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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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Hadi THS, Hardianto G, Kurniawati EM, Parathon H, Putra MDA, Wahyuningtyas R, Rahmatyah R. Martius fat pad flap procedure for management of obstetric rectovaginal fistula: A case report. Case Rep Womens Health 2023; 39:e00547. [PMID: 37781448 PMCID: PMC10539858 DOI: 10.1016/j.crwh.2023.e00547] [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: 08/08/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023] Open
Abstract
Obstetric trauma is a risk factor for rectovaginal fistula, and it is a challenge for both patients and surgeons. In this case report, we describe the surgical technique of the Martius fat pad flap for repair of a rectovaginal fistula. The patient was a 30-year-old woman, para 1, with a previous spontaneous vertex vaginal delivery of a 2500-g male baby at 37 weeks of gestation. There was a history of arrest of descent, and the patient had a third-degree perineal laceration that was repaired in the operating room. Twelve days after delivery, the patient complained about fecal vaginal discharge and was diagnosed with a rectovaginal fistula. Physical examination revealed a rectovaginal fistula with a 2 cm diameter and located 1 cm from the hymen. The tone of the external anal sphincter was within normal limits, which was confirmed with transperineal ultrasound scan. The repair was done 3 months after the previous repair in order to allow for the restoration of tissue integrity and the complete healing of the previous wound. The rectovaginal fistula was repaired with a Martius fat pad flap in a transperineal approach. After 60 days of follow-up, the wound involving the labia majora and the fistula were healed completely.
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Affiliation(s)
- Tri Hastono Setyo Hadi
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Gatut Hardianto
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Eighty Mardiyan Kurniawati
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Harry Parathon
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - M. Dimas Abdi Putra
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Riska Wahyuningtyas
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Rizqy Rahmatyah
- Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Drusany Starič K, Distefano REC, Campo G, Norčič G. Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned. Front Surg 2023; 10:1260355. [PMID: 37693638 PMCID: PMC10483572 DOI: 10.3389/fsurg.2023.1260355] [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: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
Background Rectovaginal fistulas following an obstetric anal sphincter injury's repair are rare in developed country and their management could be challenging, particularly in cases of delayed repair. This study emphasizes the importance of accurately diagnosing and promptly repairing such fistulas for optimal patient well-being. Case A 30-year-old patient presented with gas incontinence and a greenish discharge from the vagina, 6 months after delivering her baby. Examination revealed a small pinhole lesion on the posterior vaginal wall, and an endoanal ultrasound confirmed the presence of a rectovaginal fistula. Surgical repair was delayed for 9 months due to the patient's breastfeeding. The fistula was eventually repaired through a transrectal approach, with excision of the fistulous tract and closure of both the rectum and vagina. A laparoscopic protective ileostomy was also performed due to the delayed repair. However, a recurrence of the fistula was detected 8 months later, requiring a second repair. The patient underwent physiotherapy for the anal sphincter and achieved optimal sphincter function. After 6 months, the ileostomy was successfully closed, and the patient remained continent. Conclusions This case highlights the importance of early recognition and prompt repair of rectovaginal fistulas following obstetric anal sphincter injury. Delayed repairs pose greater challenges and increase the risk of recurrence. Individualized surgical approaches, skilled pelvic floor repair, and a multidisciplinary approach are crucial for successful outcomes. This case underscores the need for careful planning and consideration of patient characteristics in the management of rectovaginal fistulas, aiming to achieve optimal outcomes and patient well-being.
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Affiliation(s)
- Kristina Drusany Starič
- Division of Gynaecology and Obstetrics, Department of Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Rosario Emanuele Carlo Distefano
- Division of General Surgery and Medical Surgical Specialties, Department of Obstetrical and Gynecological Pathology, University of Catania, Catania, Italy
| | - Giorgia Campo
- Division of General Surgery and Medical Surgical Specialties, Department of Obstetrical and Gynecological Pathology, University of Catania, Catania, Italy
| | - Gregor Norčič
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Singh V, Pandey M, Yadav J, Akhtar MR, Singh MK. Two Decadal Experiences in Managing Combined Obstetric Vesicovaginal and Rectovaginal Fistulas: A Study From Northern Indian Tertiary Hospital. Cureus 2023; 15:e40198. [PMID: 37435248 PMCID: PMC10330953 DOI: 10.7759/cureus.40198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION A retrospective study of 28 patients with obstetric combined vesicovaginal fistula (VVF) and rectovaginal fistula (RVF) treated at our centre throughout the last two decades (2002 to 2022) has been conducted. MATERIAL AND METHOD In 12 patients, a preoperative diverting colostomy was performed. Six patients had single-stage surgery (both VVF and RVF repair in the same operation) of which two cases required transabdominal repair and four required transvaginal repair. RESULT All single-stage repairs (n=6) were successful in curing urine and faecal incontinence. In 22 patients, VVF was corrected initially via the transvaginal method with Martius flap interposition, followed by RVF repair three months later. In 2/22 patients, there was a leak after RVF repair; therefore, proximal diverting colostomy was performed, and RVF repair was repeated after six months. CONCLUSION All cases had effective VVF and RVF repairs, and both urine and faecal incontinence were completely cured. This study suggests the collaborative engagement of a urologist and a surgical gastroenterologist results in an advantageous outcome for the surgical treatment of these intricate obstetric fistulas.
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Affiliation(s)
| | - Mohit Pandey
- Radio Diagnosis, T. S. Misra Medical College & Hospital, Lucknow, IND
| | | | | | - Mukul K Singh
- Urology, King George's Medical University, Lucknow, IND
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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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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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Lussiez A, Nardos R, Lowry A. Rectovaginal Fistula Management in Low-Resource Settings. Clin Colon Rectal Surg 2022; 35:390-395. [PMID: 36111077 PMCID: PMC9470294 DOI: 10.1055/s-0042-1746187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rahel Nardos
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ann Lowry
- Division of Colon and Rectal Surgery, University of Minnesota, Bloomington, Minnesota
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