclesseCaen CedexFrance
| | - Eddy Cotte
- Department of Digestive Surgery, Hôpital Lyon SudCHU LyonCedexFrance,Faculty of Medicine of Lyon Sud‐Charles MérieuxUniversity Lyon 1CedexFrance
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary Pancreatic and Liver Transplant SurgeryTrousseau HospitalChambray les ToursFrance
| | - Valérie Bridoux
- Department of Digestive SurgeryRouen University HospitalRouenFrance
| | - Lisa Corbière
- Department of Digestive SurgeryCHU Rennes PontchaillouRennesFrance
| | - Jeanne Heraud
- Department of Gynecology and ObstetricsUniversity Hospital of AngersAngers Cedex 9France
| | | | | | - Jean‐Francois Hamel
- Department of Biostatistics. La Maison de la RechercheUniversity Hospital of AngersAngers Cedex 9France
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15
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Abo-Alhassan F, Trilling B, Sage PY, Tidadini F, Girard E, Faucheron JL. Long-Term Outcomes of Surgery for Rectovaginal Fistula in 100 Consecutive Patients at a Tertiary Center. J Gastrointest Surg 2022; 27:803-806. [PMID: 36279089 DOI: 10.1007/s11605-022-05490-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/20/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Fawaz Abo-Alhassan
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France.,Department of Surgery, Dijon University Hospital, F-21000, Dijon, France
| | - Bertrand Trilling
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France.,UMR 5525, University Grenoble Alpes, CNRS, TIMC-IMAG, 38000, Grenoble, France
| | - Pierre-Yves Sage
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France
| | - Fatah Tidadini
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France
| | - Edouard Girard
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France.,UMR 5525, University Grenoble Alpes, CNRS, TIMC-IMAG, 38000, Grenoble, France
| | - Jean-Luc Faucheron
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France. .,UMR 5525, University Grenoble Alpes, CNRS, TIMC-IMAG, 38000, Grenoble, France.
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16
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Otero-Piñeiro AM, Jia X, Pedersen KE, Hull T, Lipman J, Holubar S, Steele SR, Lightner AL. Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice. J Crohns Colitis 2022; 17:396-403. [PMID: 36219575 DOI: 10.1093/ecco-jcc/jjac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Rectovaginal fistula occurs in up to 10-20% of women with Crohn's disease, significantly affecting their quality of life. We sought to determine outcomes of single and repeat operative interventions. METHODS A retrospective review of all adult patients with a Crohn's related rectovaginal fistula who underwent an operation between 1995 to 2021 was performed. Data collected included patient demographics, Crohn's related medical treatment, surgical intervention, postoperative outcomes, and fistula outcomes. RESULTS A total of 166 patients underwent 360 operations; mean age was 42.8 (+/-13.2) years. Thirty-four (20.7%) patients were current and 58 (35.4%) former smokers. The most commonly performed procedure was a local approach (n=160, 44.5%) using fibrin glue, fistulotomy/fistulectomy or seton placement, followed by a transvaginal/transanal approach (n=113, 31.4%) with an advancement flap repair (including Martius advancement flap) and episoproctotomy, a transabdominal approach (n=98, 27.2%) including proctectomy or redo anastomosis and finally gracilis muscle interposition (n=8, 2.2%). The median number of operative interventions per patient was 2 (1.0-3.0) procedures. The overall fistula healing rate per patient was 71.7% (n=119) at a median follow-up of 5.5 (1.2-9.8) years. Factors that impaired healing included former smoking (OR 0.52 95%, CI 0.31 - 0.87, p=0.014) and seton insertion (OR 0.42 95%, CI 0.21-0.83, p=0.012). CONCLUSION Over two-thirds of Crohn's related rectovaginal fistulas can achieve closure with multiple surgical interventions. Smoking and seton usage negatively impact healing rates and should be avoided.
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Xue Jia
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Karina E Pedersen
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
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17
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Zeng YX, He YH, Jiang Y, Jia F, Zhao ZT, Wang XF. Minimally invasive endoscopic repair of rectovaginal fistula. World J Gastrointest Surg 2022; 14:1049-1059. [PMID: 36185557 PMCID: PMC9521462 DOI: 10.4240/wjgs.v14.i9.1049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/30/2022] [Accepted: 09/02/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Surgical techniques for repair of rectovaginal fistula (RVF) have been continually developed, but the ideal procedure remains unclear. Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting.
AIM To review the current applications and preliminary outcomes of this technique for RVF repair, aiming to give surgeons an alternative in clinical practice.
METHODS Available articles were searched according to the search strategy. And the sample size, fistula etiology, fistula type, endoscopic repair approaches, operative time and hospital stay, follow-up period, complication and life quality assessment were selected for recording and further analysis.
RESULTS A total of 11 articles were eventually identified, involving 71 patients with RVFs who had undergone endoscopic repair. The principal causes of RVFs were surgery (n = 51, 71.8%), followed by obstetrics (n = 7, 9.8%), inflammatory bowel disease (n = 5, 7.0%), congenital (n = 3, 4.2%), trauma (n = 2, 2.8%), radiation (n = 1, 1.4%), and in two patients, the cause was unclear. Most fistulas were in a mid or low position. Several endoscopic repair methods were included, namely transanal endoscopic microsurgery, endoscopic clipping, and endoscopic stenting. Most patients underwent > 1-year follow-up, and the success rate was 40%-93%, and all cases reported successful closure. Few complications were mentioned, while postoperative quality of life assessment was only mentioned in one study.
CONCLUSION In conclusion, endoscopic repair of RVF is novel, minimally invasive and promising with acceptable preliminary effectiveness. Given its unique advantages, endoscopic repair can be an alternative technique for surgeons.
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Affiliation(s)
- Yi-Xian Zeng
- Department of Proctology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Ying-Hua He
- Department of Proctology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Yun Jiang
- Department of Proctology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Fei Jia
- Department of Proctology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Zi-Ting Zhao
- Department of Proctology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Xiao-Feng Wang
- Department of Proctology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
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18
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Transvaginal approach for rectovaginal fistula: experience from a single institution. Updates Surg 2022; 74:1861-1870. [DOI: 10.1007/s13304-022-01366-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022]
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19
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Blondeau M, Labiad C, Melka D, de Ponthaud C, Giacca M, Monsinjon M, Panis Y. Postoperative rectovaginal fistula: Can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases. Colorectal Dis 2022; 24:1000-1006. [PMID: 35332647 DOI: 10.1111/codi.16124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 12/28/2022]
Abstract
AIM Management of rectovaginal fistula (RVF) remains a challenge, especially in cases of postoperative RVF as they are often large and surrounded by inflammatory and fibrotic tissue, making local repair difficult or even impossible. In this situation, colonic pull-through delayed coloanal anastomosis (DCAA) could be an interesting option. The aim of this study was to assess the results of DCAA for RVF observed after rectal surgery. METHODS All patients who underwent DCAA for RVF were reviewed. Success was defined as a patient without stoma and without any symptoms of recurrent RVF at the end of follow-up. RESULTS From January 2010 to December 2020, 28 DCAA were performed for RVF after rectal surgery for rectal cancer (n = 21) or endometriosis (n = 7). Ten patients (36%) had at least one previous local procedure before DCAA. DCAA was associated with temporary ileostomy in 22/28 cases (79%). After a mean follow-up of 23 ± 23 (2-82) months, the success rate was 86% (24/28): three patients (11%) required a definitive stoma because of poor functional results (n = 1), chronic pelvic sepsis with anastomotic leakage (n = 1) or stoma reversal refused (n = 1). Another patient (3%) presented with recurrence of RVF, 26 months after DCAA. Although not significant, the success rate was higher in cases of DCAA with diverting stoma (20/22, 91%) than without (4/6, 67%) (p = 0.191). CONCLUSION In cases of postoperative RVF, DCAA is a safe option which can avoid definitive stoma in the great majority of the patients. Concomitant use of a temporary stoma appears to slightly increase the success rate.
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Affiliation(s)
- Marc Blondeau
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Camélia Labiad
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Dan Melka
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Charles de Ponthaud
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Massimo Giacca
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Marie Monsinjon
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
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20
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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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21
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Management of rectovaginal fistulas at high risk for failure or vaginal stenosis in women of childbearing age: an innovative concept. Arch Gynecol Obstet 2022; 306:935-936. [PMID: 35503377 DOI: 10.1007/s00404-022-06593-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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22
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Objective Perfusion Assessment in Gracilis Muscle Interposition—A Novel Software-Based Approach to Indocyanine Green Derived Near-Infrared Fluorescence in Reconstructive Surgery. Life (Basel) 2022; 12:life12020278. [PMID: 35207565 PMCID: PMC8874768 DOI: 10.3390/life12020278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Gracilis muscle interposition (GMI) is an established treatment option for complex perineal fistulas and reconstruction. The outcome is limited by complications such as necrosis, impaired wound healing and fistula persistence or recurrence. Quantifiable methods of assessing muscle flap perfusion intraoperatively are lacking. This study evaluates a novel and objective software-based assessment of indocyanine green near-infrared fluorescence (ICG-NIRF) in GMI. Methods: Intraoperative ICG-NIRF visualization data of five patients with inflammatory bowel disease (IBD) undergoing GMI for perineal fistula and reconstruction were analyzed retrospectively. A new software was utilized to generate perfusion curves for the specific regions of interest (ROIs) of each GMI by depicting the fluorescence intensity over time. Additionally, a pixel-to-pixel and perfusion zone analysis were performed. The findings were correlated with the clinical outcome. Results: Four patients underwent GMI without postoperative complications within 3 months. The novel perfusion indicators identified here (shape of the perfusion curve, maximum slope value, distribution and range) indicated adequate perfusion. In one patient, GMI failed. In this case, the perfusion indicators suggested impaired perfusion. Conclusions: We present a novel, software-based approach for ICG-NIRF perfusion assessment, identifying previously unknown objective indicators of muscle flap perfusion. Ready for intraoperative real-time use, this method has considerable potential to optimize GMI surgery in the future.
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23
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Iglay K, Bennett D, Kappelman MD, Thai S, Aldridge M, Karki C, Cook SF. A systematic review of the patient burden of Crohn’s disease-related rectovaginal and anovaginal fistulas. BMC Gastroenterol 2022; 22:36. [PMID: 35090384 PMCID: PMC8796404 DOI: 10.1186/s12876-021-02079-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 12/22/2021] [Indexed: 01/09/2023] Open
Abstract
Abstract
Background
Crohn’s disease (CD)-related rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) are rare, debilitating conditions that present a substantial disease and treatment burden for women. This systematic literature review (SLR) assessed the burden of Crohn’s-related RVF and AVF, summarizing evidence from observational studies and highlighting knowledge gaps.
Methods
This SLR identified articles in PubMed and Embase that provide data and insight into the patient experience and disease burden of Crohn’s-related RVF and AVF. Two trained reviewers used pre-specified eligibility criteria to identify studies for inclusion and evaluate risk of bias using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for observational studies.
Results
Of the 582 records identified, 316 full-text articles were assessed, and 16 studies met a priori eligibility criteria and were included. Few epidemiology studies were identified, with one study estimating the prevalence of RVF to be 2.3% in females with Crohn’s disease. Seven of 12 treatment pattern studies reported that patients had or required additional procedures before and/or after the intervention of interest, demonstrating a substantial treatment burden. Seven of 11 studies assessing clinical outcomes reported fistula healing rates between 50 and 75%, with varying estimates based on population and intervention.
Conclusions
This SLR reports the high disease and treatment burden of Crohn’s-related RVF and AVF and identifies multiple evidence gaps in this field. The literature lacks robust, generalizable data, and demonstrates a compelling need for substantial, novel research into these rare and debilitating sequelae of CD.
Registration The PROSPERO registration number for the protocol for this systematic literature review is CRD42020177732.
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24
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Söderqvist EV, Cashin PH, Graf W. Surgical treatment of rectovaginal fistula-predictors of outcome and effects on quality of life. Int J Colorectal Dis 2022; 37:1699-1707. [PMID: 35779081 PMCID: PMC9262790 DOI: 10.1007/s00384-022-04206-7] [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] [Accepted: 06/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine the results after rectovaginal fistula (RVF) repair and find predictors of outcome. Primary objective was fistula healing. Secondary outcomes were morbidity and patient health-related quality of life (HRQoL). METHOD An observational study of 55 women who underwent RVF repair including both local procedures and tissue transposition 2003-2018 was performed. Baseline patient and fistula characteristics were registered, combined with a prospective HRQoL follow-up and a general questionnaire describing fistula symptoms. RESULTS Healing rate after index surgery was 25.5% (n = 14) but the final healing rate was 67.3% (n = 37). Comparing the etiologies, traumatic fistulas (iatrogenic and obstetric) had the highest healing rates after index surgery (n = 11, 45.9%) and after repeated operations at final follow-up (n = 22, 91.7%) compared with fistulas of inflammatory fistulas (Crohn's disease, cryptoglandular infection, and anastomotic leakage) that had inferior healing rates after both index surgery (n = 7, 7.1%) and at final follow-up (n = 13, 46.4%). Fistulas of the category others (radiation damage and unknown etiology) included a small amount of patients with intermediate results at both index surgery (n = 1, 33.3%) and healing rate at last follow-up (n = 2, 66.7%). The differences were statistically significant for both index surgery (p = 0.004) and at final follow-up (p = 0.001). Unhealed patients scored lower than both healed patients and the normal population in 6/8 Rand-36 domains, but the differences were not statistically significant. CONCLUSIONS Most traumatic rectovaginal fistulas closed after repeated surgery whereas inflammatory fistulas had a poor prognosis. Low healing rates after local repairs suggest that tissue transfer might be indicated more early in the treatment process. Unhealed fistulas were associated with reduced quality of life. Trial registration Clinicaltrials.gov No. NCT05006586.
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Affiliation(s)
- Erik V. Söderqvist
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Peter H. Cashin
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Wilhelm Graf
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
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Thayalan K, Krause H, Goh J. A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia. Aust N Z J Obstet Gynaecol 2021; 62:263-267. [PMID: 34611895 DOI: 10.1111/ajo.13444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings. AIMS This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long-term outcomes. MATERIALS AND METHODS A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14-year period by one operative group. RESULTS A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n = 32). Obstetric cause was implicated in 26.8% (n = 11) and other causes include 26.8% (n = 11) from vaginal and abdominal surgery, 14.6% (n = 6) from perianal abscess, 7.32% (n = 3) as complications of Crohn's disease and 2.44% (n = 1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n = 33). Post-operative symptoms were limited to flatal incontinence in 4.88% (n = 2), faecal incontinence in 2.44% (n = 1), and persistent perineal pain in 7.32% (n = 3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique. CONCLUSIONS This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post-operative symptoms.
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Affiliation(s)
- Krishanthy Thayalan
- Obstetrics and Gynaecology Trainee, Mater Mothers' Hospital, South Brisbane, QLD, Australia
| | - Hannah Krause
- Greenslopes Private Hospital, Brisbane, QLD, Australia.,Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Judith Goh
- Greenslopes Private Hospital, Brisbane, QLD, Australia.,Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia.,Griffith University, Gold Coast, QLD, Australia
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Miranda Varella Pereira G, Oliveira Brito LG, Slongo H, Carvalho de Araújo C, Benedito de Castro E, Teatin Juliato CR. Rectovaginal Fistula in Women With Pessary for Pelvic Organ Prolapse: A Case Series and Literature Review. J Low Genit Tract Dis 2021; 25:318-325. [PMID: 34542087 DOI: 10.1097/lgt.0000000000000629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In this study, we present a series of 2 cases of rectovaginal fistula (RVF) due to the use of a ring-type pessary in the conservative treatment of pelvic organ prolapse and a literature review on the management of RVF related to the use of pessaries. METHODS Two patients were selected from the medical records of the urogynecology service, and their demographic and clinical data were retrieved. An updated literature review was included presenting cases of RVF induced by or after use of a pessary. RESULTS Both patients evolved with removal of the pessary and correction of the fistula. The surgical procedures of choice were Le Fort Colpocleisis and posterior colporraphy without major complications. In the literature review, we selected 17 studies with a total of 23 cases reporting RVFs induced or followed by the use of pessaries. CONCLUSIONS Although the pessary is commonly indicated for the conservative treatment of pelvic organ prolapse, this device is not exempt from generating complications.
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Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach. Tech Coloproctol 2021; 25:1143-1149. [PMID: 34436729 DOI: 10.1007/s10151-021-02506-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 08/11/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. METHODS A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure. RESULTS Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). CONCLUSIONS The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.
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28
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Frontali A, Rottoli M, Chierici A, Poggioli G, Panis Y. Rectovaginal fistula: Risk factors for failure after graciloplasty-A bicentric retrospective European study of 61 patients. Colorectal Dis 2021; 23:2113-2118. [PMID: 33851506 DOI: 10.1111/codi.15673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/27/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022]
Abstract
AIM Graciloplasty (GP) is indicated in the case of recurrent rectovaginal fistula (RVF) after failure of previous local treatments. The aim of this study was to assess risk factors for GP failure performed for RVF. METHODS This is a retrospective study based on a prospective database on GP, coming from two expert centres. RESULTS Sixty-one patients undergoing a first GP for RVF (n = 51) or ileal-vaginal fistula after ileal pouch anal anastomosis (n = 10), with a mean age of 42 years (range 24-72), were analysed. After a mean follow-up of 56 ± 48 months (range 1-183), failure of GP (considered as persistent stoma and/or clinical RVF) was noted in 24/61 patients (39%). The failure rate was 43% (13/30) in the case of Crohn's disease, 38% (3/8) in the case of ileal-vaginal fistula after ileal pouch anal anastomosis for ulcerative colitis, 30% (3/10) in the case of obstetrical RVF, 33% (1/3) in the case of post radiotherapy RVF and 40% (4/10) for other causes (not significant). Two risk factors for failure of GP were found on univariate analysis: (1) absence of postoperative antibiotic prophylaxis-only 3/24 (13%) patients with failure of GP received postoperative antibiotic prophylaxis versus 18/37 (49%) patients with success of GP (P = 0.0053); (2) postoperative perineal infection-11/23 (48%) with failure of GP developed postoperative perineal infection versus only 4/37 (10%) patients with success of GP (P = 0.0021). CONCLUSIONS Failure of GP for RVF is observed in approximately 40% of the patients whatever the aetiology of the fistula. A reduced failure rate was associated with systematic postoperative antibiotic prophylaxis.
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Affiliation(s)
- Alice Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Matteo Rottoli
- Department of Digestive Surgery, Medical and Surgical Sciences, Ospedale Policlinico di Sant'Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Andrea Chierici
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Gilberto Poggioli
- Department of Digestive Surgery, Medical and Surgical Sciences, Ospedale Policlinico di Sant'Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
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29
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Hauch A, McKee RM, Li WY, Crowley JS, Ramamoorthy S, Dobke M. Rectovaginal Fistula Repair 1 Year Later: Lessons Learned. Ann Plast Surg 2021; 87:187-193. [PMID: 33346534 DOI: 10.1097/sap.0000000000002626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Rectovaginal (RV) fistulas are notoriously difficult to treat. Various methods for repair exist, and refinements in techniques can lead to "successful" outcomes. Review of the literature demonstrates that outcomes studies are scarce and mostly limited to comments on closure rate. We have experienced "success" in our own series with 100% closure rate, regardless of fistula etiology and comorbidities (radiation, inflammation, etc). However, long-term outcomes, including various complications and quality of life changes, have previously been underreported. METHODS Critical analysis of various outcomes after fistula repair in 14 patients was performed. Patients were surveyed and interviewed with regard to problems before and after fistula repair to obtain objective data focusing on their experience and outcomes. Conclusions are based on physician assessment and patient surveys 1 year after fistula repair and at least 6 months after ostomy reversal and are discussed within the context of data from the literature. RESULTS Overall satisfaction rate after repairs was high. All patients would undergo attempt at repair again regardless of complications or functional changes (not present before repair). After repair, sexual dyspareunia affected 5 patients (36%); however, most abstained from sexual activity when their RV fistula became apparent. No patient admitted to dyspareunia before the development of their RV fistula. Anal sphincter and defecation function, as well as stool continence, were judged by surgeons and patients uniformly as adequate. However, 3 patients (21%) complained of intermittent problems with urination. A new/different type of pain affected 2 of 4 patients with Crohn disease. One of these patients subsequently developed a new postsphincteric RV fistula. Another patient noted new intermittent vaginal discharge after ostomy reversal, and magnetic resonance imaging suggested a residual fistula, which was not seen on follow-up sigmoidoscopy and "Blue Dye Test." CONCLUSIONS We previously reported on algorithms for repair and refinements in techniques for "successful" repair of RV fistulas with zero recurrence rate. Long-term follow-up indicates, however, that although the overall satisfaction rate after surgery is high, true "success," defined as permanent fistula closure, is not necessarily problem free. Long-term morbidity and the management of other unique sequelae and problems are underreported.
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Affiliation(s)
- Adam Hauch
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
| | - Ryan M McKee
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
| | - Wai-Yee Li
- Division of Plastic and Reconstructive Surgery, City of Hope Medical Center, Duarte
| | - Jiwon S Crowley
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
| | - Sonia Ramamoorthy
- Division of Colorectal Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Marek Dobke
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
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Mudrov AA, Omarova MM, Fomenko OY, Blagodarnyi LA, Kostarev IV, Sokolova YA, Serebriy AB, Nagudov MA, Titov AY. [Surgical treatment of rectovaginal fistula with vaginal rectangular flap]. Khirurgiia (Mosk) 2021:5-11. [PMID: 34270187 DOI: 10.17116/hirurgia20210715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the early and long-term outcomes of rectovaginal fistula closure with vaginal rectangular flap. MATERIAL AND METHODS There were 61 patients with rectovaginal fistula for the period 2012-2020. Median age of patients was 35 years [31; 48]. Postpartum fictula was observed in 27 (44.2%) cases, postoperative - 10 (16.4%) patients, inflammatory - 15 (24.6%) patients, other causes - 9 (14.8%) patients. Disease recurrence occurred in 29 (47.5%) patients. RESULTS Median follow-up period was 36.2 [6; 64] months. Postoperative recurrence of rectovaginal fistula occurred in 19 (31.1%) patients. Length of hospital-stay ranged from 3 to 36 days (median 14 [12; 16]). We analyzed the relationship between the risk of disease recurrence and various factors, including etiology of rectovaginal fistula, localization and diameter of the fistula, intraoperative cautery, previous surgeries and preventive colostomy. CONCLUSION Vaginal rectangular flap is effective for rectovaginal fistula. Multivariate analysis confirmed two significant risk factors of postoperative recurrence: diameter of fistula over 5 mm and its localization in the rectum above the upper border of surgical anal canal (more than 7 mm from the dentate line).
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Affiliation(s)
- A A Mudrov
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia.,Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - M M Omarova
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - O Yu Fomenko
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia
| | - L A Blagodarnyi
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - I V Kostarev
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia.,Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - Yu A Sokolova
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia
| | - A B Serebriy
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia
| | - M A Nagudov
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia
| | - A Yu Titov
- Ryzhikh National Medical Research Centre for Coloproctology, Moscow, Russia
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Studniarek A, Abcarian A, Pan J, Wang H, Gantt G, Abcarian H. What is the best method of rectovaginal fistula repair? A 25-year single-center experience. Tech Coloproctol 2021; 25:1037-1044. [PMID: 34101044 DOI: 10.1007/s10151-021-02475-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula. METHODS Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6 months. RESULTS One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6 months (range 0-203 months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes. CONCLUSIONS Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.
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Affiliation(s)
- A Studniarek
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA.
| | - A Abcarian
- Cook County Health and Hospitals Systems, Chicago, IL, USA
| | - J Pan
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA
| | - H Wang
- Division of Epidemiology and Biostatistics, and Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago, IL, USA
| | - G Gantt
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA
| | - H Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA.,Cook County Health and Hospitals Systems, Chicago, IL, USA
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Abstract
INTRODUCTION Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics. METHODS A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques. RESULTS Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles. CONCLUSIONS Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.
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Incidence and Treatment Outcomes of Rectovaginal Fistula After Rectal Cancer Resection. Female Pelvic Med Reconstr Surg 2021; 28:115-120. [PMID: 35084372 DOI: 10.1097/spv.0000000000001063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rectovaginal fistulas, outcomes of various surgical repair and predictive factors of healing success. A retrospective cohort study of 40 cases. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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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Botulinum Toxin Injection for the Treatment of the Recurrent Rectovaginal Fistulas in Combination with Surgical Repair. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Successful laparoscopy-assisted repair of a rectovaginal fistula after low anterior resection for rectal cancer: a report of two cases. Surg Case Rep 2021; 7:68. [PMID: 33725206 PMCID: PMC7966635 DOI: 10.1186/s40792-021-01150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/03/2021] [Indexed: 11/17/2022] Open
Abstract
Background Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is troublesome and refractory. Although various surgical procedures have been previously described, no definitive procedure has shown a satisfactory outcome. We present two consecutive Japanese patients who underwent successful surgery for an RVF after low anterior resection. Case presentation The patients were two women (61-year-old and a 64-year-old). They were admitted to our hospital with a chief complaint of fecal discharge from the vagina after low anterior resection using the double-stapling technique for rectal cancer. They were diagnosed with RVF. Local surgical procedures, including diverting ileostomy, were unsuccessful in previous hospitals. Therefore, we performed laparoscopy-assisted repair of the RVF. In both patients, laparoscopically robust pelvic adhesions were dissected, and the sigmoid colon was transected at just oral side to the RVF. Thereafter, in combination with a perineal approach, the rectum, along with a previous anastomosis and fistula, were completely removed. Surgeries were completed after vaginal repair, redo coloanal anastomosis, and interposition of the dissected connective tissue. In both patients, the postoperative courses were uneventful. They complained of neither recurrence of any RVF nor fecal incontinence 1 year and 10 months after diverting stoma closure. Conclusions A laparoscopy-assisted procedure with reanastomosis and interposition of the perineal connective tissue can be an effective treatment for RVF after low anterior resection for rectal cancer.
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Grott M, Rickert A, Hetjens S, Kienle P. Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period. Int J Colorectal Dis 2021; 36:569-580. [PMID: 33386945 DOI: 10.1007/s00384-020-03825-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Gracilis muscle transposition (GMT) is an established surgical technique in the treatment of anorectal fistulas and fistulas to the vagina and the urinary system when previous closure options have failed. There is little evidence on the success rate of this procedure in the long term. METHODS This is a follow-up study on all patients undergoing GMT over a 10-year period at a tertiary referral center for complex fistulas. Postoperative function and quality of life were evaluated by standardized questionnaires (Wexner score, Fecal Incontinence Quality of Life Score (FIQL), SF-12 and a brief questionnaire designed for this study). Sexual function was evaluated by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function. RESULTS Forty-seven gracilis muscle transpositions (GMT) in 46 patients were performed. Most treated patients had (neo-)-rectovaginal fistulas (n = 29). An overall fistula closure was achieved in 34 of 46 patients (74%): in 25 cases primarily by GMT (53%) and in nine patients with persistent or recurrent fistula by additional surgical procedures. A clinically apparent relapse occurred on average 276 days (median: 180 days) after GMT (mean follow-up 73.4 months). CONCLUSION GMT in our hands has a primary closure rate of 53%, and after further procedures, this rises to 74%. Fecal continence is impaired in patients having undergone GMT. The overall quality of life in patients after GMT is only slightly impaired, and sexual function is severely impaired in female patients.
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Affiliation(s)
- M Grott
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University, Röntgenstraße 1, 69126, Heidelberg, Germany
| | - A Rickert
- Department of Surgery, St. Josefskrankenhaus Heidelberg, Akademisches Lehrkrankenhaus der Medizinischen Fakultät Mannheim der Universität Heidelberg, Landhausstraße 25, 69115, Heidelberg, Germany
| | - S Hetjens
- Department for Medical Statistics and Biomathematics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Akademisches Lehrkrankenhaus der Universität Heidelberg, Heidelberg University, Bassermannstraße 1, 68165, Mannheim, Germany.
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Perioperative Outcomes of Rectovaginal Fistula Repair Based on Surgical Approach: A National Contemporary Analysis. Female Pelvic Med Reconstr Surg 2021; 27:e342-e347. [PMID: 33181517 DOI: 10.1097/spv.0000000000000924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare the perioperative outcomes of transvaginal/perineal and abdominal approaches to rectovaginal fistula (RVF) repair using a national multicenter cohort. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify women undergoing RVF repair from 2005 to 2016. Emergent cases and those with concomitant bowel diversion were excluded. Baseline patient demographics, procedure characteristics, 30-day postoperative complications, return to the operating room, and readmission were evaluated. Baseline characteristics were compared across surgical approach. Multivariable logistic regression models identified preoperative characteristics independently associated with postoperative complications. RESULTS A total of 2288 women underwent RVF repair: 1560 (68.2%) via transvaginal/perineal approach and 728 (31.8%) via abdominal approach. Patients undergoing transvaginal/perineal repair were significantly younger (median age, 46 years vs 63 years), with lower American Society for Anesthesiologist (ASA) scores, and less frequency of diabetes mellitus, dyspnea, severe chronic obstructive pulmonary disease, hypertension, disseminated cancer, and bleeding disorders (all P < 0.01). Those undergoing abdominal repair had higher rates of major complications (25.8% vs 8.7%), minor complications (13.5% vs 6.3%), and readmission (13.2% vs 7.8%). On multivariable analyses, ASA Class 3/4, disseminated cancer, and hematocrit <30% (P < 0.01) were associated with major complications in both groups. CONCLUSIONS Patients undergoing RVF repair via abdominal approach were older with more comorbidities and had higher postoperative complications rates, likely secondary to underlying differences in the treated populations. Irrespective of surgical approach, ASA class, disseminated cancer, and preoperative anemia were associated with higher postoperative morbidity. This may enhance preoperative counseling and allow for careful patient selection.
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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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Fu W, Yi S, An M, Tang Y, Tang L, Wang Y, Yuan Y, Zhou Q, Hu Y, Wen Y. Effect of diverting stoma for rectovaginal fistula: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23202. [PMID: 33285694 PMCID: PMC7717780 DOI: 10.1097/md.0000000000023202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/17/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Rectovaginal fistula (RVF) is a pathologic channel between the anterior wall of the rectum and the posterior wall of the vagina, is rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, rectal surgery or caused by chronic inflammatory bowel disease. Once the disease will seriously affect the patient's quality of life, and generally not self-healing, most require surgical intervention. At present, diverting stoma is mainly used in patients with severe RVF or complicated RVF or patients with Crohn disease. Due to the lack of large sample, linical studies, its clinical effectiveness is still controversial. The purpose of this systematic review is to evaluate the efficacy of diverting stoma in the treatment of diverting stoma. METHODS EMBASE, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), and Chinese VIP Information will be searched systematically by 2 reviewers from the inception until October 2020. The original study that randomized controlled trials (RCTs), clinical controlled trials (CCTs), nonrandomized control trials (NCTs), and retrospective trials (RTs) of diverting stoma for RVF will be selected. In addition, similar searches will be conducted for the reference lists, researches in progress, and the citation lists of identified publications. Study selection, data extraction, and assessment of the quality will be performed independently by 2 reviewers who have been trained prior to data extraction. A meta-analysis will be conduct if the quantity and quality of the original studies included are satisfactory; otherwise, a descriptive analysis will be conducted. Review Manager 5.4 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) will be using for data synthesis and assessment the risk of bias according by Cochrane Handbook. RESULT This study will provide a comprehensive review of current evidence for the treatment of diverting stoma on RVF. CONCLUSION The conclusion of this study will provide a judging basis that whether the treatment of RVF with diverting stoma is effective. INPLASY REGISTRATION NUMBER INPLASY2020090070.
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Affiliation(s)
- Wenqiang Fu
- Jiangxi University of Traditional Chinese Medicine
| | - Sibin Yi
- Jiangxi University of Traditional Chinese Medicine
| | - Mingwei An
- The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, P.R. China
| | - Yong Tang
- The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, P.R. China
| | - Luwei Tang
- Jiangxi University of Traditional Chinese Medicine
| | - Yanru Wang
- Jiangxi University of Traditional Chinese Medicine
| | - Yishun Yuan
- Jiangxi University of Traditional Chinese Medicine
| | - Qiong Zhou
- Jiangxi University of Traditional Chinese Medicine
| | - Yanfang Hu
- Jiangxi University of Traditional Chinese Medicine
| | - Yiqi Wen
- Jiangxi University of Traditional Chinese Medicine
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Microbiome diversity predicts surgical success in patients with rectovaginal fistula. Int Urogynecol J 2020; 32:2491-2501. [PMID: 33175227 DOI: 10.1007/s00192-020-04580-2] [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: 06/25/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Growing literature details the critical importance of the microbiome in the modulation of human health and disease including both the gastrointestinal and genitourinary systems. Rectovaginal fistulae (RVF) are notoriously difficult to manage, many requiring multiple attempts at repair before correction is achieved. RVF involves two distinct microbiome communities whose characteristics and potential interplay have not been previously characterized and may influence surgical success. METHODS In this pilot study, rectal and vaginal samples were collected from 14 patients with RVF. Samples were collected preoperatively, immediately following surgery, 6-8 weeks postoperatively and at the time of any fistula recurrence. Amplification of the 16S rDNA V3-V5 gene region was done to identify microbiota. Data were summarized using both α-diversity to describe species richness and evenness and β-diversity to characterize the shared variation between communities. Differential abundance analysis was performed to identify microbial taxa associated with recurrence. RESULTS The rectal and vaginal microbiome in patients undergoing successful fistula repair was different than in those with recurrence (β-diversity, p = 0.005 and 0.018, respectively) and was characterized by higher species diversity (α-diversity, p = 0.07 and p = 0.006, respectively). Thirty-one taxa were enriched in patients undergoing successful repair to include Bacteroidetes, Alistipes and Rikenellaceae as well as Firmicutes, Subdoligranulum, Ruminococcaceae UCG-010 and NK4A214 group. CONCLUSIONS Microbiome characteristics associated with fistula recurrence have been identified. The association of higher vaginal diversity with a favorable outcome has not been previously described. Expansion of this pilot project is needed to confirm findings. Taxa associated with successful repair could be targeted for subsequent therapeutic intervention.
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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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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Post surgical rectovaginal fistula: who really benefits from stoma diversion? Updates Surg 2020; 73:165-171. [PMID: 32449033 DOI: 10.1007/s13304-020-00810-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022]
Abstract
To analyze the role of stoma diversion and timing of stoma maintenance in the healing of post-surgical Recto Vaginal Fistulae (psRVF). A retrospective analysis of a prospectively maintained registry. All patients with a psRVF diagnosed at IRCCS Sacro Cuore-Don Calabria Hospital of Negrar di Valpolicella from January 2002 to December 2016 were analyzed. The baseline treatment was a fecal diversion. Patients were divided into two groups according to healing time: < 6 months (Group 1) or > 6 months (Group 2). 2043 women underwent rectal resections in the study period. We recorded 37 patients with psRVF (1.8%). Nineteen women (51.3%) healed (Group 1) within 6 months. The median time of psRVF recovery in group 1 was 99.7 days. Concomitant local treatment of the fistula did not influence the healing rate (p 0.8). Colostomies were significantly higher in group 1 (p 0.003). The size of the psRVF influenced the success rate of fistula healing with loop stoma (p 0.07). A multivariate analysis the presence of fever and pelvic abscess (pelvis sepsis) were significantly associated with diversion failure (p 0.035). A step-up approach with the maintenance of loop stoma at least for six months for all patients with psRVF could be changed. Patients with larger fistula and pelvic sepsis at index procedure should be addressed earlier to a specific second-level treatment.
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Kersting S, Athanasiadis CJ, Jung KP, Berg E. Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas. Colorectal Dis 2019; 21:1429-1437. [PMID: 31245912 DOI: 10.1111/codi.14741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/10/2019] [Indexed: 12/12/2022]
Abstract
AIM Successful treatment of complex rectovaginal fistulas (RVFs) continues to be a surgical challenge. Interposition of well-perfused tissue, such as gracilis muscle, is one treatment option. The aim of this study was to investigate the operative results, sexual function and quality of life after gracilis muscle transposition (GMT) in the authors' own group of patients. METHOD The study included 19 women with RVF (mean age 48 years). The postoperative outcome was evaluated by a questionnaire and clinical examination. RESULTS The postoperative follow-up period was 7 months to 3.5 years (mean 23 months). GMT led to primary healing of RVF in 10 (53%) patients. Recurrences were observed in nine (47%) patients with RVF, in four (44%) of whom healing was achieved as a result of further interventions. Following GMT, two complications (abscess formation) requiring revision occurred. Although 42% of the patients reported certain limitations following muscle removal, GMT is a procedure that has a positive influence on the healing rate (74%), quality of life, continence and patient satisfaction. CONCLUSION GMT is a procedure that allows healing in the majority of patients with RVFs, and it should be considered especially in patients with recurrent fistulas, in whom a correlation between decreasing healing rates and the number of previous operations has been demonstrated.
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Affiliation(s)
- S Kersting
- Department of General Surgery, Katharinen-Hospital Unna, Unna, Germany
| | - C-J Athanasiadis
- Department of Coloproctology, Prosper-Hospital Recklinghausen, Recklinghausen, Germany
| | - K-P Jung
- Department of Coloproctology, Prosper-Hospital Recklinghausen, Recklinghausen, Germany
| | - E Berg
- Department of Coloproctology, Prosper-Hospital Recklinghausen, Recklinghausen, Germany
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Ryoo SB, Oh HK, Ha HK, Han EC, Kwon YH, Song I, Moon SH, Choe EK, Park KJ. Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences. Ann Surg Treat Res 2019; 97:149-156. [PMID: 31508396 PMCID: PMC6722290 DOI: 10.4174/astr.2019.97.3.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/04/2019] [Accepted: 07/19/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures. Methods Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted. Results The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058). Conclusion Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.
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Affiliation(s)
- Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heung-Kwon Oh
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heon-Kyun Ha
- Division of Colorectal Surgery, Department of Surgery, Myongji Hospital, Goyang, Korea
| | - Eon Chul Han
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Yoon-Hye Kwon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Song
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hui Moon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Choe
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Kyu Joo Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Woo IT, Park JS, Choi GS, Park SY, Kim HJ, Lee HJ. Optimal strategies of rectovaginal fistula after rectal cancer surgery. Ann Surg Treat Res 2019; 97:142-148. [PMID: 31508395 PMCID: PMC6722289 DOI: 10.4174/astr.2019.97.3.142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is a type of anastomotic leakage. The aim of this study was to find out the difference of leakage, according to RVF presence or absence and to identify the optimal strategy for RVF. Methods All female patients who underwent low anterior resection with colorectal anastomosis or coloanal anastomosis (n = 950) were retrospectively analyzed. Patients' demographics and perioperative outcomes were analyzed between the RVF group and leakage without the RVF (nRVF) group. We performed 4 types of procedures—primary repair, diverting stoma, redo coloanal anastomosis (RCA), and conservative procedure—to treat RVF, and calculated the success rates of each type of procedure. Results The leakage occurred in 47 patients (4.9%). Among them, 18 patients (1.9%) underwent an RVF and 29 (3.0%) underwent nRVF. The RVF group received more perioperative radiotherapy (27.8% vs. 3.4%, P < 0.015) and occurred late onset after surgery (181.3 ± 176.4 days vs. 23.2 ± 53.6 days, P < 0.001) more than did the nRVF group. In multivariate analysis for the risk factor of the RVF group, the RVF group was statistically associated with less than 5 cm of anastomosis more than was the no-leakage group. A total of 35 procedures were performed in 18 patients with RVF for treatment. RCA showed satisfactory success rates (85.7%, n = 6) and, primary repair (transanal or transvaginal) showed acceptable success rate (33.3%, n = 8). Conclusion After low anterior resection for rectal cancer, RVF was strongly correlated with a lower level of primary tumor location. Among the patients who underwent leakages, receipt of perioperative radiotherapy was significantly high in the RVF group than that of the nRVF group. Additionally, this study suggests that RCA might be considered another successful treatment strategy for RVF.
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Affiliation(s)
- In Teak Woo
- Department of General Surgery, Soonchunhyang University Gumi Hospital, Gumi, Korea.,Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Fu J, Liang Z, Zhu Y, Cui L, Chen W. Surgical repair of rectovaginal fistulas: predictors of fistula closure. Int Urogynecol J 2019; 30:1659-1665. [PMID: 31468097 PMCID: PMC6795627 DOI: 10.1007/s00192-019-04082-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
Introduction and hypothesis We report the clinical outcome of surgical repair for rectovaginal fistula (RVF) carried out by one operative team. We also investigate the predictive factors for fistula healing. Methods A retrospective cohort of 63 patients underwent local surgical repair of RVF during January 2008 and December 2017 by one operative group. The clinical features of the patients were reviewed. The association between fistula closure and diverse clinical parameters, including operative method, fistula location, prior repair, and diverting stoma, was analyzed. Results Sixty-three consecutive patients underwent 80 local surgical repairs by our surgical team. Forty-five patients eventually healed after an average of 1.22 procedures. The overall success rate per procedure was 71.2%, whereas the closure rate of the first operation was 55.5% (n = 35). The etiology of the fistula did not impact on the success rate of surgical repair. The history of prior repair predicted a lower success rate on both overall procedure (RR = 0.59, 95% CI 0.41–0.85, p = 0.008) and the first repair in our institution (RR = 0.50, 95% CI 0.31–0.80, p = 0.003). There was no difference in closure rate between the stoma group and the non-stoma group. Nevertheless, among the 15 patients who underwent more than one operation in our center, a diverting stoma seemed to be necessary (10 patients healed in the stoma group and none of the patients healed in the non-stoma group, p = 0.02). Conclusions History of prior surgical repair is a risk factor for failure. Diverting stoma did not increase the overall closure rate, but it seemed to be necessary for patients in whom the first operation failed.
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Affiliation(s)
- Jihong Fu
- Department of Colorectal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Zhonglin Liang
- Department of Colorectal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Yilian Zhu
- Department of Colorectal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Wei Chen
- Department of Colorectal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China.
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