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Lohsiriwat V, Jitmungngan R. Rectovaginal fistula after low anterior resection: Prevention and management. World J Gastrointest Surg 2021; 13:764-771. [PMID: 34512900 PMCID: PMC8394379 DOI: 10.4240/wjgs.v13.i8.764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/17/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Rectovaginal fistula after low anterior resection for rectal malignancy is one of the most challenging postoperative complications because it is difficult to treat and may complicate plans of adjuvant therapy. This problematic complication could lead to multiple operations, stoma formation, sexual dysfunction, fecal incontinence and psychosocial ramifications. This review comprehensively covers an overview of its incidence, risk factors, presentation and evaluation, management (ranging from conservative measures, endoscopic treatment and local tissue repair to radical resection and redo anastomosis) and treatment outcomes of rectovaginal fistula after low anterior resection. Notably, these therapeutic options and outcomes are influenced by several factors, including the size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis and surrounding tissue, presence of diverting stoma, previous attempted repair, and the surgeon’s experience. Also, strategies to prevent rectovaginal fistula after low anterior resection are presented with illustrations. Finally, a decision-making algorithm for managing this complication is proposed.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Romyen Jitmungngan
- Department of Surgery, The Golden Jubilee Medical Center, Mahidol University, Nakhon Pathom 73170, Thailand
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Fiori E, Crocetti D, Sapienza P, Cirocchi R, Sterpetti AV, Miccini M, Accordino M, Costi S, Lapolla P, Mingoli A, De Toma G, Lamazza A. Palliative Surgery or Metallic Stent Positioning for Advanced Gastric Cancer: Differences in QOL. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:428. [PMID: 33925171 PMCID: PMC8146574 DOI: 10.3390/medicina57050428] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/12/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Twenty percent of the patients affected with stage IV antropyloric stomach cancer are hospitalized with a gastric outlet obstruction syndrome (GOOS) requiring its resolution to improve the quality of life (QoL). We present our preliminary short- and mid-term results regarding the influence of endoscopic placement of self-expandable metal stent (SEMS) or open stomach-partitioning gastrojejunostomy in QoL. MATERIALS AND METHODS In this prospective randomized longitudinal cohort trial, we randomly assigned 27 patients affected with stage IV antropyloric stomach cancer into two groups: Group 1 (13 patients) who underwent SEMS positioning and Group 2 (14 patients) in whom open stomach-partitioning gastrojejunostomy was performed. The Karnofsky performance scale and QoL assessment using the EQ-5D-5L™ questionnaire was administered before treatment and thereafter at 1, 3, and 6 months. Results: At 1-month, index values showed a statistically significant deterioration of the QoL in patients of Group 2 when compared to those of Group 1 (p = 0.004; CI: 0.04 to 0.21). No differences among the groups were recorded at 3-month; whereas, at 6-month, the index values showed a statistically significant deterioration of the QoL in patients of Group 1 (p = 0.009; CI: -0.25 to -0.043). CONCLUSIONS Early QoL of patients affected with stage IV antropyloric cancer and symptoms of GOOS is significantly better in patients treated with SEMS positioning but at 6-month the QoL significantly decrease in this group of patients. We explained the reasons of this fluctuation with the higher risk of re-hospital admission in the SEMS group.
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Affiliation(s)
- Enrico Fiori
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Daniele Crocetti
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Paolo Sapienza
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Roberto Cirocchi
- Department of Surgical and Biomedical Sciences, Perugia University, 06123 Terni, Italy;
| | - Antonio V. Sterpetti
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Michelangelo Miccini
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Marcello Accordino
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Silvano Costi
- Department of Economics and Finance, LUISS Guido Carli, 00198 Rome, Italy;
| | - Pierfrancesco Lapolla
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Andrea Mingoli
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Giorgio De Toma
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
| | - Antonietta Lamazza
- Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, 00161 Rome, Italy; (E.F.); (P.S.); (A.V.S.); (M.M.); (M.A.); (P.L.); (A.M.); (G.D.T.); (A.L.)
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Woo IT, Park JS, Choi GS, Park SY, Kim HJ, Lee HJ. Optimal strategies of rectovaginal fistula after rectal cancer surgery. Ann Surg Treat Res 2019; 97:142-148. [PMID: 31508395 PMCID: PMC6722289 DOI: 10.4174/astr.2019.97.3.142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is a type of anastomotic leakage. The aim of this study was to find out the difference of leakage, according to RVF presence or absence and to identify the optimal strategy for RVF. Methods All female patients who underwent low anterior resection with colorectal anastomosis or coloanal anastomosis (n = 950) were retrospectively analyzed. Patients' demographics and perioperative outcomes were analyzed between the RVF group and leakage without the RVF (nRVF) group. We performed 4 types of procedures—primary repair, diverting stoma, redo coloanal anastomosis (RCA), and conservative procedure—to treat RVF, and calculated the success rates of each type of procedure. Results The leakage occurred in 47 patients (4.9%). Among them, 18 patients (1.9%) underwent an RVF and 29 (3.0%) underwent nRVF. The RVF group received more perioperative radiotherapy (27.8% vs. 3.4%, P < 0.015) and occurred late onset after surgery (181.3 ± 176.4 days vs. 23.2 ± 53.6 days, P < 0.001) more than did the nRVF group. In multivariate analysis for the risk factor of the RVF group, the RVF group was statistically associated with less than 5 cm of anastomosis more than was the no-leakage group. A total of 35 procedures were performed in 18 patients with RVF for treatment. RCA showed satisfactory success rates (85.7%, n = 6) and, primary repair (transanal or transvaginal) showed acceptable success rate (33.3%, n = 8). Conclusion After low anterior resection for rectal cancer, RVF was strongly correlated with a lower level of primary tumor location. Among the patients who underwent leakages, receipt of perioperative radiotherapy was significantly high in the RVF group than that of the nRVF group. Additionally, this study suggests that RCA might be considered another successful treatment strategy for RVF.
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Affiliation(s)
- In Teak Woo
- Department of General Surgery, Soonchunhyang University Gumi Hospital, Gumi, Korea.,Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon? Gastrointest Endosc Clin N Am 2019; 29:549-562. [PMID: 31078252 DOI: 10.1016/j.giec.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.
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Abstract
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.
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Affiliation(s)
- Mahmoud Abu Gazala
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
| | - Steven D Wexner
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
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Lamazza A, Fiori E, Sterpetti AV, Schillaci A, De Cesare A, Lezoche E. Endoscopic placement of self-expandable metallic stents for rectovaginal fistula after colorectal resection: a comparison with proximal diverting ileostomy alone. Surg Endosc 2016; 30:797-801. [PMID: 26017913 DOI: 10.1007/s00464-015-4246-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/15/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Self-expandable metal stents can be used to treat patients with rectovaginal fistula after colorectal resection for cancer. METHODS Fifteen patients with rectovaginal fistula, after colorectal resection for cancer, were treated with endoscopic placement of a self-expandable metal stent. In four patients, a diverting proximal stoma had been performed elsewhere. Mean age was 58 years. All patients had preoperative radiotherapy. In ten patients, the stent was placed as initial form of treatment. Four patients were referred after multiple failed operations. The control group consisted of ten patients who had rectovaginal fistula and underwent proximal diverting ileostomy and percutaneous drainage of the surrounding abscess RESULTS One patient was not able to tolerate the stent, which was removed. At a mean follow-up of 22 months, the rectovaginal fistula healed in 12 patients. In the remaining two patients, the fistula has reduced significantly in size to allow a successful flap transposition. The fistula healed only in five out of the ten patients who had only a proximal ileostomy. CONCLUSIONS Endoscopic placement of self-expandable metal stents represents a valid adjunctive to treat patients with rectovaginal fistula, after colorectal resection for cancer.
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Affiliation(s)
- Antonietta Lamazza
- Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, 00167, Rome, Italy
| | - Enrico Fiori
- Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, 00167, Rome, Italy
| | - Antonio V Sterpetti
- Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, 00167, Rome, Italy.
| | - Alberto Schillaci
- Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, 00167, Rome, Italy
| | - Alessandro De Cesare
- Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, 00167, Rome, Italy
| | - Emanuele Lezoche
- Policlinico Umberto I, University of Rome La Sapienza, Viale del Policlinico, 00167, Rome, Italy
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