Surgical repair of rectovestibular fistula with normal anus

HIV-associated rectovaginal fistulae in children: a single-centre retrospective study in the antiretroviral era

PURPOSE

Acquired rectovaginal fistulae (RVF) are a complication of paediatric HIV infection. We report our experience with the surgical management of this condition.

METHODS

We retrospectively reviewed the records of paediatric patients with HIV-associated RVF managed at Chris Hani Baragwanath Academic Hospital (2011-2023). Information about HIV management, surgical history, and long-term outcomes was collected.

RESULTS

Ten patients with HIV-associated RVF were identified. Median age of presentation was 2 years (IQR: 1-3 years). Nine patients (9/10) underwent diverting colostomy, while one demised before the stoma was fashioned. Fistula repair was performed a median of 17 months (IQR: 7.5-55 months) after colostomy. An ischiorectal fat pad was interposed in 5/9 patients. Four (4/9) patients had fistula recurrence, 2/9 patients developed anal stenosis, and 3/9 perineal sepsis. Stoma reversal was performed a median of 16 months (IQR: 3-25 months) after repair. Seven patients (7/9) have good outcomes without soiling, while 2/9 have long-term stomas. Failure to maintain viral suppression after repair was significantly associated with fistula recurrence and complications (φ = 0.8, p < 0.05).

CONCLUSION

While HIV-associated RVFs remain a challenging condition, successful surgical treatment is possible. Viral suppression is a necessary condition for good outcomes.

Transanal fistula repair for the treatment of rectovestibular fistula with normal anus in female children: a 5-year single-center experience

PURPOSE

The purpose of this study was to review a 5-year operative experience of transanal fistula repair for the treatment of rectovestibular fistula with a normal anus in female children.

METHODS

In this study, we conducted a retrospective review of children diagnosed with rectovestibular fistula with normal anus who underwent transanal fistula repair in the department of General Surgery, Children's Hospital of Chongqing Medical University. Clinical data were retrospectively analyzed.

RESULTS

A total of 56 female children were included in the study. The patients' ages ranged from 1 year 10 months to 15 years 11 months, with an average age of 5 years 1 month. These children had a clear history of gas or loose stool leakage through the vestibular area, with or without a history of vestibular infection. All patients had a normal anus and underwent transanal fistula repair. Follow-up was conducted through telephone or outpatient visits for a duration of 10 months to 5 years (average follow-up duration 19 months). Three patients experienced minimal secretion from the external orifice of the vestibular fistula within two weeks after the operation, but were successfully treated with sitting bath therapy without any relapse. Another three cases had a recurrence of the fistula, and two of them underwent transanal fistula repair at our center again, resulting in a successful cure after reoperation. The remaining case has not yet undergone reoperation. In the long-term follow-up, all the children had satisfactory anal appearance, with no fecal incontinence, anorectal stenosis, or fistula infection.

CONCLUSION

Transanal fistula repair is a simple, safe, and effective surgical method to treat female children with rectovestibular fistula with a 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.

Risk factors for the recurrence of perineal canal

PURPOSE

The aim of this study was to investigate risk factors for recurrence in the perineal canal (PC).

METHODS

Patients with PC who underwent operations were enrolled in this study and were divided into recurrence and non-recurrence groups. Preoperative infection, the age at the operation, the presence of colostomy and the treatment procedure for fistula were retrospectively investigated. Regarding the treatment procedure for fistula, either closure of the rectal wall with stitches or ligation of fistula in the rectum was performed. These factors were compared between the two groups.

RESULTS

Six of 17 patients with PC who underwent surgical treatment had recurrence. There were no significant differences in the incidence of preoperative infection, age at operation or presence of colostomy (p = 0.60, 0.38, 1.00, respectively). In the recurrence group, all patients were treated by closure of the rectal wall. In the non-recurrence group, five were treated by the closure of the rectal wall with stitches and six by ligation of the fistula. There was a significant association between recurrence and the treatment procedure for fistula (p = 0.04).

CONCLUSION

Closure of the rectal wall with stitches is a risk factor for the recurrence of PC.

Vestibulo-Rectal Pull Through in H-Fistula in Girls

Aims and Objectives:

Vestibulo-rectal pull-through (VRPT) in H-fistula in girls was first described by Chatterjee et al. We are presenting our experience with this approach in 47 cases.

Materials and Methods:

We have total 47 cases of which one is a recurrent fistula operated outside. A circumferential incision is made around the fistula in the vestibule; fistula tract is dissected liberally and delivered by invagination into the bowel. Then, the fistula tract is excised adequately and closed from within the bowel lumen so that no anterior outpouching of the rectum remains. The perineal body is repaired through the vestibular incision. In no cases, protective colostomy was performed. Only the recurrent fistula case had colostomy done in another institution.

Results:

Complete cure was obtained in 45 out of 47 cases. Two of our earlier cases had recurrences perhaps due to inadequate mobilization, but in later cases, we had no recurrence.

Conclusion:

VRPT yields good result without the need for colostomy. Incisions on the perineal skin or the anal verge are avoided, thus improving the cosmetic outcome.

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.

Anterior perineal fistulectomy in repairing H-type rectovestibular fistula with a normal anus in female children

The purpose of this study was to review a 7-year operative experience of anterior perineal fistulectomy in repairing H-type rectovestibular fistula with a normal anus in female children. From January 2007 to December 2013, 105 female children with H-type rectovestibular fistula and a normal anus underwent anterior perineal fistulectomy in the Department of General Surgery, Beijing Children's Hospital, Capital Medical University. Clinical data were retrospectively analyzed. Patients' age ranged from 6 months to 13 years 10 months, with an average age 5 years 2 months. The clinical feature of this disease was a definite history of vestibular infection at about 30 days after birth and leakage of gas or loose stool through vestibular fistular orifice after the infection was controlled. All patients had a normal anus. Follow-up through telephone or outpatient visits from 6 months to 7 years (median, 5.2 years), showed that all the patients were continent and had regular bowel movements. Among the 105 patients, 97 (92.4%) gained primary healing with a satisfactory appearance; 8 (7.6%) patients relapsed, among which 5 healed after hip bathing treatment within 3 weeks, 2 required another anterior perineal fistulectomy 7 months later and were cured, and the last one had another anterior perineal fistulectomy 1 year 10 months later but relapsed again, which healed after hip bathing treatment within 3weeks after the second surgery. Anterior perineal fistulectomy is a simple, safe and reliable surgical method to treat H-type rectovestibular fistula with a normal anus.

Neonatal Sweet's Syndrome Associated with Rectovestibular Fistula with Normal Anus

Sweet's syndrome, characterized by fever and a painful erythematous rash with a dermal neutrophilic infiltrate, develops primarily due to paraneoplastic phenomena in adults. Sweet's syndrome is very rare in neonates. We report a Japanese female neonate (age <2 months), who developed Sweet's syndrome with episodes of perineal infection in association with congenital rectovestibular fistula with normal anus. Sweet's syndrome was diagnosed basing on clinical features and histopathology of biopsied skin tissues. Rectovestibular fistula was confirmed after the signs of inflammation subsided and the rash disappeared. In the literature, we found another case of neonatal Sweet's syndrome associated with rectovestibular fistula in a Japanese female neonate. The perineal region should be screened for anomalies following diagnosis of Sweet's syndrome in neonates.

Use of an endorectal mucosal advancement flap to treat H-type rectovestibular fistula in patients with a normal anus

The combination of an H-type rectovestibular fistula (RVF) and a normal anus is a rare type of anorectal malformation, resulting in abnormal communication between the normal rectum and vestibule in girls. Among the surgical methods used to treat this condition are simple fistula resection and extensive perineal dissection, but postoperative fistula recurrence is frequent. We utilized the endorectal mucosal advancement flap technique on three patients with H-type RVFs and a normal anus, all of whom had favorable outcomes.

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.

Management of H-type rectovestibular and rectovaginal fistulas

INTRODUCTION

H-type rectovestibular or rectovaginal fistulas are rare entities in the spectrum of anorectal malformations seen in North America. Management options described in the literature have included perineal repair, anterior perineal anorectoplasty, vestibuloanal pull-through, and limited or formal posterior sagittal anorectoplasty, with a reported recurrence rate of 5% to 30%. We describe our approach and outcome in the management of these patients.

METHODS

In a series of 1170 females with anorectal malformation, we cared for 8 patients who had an H-type rectovestibular or rectovaginal fistula and reviewed their clinical presentation, diagnosis, operative technique, and postoperative course.

RESULTS

The patients' presenting symptoms included passage of stool per vagina (6), constipation (3), labial abscess (1), and recurrent urinary tract infection (1). There was associated anorectal stenosis in 3 patients. The remaining 5 patients had normal anal openings. Endoscopy was not helpful in locating the fistulas, but the fistulas were all demonstrated on direct inspection under anesthesia. The fistula was located in the vestibule (4), vagina (3), or labia (1). One patient had an associated presacral mass. Two patients had been operated on twice previously using a perineal repair and a protective colostomy and presented with third recurrences. In 5 cases, a posterior sagittal approach was used, placing sutures circumferentially around the fistulous opening on the rectal side, ligating the fistula, and pulling down a normal segment of rectum to be placed in front of the repaired vaginal wall. In our last 3 cases, we performed a transanal mobilization of the anterior rectal wall, leaving the perineal body intact. After our repairs, the patients have been followed up for 3 months to 15 years with a median of 15 months, and we have seen no recurrences.

CONCLUSIONS

In addition to vaginal passage of stool, an H-type fistula should be suspected when there is a labial abscess in an infant, and an associated anal stenosis or presacral mass must be checked for. Direct inspection is the key, with a careful look in the vestibule, because endoscopy may miss the fistula. The essential technical point for repair is to get healthy anterior rectal wall to cover the area of fistula on the posterior vagina. A transanal approach, leaving the perineal body intact, is an excellent option for this repair.

Rectovestibular fistula with normal anus: a simple resection or an extensive perineal dissection?

PURPOSE

The purpose of the study was to review a 10-year experience of operative procedures for rectovestibular fistula with normal anus (RVFNA) at one institution.

MATERIALS AND METHODS

From January 1999 to December 2008, 182 female patients of RVFNA were treated surgically in the Department of Surgery, Beijing Children's Hospital, Capital Medical University, China. The patients' age ranged from 4 months to 15 years, with a mean age of 3.4 years. Fourteen children had a failed previous operation in other institutions. One hundred fifty-six patients (85.71%) had a definite history of vulvar inflammation within 3 months after birth and fecal leakage thereafter. In 61 of the 156 patients, a perineal abscess appeared after an episode of diarrhea. Four cases (2.20%) had associated anomalies of the VACTERL type. One hundred seventy-three patients (95.05%) had 1 external opening, whereas 9 others (4.95%) had 2 external openings separated by a skin bridge. In all cases, the internal orifice opened above the dentate line. The fistula in 135 cases (74.18%) presented as an opening with a small diameter (<5 mm). In our series, vestibular-rectal pull-through procedure was performed in 98 cases, transanal procedure in 69 cases, and anterior perineal anorectoplasty in 15 cases. None had a diverting colostomy.

RESULTS

Recurrence of fistula occurred in 5 to 10 days after operation in 21 cases (11.54%). Eight of them healed spontaneously after daily sitz bath with 3% boric acid, whereas other 13 patients (7.14%) required reoperation. Follow-up was obtained by telephone or by personal visit in the outpatient department, from 3 months to 10 years (median, 5.7 years). All the patients were continent and had regular bowel movement.

CONCLUSIONS

Most RVFNA was acquired after infection. Procedure requiring extensive perineal dissection and diverting colostomy are unnecessary in most RVFNA cases. We performed simple resection in most patients with satisfactory results. In the cases with a large external opening and abnormal perineal appearance, a more extensive perineal dissection might be necessary.

Transanal approach in repairing acquired rectovestibular fistula in females

AIM: To summarize the operative experience of the transanal approach in acquired rectovestibular fistula repair.

METHODS: Ninety-six cases of acquired rectovestibular fistula in young females were analyzed retrospectively. The etiology and operative procedure were discussed. Operative essential points were, the patient was laid in prone frog position, with the knees and hips flexed at 90^o; the perineum was elevated; and the anal opening was exposed. Four stay sutures were applied to the margin of the fistular orifice in the anal opening at points 3, 6, 9 and 12 o’clock. A circular incision of mucosa surrounding the stay sutures was made. The fistula was dissected from its anal opening to its vestibular opening. The wound of vestibule was sutured, and the rectoanal wound was then sutured transversely.

RESULTS: All the 96 patients recovered uneventfully from operation with a successful rate of 93.75%.

CONCLUSION: The transanal approach in the treatment of the acquired rectovestibular fistula is a simple and feasible technique.

[Congenital rectovestibular fistula. An unusual diagnosis that should not be ignored]

Rectovestibular fistula without anorectal malformation is a rare anomaly.

OBSERVATION

A six-week-old baby was hospitalized for a greater labium abscess. Stools leakage was secondary noted in the vagina and in abscess area. Clinical examination under anesthesia concluded to a congenital rectovestibular fistula with secondary drainage in the greater labium. Surgical treatment without colostomy led to recovery.

COMMENTS

Congenital recto-vestibular fistula is a difficult diagnosis. It should be evoked when vaginal fecal leakage occurs in the absence of anorectal malformation or perineal injury. Fistula location is often confirmed by clinical examination under anesthesia. Treatment is surgical and allowed recovery without any functional damage.