Rectovaginal fistula: a new approach by stapled transanal rectal 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.

A new method to repair recto-vaginal fistula: Use of human amniotic membrane in an animal model

BACKGROUND

Recto-vaginal fistula is primarily one of the co-morbidities of vaginal delivery. These patients suffer from persistent malodor vaginal discharge. Various surgical techniques have been employed by surgeons in the course of time. This is the first trial of applying Human Amniotic Membrane (HAM) as a bio-prosthesis in repairing recto-vaginal fistula.

MATERIALS AND METHODS

In a prospective animal study, 8 mixed-breed female dogs weighing 23-27 kg with the age of 12-18 months were selected. They were randomly divided into two groups for standard recto-vaginal fistula repair and fistula repair with human amniotic membrane. The Kruskal-Wallis and Mann Whitney tests were performed to indicate statistical differences.

RESULTS

After 6 weeks, fistulas were evaluated both grossly and microscopically. In gross examination, there were no difference between the two groups and healing of fistula seemed to have been occurred in all dogs expect for one which had a persistent patent fistulous tract. Microscopic healing was scored according to epithelialization, collagenization inflammation, ulcer and necrosis of samples. Healing score was significantly higher in the HAM group than the standard group (P = 0.029).

CONCLUSION

Our findings revealed that using HAM as a bio-prosthesis to repair recto-vaginal fistula would result in better surgical and histological outcomes comparing to simple repair.

Rectovaginal fistula: a new technique and preliminary results using collagen matrix biomesh

BACKGROUND

A rectovaginal fistula (RVF) is a debilitating condition that is difficult to treat. Many available techniques are invasive and involve extensive surgery. A local procedure with good closure rates would be preferable as a first step in the treatment of RVF. The aim of this study was the development of a local technique for the closure of RVF with good closure rates to prevent the use of more invasive procedures.

METHODS

This was a pilot study. Patients with RVF who had undergone multiple operations in the pelvic area, local radiotherapy, chemotherapy or had been diagnosed with Crohn's disease were included in the study. All had a history of surgery for RVF. A cross-linked collagen matrix biomesh was placed in the rectovaginal septum using a transperineal or a transvaginal approach. The main outcome measure in this study was the closure rate reported as absence of the fistula at 1 year.

RESULTS

Twelve patients were included in the study. Absence of fistula at 1 year was 0.64 (95 % confidence interval 0.30-0.85). Three patients (25.0 %) developed a recurrence, two were reoperated on with a gracilis flap transposition, and one was treated with laparoscopic ligation. In one patient (8.3 %), the fistula failed to close within 3 months after the mesh placement.

CONCLUSIONS

Our technique shows promising results. A local and simple technique with acceptable closure and morbidity rates, like our local repair with biomesh, would be ideal as a first step in treating RVFs. Long-term results are needed.

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.

Results in the long-term course after stapled transanal rectal resection (STARR)

PURPOSE

Stapled transanal rectal resection (STARR) has recently been recommended for patients with obstructed defecation caused by rectocele and rectal wall intussusception. Our study investigates the long-term results and predictive factors for outcome.

METHODS

Between November 2002 and February 2007, 80 patients (69 females) were operated on using the STARR procedure and included in the following study. Symptoms were defined according to the ROME II criteria. Preoperative assessment included clinical examination, colonoscopy, video defecography, and dynamic MRI. Preoperatively and during follow-up visits, we evaluated the Cleveland Constipation Score (CCS) to rate the severity of outlet obstruction and the Wexner Incontinence Score to rate anal incontinence. Patients were asked to judge the outcome of the operation as improved or poor/dissatisfied. We performed a univariate analysis for 11 patient- and disease-related factors to detect an association with outcome.

RESULTS

The median follow-up was 39 months (range 20-78). Major postoperative complications (one staple line insufficiency, one urosepsis, one prolonged urinary dysfunction with indwelling catheter) were found in 3.8%. The result after STARR procedure was a success in the long-term follow-up in 62 patients (77.5%), although the improvement did not persist in 15 patients (18.7%). The mean value of the CCS decreased significantly from 9.3 before surgery to 4.6 after 2 years and increased again slightly to 6.5 after 4-6 years. The Median Wexner Incontinence Score was 3.3 at baseline, but rose significantly to 6.0. However, a third of patients who reported deteriorated continence developed the symptoms 1-4 years after surgery. Of the factors investigated for the prediction of outcome, we could only identify the number of pelvic floor changes in defecography or dynamic MRI as being associated with the success of the operation.

CONCLUSION

Our study indicates that STARR is a safe procedure. A significant improvement of symptoms is to be expected, but this improvement may deteriorate with time. Patients' satisfaction is also associated with the occurrence of urge to defecate or incontinence. It remains difficult to predict outcome.

Management of sexual assault-related large rectovaginal fistula in an eight-year-old

Rectovaginal fistula may be a complication sexual assault in children. Management of these cases could be daunting with possibilities of significant psychological and physical morbidity. An eight-year-old girl presented with vulvar fecal leakage from a large rectovaginal fistula two weeks after sexual assault. The child was managed by initial diverting colostomy and the fistula repair was carried out via a posterior sagittal approach. This report highlights significance of initial thorough evaluation in cases with suspected traumatic rectovaginal fistula, and demonstrates benefits of posterior sagittal approach in the definitive treatment of large-sized fistula.

Current treatment of rectovaginal fistula in Crohn’s disease

Rectovaginal fistula (RVF) continues to be the most difficult perianal manifestation of Crohn’s disease to treat. This devastating and disabling complication has a significant impact on patients’ quality of life and presents unique management challenges. Current therapeutic approaches include many medical therapeutics and surgical treatments with a wide range of success rates reported. However, current evidence is lacking to support any recommendation. The choice of repair depends on various patient and disease factors and basic surgical tenets. In this article, we review the current options to consider in the treatment of Crohn’s-related RVF, and try to evaluate their effects on fistulae closure and quality of life.

Transverse Singapore flap for reconstruction of a congenital rectovaginal fistula in an 18-month-old infant

Many different types of flaps have been used for reconstruction of rectovaginal fistulae. This is the first report of using a transverse Singapore flap for repairing a large 3 cm by 3-cm complex congenital rectovaginal fistula in an 18-month-old infant with VATER syndrome. A right transverse Singapore flap was used to reconstruct both the posterior wall of the vagina and the anterior wall of the rectum while simultaneously joining the 2 structures to the perineum. Despite minor postoperative delayed healing which resolved, the patient has maintained a functionally and cosmetically satisfactory result at 20-month follow-up. For complex rectovaginal fistulae reconstruction in the pediatric patient, the transverse Singapore flap is a reliable and viable option for the reconstructive surgeon.