Congenital anal fistula with normal anus

Perineal canal repair using modified Tsuchida’s technique

Background

The perineal canal is a rare variety of anorectal malformations, identified by different nomenclatures like H fistula, double termination of the alimentary canal, and anovestibular fistula. Various approaches to repair this anomaly have been proposed.

The present study aimed to review the results of perineal canal repair with modified Tsuchida’s technique, in seven girls treated in our unit between 2014 and 2019. These were classified as acquired and congenital type of perineal canal, depending upon their clinical presentations.

Results

Of the total seven cases, it was found that three of them had a perineal abscess and persistent anovestibular fistula formation, and they underwent definitive repair of the perineal canal after 12 weeks as they did not respond to the conservative management. Four girls had congenital anovestibular fistula without infection. All the patients underwent covering colostomy and definitive repair by modified Tsuchida’s technique. One patient had a recurrence of the fistula, due to early closure of colostomy and underwent redo repair. One patient with known immune deficiency died before colostomy closure due to severe sepsis. During the last follow-up, all six girls were continent (Kelly’s score 6/6), and the perineum had healed well.

Conclusion

The perineal canal can be acquired or congenital. Irrespective of its etiology, modified Tsuchida’s technique has been found to be an easy and satisfactory method of its repair.

Diversities of H-type anorectal malformation: a systematic review on a rare variant of the Krickenbeck classification

Congenital H-type fistula is a rare congenital rectourogenital connection with an external anal opening in a normal or ectopic position. A systematic review was done to study the anatomical types of congenital H-type fistula, embryology, clinical presentation, relative gender distribution, associated anomalies, investigative modalities, and recent advances in treatment of these lesions. A PubMed search included H-type anorectal malformation; H-type anorectal malformations; H-type anorectal; and H-type congenital anorectal that gave 9;43;76;26 abstracts, respectively. Relevant studies and cited articles were studied omitting duplicate search. The reported incidence is 0.1-16 % of all anorectal malformation. The H-type anorectal malformation is 2.5-6 times more common in females and usually associated with a normal anus. In males, the anomaly is usually a variant with an ectopic anus or a perineal fistula. Anatomical types include anovestibular; rectovestibular; rectovaginal fistula in females and rectourethral (bulbar, prostatic, bladder neck) and rectovesical fistula in males. Variants identified include H-type fistula with perineal fistula, perineal groove, H-type sinus, H-type canal, and acquired H-type fistula. This review compiles the available literature over last six decades. Various surgical corrective procedures have been described. The high recurrence decreases with a learning curve and experience.

The surgical management of H-type rectovestibular fistula: a case report and brief review of the literature

H-type rectovestibular fistula is a rare anorectal malformation with poor consensus on an optimal operative management. We report our management of a recurrent fistula and review previously described operative techniques. Full excision of the tract without apposing suture lines or perineal body dissection simplifies the repair while minimizing complications and recurrence risk.

Perineal canal: a special entity of anorectal malformations in Vietnam

PURPOSE

We report our clinical experience with the perineal canal and suggest the management.

MATERIALS AND METHODS

Retrospective chart review of patients with perineal canal were classified by lesion characteristics into Group I: active perineal inflammation, Group II: vulvar excoriation and Group III: no active inflammation. Group III patients underwent primary surgical repair. Group I and II patients underwent repair after medical management. The fistula was repaired by the modified Tsuchida's technique consisting of an anterior anopullthrough and excision of the fistula tract (reverse order).

RESULTS

Between September 1999 and August 2003, we treated 120 cases of perineal canal. Group I, II and III consisted of 74, 12 and 34 patients, respectively. In two patients of Group I (2.7%), the fistula tract spontaneously closed. The remaining 118 patients were surgically treated with the modified Tsuchida's technique. Recurrences were similar between patients treated with colostomy (1/28 or 3.6%) versus without colostomy (3/90 or 3.0%), as well as between patients initially treated with primary repair (3/102 or 2.9%) versus patients undergoing reoperation with redo repair (1/16 or 6.25%).

CONCLUSIONS

With proper initial medical treatment, the perineal canal could be repaired successfully in one stage with the modified Tsuchida's technique.

Anovestibular fistula with normal anal opening: Is it always congenital?

Aim:

To review 12 cases of anovestibular fistula with normal anal opening.

Methods:

Retrospective analysis of 12 children with anovestibular fistula and normal anal opening were treated between the years 2000 and 2007. Of these, 11 patients were diagnosed as having acquired anovestibular fistula with normal anal opening and were managed by conservative management.

Results:

Most of them presented with diarrhea and labial redness. One patient was considered to have fistula of congenital origin and was managed surgically. Eleven patients presented between the ages of 1.5–11 months and were considered as cases of acquired anovestibular fistula and only two of them required surgical management in the form of colostomy and fistula excision. Others were successfully managed by conservative treatment; the fistulous output and labial redness decreased gradually within a period of 5–19 (average 11.5) days.

Conclusions:

Not all presentations of anovestibular fistula with normal anal opening can be considered as congenital. Presence of inflammation, paramedian fistula, and a favourable response to conservative management/colostomy suggest acquired etiology. Trial of conservative management should be given in the acquired variety.

Anovestibular fistula with normal anus

PURPOSE

The purpose of the study was to review a rare anomaly of anorectal malformations in girls, congenital anovestibular fistula (AVF) with normal anus, over a 12-year period.

MATERIALS AND METHODS

A total of 24 female patients of AVF with normal anus were treated in the Department of Pediatric Surgery, Chittagong Medical College and Hospital, Chittagong, Bangladesh, from January 1994 to June 2006. Clinical features, operative findings, operative procedures, postoperative complications, and outcomes were analyzed.

RESULTS

Age ranged from 1 day to 7 years (mean, 10.5 months). All 24 female patients presented with passage of stools through 2 perineal openings. In addition, vulvar abscesses were noted in 5 cases. Vestibular opening of the fistula was found behind the vagina in 18 patients, and the anal opening of the fistula was on the anterior anal wall above the dentate line in 20 cases. There were no associated abnormalities. After adequate bowel preparation, 22 patients underwent excision of the fistulous tract with reconstruction of anal wall without a diverting colostomy. All 5 patients with vulvar abscess experienced wound disruption and required reoperation. All 24 girls have normal bowel motions at follow-up.

CONCLUSIONS

In the management of AVF with normal anus, primary repair without colostomy is a safe option. In cases of abscess or infection, definitive operation should be deferred until adequate healing is achieved.

Recto-vestibular disruption defect resulted from the malpractice in the treatment of the acquired recto-vestibular fistula in infants

AIM: To explore the pathogenesis of the rectovestibular disruption (RVD) defect and to recommend a successful repair, and prevention of it.

METHODS: Clinical records of 15 girls, age ranged from 3 to 15 (median, 7.5) years, with acquired rectovestibular fistula (RVF) mistreated before were retrospectively reviewed. All of them presented an abnormal appearance of perineum and were suffering from some degree of fecal incontinence, and those were graded III to IV by Li Zheng’s Score. Repair of anal sphincters and reconstruction of perineum body and skin by anterior perineal rectoanoplasty were performed in all cases.

RESULTS: Operation in all cases was successful. The perineum looked practically normal and fecal continence score rose up to VI by Li Zheng’s Score.

CONCLUSION: The conventional treatment for anal fistula, lay-open or string-treatment, should be considered as malpractice of RVF, and certainly leads to the RVD defect, and the anterior perineal rectoanoplasty could cure it satisfactorily.

Congenital H-type anovestibuler fistula

The congenital H-type fistula between the anorectum and genital tract besides a normal anus is a rare entity in the spectrum of anorectal anomalies. We described a girl with an anovestibuler H-type fistula and left vulvar abscess. A 40-day-old girl presented symptoms after her parents noted the presence of stool at the vestibulum. On the physical examination, anus was in normal location and size, and had normal sphincter tone. A vestibuler opening was seen in the midline just below of the hymen. A fistulous communication was found between the vestibuler opening and the anus, just above the dentate line. There was a vulvar abscess which had a left lateral vulvar drainage opening 15 mm left lateral to the perineum. After the management of local inflammation and abscess, the patient was operated for primary repair of the fistula. A protective colostomy wasn’t performed prior the operation. A profuse diarrhea started after 5 hours of postoperation. After the diarrhea, a recurrent fistula was occurred on the second postoperative day. A divided sigmoid colostomy was performed. 2 months later, and anterior sagital anorectoplasty was reconstructed and colostomy was closed 1 month later. Various surgical techniques with or without protective colostomy have been described for double termination repair. But there is no consensus regarding surgical management of double termination.

Surgical repair of rectovestibular fistula with normal anus

PURPOSE

The aim of this study was to evaluate the authors' surgical approach and technique in patients with congenital rectovestibular fistula with a normal anus (CRF).

METHODS

During the period between 1981 and 1995, 19 girls from 2 months to 13 years of age were treated surgically for CRF by a primary perineal approach. After appropriate bowel preparation, the patient was placed in a lithotomy position. A probing catheter was placed in the fistula. A perineal transverse skin incision was made on the midpoint between the posterior commissure and the anus, and the underlying tissue was dissected. The fistula was divided, and the both ends were closed by interrupted sutures. The external sphincter muscle was mobilized to interpose between the vestibular and rectal stumps of the fistula. Postoperative feeding was begun on day 6.

RESULTS

A protecting colostomy was created in the early 4 patients. Fifteen patients underwent a primary fistula division without colostomy. In those without colostomy, 1 patient had a reopening of the fistula 6 days after the primary repair. In this patient, colostomy was created, and the fistula was divided 6 months later by the same approach. After a follow-up of 3 to 17 years, all patients have normal bowel habit.

CONCLUSION

A primary perineal approach is appropriate for the treatment of CRF.

Congenital H-type anourethral fistula with severe urethral hypoplasia: case report and review of the literature

Congenital H-type anourethral fistula with severe urethral hypoplasia and normal anus is an extremely rare variant of anorectal malformations among boys. The authors report a case of a 5-year-old boy who underwent successful management of severe urethral hypoplasia with progressive augmentation by dilating urethra anterior gently and achieving a functionally normal urethra with minimal morbidity. H-type anourethral fistula was excised subsequently through anterior perianal approach.

Management of congenital and acquired H-type anorectal fistulae in girls by anterior sagittal anorectovaginoplasty

METHODS

Thirteen girls with congenital or acquired H-type anorectal fistulae underwent surgery between 1991 and 1996. In all cases, besides a normally placed anal canal, there was a fistulous communication between the anorectum and the genital tract. On the basis of the level of fistulous communication, these cases were divided into three groups: high, intermediate, and low (perineal canal). All patients underwent anterior sagittal anorectovaginoplasty. Surgical technique included division of all intervening tissue in midline between the perineal skin and the fistula. The whole fistulous tract was excised, and the remaining surrounding tissue was repaired in different layers. Of 13 patients, 12 were operated on without a protective colostomy.

RESULTS

There was no recurrence in any case, and all patients had good cosmetic results with a normal sphincter control. Although various techniques have been suggested for the surgical correction of H-type anorectal fistulae, most of them are applicable only to the low-lying fistula (perineal canal).

CONCLUSIONS

To date, there is no satisfactory method available for correction of high fistula. The methods suggested for high fistula (abdominoperineal pull-through and endorectal pull-through) appear to be too extensive for this condition. Our technique of anterior sagittal anorectovaginoplasty can be used not only for low fistula but can also be used for intermediate and high types of fistulae. This technique is simple, safe, takes less time, and achieves good anatomic and functional reconstruction of the perineum.

Management of perineal canal anomaly

A 6-year-old girl presented due to passage of stool through her vulva since birth. Examination revealed a fistulous tract between vestibule of the vagina and an otherwise normally formed anal canal. The tract was successfully excised through an anterior sagittal approach with a defunctioning sigmoid colostomy, which was closed 12 weeks later. The embryology, morbid anatomy, and treatment of this rare congenital anomaly are discussed along with a review of the literature.

Anorectal malformation: a new anatomic variant resembling an H-type fistula

A new anatomic variant of an anorectal malformation resembling an H-type fistula was observed in a newborn girl. This variant consisted of a high-grade stenosis of the anal canal below the level of the levator muscle with a blind-ending fistulous tract originating from the stenotic segment and running toward the posterior wall of the vestibulum. The embryogenesis of this malformation remains to be seen.

H-type anorectal malformations: incidence and clinical characteristics

To establish the incidence of H-type anorectal malformations (ARM), the hospital records of 629 patients with ARM were studied. Patients who had a congenital rectourogenital connection and an external anal opening in a normal or ectopic position were considered to have an H-type malformation. Twenty (3.2%; 14 females, 6 males) of the 629 patients studied had an H-type ARM. Major associated anomalies were found in 60% of these patients. Thirteen patients (12 females, 1 male) had a normally placed anus; the H fistula was low rectovestibular in 10, rectovaginal in 2, and rectourethral in 1. Seven patients had an ectopic anal opening. Three males had a rectourethral H fistula; in two of these there was a double fistula. Two males had a rectovesical H fistula. Of the two females with ectopic anal openings, one had a high rectovaginal H fistula and the other had a low fistula. In only one case was the diagnosis of H fistula made immediately after birth. Three patients died of severe cardiac abnormalities during the neonatal period or early infancy. Primary perineal repair or a limited posterior surgical anorectoplasty (PSARP) was used in 15 cases; formal PSARP was used for the other two. Four patients had between one and 4 recurrences; all but one of these fistulas were repaired subsequently. Long term (median follow-up period, 12 years; range, 4 to 38 years), 12 patients had good bowel function and no faecal soiling; four of these had constipation that was manageable with laxatives. Two patients (aged 10 and 12 years) had daily soiling. Two others were too young to evaluate, and one (with severe mental retardation) has a permanent colostomy.

The various types of anorectal fistula in male imperforate anus

The purpose of this paper is to provide a review of the anorectal fistulas occurring in male imperforate anus, with a suggested classification based on the site of termination of the fistula, namely, the bladder, the urethra, and the perineum. The fistulas included in these categories are discussed in some detail, with reference to previous cases or descriptions in the literature and with some personal observations.

Congenital urethral fistula with normal anus: a report of two cases

Congenital rectourethral or anourethral fistulae without imperforate anus in males are rare, representing less than 1% of anorectal malformations. We report our experience with two males with "N type" urethral fistulae. One, a 5-year-old boy, presented with recurrent urinary tract infections (UTIs) and passage of urine per anus. Investigations included a voiding cystourethrogram (VCUG), which demonstrated a fistula from the urethra to the anus. On physical examination, a small perianal opening was noted just outside the anus, which drained a small amount of urine after voiding. The fistula was excised via a perineal approach. The second patient is a 5-year-old boy with a long history of recurrent UTI requiring multiple hospitalizations since the newborn period. Chronic renal failure developed as a complication of repeated urinary tract infections. Investigations showed a single hydronephrotic pelvic kidney and a small bladder. He underwent numerous diagnostic and reconstructive procedures including cystoscopy and augmentation cystoplasty. Recurrent infections continued and an N type anourethral fistula was eventually diagnosed. The fistula was located between the anal canal and the membranous urethra. An anterior perineal approach was also used. Both fistulae were easily located, and reconstructive surgery of the urethra was not required. Postoperative VCUGs in both patients were normal. They have been free of infection with normal urinary continence since resection of the fistula. Congenital N type anourethral fistulae are rare, but should be considered in cases of recurrent urinary tract infections. The diagnosis may be missed by endoscopic procedures, but VCUG should demonstrate the fistulous tract.

Anal fistula

Anal fistula is a common cause of chronic irritation to both patients and surgeons. Treatment failure rates may be decreased by a good appreciation of normal anorectal anatomy and fistula pathoanatomy, as well as a wide and practical knowledge of the possible treatment regimens. The various treatment options available for acute abscesses as well as simple and complex anal fistulae are presented and discussed. Identification of the patient at risk of postoperative anal incontinence or of the difficult or high fistula may allow treatment in a specialized proctology unit.