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Yuan Y, Li S, Li F, Zhou Y, Qiang S, Che K, Wang K, Yang K, Li Q. Modified Internal Pudendal Artery Perforator Flap Interposition for Rectovaginal Fistula. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:699-705. [PMID: 38373234 DOI: 10.1097/spv.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
IMPORTANCE Rectovaginal fistula (RVF) is a challenging condition associated with recurrences and significant functional impairment. OBJECTIVES The internal pudendal artery perforator (IPAP) flap has become a viable option for reconstructing the vagina and perineal regions. This study aims to introduce a modified technique of IPAP flap interposition and evaluate its postoperative outcomes in the treatment of low RVF. STUDY DESIGN Sixteen patients with RVF who underwent modified IPAP flap interposition between 2016 and 2021 were retrospectively enrolled. Recurrence rate, the satisfaction of vulvar appearance (Visual Analog Scale), and quality of sexual life (Female Sexual Function Index score) were followed up and analyzed. RESULTS All patients presented with low fistula with a mean diameter of 8.3 mm. The mean width and length of the IPAP flaps were 3.8 and 6.2 cm, respectively. The mean follow-up period was 14.1 months. All patients achieved successful healing without recurrence. High satisfaction was reported for the cosmetic effect of the vulva with a mean Visual Analog Scale score of 8.4. The proportion of female sexual disorder exhibited a statistically significant reduction, decreasing from 100% preoperatively to 38% after surgery ( P < 0.05). CONCLUSIONS The modified IPAP flap interposition is a reliable and safe option for repairing low RVF, with high success rates and minimal donor site morbidity. Moreover, this procedure provides a suitable volume flap and preserves the vaginal physiological environment, which benefits postoperative sexual function.
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Affiliation(s)
- Ye Yuan
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Senkai Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengyong Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhou
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuai Qiang
- Plastic Surgery Department, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kexin Che
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keke Wang
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Yang
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Li
- From the Gynecological Plastic Surgery Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Williams PJ, St John S, Kazazian K, Okrainec AE, Chadi SA. Low anterior resection with natural orifice specimen extraction performed with the HUGO robotic assisted surgery system-a video vignette. Colorectal Dis 2024; 26:1467-1468. [PMID: 38706088 DOI: 10.1111/codi.16995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 03/30/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Phillip J Williams
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shabier St John
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karineh Kazazian
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Allan E Okrainec
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sami A Chadi
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery and Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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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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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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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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Franco I, Viswanathan AN. Radiation oncology management of stage III and IVA cervical carcinoma. Int J Gynecol Cancer 2022; 32:231-238. [PMID: 35256408 PMCID: PMC9899098 DOI: 10.1136/ijgc-2021-002491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/21/2021] [Indexed: 02/06/2023] Open
Abstract
Worldwide, stage III-IVA carcinomas of the uterine cervix comprise a significant proportion of cases at presentation, and have a higher rate of recurrence and worse overall survival. This review will discuss the epidemiology, prevention strategies, clinical presentation, and treatment recommendations for stage III-IVA cervical cancer. The focus will be on the role of radiation therapy, concurrent chemoradiotherapy, and brachytherapy, including the potential benefits and anticipated toxicities. The unique challenges and considerations of fistula formation and approaches to management will be highlighted, and follow-up care and future directions discussed. As low and middle income countries bear the highest burden of advanced stage carcinoma of the uterine cervix, this review will address the unique needs of global communities.
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Affiliation(s)
- Idalid Franco
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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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: 5] [Impact Index Per Article: 2.5] [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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Rektovaginale Fisteln. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00567-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Bensardi FZ, Kabura S, Layla E, El Bakouri A, Bouali M, El Hattabi K, Fadil A. Bartholin's gland abscess a rare cause of rectovaginal fistula: A case report and literature review. Int J Surg Case Rep 2021; 86:106344. [PMID: 34500248 PMCID: PMC8429961 DOI: 10.1016/j.ijscr.2021.106344] [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: 07/21/2021] [Revised: 08/17/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Rectovaginal fistula (RVF) is an abnormal communication between the vagina and the rectum. RVFs caused by Bartholin's gland infection are very rare. We present the case of recurrent rectovaginal fistula complicating a bartholin's gland abcess successfully treated with a Martius flap. The aim of this work is to demonstrate the possibility of complication of bartholin's gland infection by a rectovaginal fistula and the efficacy of Martius flap procedure for recurrent RVF of the low third part of the vagina. Observation It is a 30-year-old woman admitted to our department for recurrent RVF due to an abscess of the Bartholin's glands. She was previously treated with a vaginal advancement flap which failed with persistence of the fistula and its symptoms. The patient underwent a RVF repair by Martius flap with complete healing of the fistula. Discussion Rectovaginal fistula is a complex pathology with psycho-social, individual, family, religious and ethno-environmental repercussions. Its main aetiologies are obstetric, rectal surgery. Several techniques including the vaginal or anal advancement flap and the Martius flap are used for the treatment of rectovaginal fistulas. For recurrent fistulas, the Martius flap seems to be the most indicated with better results. Conclusion Rectovaginal fistula remain a challenge for surgeons and have major psycho-socio-economic repercussions for the patient. The complication of Bartholin's gland infection by rectovaginal fistula is rare. The Martius flap technique is the method of choice for recurrent rectovaginal fistulas of the lower third of the vagina or in association with other pathologies. Recovaginal fistula is a challenge for surgeons. The rectovaginale fistula due to Bartholin’s gland abcess is very rare Care must be taken during the management of this pathology which affetcs 2% of women during their life for avoiding that complication The Martius flap is the method of choice for the treatment of rectovaginale fistula of the low third inferior part of the vagina
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Affiliation(s)
- F Z Bensardi
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
| | - S Kabura
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
| | - ElAttar Layla
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
| | - A El Bakouri
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
| | - M Bouali
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
| | - K El Hattabi
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
| | - A Fadil
- Service of Emergency of the Visceral Surgery, Ibn Rochd University Hospital Centre, Morocco; Hassan II University of Casablanca, Medicine and Pharmacy Faculty, Morocco; Department of Surgery, Ibn Rochd-Casablanca University Hospital Centre, Morocco
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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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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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12
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Rectoneovaginal fistula after sex reassignment surgery. Description of our experience and literature review. Actas Urol Esp 2021; 45:239-244. [PMID: 33139068 DOI: 10.1016/j.acuro.2020.08.012] [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: 07/11/2020] [Accepted: 08/22/2020] [Indexed: 11/20/2022]
Abstract
Male-to-female reassignment surgery or vaginoplasty includes those surgical procedures that aim to recreate a functional and cosmetically acceptable female perineum with minimal scarring. The technique of choice at our center is penile inversion vaginoplasty with or without scrotal skin grafts. We present 4 cases diagnosed with rectoneovaginal fistulas treated at our center with favorable evolution. The first patient was diagnosed in the late postoperative period during dilation. She underwent 2 failed vaginal repair attempts. Finally, a temporary colostomy and a rectal flap were performed. The second patient was diagnosed 2 weeks after the initial surgery due to aggressive dilation and was treated with a temporary colostomy and secondary wound closure. The third patient was diagnosed on the fifth post-operative day after removal of the vaginal packing. Dietary restriction was indicated, and a rectal flap was performed. A fourth patient was diagnosed within the late postoperative period; she was submitted to surgical exploration and a rectal wall flap was created. Rectoneovaginal fistulas after sex reassignment surgery has an incidence of about 2-17% and they are the most common type of fistula after this procedure. In most cases, it is secondary to rectal injury during the initial surgery. The management of these fistulas ranges from primary closure, diverting colostomies, conservative management, or the performance of flaps. A multidisciplinary team approach is recommended for the diagnosis and treatment of this complication.
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Li Q, Sun J, Yin L, Ji F. Rectovaginal Fistula With Double Vagina and Anastomotic Stenosis: A Case Report Following Rectal Cancer Surgery. Front Oncol 2021; 11:549211. [PMID: 33680958 PMCID: PMC7934615 DOI: 10.3389/fonc.2021.549211] [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: 04/05/2020] [Accepted: 01/06/2021] [Indexed: 11/22/2022] Open
Abstract
Rectovaginal fistula (RVF) occurs as a result of abnormal epithelialized connections between the rectum and vagina. Rectal cancer surgery remains the major cause of RVF. Here, we report a rare postoperative complication in which a patient with a double uterine and vagina received RVF following rectal cancer surgery. The patient received radiotherapy and developed rectal anastomotic stenosis leading to scar hyperplasia around the fistula, making repair difficult. Complex RVF is prone to release, which despite the multitude of procedures and treatments reported, optimal strategies remain controversial. Our previous studies showed how the use of rectal mucosal advancement flap (RMAF) with transanal endoscopic surgery (TES) can repair mid-low RVF. We successfully repaired RVF and rectal anastomotic stenosis with staging TES in this complex case. This highlights the safety and utility of TES treatment for complex RVF. Further studies are now required to confirm its effectiveness.
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Affiliation(s)
- Qiwei Li
- Department of General Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianhua Sun
- Department of General Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lu Yin
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fu Ji
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Effects of Fourth-Degree Perineal Lacerations on Women's Physical and Mental Health. J Obstet Gynecol Neonatal Nurs 2021; 50:133-142. [PMID: 33472041 DOI: 10.1016/j.jogn.2020.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To describe the physical and emotional effects of fourth-degree perineal lacerations that occur during childbirth. DESIGN Descriptive phenomenology. SETTING Internet survey. PARTICIPANTS Eighteen women from the United States, the United Kingdom, Australia, and Canada who sustained fourth-degree perineal lacerations during childbirth. METHODS Women were recruited from the Facebook support group Mothers With 4th Degree Tears. Participants were asked to describe the physical and emotional effects of these severe birth injuries on their daily lives. I analyzed these data using Colaizzi's method for phenomenological analysis. RESULTS The devastating effects of these birth-related injuries permeated all aspects of the lives of participants. Participants did not receive adequate information about their perineal lacerations, and clinicians often dismissed their concerns. Some participants struggled with postpartum depression and posttraumatic stress disorder. I identified seven themes that described the effects of fourth-degree perineal lacerations: Why Wasn't I Informed I Had This Injury?; The Unthinkable: Fecal Incontinence and So Much More; It Has Cost Me So Much; Seeking Relief: Enduring Surgery After Surgery; Why Didn't Anyone Ask Me About My Mental Health?; To Have More Children, That Is The Question; And Are there Any Positives In All Of This? CONCLUSION Women need information to prepare for recovery from their severe perineal injuries related to what to expect, how to care for themselves, and what resources are available. Clinicians have a responsibility to provide a caring environment in which women feel safe to disclose any problems they are experiencing as a result of their perineal injuries. Little, if any, attention is focused on women's mental health by clinicians or researchers as women struggle with the aftermath of fourth-degree perineal lacerations.
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Sarasqueta C, Zunzunegui MV, Enríquez Navascues JM, Querejeta A, Placer C, Perales A, Gonzalez N, Aguirre U, Baré M, Escobar A, Quintana JM. Gender differences in stage at diagnosis and preoperative radiotherapy in patients with rectal cancer. BMC Cancer 2020; 20:759. [PMID: 32795358 PMCID: PMC7427942 DOI: 10.1186/s12885-020-07195-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Few studies have examined gender differences in the clinical management of rectal cancer. We examine differences in stage at diagnosis and preoperative radiotherapy in rectal cancer patients. Methods A prospective cohort study was conducted in 22 hospitals in Spain including 770 patients undergoing surgery for rectal cancer. Study outcomes were disseminated disease at diagnosis and receiving preoperative radiotherapy. Age, comorbidity, referral from a screening program, diagnostic delay, distance from the anal verge, and tumor depth were considered as factors that might explain gender differences in these outcomes. Results Women were more likely to be diagnosed with disseminated disease among those referred from screening (odds ratio, confidence interval 95% (OR, CI = 7.2, 0.9–55.8) and among those with a diagnostic delay greater than 3 months (OR, CI = 5.1, 1.2–21.6). Women were less likely to receive preoperative radiotherapy if they were younger than 65 years of age (OR, CI = 0.6, 0.3–1.0) and if their tumors were cT3 or cT4 (OR, CI = 0.5, 0.4–0.7). Conclusions The gender-specific sensitivity of rectal cancer screening tests, gender differences in referrals and clinical reasons for not prescribing preoperative radiotherapy in women should be further examined. If these gender differences are not clinically justifiable, their elimination might enhance survival.
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Affiliation(s)
- Cristina Sarasqueta
- Biodonostia Health Research Institute - Donostia University Hospital, Paseo Dr. Beguiristain s/n (Gipuzkoa), 20014, Donostia-San Sebastián, Spain. .,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.
| | - Mª Victoria Zunzunegui
- Professeure honoraire. École de santé publique (ESPUM) Departement de médecine sociale et préventive, Université de Montréal, Pavillon 7101, salle 3111 7101, Avenue du Parc Montréal, Québec, H3N 1X9, Canada
| | - José María Enríquez Navascues
- Department of General and Digestive Surgery, Donostia University Hospital, Paseo Dr. Beguiristain 109 (Gipuzkoa), 20014, Donostia-San Sebastián, Spain
| | - Arrate Querejeta
- Radiotherapic Oncology, Donostia University Hospital, Paseo Dr. Beguiristain 109 (Gipuzkoa), 20014, Donostia-San Sebastián, Spain
| | - Carlos Placer
- Department of General and Digestive Surgery, Donostia University Hospital, Paseo Dr. Beguiristain 109 (Gipuzkoa), 20014, Donostia-San Sebastián, Spain
| | - Amaia Perales
- Biodonostia Health Research Institute, Paseo Dr. Beguiristain s/n (Gipuzkoa), 20014, Donostia-San Sebastián, Spain
| | - Nerea Gonzalez
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Galdakao-Usansolo Hospital, Labeaga Auzoa, 48960, Galdakao, Bizkaia, Spain
| | - Urko Aguirre
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Galdakao-Usansolo Hospital, Labeaga Auzoa, 48960, Galdakao, Bizkaia, Spain
| | - Marisa Baré
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.,Clinical Epidemiology and Cancer Screening, Corporació Sanitaria Parc Taulí, Parc Taulí 1, 08208 Sabadell, Barcelona, Spain
| | - Antonio Escobar
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Hospital Basurto, Avda Montevideo, 18, 48013, Bilbao, Bizkaia, Spain
| | - José María Quintana
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Galdakao-Usansolo Hospital, Labeaga Auzoa, 48960, Galdakao, Bizkaia, Spain
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16
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Pellino G, Solis-Peña A, Espín-Basany E. Repair of a rectovaginal fistula using a robotic transanal minimally invasive surgical technique - a video vignette. Colorectal Dis 2020; 22:724-725. [PMID: 31943678 DOI: 10.1111/codi.14965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 11/26/2019] [Indexed: 02/08/2023]
Affiliation(s)
- G Pellino
- Colorectal Surgery Unit, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - A Solis-Peña
- Colorectal Surgery Unit, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - E Espín-Basany
- Colorectal Surgery Unit, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
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17
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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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18
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Trompetto M, Realis Luc A, Novelli E, Tutino R, Clerico G, Gallo G. Use of the Martius advancement flap for low rectovaginal fistulas. Colorectal Dis 2019; 21:1421-1428. [PMID: 31260184 DOI: 10.1111/codi.14748] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/10/2019] [Indexed: 01/27/2023]
Abstract
AIM The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short- and long-term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues. METHOD Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien-Dindo classification. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre- and postoperatively. RESULTS The mean follow-up was 42 ± 29 months (range 3-101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45-70 min), and the median hospital stay was 3.5 days (range 3-5 days). No major complications occurred. Pre- and postoperative CCIS did not differ [1 (range 0-3.5)]. The postoperative SF-12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001). CONCLUSION The Martius procedure should be considered as the first-line method of treatment in carefully selected cases of LRVF.
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Affiliation(s)
- M Trompetto
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - A Realis Luc
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - E Novelli
- Department of Biostatistics, S. Gaudenzio Clinic, Novara, Italy
| | - R Tutino
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy.,Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - G Clerico
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - G Gallo
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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19
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Drumond DG, Chebli JMF, Speck NMDG, Chebli LA, Pannain GD, Esperança SD, Condé CDMS. Case Report: Treatment for Rectovaginal Fistula in Crohn's Disease Using Fractionate CO 2 Vaginal Laser with Anti-TNF Therapy. PHOTOBIOMODULATION PHOTOMEDICINE AND LASER SURGERY 2019; 37:451-454. [PMID: 31210577 DOI: 10.1089/photob.2019.4643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Rectovaginal fistulas (RVFs) are defined as any connection between the anorectum and the vagina. They can have several causes, being Crohn's disease, the second leading cause of RVFs, responsible for ∼10% of the RVFs. Despite the advances in surgical and clinical treatment, there is no consensus regarding the best line of treatment. Objective: To report another therapeutic option, we describe the case of a patient with Crohn's disease and RVF refractory to anti-tumor necrosis factor (TNF) therapy, submitted to intravaginal CO2 fractional laser treatment. Materials and methods: Three laser sessions with monthly interval and analysis by clinical examination, sexual evaluation questionnaire, and magnetic resonance of the pelvis were performed. Results: We obtained an important improvement of the symptoms and of the dimension of the fistulous path. Conclusions: We believe this method to be a complementary, promising, and safe therapeutic alternative for the management of vaginal fistula. Future studies using this therapeutic strategy are needed to confirm the efficacy of this method in this clinical setting.
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Affiliation(s)
- Denise Gasparetti Drumond
- 1 Department of Surgery, Faculty of Medicine, Universidade Federal de Juiz de Fora Faculdade de Medicina, Juiz de Fora, Brazil
| | - Júlio Maria Fonseca Chebli
- 2 Department of Medical Clinic, Universidade Federal de Juiz de Fora Faculdade de Medicina, Juiz de Fora, Brazil
| | | | - Liliana Andrade Chebli
- 4 Department of Medical Clinic, Universidade Federal de Juiz de Fora Faculdade de Medicina, Juiz de Fora, Brazil
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20
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Stem Cell Therapy: A Compassionate Use Program in Perianal Fistula. Stem Cells Int 2019; 2019:6132340. [PMID: 31191678 PMCID: PMC6525789 DOI: 10.1155/2019/6132340] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/26/2019] [Indexed: 02/06/2023] Open
Abstract
Aim To report our experience in a compassionate use program for complex perianal fistula. Methods Under controlled circumstances and approved by European and Spanish laws, a compassionate use program allows the use of stem cell therapy for patients with nonhealing diseases, mostly complex fistula-in-ano, who do not meet criteria to be included in a clinical trial. Candidates had previously undergone multiple surgical interventions that had failed. The intervention consisted of surgery (with closure of the internal opening or a surgical flap performance), followed by stem cell injection. Three types of cells were used for implant: stromal vascular fraction, autologous expanded adipose-derived, or allogenic adipose-derived stem cells. Healing was evaluated at 6th month follow-up. Outcome was classified as partial response or healing. Relapse was evaluated 1 year later. Maximum follow-up period was 48 months. Results 45 patients (24 male) were included; the mean age was 45 years, which ranged from 24 to 69 years. Since some of them received repeated doses, 52 cases were considered (42 fistula-in-ano, 7 rectovaginal fistulas, 1 urethrorectal fistula, 1 sacral fistula, and 1 hidradenitis suppurativa). Regarding fistula-in-ano, there were 18 Crohn's-associated and 24 cryptoglandular. 49 cases (94.2%) showed partial response starting 6.5 weeks of follow-up. 24 cases (46.2%) healed in a mean time of 5.5 months. A year later, all patients cured remained healed. No adverse effects related to stem cell therapy were reported. Conclusion Stem cells are safe and useful for treating anal fistulae. Healing can be achieved in severe cases.
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21
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Treatment of Rectovaginal Fistula Using Sphincteroplasty and Fistulectomy. Obstet Gynecol Int 2018; 2018:5298214. [PMID: 29853904 PMCID: PMC5960505 DOI: 10.1155/2018/5298214] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 12/29/2022] Open
Abstract
Aim To assess the results of the treatment of rectovaginal fistulas with incontinence and impaired anal tonus. Materials and Methods This study comprised three rectovaginal fistula groups that were treated using sphincteroplasty and fistulectomy: group 1: eight women with simple rectovaginal fistula due to birth trauma; group 2: six rectovaginal fistula cases that were associated with chronic inflammatory diseases; and group 3: five cases with at least one failed repair attempt. In the second step, operations that took place before the year 2000 were compared to the operations that took place after the year 2000 in terms of demographic and clinical characteristics. Results All of the simple rectovaginal fistula cases healed after the operation. Five of the group 2 patients healed after the operation. However, 1 patient with Crohn's disease needed to undergo reoperation, but successfully healed after 6 months. On the contrary, 3 patients in group 3 healed (60%) whereas 2 of them failed to heal. Clinical characteristics of the patients were different between the groups (before and after the year 2000). Conclusion The choice of operation must be done according to the patient's underlying pathology. Proper management of associated inflammatory diseases and systemic disorders is recommended for necessary complex cases.
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22
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Al-Asali F, Kilani R, Rshoud F, Mahfouz IA. A Rare Case of Rectovaginal Fistula Due to Consensual Sexual Intercourse. Sultan Qaboos Univ Med J 2018; 18:e107-e109. [PMID: 29666692 DOI: 10.18295/squmj.2018.18.01.019] [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: 08/01/2017] [Revised: 10/29/2017] [Accepted: 12/07/2017] [Indexed: 11/16/2022] Open
Abstract
Rectovaginal fistulae after sexual intercourse are rare. We report a healthy recently married 21-year-old woman who presented to the Jordan Healthcare Centre, Amman, Jordan in 2014 with a five-week history of passing flatus and stool from the vagina. Six weeks prior, she had sustained a rectovaginal injury during initial consensual sexual intercourse, leading to the development of a distal rectovaginal fistula. A successful transvaginal repair was performed nine weeks after presentation which resulted in the complete resolution of her symptoms.
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Affiliation(s)
- Fida Al-Asali
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Rami Kilani
- Department of Minimally Invasive Surgery, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Firas Rshoud
- Department of Reproductive Medicine & Infertility, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Ismaiel A Mahfouz
- Department of Obstetrics & Gynaecology, Jordan Healthcare Centre, Amman, Jordan
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23
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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