Spontaneous rectovaginal fistula and repair using bulbocavernosus muscle flap

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

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.

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

BACKGROUND

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

INTERVENTION(S)

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Minimally invasive treatment of rectovaginal fistula

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Martius advancement flap for low rectovaginal fistula: short- and long-term results

AIM

Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short- and long-term results of the Martius flap procedure.

METHOD

Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined.

RESULTS

Crohn's disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn's disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2-31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right-sided flap was associated with a higher success rate (P = 0.0442).

CONCLUSION

The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.

Innovative technique for the closure of rectovaginal fistula using Surgisis mesh

BACKGROUND

The aim of this prospective study was to analyse the efficacy of Surgisis mesh for closure of rectovaginal fistulas. Prospective data were collected from two centres.

METHODS

All patients with a rectovaginal fistula who underwent definitive surgery using Surgisis mesh were prospectively enrolled in this study. Inclusion criteria included a rectovaginal fistula in the lower two-thirds of the rectovaginal septum. Surgery was performed with a standardized technique including combined transrectal and transvaginal excision of the rectovaginal fistula with transvaginal placement of the mesh. Success was defined as closure of both internal and external (perianal and vaginal) openings, absence of drainage without further intervention, and no abscess formation.

RESULTS

Over a period of 16 months, a total of 21 mesh procedures were performed in two centres. The mean age of the patients was 47 years (18-59 years). Of the 21 patients, 18 (86%) had recurrent rectovaginal fistula, and the mean number of prior attempts was 2.3 (0-8). The majority of patients (nine) had Crohn's disease-associated fistula, followed by six with iatrogenic fistula, two with radiation-induced fistula, two with obstetric injury-induced fistula, and two with idiopathic fistula. The mesh procedure was performed under faecal diversion in eight patients (38%). The mean operative time was 38 min; no intraoperative morbidity occurred. Patients were discharged from hospital on day 4. After a mean follow-up of 12 months (range, 3-18 months), the overall success rate after primary mesh procedure was 71% (15/21; 6 patients had failure or recurrence). All patients with failure or recurrence were reoperated upon. Out of these six patients who were reoperated upon, four had definite healing (75%). Among the eight patients who had faecal diversion, four (50%) had reversal of their stoma.

CONCLUSION

The preliminary success rate for this innovative technique using Surgisis mesh for the closure of rectovaginal fistulas is promising. Further studies are needed to assess the definite role of this novel technique in comparison to traditional surgical procedures.

Benign rectovaginal fistulas: management and results of a personal series

BACKGROUND

Treatment of benign rectovaginal fistula has a high failure rate and entails difficult decisions. The purpose of this retrospective study was to clarify the concepts which may improve its management.

METHODS

Between 1983 and 2004, 46 consecutive women of median age 41 years were treated by the same surgeon. Etiology of simple fistulas was iatrogenic (n=6), obstetric (n=4) and septic (n=3). Complex fistulas were due to inflammatory bowel diseases (IBD) (n=18, 11 pouchvaginal) or were iatrogenic (n=9), actinic (n=5) or septic (n=1). Surgical techniques included endorectal or vaginal advancement flaps, fistulectomy and sphincteroplasty, vaginal/rectal closure and epiploplasty, restorative proctectomy and restorative proctocolectomy. In 20 patients, a diverting stoma was performed as a single procedure or concomitant to the curative attempt.

RESULTS

Overall, 33 of the 39 fistulas (85%) treated for cure healed, including all simple fistulas and 20 complex fistulas (8 iatrogenic, 3 actinic, 2 ulcerative colitis without restorative proctocolectomy; 5 pouch vaginal; 1 septic; 1 Crohn's disease) (p=0.009). The first operation for the fistula was curative in 20 of 39 fistulas, including 10 of 13 simple and 10 of 26 complex fistulas (p=0.023). There was no significant age difference between cured and not-cured patients.

CONCLUSIONS

Simple versus complex fistulas is the most determinant factor for healing. In IBD fistulas, ulcerative colitis shows better prognosis than Crohn's disease. For complex fistulas, a temporary diverting stoma seems necessary.

Martius flap: an adjunct for repair of complex, low rectovaginal fistula

BACKGROUND

Complex, rectovaginal fistula (RVF) are uncommon but difficult therapeutic problems. Local repair and flap advancement techniques have a high incidence of recurrence with poor functional outcomes. Transperineal repair with anal sphincter reconstruction, when indicated, and placement of a Martius flap (bulbocavernosus pedicled transplant) result in improved rates of repair and better functional outcomes.

METHODS

A consecutive series of patients were retrospectively reviewed from a prospective database between 2002 and 2006. Data were gathered from 2 colon- and rectal-specialty practices. Patient demographics and operative and functional outcomes were documented.

RESULTS

Sixteen patients with a mean age of 39.5 years (17-62) were treated. Etiology of the fistula was obstetric (9), cryptoglandular (5), and Crohn's disease (2). They had undergone a mean of 1.5 (0-4) prior repairs, and 6 had a preexisting diverting stoma before repair. Preoperatively, anal sphincter disruption was identified in 11 patients, and fecal incontinence was identified in 5 patients all with anal sphincter disruption. Dyspareunia was identified in 1 of 13 sexually active patients preoperatively. At a mean follow-up of 75 weeks (24-190), 1 recurrent fistula was identified (6.2%). Stomas were reversed in all patients. Two patients complained of fecal incontinence postoperatively. Five patients had dyspareunia postoperatively (5/16, 31%). One patient had a labial wound complication requiring local wound care.

CONCLUSION

Selected complex RVF can be reliably repaired with good functional outcomes using the Martius flap with anal sphincter reconstruction. Persistent or recurrent fecal incontinence and dyspareunia are common sequela of the underlying perineal injury and repair. No acute or delayed morbidity related to the Martius flap was identified.