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1
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Li X, Shao W, Sun G. A single-center retrospective analysis of endorectal advancement flaps used for the treatment of simple rectovaginal fistulas. Scand J Gastroenterol 2025; 60:307-311. [PMID: 39987924 DOI: 10.1080/00365521.2025.2468493] [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: 09/06/2024] [Revised: 02/09/2025] [Accepted: 02/12/2025] [Indexed: 02/25/2025]
Abstract
OBJECTIVE To investigate the effectiveness of endorectal advancement flaps for middle and low rectovaginal fistulas. METHODS A retrospective cohort of 57 patients who underwent surgery via an endorectal advancement flap in the RVF between July 2007 and March 2022 was generated. The clinical features of the patients were reviewed. The associations between fistula closure and diverse clinical parameters, including age, body mass index, diameter of the fistula, prior repair, pathological type, diverting stoma and operative method, were analyzed. RESULTS Congenital (n = 19, 33.33%) and obstetric (n = 19, 33.33%) injuries were the most common etiologies of rectovaginal fistulas. The success rate in patients who underwent a first repair was 66.7%, and the overall success rate was 70.2% after repetition of the same technique. There were no significant differences in the closure rate between the success and failure groups in age, body mass index, prior repair, preoperative colostomy, or pathological type (p > 0.05). However, a diameter greater than 1 cm predicted a lower success rate for both the first repair (p < 0.05) and the overall procedure (p < 0.05). Two cases of failure with a diameter greater than 1 cm succeeded after a sphincter repair procedure half a year later. CONCLUSION The endorectal advancement flap is safe and effective for removing simple rectovaginal fistulas at the middle and lower positions. A diameter greater than 1 cm is an independent risk factor for this surgical technique, and sphincteroplasty may be a better choice for this condition.
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Affiliation(s)
- Xuexiao Li
- Department of Coloproctology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Wanjin Shao
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, China
| | - Guidong Sun
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, 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; 94:1471-1479. [PMID: 38475976 DOI: 10.1111/ans.18922] [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: 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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Murad-Regadas SM, Regadas FSP, Regadas Filho FSP, de Mendonça Filho JJA, da Penha CBR, da Cunha CMQ. Rectovaginal fistula: Which surgical technique do I choose?-A video vignette. Colorectal Dis 2024; 26:1650-1651. [PMID: 38923113 DOI: 10.1111/codi.17087] [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: 05/05/2024] [Revised: 05/29/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Sthela M Murad-Regadas
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - F Sergio P Regadas
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - F Sergio P Regadas Filho
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Ceará, Brazil
| | | | - Camila B R da Penha
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Ceará, Brazil
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Zhang M, Zhao X, Mao J, Shi A, Lyu X, Lyu Y, Yan X. Comparative study on the establishment efficacy of four types of animal models of rectovaginal fistula in rabbits. Sci Rep 2024; 14:12462. [PMID: 38816430 PMCID: PMC11139911 DOI: 10.1038/s41598-024-63128-2] [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: 02/23/2024] [Accepted: 05/24/2024] [Indexed: 06/01/2024] Open
Abstract
Various surgical methods have so far been developed for treating rectovaginal fistula (RVF), each with its own advantages and disadvantages. The lack of standardized animal models of RVF is a major reason for the failure to establish a unified and effective surgical method for the treatment of RVF. This study aimed to explore the feasibility of an RVF animal model by magnetic compression and compare it with the traditional modeling method. Thirty-two female Japanese white rabbits were randomly divided into four groups: A, B, C, and D, based on how the rectovaginal septum was treated. The operation time, intraoperative blood loss, and model success rate of each group were determined. The experimental animals were euthanized 2 weeks after the operation. Their rectovaginal septum specimens were obtained. RVF was observed by the naked eye. The fistula size was measured. Histological changes of fistula were observed by hematoxylin and eosin and Masson staining. All rabbits completed the RVF model and survived 2 weeks after the operation. Groups A and B had no bleeding, while groups C and D had < 0.5 mL of bleeding. The magnet detached in 4-6 days in group A, while it remained in place for 2 weeks after surgery in group B. Only one group D rabbit had a plastic hose for 2 weeks after surgery. The RVFs of groups A and C healed by themselves. In group B, the fistula was well formed. In group D, fistula healing was observed in three animals and the diameter of the fistulas was only 2.82-4.64 mm in the other four animals. Groups B and D had a scar on the inner surface of fistulas. Our study shows that the magnetic compression technique based on the T-shaped magnet is a highly useful method to establishing a continuous and stable RVF model in rabbits.
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Affiliation(s)
- Miaomiao Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Magnetic Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Xuhe Zhao
- Zonglian College, Xi'an Jiaotong University, Xi'an, China
| | - Jianqi Mao
- Zonglian College, Xi'an Jiaotong University, Xi'an, China
| | - Aihua Shi
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Xin Lyu
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 3 Shang Qin Road, Xincheng District, Xi'an, 710004, Shaanxi, China.
| | - Yi Lyu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
- Shaanxi Provincial Key Laboratory of Magnetic Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
| | - Xiaopeng Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
- Shaanxi Provincial Key Laboratory of Magnetic Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
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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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6
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Drefs M, Schömer Cuenca S, Wirth U, Kühn F, Burian M, Werner J, Zimmermann P. Predictors of outcome for treatment of enterovaginal fistula : Therapeutical strategies for treatment. Int J Colorectal Dis 2023; 38:187. [PMID: 37420132 PMCID: PMC10329052 DOI: 10.1007/s00384-023-04453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary. METHODS The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure. RESULTS Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031). CONCLUSION Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | | | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Maria Burian
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Petra Zimmermann
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany.
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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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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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9
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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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10
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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: 0.7] [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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11
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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: 76] [Impact Index Per Article: 25.3] [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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12
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Surgical treatment of deep-lying ano-/rectovaginal fistulas using a de-epithelialized “Singapore flap” (pudendal thigh flap). Eur Surg 2022. [DOI: 10.1007/s10353-022-00759-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Summary
Background
Rectovaginal fistulas represent 5% of all anorectal fistulas. For affected women, this pathology is associated with a reduction in quality of life (QoL) and self-esteem. Most commonly used methods of surgical closure have high recurrence rates or permanent perineal complaints, which in turn lead to negative effects on QoL and self-esteem. A fistula closure, using the “de-epithelialized Singapore flap” (SF), can be a good alternative therapy strategy.
Method
Our retrospective case series processes the long-term results of seven patients who were operated on for ano-/rectovaginal fistula using the SF. All patients underwent surgery at the University Hospital Graz, between May 2012 and July 2015. The data of the surgical follow-up examinations were collected and an additional telephone survey was carried out. The procedure is presented based on a structured description. All procedures were performed jointly by the Department of General Surgery and the Department of Plastic Surgery.
Results
The average age of the seven patients was 46.14 years (23–72 a). Five patients had a total of 12 previous operations with frustrating results. Of the seven patients treated, six had a permanent fistula closure (85.7%). The results of the telephone survey (n = 6) showed a high level of patient satisfaction (100%), and an improvement in QoL (83.3%), through our surgical method. In our cohort, neither urinary nor fecal incontinence occurred.
Conclusion
The treatment of an ano-/rectovaginal fistula using the “de-epithelialized pudendal thigh flap” (Singapore flap) is a promising treatment alternative. In particular, patients who have had previous proctological interventions show a benefit from this procedure.
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13
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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: 7] [Impact Index Per Article: 2.3] [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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14
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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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15
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Lohsiriwat V, Jitmungngan R. Rectovaginal fistula after low anterior resection: Prevention and management. World J Gastrointest Surg 2021; 13:764-771. [PMID: 34512900 PMCID: PMC8394379 DOI: 10.4240/wjgs.v13.i8.764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/17/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Rectovaginal fistula after low anterior resection for rectal malignancy is one of the most challenging postoperative complications because it is difficult to treat and may complicate plans of adjuvant therapy. This problematic complication could lead to multiple operations, stoma formation, sexual dysfunction, fecal incontinence and psychosocial ramifications. This review comprehensively covers an overview of its incidence, risk factors, presentation and evaluation, management (ranging from conservative measures, endoscopic treatment and local tissue repair to radical resection and redo anastomosis) and treatment outcomes of rectovaginal fistula after low anterior resection. Notably, these therapeutic options and outcomes are influenced by several factors, including the size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis and surrounding tissue, presence of diverting stoma, previous attempted repair, and the surgeon’s experience. Also, strategies to prevent rectovaginal fistula after low anterior resection are presented with illustrations. Finally, a decision-making algorithm for managing this complication is proposed.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Romyen Jitmungngan
- Department of Surgery, The Golden Jubilee Medical Center, Mahidol University, Nakhon Pathom 73170, Thailand
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16
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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: 1.3] [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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17
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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: 1.3] [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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18
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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: 3] [Impact Index Per Article: 0.8] [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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20
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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: 1.3] [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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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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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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Grüter AAJ, Van Oostendorp SE, Smits LJH, Kusters M, Özer M, Nieuwenhuijzen JA, Tuynman JB. Minimally invasive perineal redo surgery for rectovesical and rectovaginal fistulae: A case series. Int J Surg Case Rep 2020; 77:733-738. [PMID: 33395885 PMCID: PMC7724097 DOI: 10.1016/j.ijscr.2020.11.067] [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: 10/01/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Iatrogenic recto-urogenital fistulae are refractory complications that rarely heal without surgical intervention. The ongoing local infection causes pain, discomfort and substantially impacts quality of life. Surgical repair requires adequate exposure and space to fill with healthy tissue, which is a major challenge in pelvic redo surgery. An abdominal approach to repair the fistula is associated with major morbidity and often fails to expose the deep pelvis. In our experience a novel transperineal minimally invasive approach a utilizing single incision laparoscopic surgery (SILS) technique could offer improved results. PRESENTATION OF CASES In the present study, three cases of patients with recto-urogenital fistulae after pelvic surgery are described. Two patients were diagnosed with a rectovesical fistula and one patient with a rectovaginal fistula. In all three cases, a minimally invasive perineal approach, using a SILS port, was used to perform surgical repair. The closure of the fistulae involved: a separate repair of the urethra/bladder or vaginal defect and the rectal defect, followed by interposition of vascularized tissue by either a pudendal thigh fasciocutaneous flap or omentoplasty. DISCUSSION AND CONCLUSION This study is the first to report on a minimally invasive perineal approach, utilizing a SILS technique for recto-urogenital fistulae repair after previous pelvic surgery. The current approach improves exposure, creates surgical space, optimizes view and allows the interposition of vascularized tissue, without causing substantial blood loss and avoiding major abdominal surgery.
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Affiliation(s)
- A A J Grüter
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - S E Van Oostendorp
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - L J H Smits
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - M Kusters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - M Özer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Plastic Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - J A Nieuwenhuijzen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Urology, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - J B Tuynman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands.
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Vaneerdeweg W, Hubens G, Chapelle T, Eyskens E. Rectovaginal Fistulas. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2000.12098526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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Ziouziou I, Ammouri S, Ouazni M, Sumba H, Koutani A, Iben Attya Andaloussi A. Recto-vaginal fistulas: A case series. Int J Surg Case Rep 2020; 72:147-152. [PMID: 32535530 PMCID: PMC7298318 DOI: 10.1016/j.ijscr.2020.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 01/13/2023] Open
Abstract
Falandry and Martius’ techniques were used firstly for vesico-vaginal fistulas with satisfying long-term functional results. The same techniques are feasible and safe for rectovaginal fistula repair. In this case series, patients had an improvement of their self-image and health-related quality of life. Temporary colostomy is recommended before this reconstructive surgery. Introduction Rectovaginal fistula (RVF) is defined as an abnormal communication between the anterior wall of the rectum and the posterior wall of the vagina. Many surgical techniques have been described in the treatment of RVF. However, none has proved its superiority. The aim of the study was to evaluate the functional results of surgical treatment of RVF using Martius and Falandry techniques in order to assess the feasibility and the efficacy of these techniques which were first described for vesico-vaginal fistulas. Methods The study was a retrospective case series conducted in a single centre: Department of general surgery at Ibn Sina University Hospital in Rabat. We included patients with rectovaginal fistula consecutively recruited from 2011 to 2014. 10 patients developed RVF after surgery for rectal cancer (9 cases), uterine cancer (1 case). One patient had RVF for ano-rectal malformation. Colostomy was performed before the treatment of fistula in 9 cases (82 %). They underwent surgical treatment using Falandry (8 patients) and Martius techniques (3 patients) performed by an experienced urologist surgeon. Results No postoperative complications were recorded. Time to discharge was postoperative day 3–4. There was a complete disappearance of RVF in 8 patients (72.7 % of cases), relapse in 2 cases (18 %), and failure in one case (9%). The average follow-up was 12.6 +/-10 months. Functionally, no long-term cases of fecal incontinence or dyspareunia were noted. Conclusion The choice of surgical technique in the treatment of RVF remains difficult because of poor literature data and absence of consensus. RVF repair results either by Martius or Falandry techniques are encouraging with low morbidity.
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Affiliation(s)
- Imad Ziouziou
- Service d'urologie, CHU d'Agadir, Agadir, Morocco; Equipe de recherche en médecine translationnelle et épidémiologie, Laboratoire des sciences de la santé, Faculté de médecine et de pharmacie, Université Ibn Zohr, Agadir, Morocco.
| | - Safaa Ammouri
- Service de gynécologie-obstétrique et d'endoscopie gynécologique, Maternité Soussi, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
| | - Mohammed Ouazni
- Service de chirurgie viscérale, CHU d'Agadir, Faculté de médecine et de pharmacie, Université Ibn Zohr, Agadir, Morocco
| | - Harrison Sumba
- Service d'urologie B, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
| | - Abdellatif Koutani
- Service d'urologie B, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
| | - Ahmed Iben Attya Andaloussi
- Service d'urologie B, CHU Ibn Sina, Faculté de médecine et de pharmacie, Université Mohamed V, Rabat, Morocco
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Picciariello A, Papagni V, De Fazio M, Martines G, Memeo R, Vitarelli A, Dibra R, Altomare DF. Functional outcome and quality of life evaluation of graciloplasty for the treatment of complex recto-vaginal and recto-urethral fistulas. Updates Surg 2020; 72:205-211. [PMID: 31927754 DOI: 10.1007/s13304-020-00704-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/02/2020] [Indexed: 01/11/2023]
Abstract
Recto-vaginal (RVF) and recto-urethral (RUF) fistulas are infrequent but disabling conditions that severely affect patients' quality of life. Considering the high recurrence rate after conservative approaches, the best surgical treatment is still challenging. The aim of this study was to evaluate the outcome of graciloplasty to treat patients with complex RVF or RUF, and to investigate its effect on the quality of life. Fourteen patients with RVF and RUF who underwent graciloplasty between 2003 and 2017 were retrospectively enrolled. The main outcome was the healing rate of fistulas. Postoperative patients satisfaction was evaluated administering the Clinical Patient Grading Assessment Scale (CPGAS), SF-36 questionnaires and Changes in Sexual Functioning (CSF) questionnaires. The Wexner score was calculated in case of preoperative faecal incontinence. RVF and RUF were iatrogenic in 11 patients and due to Crohn's disease in 3 cases. After 1 year of follow-up (IQR 10-14 months), the success rate of the procedure was 78%. Out of three patients with RVF due to Crohn's disease, two healed after the procedure. Six months after surgery, all eight SF-36 domains significantly improved except for "body pain"; CSF score significantly increased from 35.5 (IQR 31-38.7) to 44 (IQR 37.7-48.5); CPGAS score improved from a median value of 0 (IQR 0-0) to 4 (IQR 3.2-4). The Wexner score was calculated only in 5 patients with preoperative faecal incontinence and it significantly decreased from a median value of 12 (IQR 11-14) to 5 (IQR 4-5). Graciloplasty could be considered as a first option treatment for complex or recurrent RVF and RUF. It shows a good healing rate even in case of unfavourable factors like Crohn's disease.
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Affiliation(s)
- Arcangelo Picciariello
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy.
| | - Vincenzo Papagni
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Michele De Fazio
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
- Inter-Department Research Center for Pelvic Floor Disease (CIRPAP), University "Aldo Moro" of Bari, Bari, Italy
| | - Gennaro Martines
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Antonio Vitarelli
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Rigers Dibra
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Donato F Altomare
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
- Inter-Department Research Center for Pelvic Floor Disease (CIRPAP), University "Aldo Moro" of Bari, Bari, Italy
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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: 1.8] [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: 29] [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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Lin HC, Huang L, Chen HX, Zhou Q, Ren DL. Stapled Transperineal Fistula Repair of Rectovaginal Fistula: A Preliminary Experience. Surg Innov 2018; 26:66-71. [PMID: 30196767 DOI: 10.1177/1553350618799452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE This study is designed to assess the safety, efficacy, and postoperative outcomes of stapled transperineal repair in management of rectovaginal fistula (RVF). METHODS A prospective database of patients with RVF undergoing stapled transperineal repair between May 2015 and December 2017 was established and studied retrospectively. RESULTS Seven consecutive RVF patients underwent stapled transperineal repair. The mean operative time was 119 ± 42 minutes. The estimated blood loss during operation was 24 ± 14 mL. Concomitant levatorplasty was performed with 4 patients and sphincteroplasty with 2 patients. Over a median follow-up of 6 months (range 3-33 months), no case was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (mean preoperative vs postoperative Wexner scores 3 [range 3-4] vs 1 [range 1-2], respectively; P = .01). CONCLUSIONS Stapled transperineal repair of RVF appears safe and effective. The initial results are encouraging, suggesting the need for a more formal prospective assessment of this technique as part of a randomized trial for the management of low- and mid-vaginal fistulas.
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Affiliation(s)
- Hong-Cheng Lin
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Liang Huang
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Hua-Xian Chen
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Qian Zhou
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Dong-Lin Ren
- 1 The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
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Rottoli M, Vallicelli C, Boschi L, Cipriani R, Poggioli G. Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn’s disease a risk factor for failure? A prospective cohort study. Updates Surg 2018; 70:485-490. [DOI: 10.1007/s13304-018-0558-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/30/2018] [Indexed: 01/11/2023]
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Gallo G, Realis Luc A, Clerico G, Trompetto M. Martius' flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn's disease, endometriosis and a mullerian anomaly. BMC Surg 2017; 17:107. [PMID: 29162069 PMCID: PMC5697073 DOI: 10.1186/s12893-017-0309-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/14/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn's disease that negatively affects patients' social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options. CASE PRESENTATION We describe a 31-year-old female patient with a Crohn's disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient's medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius' flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy. CONCLUSION Martius' flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn's disease. The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate.
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Affiliation(s)
- Gaetano Gallo
- Department of Colorectal Surgery, Santa Rita Clinic, Vercelli, Italy
- Department of Surgical and Medical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | | | - Giuseppe Clerico
- Department of Colorectal Surgery, Santa Rita Clinic, Vercelli, Italy
| | - Mario Trompetto
- Department of Colorectal Surgery, Santa Rita Clinic, Vercelli, Italy
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Wright M, Thorson A, Blatchford G, Shashidharan M, Beaty J, Bertelson N, Aggrawal P, Taylor L, Ternent CA. What happens after a failed LIFT for anal fistula? Am J Surg 2017; 214:1210-1213. [PMID: 29146001 DOI: 10.1016/j.amjsurg.2017.08.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/27/2017] [Accepted: 08/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented. METHODS Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016. RESULTS 53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment. CONCLUSION Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.
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Affiliation(s)
- Moriah Wright
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Alan Thorson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Garnet Blatchford
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Maniamparampil Shashidharan
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Jennifer Beaty
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Noelle Bertelson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Piyush Aggrawal
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Lindsay Taylor
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Charles A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA.
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Park SO, Hong KY, Park KJ, Chang H, Shin JY, Jeong SY. Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up. Int J Colorectal Dis 2017; 32:1029-1032. [PMID: 28210852 DOI: 10.1007/s00384-017-2784-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Rectovaginal fistulas are difficult to treat completely, especially when patients present with a history of multiple surgeries and radiation therapy. We aimed to evaluate the efficacy of gracilis muscle flap transposition to treat rectovaginal fistula. METHODS We performed a retrospective chart review of all gracilis muscle transposition cases and other procedures between January 2009 and July 2016. RESULTS Total 53 cases were reviewed. A total of 11 patients underwent gracilis muscle flap transposition for rectovaginal fistula repair, with 8 patients showing good results without recurrence (total success rate, 72.7%). Comparison of this patient group with patients who had undergone other surgical procedures for rectovaginal fistula repair showed that those who received a gracilis transposition flap had significantly higher average number of previous surgeries (2.18 ± 1.17 vs. 1.1 ± 1.25) and had previously undergone radiotherapy at a significantly higher rate (63.6 vs. 26.2%). Furthermore, none of our patients complained of donor site discomfort. CONCLUSIONS Based on these results, we recommend using the gracilis muscle flap for rectovaginal fistula repair in cases where there is a history of radiotherapy and had surgical failure more than twice.
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Affiliation(s)
- Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyo Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jin Yong Shin
- Department of Plastic and Reconstructive Surgery, Medical School of Chonbuk National University, Jeonju, South Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Abstract
Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.
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Affiliation(s)
- Mahmoud Abu Gazala
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
| | - Steven D Wexner
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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She ZF, Yan XP, Ma F, Wang HH, Yang H, Shi AH, Wang L, Qi X, Xiao B, Zou YL, Lv Y. Treatment of rectovaginal fistula by magnetic compression. Int Urogynecol J 2016; 28:241-247. [PMID: 27530520 DOI: 10.1007/s00192-016-3097-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Rectovaginal fistula (RVF) is an abnormal epithelium-lined connection between the rectum and vagina. The primary effective treatment is surgical repair, but recurrence remains a challenge. Magnetic compression anastomosis (MCA), an alternative to suturing, has been developed to generate an anastomosis between various hollow viscera. We hypothesized that the MCA approach could be used to treat RVF. METHOD We designed a novel MCA device for RVF treatment and evaluated the magnetic compression procedure in a RVF pig model in comparison with the traditional suturing procedure. Following satisfactory outcomes, we also applied the MCA procedure to a human patient with recurrent RVF. The MCA device was designed based on the anatomical characteristics of the pig vagina and previous literature. The pig RVF model were established surgically (n = 12), and compression and control groups were each treated. The data were analyzed by one-way analysis of variance. RESULTS qqExcept in one animal in each group, the RVF site was smooth and healing was complete. Histological analysis confirmed complete healing of the RVF with high histological continuity to neighboring tissues. The compression procedure applied to our patient with RVF was successful. The patient recovered quickly without complications, and RVF did not recur during a 15-month follow-up. CONCLUSIONS From this preliminary investigation, MCA using our novel device appears to be a safe, simple, and effective nonsurgical procedure for the treatment of RVF.
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Affiliation(s)
- Zhan-Fei She
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China.,Department of General Surgery, Ordos Central Hospital, Ordos, Inner Mongolia, 017000, China
| | - Xiao-Peng Yan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China
| | - Feng Ma
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China
| | - Hao-Hua Wang
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China
| | - Huan Yang
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China
| | - Ai-Hua Shi
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China.,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China
| | - Liang Wang
- Department of General Surgery, Ordos Central Hospital, Ordos, Inner Mongolia, 017000, China
| | - Xin Qi
- Department of General Surgery, Ordos Central Hospital, Ordos, Inner Mongolia, 017000, China
| | - Bin Xiao
- Department of General Surgery, Ordos Central Hospital, Ordos, Inner Mongolia, 017000, China
| | - Yu-Liang Zou
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China. .,XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China. .,Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi Province, 710061, China.
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Should Immunomodulation Therapy Alter the Surgical Management in Patients With Rectovaginal Fistula and Crohn's Disease? Dis Colon Rectum 2016; 59:670-6. [PMID: 27270520 DOI: 10.1097/dcr.0000000000000614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rectovaginal fistula in Crohn's disease is challenging for both healthcare providers and patients. The impact of immunomodulation therapy on healing after surgery is unclear. OBJECTIVE The purpose of this study was to examine whether immunomodulation therapy impacts healing after surgery for rectovaginal fistula in Crohn's disease. DESIGN This was a retrospective analysis with a follow-up telephone survey. SETTINGS The study was conducted at two major tertiary referral centers. PATIENTS All of the patients who underwent rectovaginal fistula repair from 1997 to 2013 at our centers were included. MAIN OUTCOME MEASURES A χ test and logistical regression analysis were used to study treatment outcomes according to type of procedure, recent use of immunosuppressives, and number of previous attempted repairs. Age, BMI, smoking, comorbidities, previous vaginal delivery/obstetric injury, use of probiotics, diverting stoma, and use of seton were also analyzed. RESULTS A total of 120 (62%) patients were contacted, and 99 (51%) of them agreed to participate in the study. Mean follow-up after surgical repair was 39 months. Procedures included advancement flap (n = 59), transvaginal repair (n = 14), muscle interposition (n = 14), episioproctotomy (n = 6), sphincteroplasty (n = 3), and other (n = 3); overall, 63% of patients experienced healing. Sixty-eight patients underwent recent immunomodulation therapy but did not exhibit statistical significance in outcome after surgical repair. In the subset of patients with fistula related to obstetric injury, a 74% (n = 26) healing rate after surgical repair was observed. Age, BMI, diabetes mellitus, use of steroids, probiotics, seton before repair, fecal diversion, and number of repairs did not affect healing. LIMITATIONS This was a retrospective analysis; the high volume tertiary referral inflammatory bowel disease centers studied may not be reflective of rectovaginal fistula presentation, treatment, or results in all patients, and the 3-year follow-up may not be sufficiently long. CONCLUSIONS Despite a relatively low success rate (63%) in healing after surgical repair of a rectovaginal fistula, the recent use of immunomodulation therapy did not negatively impact healing. However, tissue interposition techniques had the highest success rates.
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Akiba RT, Rodrigues FG, da Silva G. Management of Complex Perineal Fistula Disease. Clin Colon Rectal Surg 2016; 29:92-100. [PMID: 27247533 DOI: 10.1055/s-0036-1580631] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Management of complex perineal fistulas such as high perianal, rectovaginal, pouch-vaginal, rectourethral, or pouch-urethral fistulas requires a systematic approach. The first step is to control any sepsis with drainage of abscess and/or seton placement. Patients with large, recurrent, irradiated fistulas benefit from stoma diversion. In patients with Crohn's disease, it is essential to induce remission prior to any repair. There are different approaches to repair complex fistulas, from local repairs to transperineal and transabdominal approaches. Simpler fistulas are amenable to local repair. More complex fistulas, such as those secondary to irradiation, require interposition of healthy, well-vascularized tissue. The most common flap used for this treatment is the gracilis muscle with good outcomes reported. Once healing is confirmed by imaging and endoscopy, the stoma is reversed.
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Affiliation(s)
- Ricardo Tadayoshi Akiba
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, Florida
| | - Fabio Gontijo Rodrigues
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, Florida
| | - Giovanna da Silva
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, Florida
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Sugrue J, Kaminski J, Patel S, Park J, Prasad L, Marecik S. Repair of a recurrent traumatic rectovaginal fistula using vaginal wall plication to reinforce a rectal wall advancement flap. J Vis Surg 2016; 2:65. [PMID: 29078493 DOI: 10.21037/jovs.2016.02.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/07/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Rectovaginal fistulas (RVF) can cause significant physical discomfort and psychological distress for patients and remain amongst the most challenging disorders for surgeons. METHODS A 28-year-old female with a history of a traumatic cloaca repaired 12 years prior was diagnosed with a recurrent RVF and underwent repair using a rectal wall advancement flap reinforced with posterior vaginal wall plication. This case is used to demonstrate surgical technique. The study adhered to the prescribed ethical guidelines. Informed consent was obtained from the patient to use the video recording of her operation for educational purposes. RESULTS The patient had an uneventful postoperative course. The fistula was fully healed without any signs or symptoms of recurrence at 8 weeks follow-up exam. Her protective ileostomy was successfully closed. CONCLUSIONS Transanal repair of a RVF through creation of a rectal advancement flap and plication of redundant vaginal wall can be used to treat appropriately selected patients with significant tissue defects.
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Affiliation(s)
- Jeremy Sugrue
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jan Kaminski
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Supriya Patel
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Division of Colon and Rectal Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - John Park
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Leela Prasad
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Slawomir Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Abstract
Rectovaginal fistulae are abnormal epithelialized connections between the rectum and vagina. Fistulae from the anorectal region to the posterior vagina are truly best characterized as anovaginal or very low rectovaginal fistulae. True rectovaginal fistulae are less common and result from inflammatory bowel disease, trauma, or iatrogenic injury. A very few patients are asymptomatic, but the symptoms of rectovaginal fistula are incredibly distressing and unacceptable. Diagnostic approach, timing, and choice of surgical intervention, including sphincteroplasty, gracilis flaps, Martius flaps, and special circumstances are discussed.
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Affiliation(s)
- Bidhan Das
- Division of Colon and Rectal Surgery, Department of Surgery, University of Texas-Houston, Houston, Texas
| | - Michael Snyder
- Department of Surgery, University of Texas-Houston, Houston, Texas
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Transvaginal primary repair of a suprasphincteric rectovaginal fistula. Int Urogynecol J 2016; 27:821-3. [PMID: 26779914 DOI: 10.1007/s00192-015-2923-2] [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: 10/21/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair. METHODS An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps. RESULTS Anatomy restoration was completed without complications. CONCLUSION The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.
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Lambertz A, Lüken B, Ulmer T, Böhm G, Neumann U, Klink C, Krones C. Influence of diversion stoma on surgical outcome and recurrence rates in patients with rectovaginal fistula – A retrospective cohort study. Int J Surg 2016; 25:114-7. [DOI: 10.1016/j.ijsu.2015.12.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/23/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023]
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Lalwani S, Varma V, Kumaran V, Mehta N, Nundy S. Complex Rectovaginal Fistula-an Experience at a Tertiary Care Centre. Indian J Surg 2015; 77:1142-7. [PMID: 27011526 PMCID: PMC4775704 DOI: 10.1007/s12262-015-1218-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/05/2015] [Indexed: 01/10/2023] Open
Abstract
Complex rectovaginal fistulae are difficult to manage. With an initial failed attempt, a simple fistula becomes complex and the success rate of a subsequent repair decreases. A review of our prospectively maintained records over a period of 16 years revealed 25 patients with rectovaginal fistulae. A variety of procedures was performed in these patients according to their aetiology, site and if there had been a previous attempt at repair. The mean age of the patients was 45 years. The most common cause was operative trauma in 14 cases. Ten patients had previous attempts at repair which had not been successful. The surgical procedures we performed included re-enforcement flaps, resection with diversion, repair with re-enforcement with omentum and simple diversion. Two patients developed recurrence, and one of them healed after a second repair. No recurrence developed in 10 patients who had failed attempts at repair elsewhere. Our experience has shown that most complex rectovaginal fistulae can be successfully repaired but they might require repeated operations. Faecal diversion is usually necessary, and in recurrent fistulae, we found that rather than a local repair, a muscle flap or omental interposition improves the chances of healing.
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Affiliation(s)
- Shailendra Lalwani
- Department of Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, Room No 2222, New Delhi, 110060 India
| | - Vibha Varma
- Department of Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, Room No 2222, New Delhi, 110060 India
| | - Vinay Kumaran
- Department of Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, Room No 2222, New Delhi, 110060 India
| | - Naimish Mehta
- Department of Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, Room No 2222, New Delhi, 110060 India
| | - Samiran Nundy
- Department of Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, Room No 2222, New Delhi, 110060 India
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Subhas G, Alva S, Longo WE. Re-operative surgery for genitourinary fistulae to the colorectum. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Maeda K, Koide Y, Hanai T, Sato H, Masumori K, Matsuoka H, Katsuno H. The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula. Colorectal Dis 2015; 17:1002-6. [PMID: 25891199 DOI: 10.1111/codi.12977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023]
Abstract
AIM Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula. METHOD Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome. RESULTS Birth injury (n = 7), low anterior resection for rectal cancer (n = 3), pouch surgery for ulcerative colitis (n = 2) and a procedure for prolapse and haemorrhoids (n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure. CONCLUSION Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed.
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Affiliation(s)
- K Maeda
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Y Koide
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - T Hanai
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Sato
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - K Masumori
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Katsuno
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Kobayashi H, Sugihara K. Successful management of rectovaginal fistula treated by endorectal advancement flap: report of two cases and literature review. SPRINGERPLUS 2015; 4:21. [PMID: 25694858 PMCID: PMC4325007 DOI: 10.1186/s40064-015-0799-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/06/2015] [Indexed: 01/15/2023]
Abstract
Introduction Rectovaginal fistula (RVF) sometimes has a difficulty in treatment. This report describes two patients who suffered from RVF. Case descriptions One patient was a 76-year-old woman who had a RVF over 30 years after the 3rd childbirth. She underwent endorectal advancement flap (ERAF). She had a nighttime soiling after ERAF once a month, which disappeared one year after surgery. Second patient was a 23-year-old woman who had a RVF one month after the first childbirth. She underwent ERAF, and did not have any complications. Discussion and evaluation Both patients did not develop recurrence for four years. Quality of life after ERAF was satisfactory in both patients. ERAF is a safe procedure in terms of both short and long outcomes. We also present a review of the literature concerning ERAF for RVF. Conclusions ERAF can be a potential option as a treatment for RVF.
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Affiliation(s)
- Hirotoshi Kobayashi
- Center for Minimally Invasive Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519 Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Puborectal sling interposition combined with seton drainage for pouch-vaginal fistula after rectal cancer surgery with colonic J pouch-anal reconstruction: report of a case. Int Surg 2014; 99:710-3. [PMID: 25437575 DOI: 10.9738/intsurg-d-13-00187.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The management of postoperative rectovaginal fistula (RVF) after rectal cancer surgery is difficult and requires reconstruction of the anastomotic site and fistula. Though various surgical procedures have been reported for the repair of RVFs, the results of surgical repair are often unsatisfactory, and failure of the initial repair leads to difficulty in the later operations. Furthermore, it has been reported that cases associated with local infection result in low success rates. We report a case of an 80-year-old woman with a recurrent colonic J pouch-vaginal fistula after anoabdominal rectal resection with partial internal sphincteric resection, who achieved a good outcome following a repair using a puborectal sling interposition combined with seton drainage. It may be a useful option for RVF management in repair of such pouch-vaginal fistula after coloanal anastomosis with intersphincteric resection.
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