TEMS: an alternative method for the repair of benign recto-vaginal fistulae

Minimally invasive endoscopic repair of rectovaginal fistula

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.

Combined transabdominal-transanal surgical approach for iatrogenic rectovaginal fistula: two case reports

Rectovaginal fistula (RVF) is a type of anastomotic leakage that may occur after low anterior resection for rectal cancer. The repair of RVF can be challenging because of the scar tissue stenosis and incomplete obstruction. Two patients presented in our department with vaginal faecal discharge almost 7 months after the radical resection of rectal cancer. On vaginal examination, titanium nails related to the rectal surgery were found in the vaginal wall. The patients were diagnosed with RVF. Considering that RVF positions in the patients were high and might adhere to the pelvic tissue, a combined transabdominal-transanal resection and vaginal repair surgery was performed. About 3 months after surgery, both patients underwent colonic closure surgery, with consequent good recovery. A combined transabdominal-transanal approach may provide distinct advantages in surgical repair of difficult cases of RVF.

Successful repair of recurrent rectovaginal fistula by stratified suture using transanal endoscopic microsurgery: A CARE-compliant case report

BACKGROUND

Rectovaginal fistulas (RVFs) are abnormal connections between the rectum and vagina. Although many surgical approaches to correct them have been attempted, management of RVFs still remains a challenge, especially for recurrent RVFs.

METHODS

In the present study, we report a case in a 22-year-old female with a chief complaint of obvious passages of flatus or stool through the vagina for 10 years. She had suffered a vaginal trauma from a violent accident 10 years prior, and gradually noticed the uncontrollable passage of gas or feces from the vagina 2 weeks later.The patient underwent a transvaginal direct repair surgery at local hospital 9 years ago, but the symptoms recurred 1 month after the surgery. After 2-years monitoring, the patient underwent another transvaginal repair surgery (fistulectomy followed by direct suture) at another hospital, but the fistula recurred again. We initially performed a temporary protective transversostomy upon admission. After 8-months of observation, a methylene blue test was conducted and the diagnosis of recurrent RVF was confirmed. Subsequently, we performed a successful repair by stratified suture using transanal endoscopic microsurgery (TEM). The scar tissue on the posterior wall of the vagina and the anterior wall of the rectum were meticulously excised until the margin of the excisional line showed healthy tissue. In addition, the fistulous tract was completely removed. The edges of the fistula on the posterior wall of the vagina were closed by simple continuous suturing, and the rectal anterior wall was sutured in the same manner.

RESULTS

During a 1-year follow-up period, the fistulae were not recurrent and no complication such as incontinences or rectal bleeding were found. The latest Wexner score was 3.

CONCLUSION

We present a case of successful treatment with stratified suture using TEM throughout the procedure. We strongly recommend this efficient and minimally invasive procedure for recurrent RVFs.

The increasing number of surgical procedures for female genital fistula in England: analysis of Hospital Episode Statistics (HES) data

The aim of this study was to describe the number and trend of surgical procedures for female genital fistula in England. An online search of Hospital Episode Statistics (HES) data was carried out. Data were available for the 4-year period from 2002-03 until 2005-06. The total number of surgical procedures carried out for female genital fistula steadily increased by 28.7% from 616 in 2002-03 to 793 in 2005-06. The number of surgical procedures performed for rectovaginal fistula exceeded the total number of surgical procedures carried out for vesicovaginal and urethrovaginal fistula in each year of the study period. This pattern needs to be monitored and investigated further.

The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study

BACKGROUND

Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear.

OBJECTIVE

A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas.

DATA SOURCES

Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles.

STUDY SELECTION

Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results.

INTERVENTION(S)

Any surgical intervention for the closure of rectovaginal fistulas was included.

MAIN OUTCOME MEASURES

The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning.

RESULTS

Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable.

LIMITATIONS

The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis.

CONCLUSIONS

No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.

Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas

AIM

Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery.

METHOD

A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig-Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome.

RESULTS

Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn's disease had no ileostomy raised. At a median follow-up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re-operation and bovine plug repair combined with a mucosa flap.

CONCLUSIONS

Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.

Minimally invasive treatment of rectovaginal fistula

BACKGROUND

Rectovaginal fistulas (RVFs) are a rare surgical condition. Their treatment is extremely difficult, and no standard surgical technique is accepted worldwide. This report describes a new approach using transanal endoscopic microsurgery (TEM) to treat RVFs.

METHODS

A retrospective review of 13 patients who underwent repair of rectovaginal fistula using TEM between 2001 and 2008 was undertaken. The surgical technique is widely described, and the advantages of the endorectal approach are noted.

RESULTS

The median follow-up period was 25 months, and the median age of the patients was 44 years (range, 25-70 years). The mean operative time was 130 min (range, 90-150 min), and the hospital stay was 5 days (range, 3-8 days). One patient experienced recurrence. This patient underwent reoperation with TEM and experienced re-recurrence. Two patients had minor complications (hematoma of the septum and abscess of the septum), which were treated with medical therapy. For two patients, a moderate sphincter hypotonia was registered.

CONCLUSIONS

A new technique for treating RVFs using TEM is presented. The authors strongly recommend this approach that avoids any incision of the perineal area, which is very painful and can damage sphincter functions.

Indications and techniques of transanal endoscopic microsurgery (TEMS)

Transanal endoscopic microsurgery (TEMS) has recently reemerged as a valuable technique for the management of rectal neoplasms - both benign and malignant. Since the original description of this technique in the early 1980s, TEMS has emerged as the approach of choice for most benign rectal tumors because of the excellent views provided and superior dissection techniques possible when compared to traditional transanal excision. Many published reports demonstrate that the lowest rates of recurrence are associated with TEMS probably because of full-thickness excision with negative margins. Increasingly, TEMS is being applied to primary rectal cancer when used alone as a full-thickness excision alone or in combination with additional therapies, depending on tumor stage. There is now a significant evidence base to suggest that this approach should be considered as part of a multidisciplinary approach to rectal cancer. This paper describes indications and techniques for this technology.

Benign rectal strictures managed with transanal resection--a novel application for transanal endoscopic microsurgery

OBJECTIVE

Six cases of management of rectal strictures by transanal endoscopic microsurgery (TEM) are described.

METHOD

Patients are placed in the lithotomy - Trendelenburg position and the stricture is resected from 4-8 o'clock through the entire thickness of the fibrosis. The upper resection edge is mobilized including all layers of the rectal wall and the defect is sutured along the circumference.

RESULTS

Satisfactory anatomical and functional long-term results were obtained in 5 of 6 patients.

CONCLUSION

TEM resection of benign strictures is feasible in some patients and should be tested in a randomized study against known procedures.