医源性直肠阴道瘘的成因分析和治疗方法探讨

Pathogenic analysis and treatment methods for iatrogenic rectovaginal fistula

目的探讨医源性直肠阴道瘘的形成原因和各种治疗方法。方法对52例医源性直肠阴道瘘病例的临床资料进行回顾性分析。结果发生于妇科手术后22例(42.3%),产伤(接生处理不当)后14例(26.9%),结直肠手术后13例(25.0%),其他原因所致3例(5.8%)。瘘口位于低位直肠27例(51.9%),中位直肠10例(19.2%),高位直肠15例(28.9%)。仅予非手术治疗9例(17.3%),接受永久性转流性肠造口(袢式横结肠造口)8例(15.4%),经各种途径手术修补35例(67.3%)。9例非手术治疗无效。接受永久性肠造口的8例术后症状减轻但瘘口未愈。35例手术修补的总治愈率为77.1%(27/35);其中经肛门括约肌途径(Mason术)、经肛门、经腹、经会阴和经阴道途径修补术的治愈率分别为100%(8/8),100%(2/2),83.3%(5/6),0%(0/1)和66.7%(12/18)。在中、低位直肠阴道瘘的手术修补中,Mason术的治愈率高于经阴道修补术(100%∶66.7%)。结论医源性直肠阴道瘘系因产伤或手术处理不当损伤直肠阴道隔所致。手术修补是直肠阴道瘘惟一的治愈手段。Mason术是治疗中、低位(尤其是中位)直肠阴道瘘的理想术式。

Objective To investigate the causes and outcome of different treatment methods of iatrogenic rectovaginal fistula. Methods Clinical data of 52 patients with iatrogenic rectovaginal fistula were analyzed retrospectively. Results Twenty-two fistulae occurred after gynecological operation （42.3 % ） , fourteen after obstetric injury （26. 9% ） , thirteen after colorectal operation （25. 0% ） and three due to miscellaneous causes （5.8%）. The fistulae were located in the lower rectum in 27 cases（51.9% ） , mid rectum in 10 cases （ 19.2% ） and upper rectum in 15 cases （28.9%）. They were treated by non-surgical treatment in 9 cases （ 17.3 % ） , permanent diverting stoma （ loop transverse colostomy ） in 8 cases （ 15.4 % ） , and surgical repair by various approaches in 35 cases （67. 3% ）. The fistulae of all nine patients who received non-surgical treatment failed to heal. Eight patients who received permanent diverting stoma had symptomatic improvement without fistula healing. The overall cure rate of surgical repairs in 35 cases was 77. 1% （27/ 35 ）. The cure rates of trans-sphincteric （ Mason＇s operation ） , transanal, transabdominal, transperineal and transvaginal approaches were 100% （8/8）, 100% （2/2）, 83. 3% （5/6）, 0% （0/1） and 66. 7% （12/18 ） , respectively. The cure rate of Mason＇s operation for the mid and lower rectovaginal fistulae was higher than that of transvaginal approach （ 100 % vs 66.7 % ） . Conclusions Iatrogenic rectovaginal fistula is caused by obstetric injury or injury of rectovaginal septum due to surgical mismanagement. Surgical repair is the only method that can cure rectovaginal fistulae. Mason＇s operation is a favorable treatment method for the mid and lower （especially mid ） rectovaginal fistulae.