Simple rectovaginal fistulas

Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice

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.

Minimally invasive endoscopic repair of rectovaginal fistula

BACKGROUND

Surgical techniques for repair of rectovaginal fistula (RVF) have been continually developed, but the ideal procedure remains unclear. Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting.

AIM

To review the current applications and preliminary outcomes of this technique for RVF repair, aiming to give surgeons an alternative in clinical practice.

METHODS

Available articles were searched according to the search strategy. And the sample size, fistula etiology, fistula type, endoscopic repair approaches, operative time and hospital stay, follow-up period, complication and life quality assessment were selected for recording and further analysis.

RESULTS

A total of 11 articles were eventually identified, involving 71 patients with RVFs who had undergone endoscopic repair. The principal causes of RVFs were surgery (n = 51, 71.8%), followed by obstetrics (n = 7, 9.8%), inflammatory bowel disease (n = 5, 7.0%), congenital (n = 3, 4.2%), trauma (n = 2, 2.8%), radiation (n = 1, 1.4%), and in two patients, the cause was unclear. Most fistulas were in a mid or low position. Several endoscopic repair methods were included, namely transanal endoscopic microsurgery, endoscopic clipping, and endoscopic stenting. Most patients underwent > 1-year follow-up, and the success rate was 40%-93%, and all cases reported successful closure. Few complications were mentioned, while postoperative quality of life assessment was only mentioned in one study.

CONCLUSION

In conclusion, endoscopic repair of RVF is novel, minimally invasive and promising with acceptable preliminary effectiveness. Given its unique advantages, endoscopic repair can be an alternative technique for surgeons.

Surgical treatment of deep-lying ano-/rectovaginal fistulas using a de-epithelialized “Singapore flap” (pudendal thigh flap)

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.

Surgical treatment of rectovaginal fistula-predictors of outcome and effects on quality of life

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.

Rectovaginal Fistula in Women With Pessary for Pelvic Organ Prolapse: A Case Series and Literature Review

OBJECTIVE

In this study, we present a series of 2 cases of rectovaginal fistula (RVF) due to the use of a ring-type pessary in the conservative treatment of pelvic organ prolapse and a literature review on the management of RVF related to the use of pessaries.

METHODS

Two patients were selected from the medical records of the urogynecology service, and their demographic and clinical data were retrieved. An updated literature review was included presenting cases of RVF induced by or after use of a pessary.

RESULTS

Both patients evolved with removal of the pessary and correction of the fistula. The surgical procedures of choice were Le Fort Colpocleisis and posterior colporraphy without major complications. In the literature review, we selected 17 studies with a total of 23 cases reporting RVFs induced or followed by the use of pessaries.

CONCLUSIONS

Although the pessary is commonly indicated for the conservative treatment of pelvic organ prolapse, this device is not exempt from generating complications.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Treatment of Rectovaginal Fistula Using Sphincteroplasty and Fistulectomy

Aim

To assess the results of the treatment of rectovaginal fistulas with incontinence and impaired anal tonus.

Materials and Methods

This study comprised three rectovaginal fistula groups that were treated using sphincteroplasty and fistulectomy: group 1: eight women with simple rectovaginal fistula due to birth trauma; group 2: six rectovaginal fistula cases that were associated with chronic inflammatory diseases; and group 3: five cases with at least one failed repair attempt. In the second step, operations that took place before the year 2000 were compared to the operations that took place after the year 2000 in terms of demographic and clinical characteristics.

Results

All of the simple rectovaginal fistula cases healed after the operation. Five of the group 2 patients healed after the operation. However, 1 patient with Crohn's disease needed to undergo reoperation, but successfully healed after 6 months. On the contrary, 3 patients in group 3 healed (60%) whereas 2 of them failed to heal. Clinical characteristics of the patients were different between the groups (before and after the year 2000).

Conclusion

The choice of operation must be done according to the patient's underlying pathology. Proper management of associated inflammatory diseases and systemic disorders is recommended for necessary complex cases.

Outcomes of Rectovaginal Fistula Repair

OBJECTIVES

Rectovaginal fistulae (RVF) often represent surgical challenges, and treatment must be individualized. We describe outcomes after primary surgical repair stratified by fistula etiology and surgical approach.

METHODS

This retrospective cohort study included women who underwent surgical management of RVF at a tertiary care center between July 1, 2001 and December 31, 2013. Cases were stratified according to the following etiology: cancer (RVF-C), inflammatory bowel disease or infectious (RVF-I), and other (RVF-O). Patients with prior surgical treatment of RVF were excluded. Surgical approaches included local (seton, plug), transvaginal or endorectal, abdominal, diversion alone, or definitive (completion proctocolectomy with permanent colostomy or pelvic exenteration). Recurrence-free survival was estimated using the Kaplan-Meier method, and comparisons between subgroups were evaluated based on fitting Cox proportional hazards models. Censoring occurred at last relevant clinical follow-up. Factors contributing to recurrence-free survival were evaluated including age, body mass index, smoking status, fistula etiology, ileostomy, and surgical approach.

RESULTS

During the study period, 107 women underwent surgical repair of RVF. The most common fistula etiology was RVF-I (54.2%), followed by RVF-O (23.4%), and RVF-C (22.4%). Ninety-four women underwent fistula repair by the local (29.9%), transvaginal/endorectal (25.2%), abdominal approach (19.6%), or diversion alone (13.1%), whereas 13 underwent definitive surgery (12.2%). Recurrence-free survival was significantly different depending on surgical approach (P < 0.001), but not etiology (P = 0.71). Recurrence-free survival (95% confidence interval) at 1 year after surgery was 35.2% (21.8%-56.9%) for the local approach, 55.6% (37.0%-83.3%) for the transvaginal or endorectal approach, 95% (85.9%-100%) for the abdominal approach, and 33.3% (15%-74.2%) for those with diversion only.

CONCLUSIONS

Recurrence rates after RVF repair are high and did not differ by fistula etiology. Abdominal repair of RVF had significantly fewer recurrences.

Updates on the diagnostic tools for evaluation of pelvic floor disorders

PURPOSE OF REVIEW

Pelvic floor disorders are common and cause significant morbidity for women. Recent advances in the evaluation of women with pelvic floor dysfunction have improved diagnostic accuracy and, with the development and use of validated patient-reported outcomes, has improved measurement of outcomes important to patients. We describe recent advances in the evaluation and measurement of pelvic floor disorders (PFDs).

RECENT FINDINGS

We describe recent developments in pelvic floor assessment of women with pelvic floor dysfunction.

SUMMARY

Complex integration of multiple anatomic structures and their function are necessary for pelvic floor function. Although the pillars of a complete assessment are a thorough history and physical exam, diagnostic tools can aid in fleshing out the correct and complete analysis of the patient suffering from PFDs.

Management of rectovaginal fistulas and patient outcome

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.

Repair of a recurrent traumatic rectovaginal fistula using vaginal wall plication to reinforce a rectal wall advancement flap

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.

Stable gastric pentadecapeptide BPC 157 heals rectovaginal fistula in rats

AIM

Rectovaginal fistula is a devastating condition providing more than 99% of patients for surgical treatment. We hypothesized that rectovaginal fistula may be healed by therapy with stable gastric pentadecapeptide BPC 157, in consistence with its initial clinical application and effect on external fistulas.

MAIN METHODS

BPC 157 (10μg/kg or 10ng/kg) was given perorally, in drinking water (0.16μg/ml or 0.16ng/ml, 12ml/rat/day) till sacrifice, or alternatively, intraperitoneally, first application at 30min after surgery, last at 24h before sacrifice. Controls simultaneously received an equivolume of saline (5.0ml/kg ip) or water only (12ml/rat/day). The assessment (i.e., rectal and vaginal defect, fistula leakage, defecation through the fistula, adhesions and intestinal obstruction as healing processes) was at day 1, 3, 5, 7, 10, 14 and 21.

KEY FINDINGS

Regularly, rectovaginal fistulas exhibited poor healing, with both of the defects persisting, continuous fistula leakage, defecation through the fistula, advanced adhesion formation and intestinal obstruction. By contrast, BPC 157 given perorally or intraperitoneally, in μg- and ng-regimens rapidly improved the whole presentation, with both rectal and vaginal defects simultaneously ameliorated and eventually healed. The maximal instilled volume was continuously raised till the values of healthy rats were achieved, there were no signs of defecation through the fistula. A counteraction of advanced adhesion formation and intestinal obstruction was achieved. Microscopic improvement was along with macroscopic findings.

SIGNIFICANCE

BPC 157 effects appear to be suited to induce a full healing of rectovaginal fistulas in rats.

Large rectovaginal fistula due to a cube pessary despite routine follow-up; but what is 'routine'?

Vaginal pessaries are generally considered a safe and effective form of management for pelvic organ prolapse. Serious complications such as rectovaginal fistula can develop with or without regular follow-up. This case report describes the rapid development over a 10-week period of a large rectovaginal fistula in a 75-year-old woman, despite routine follow-up and replacement of her cube pessary. Currently, there is a lack of evidence-based guidelines for pessary care and, in particular, the frequency of pessary replacement. Intervals for pessary replacements vary greatly and are often based on the manufacturer's recommendations. This case highlights the rapidity at which serious complications can develop and also represents the first reported case of a cube pessary-induced rectovaginal fistula.

German S3-Guideline: rectovaginal fistula

Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease.

Methods: A systematic review of the literature was undertaken.

Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction).

Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well.

Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient.

Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.

Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients

AIM

The aim of this study is to prospectively evaluate 40 patients with a high rectovaginal fistula treated by a laparoscopic fistula division and closure, followed by an omentoplasty.

PATIENTS AND METHODS

Forty patients with a rectovaginal fistula, between the middle third of the rectum and the posterior vaginal fornix, resulting from different causes (IBD, iatrogenic and birth trauma) were treated by a laparoscopic excision of the fistula and insertion of an omentoplasty in the rectovaginal septum. The patients completed the gastrointestinal quality of life index questionnaire (GIQLI) and the Cleveland Clinic incontinence score (CCIS). All tests were performed at regular intervals after treatment.

RESULTS

In 38 (95%) patients with a median age of 53 years (range 33-72), the surgical procedure was feasible. In two patients, the fistula was closed without an omentoplasty, and a diverting stoma was performed. The median follow-up was 28 months (range 10-35). Two patients (5%) developed a recurrent fistula. In one patient, the interposed omentum became necrotic and was successfully treated laparoscopically. In another patient, an abscess developed, which needed drainage procedures. The mean CCIS was 9 (range 7-10) before treatment and 10 (range 7-13) after treatment (p = 0.5 Wilcoxon). The median GIQLI score was 85 (range 34-129) before treatment and 120 (range75-142) after treatment (p = 0.0001, Wilcoxon).

CONCLUSIONS

Laparoscopic fistula excision combined with omentoplasty is a good treatment modality with a high healing rate for high rectovaginal fistulas and an acceptable complication rate.

Are there predictors of outcome following rectovaginal fistula repair?

BACKGROUND

Rectovaginal fistula is a distressing condition for patients and for physicians who are continuously challenged in providing durable treatment options. The aim of this study is to assess the results of rectovaginal fistula repair and identify predictive factors for poor outcome.

METHODS

Retrospective analysis of patients who underwent rectovaginal fistula repair from 1988 to 2008 was performed. chi tests and logistical regression analysis were used to study treatment outcomes according to the following fistula characteristics: etiology, size, location, and number of prior attempts at fistula repair. In addition, patient factors such as age, body mass index, smoking history, comorbid condition of diabetes, use of steroid and immunosuppressive medications, number of prior vaginal deliveries, and presence of a diverting stoma were analyzed.

RESULTS

A total of 184 procedures were performed in 125 patients. Inflammatory bowel disease was the most common indication for surgery (45.6%), followed by obstetric injury (24%) and surgical trauma (16%). The mean duration of fistula presence was 31.2 months. The procedures performed included endorectal advancement flap (35.3%), gracilis muscle interposition (13.6%), seton placement (13.6%), and transperineal (8.7%) and transvaginal repair (8.1%). The overall success rate per procedure was 60%, with no difference in recurrence rates based on the type of repair. Patients with Crohn's disease had more recurrent fistulas (44.2% success per procedure; P < .01), although 78% eventually healed after an average of 1.8 procedures. Patients with obstetric injuries had an 89% success rate after an average of 1.3 procedures per patient, which is similar to the success rate for traumatic fistulas. Pouch vaginal fistulas had a 91% success rate after an average of 1.6 procedures per patient. The overall success rate per patient was 88% after multiple procedures with a mean follow-up of 16.3 months. Age, body mass index, diabetes, use of steroids and immunosuppressive agents, size and location of the fistula, number of vaginal deliveries, time interval between a recurrent episode and subsequent repair, and the presence of fecal diversion did not affect outcomes. The presence of Crohn's disease and a smoking history are strongly associated with rectovaginal fistula recurrence (P = .02).

CONCLUSIONS

Despite a relatively low initial success rate (60%), most rectovaginal fistulas can be successfully repaired with subsequent operations. Crohn's disease and smoking are associated with adverse outcomes.

Interposition of vital bulbocavernosus graft in the treatment of both simple and recurrent rectovaginal fistulas

OBJECTIVE

The objective of the study is to assess the efficacy of vital bulbocavernosus graft transposition in the treatment of rectovaginal fistula.

MATERIALS AND METHODS

From March 2003 to October 2007, nine consecutive patients diagnosed with rectovaginal fistula were refereed to our institute. All patients were treated using an interposing vital bulbocavernosus graft between rectum and vagina.

RESULTS

Median patient age was 33 years (range, 19-61) and seven of the nine patients had undergone between one and six fistula repair sessions prior to this grafting procedure. The etiology included congenital in three, surgery injury in four, obstetric in one, and radiation in one. No wound infections or abscesses occurred postoperatively, and the in-hospital mortality rate was zero. No recurrence was reported during the follow-up period and all patients had normal fecal continence. Only one patient had mild dyspareunia and no further surgical treatment needed.

CONCLUSION

Both simple and complex rectovaginal fistula can be reliably repaired using a bulbocavernosus graft.

Long-Term Outcome of Endorectal Advancement Flap for Complex Anorectal Fistulae

The purpose of this study was to determine the long-term outcome of endorectal advancement flap (ERF) for complex anorectal fistulae. A total of 38 ERF were performed in 36 patients (2003–2007). Mean age was 45 years. The most common fistula type was transsphincteric. Eighty-one per cent of patients had prior surgical interventions. Primary closure rate was 83 per cent. Of the six initial failures, four were noted in patients operated for recurrent rectovaginal fistula. Postoperative complications occurred in seven patients (19%). During a mean follow-up of 27 months, recurrent disease was noted in five patients (14%). All recurrences were noted in patients with left sided fistulae. At last follow-up, all patients had healed their fistula except for two. We conclude that ERF closed most complex anorectal fistulae with an acceptable complication rate and low recurrence rate. Recurrent rectovaginal fistula was associated with a lower closure rate.

Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients

BACKGROUND

The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas.

MATERIAL AND METHODS

A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral).

RESULTS

Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%.

CONCLUSION

The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Rectovaginal fistula: a new approach by stapled transanal rectal resection

Many surgical procedures have been developed to repair rectovaginal fistulas even if no "procedure of choice" is reported. The authors report a case of relatively uncommon, complex, medium-high post-obstetric rectovaginal fistula without sphincteral lesions and treated with a novel tailored technique. Our innovative surgical management consisted of preparing the neck of the fistula inside the vagina and folding it into the rectum so as to enclose the fistula within two semicontinuous sutures (stapled transanal rectal resection); no fecal diversion was performed. Postoperative follow-up at 9 months showed no recurrence of the fistula.

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.

Valor actual de la ecografía endoanal en el diagnóstico de la enfermedad proctológica benigna

Endoanal ultrasound is undoubtedly one of the major advances that has taken place in the evaluation of anorectal disease and pelvic floor disorders in the last decade. The main indications for endoanal ultrasound are evaluation of the morphology of the sphincteric apparatus in patients with fecal incontinence, the localization of perianal abscesses and fistulas, the staging of anal cancer and follow-up of squamous cell carcinoma after conservative treatment, and the study and morphological confirmation of lateral internal sphincterotomy in patients with fissure-in-ano, amongst others. In this article we review the main indications and use of endoanal ultrasound in the diagnosis of benign proctological disease.

Surgeon-performed ultrasound: endorectal ultrasound

Endorectal (ERUS) and endoanal (EAUS) ultrasound imaging is increasingly being performed by surgeons in the office and outpatient setting for the assessment of both benign and malignant disease. Multiple studies have demonstrated the accuracy of these modalities in identifying pertinent anatomy and anatomic abnormalities. The ultrasound is easily tolerated by most patients, and is easily performed with minimal preparation on the patient's part. The ability of the surgeon to perform and interpret this straight forward diagnostic procedure allows for the simplification of the diagnostic process and a more rapid determination of treatment options for the patient.

Anovaginal Fistulas: Evaluation with Endoanal MR Imaging

PURPOSE

To evaluate endoanal magnetic resonance (MR) imaging in the assessment of anovaginal fistulas and associated findings.

MATERIALS AND METHODS

In a retrospective descriptive study, two radiologists systematically reviewed MR findings in 20 patients with a clinically proved anovaginal fistula and looked for the main fistula tract, the internal opening in the anal canal and/or vagina, secondary fistula tracts, abscesses within the rectovaginal septum, and sphincter damage. Interobserver variability was calculated, and clinical records were searched for possible underlying causes that could explain the complexity of anovaginal fistulas. The kappa value was calculated. Patients with or without a complex anovaginal fistula were compared in regard to the presence of any underlying disease or condition. Statistical significance was calculated with the Fisher exact test.

RESULTS

In all 20 patients, anovaginal fistulas were identified on T2-weighted MR images as predominantly high-signal-intensity linear abnormalities extending between the anal canal and the vagina. In all patients, the fistulas were typically located in the sagittal plane, and the mean distance from the anal verge to the fistula was 25.0 mm (range, 13-32 mm). The internal opening in the anal canal was detected in all patients. The internal opening in the vagina was detected in 19 (95%) patients. In seven (35%) patients, an anovaginal fistula with an additional abnormality was found and included an abscess within the rectovaginal septum (n = 1), a perianal fistula (n = 3), and a perianal fistula in combination with an abscess (n = 3). Defects of the external anal sphincter were present in three (15%) patients. There was complete agreement between observers for all items on endoanal MR images, except for the presence of secondary fistula extensions (agreement, 90%; kappa, 0.74). History of obstetric trauma, pelvic floor surgery, or Crohn disease was present in 10 (50%) patients. Of these patients, six (60%) had a complex anovaginal fistula and four (40%) had a simple anovaginal fistula. In the remaining 10 patients without relevant medical history, one (10%) had a complex anovaginal fistula. This difference tended toward statistical significance (P =.057).

CONCLUSION

Endoanal MR imaging allows evaluation of anovaginal fistulas and additional abnormalities, such as abscesses within the rectovaginal septum, secondary perianal fistula tracts, and sphincter damage.