Operative considerations for rectovaginal fistulas

To describe the etiology, anatomy and pathophysiology of rectovaginal fistulas(RVFs); and to describe a systematic surgical approach to help achieve optimal outcomes. A current review of the literature was performed to identify the most up-to-date techniques and outcomes for repair of RVFs. RVFs present a difficult problem that is frustrating for patients and surgeons alike. Multiple trips to the operating room are generally needed to resolve the fistula, and the recurrence rate approaches40% when considering all of the surgical options. At present, surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with colo-anal reconstruction. There are general principles that will allow the best chance for resolution of the fistula with the least morbidity to the patient. These principles include: resolving the sepsis, identifying the anatomy, starting with least invasive surgical options, and interposing healthy tissue for complex or recurrent fistulas.

Contemporary surgical management of rectovaginal fistula in Crohn's disease

Rectovaginal fistula is a disastrous complication of Crohn's disease(CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a women's quality of life. Successful management is possible only after accurate and complete assessment of the entire gastrointestinal tract has been performed. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics. Before treatment is undertaken, establishing reasonable goals and expectations of therapy is essential for both the patient and surgeon. This article aims to highlight the various surgical techniques and their outcomes for repair of CD associated rectovaginal 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.

Stapled transperineal repair for low-and mid-level rectovaginal fistulas:A 5-year experience and comparison with sutured repair

BACKGROUND Currently,rectovaginal fistula(RVF)continues to be a surgical challenge worldwide,with a relatively low healing rate.Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIM To evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODS This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University(Guangzhou,China).Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included.Among the 82 total patients,37 underwent repair with direct suturing and 45 underwent repair with stapling.Patient demographic data,Wexner faecal incontinence score,and operative data were analyzed.Recurrence rate and associated risk factors were assessed.RESULTS The direct suture and stapled repair groups showed similar clinical characteristics for aetiology,surgical history,fistula features,and perioperative Wexner score.The stapled repair group did not show superior results over the suture repair group in regard to operative time,blood loss,and hospital stay.However,the stapled repair group showed better postoperative Wexner score(1.04±1.89 vs 2.73±3.75,P=0.021),less intercourse pain(1/45 vs 17/37,P=0.045),and lower recurrence rate(6/45 vs 17/37,P=0.001).There was no protective effect from previous repair history,smaller diameter of fistula(<0.5 cm),better control of defecation(Wexner<10),or stapled repair.Direct suture repair and preoperative high Wexner score(>10)were risk factors for fistula recurrence.Furthermore,stapled repair gave better efficacy in treating complex RVFs(i.e.,multiple transperineal repair history,mid-level fistula position,and poor control of defecation).CONCLUSION Stapled transperineal repair is advantageous for management of RVF,providing a high primary healing rate and low recurrence rate.

Rectovaginal fistula after low anterior resection:Prevention and management

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.

Salvage irrigation-suction in gracilis muscle repair of complex rectovaginal and rectourethral fistulas

AIM:To evaluate the efficacy of gracilis muscle transposition and postoperative salvage irrigation-suction in the treatment of complex rectovaginal fistulas(RVFs)and rectourethral fistulas(RUFs).METHODS:Between May 2009 and March 2012,11female patients with complex RVFs and 8 male patients with RUFs were prospectively enrolled.Gracilis muscle transposition was undertaken in all patients and postoperative wound irrigation-suction was performed in patients with early leakage.Efficacy was assessed in terms of the success rate and surgical complications.SF-36 quality of life(QOL)scores and Wexner fecal incontinence scores were compared before and after surgery.RESULTS:The fistulas healed in 14 patients after gracilis muscle transposition;the initial healing rate was73.7%.Postoperative leakage occurred and continuous irrigation-suction of wounds was undertaken in 5patients:4 healed and 1 failed,and postoperative fecal diversions were performed for the patient whose treatment failed.At a median follow-up of 17 mo,the overall healing rate was 94.7%.Postoperative complications occurred in 4 cases.Significant improvement was observed in the quality outcomes framework scores(P<0.001)and Wexner fecal incontinence scores(P=0.002)after the successful healing of complex RVFs or RUFs.There was no significant difference in SF-36 QOL scores between the initial healing group and irrigationsuction-assisted healing group.CONCLUSION:Gracilis muscle transposition and postoperative salvage wound irrigation-suction gained a high success rate in the treatment of complex RVFs and RUFs.QOL and fecal incontinence were significantly improved after the successful healing of RVFs and RUFs.

Laparoscopic stapler repair of high rectovaginal fistula: A case report

For thousands of years, women simply tolerated the distressing symptoms generated by rectovaginal fistulas (RVFs). This is no longer necessary because most RVFs can be surgically corrected via a number of approaches. Most rectovaginal fistulas are acquired;obstetric injury alone accounts for nearly 88% of the cases. The high fistulas are repaired by abdominal approach, while middle or low fistulas are best approached perineally. There are only few case reports of laparoscopic RVF repair noted in literature till date. Laparoscopic repair of RVF is challenging and requires advanced laparoscopic skill. Laparoscopy is a better alternative in selected cases of RVF and yields faster recovery and good patient compliance. We present a case of high RVF managed laparoscopically by using stapler.

Minimally invasive endoscopic repair of rectovaginal fistula

BACKGROUND Surgical techniques for repair of rectovaginal fistula(RVF)have been continually developed,but the ideal procedure remains unclear.Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting.AIM To review the current applications and preliminary outcomes of this technique for RVF repair,aiming to give surgeons an alternative in clinical practice.METHODS Available articles were searched according to the search strategy.And the sample size,fistula etiology,fistula type,endoscopic repair approaches,operative time and hospital stay,follow-up period,complication and life quality assessment were selected for recording and further analysis.RESULTS A total of 11 articles were eventually identified,involving 71 patients with RVFs who had undergone endoscopic repair.The principal causes of RVFs were surgery(n=51,71.8%),followed by obstetrics(n=7,9.8%),inflammatory bowel disease(n=5,7.0%),congenital(n=3,4.2%),trauma(n=2,2.8%),radiation(n=1,1.4%),and in two patients,the cause was unclear.Most fistulas were in a mid or low position.Several endoscopic repair methods were included,namely transanal endoscopic microsurgery,endoscopic clipping,and endoscopic stenting.Most patients underwent>1-year follow-up,and the success rate was 40%-93%,and all cases reported successful closure.Few complications were mentioned,while postoperative quality of life assessment was only mentioned in one study.CONCLUSION In conclusion,endoscopic repair of RVF is novel,minimally invasive and promising with acceptable preliminary effectiveness.Given its unique advantages,endoscopic repair can be an alternative technique for surgeons.

Two Cases of Complicated Rectovaginal Fistula Treated by Hanging Line Method Were Reported and Reviewed in the Literature

This paper retrospectively analyzes the complicated rectovaginal fistula in 2 cases after the successful treatment. Through literatures collected, with the difficulties and contradictions of the treatment of complicated rectovaginal fistula as the starting point, the currently used hanging line method, the advantage and deficiency of surgical treatment in recent years, and the change of treatment method were reviewed. We wish to explore which current treatments could be a better choice.

Fecal diversion in complex anal fistulas:Is there a way to avoid it?

Temporary fecal diversion by a diverting colostomy or ileostomy is occasionally performed for serious complex fistulas.The main indications are highly complex and extensive cryptoglandular anal fistula,anal fistula associated with severe anorectal Crohn’s disease,recurrent rectovaginal fistula,radiation-induced fistula and anal fistula with associated necrotizing fasciitis.The purpose of stoma formation is to divert the fecal stream away from the anorectum and the perianal region so as to control the infective process and prevent trauma to the operated repaired tissues.Once the fistula has healed,the diverting stoma is closed.However,two questions are relevant.First,is it certain that the same disease would not relapse(or the fistula would not recur)once the colostomy is closed?Second,is there a non-surgical method which can obviate the need for a diverting colostomy?An attempt is made to answer both these questions in this review.

磁压榨技术建立兔直肠阴道瘘模型

目的探讨利用磁压榨技术建立兔直肠阴道瘘动物模型的可行性。方法自行设计适用于制备兔直肠阴道瘘模型的磁性装置。以8只新西兰雌兔作为实验对象,耳缘静脉注射麻醉后取仰卧位,分别经阴道及肛门将子、母磁体置于直肠阴道隔两侧,并使子、母磁体对位相吸。记录手术操作时间,观察术后实验兔一般状态,记录磁体排出时间,术后1周处死实验兔获取直肠阴道瘘标本,肉眼观察直肠阴道瘘形成情况。结果8只实验兔成功制备了直肠阴道瘘动物模型,手术操作过程顺利,平均用时(1.63±0.70)min,术后兔一般状况良好。术后(4.63±0.99)d磁体排出体外,术后1周获取直肠阴道瘘标本,肉眼观察可见直肠阴道瘘形成良好。结论利用磁压榨技术建立兔直肠阴道瘘模型具有操作简单、模型制备成功率高的优点。

多功能数字化胃肠机对直肠阴道瘘诊断的临床应用

目的:探讨多功能数字化胃肠机造影检查对直肠阴道瘘诊断的临床价值。方法:分析我院2012年到2022年期间经临床诊断为直肠阴道瘘30例患者数字化多功能胃肠机检查后的影像资料。结果:30例中有6例(20%)低位瘘为先天性直肠阴道瘘,24例(80%)为后天性直肠阴道瘘,其中高位瘘23例(76.7%),中位瘘1例(3.3%)。按瘘口直径分类:小型直肠阴道瘘有12例(40%),中型直肠阴道瘘有17例(56.7%),大型直肠阴道瘘1例(3.3%)。影像表现均显示在直肠与阴道间的瘘管显影,瘘管位置、形态及其走行可清晰显示,并且可见造影剂经瘘管流入阴道并排出体外。结论:多功能数字胃肠机在直肠阴道瘘造影检查中能动态观察造影剂在瘘管内的走行情况及与邻近解剖结构的关系,为临床治疗方案提供参考价值。

Management of perianal fistulas in Crohn's disease:An upto-date review

Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.

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.

Vesico-Vaginal and Recto-Vaginal Fistula and Death Caused by a Vaginal Foreign Body in a Body-Packer

Foreign body retained for long duration sometimes causes vesico-vaginal and recto-vaginal fistula. We report a 60-year-old woman with vaginal foreign body causing vesico-vaginal and recto-vaginal fistula;she died after foreign body removal due to septic shock. The patient had vaginal purulent discharge, abdominal pain, and a septic shock. A fragment of stone (limestone) was present in the vagina, which was removed. The patient developed urinary incontinence and fecal incontinence after removal of the foreign body. The examination demonstrated the presence of vesico-vaginal and recto-vaginal fistula. The patient died four days after removal of the foreign body due to septic shock and multi-visceral failure. During the extraction foreign body, bacteria could be disseminated into the systemic circulation and might cause septic shock. Thus, wide-spectrum antibiotic therapy must be used before the procedure, which may decrease the chance of septic shock.

4例猫Ⅱ型肛门闭锁的病例分析

4例患猫因断奶后未见排便或外阴处排便而就诊,通过临床症状、X射线检查及直肠、阴道检查后,病例1,2确诊为直肠阴道瘘,病例3,4确诊为直肠前庭瘘。所有病例均进行了手术治疗,其中病例1,3因肛门狭窄进行了二次手术。长期随访结果显示4个病例均可顺畅排便且粪便成型,但病例2仍有肛门外括约肌无力的症状。说明猫Ⅱ型肛门闭锁应尽快进行手术治疗,术后并发症发生率虽然较高,但及时识别并处理通常预后良好。

基于放疗相关直肠阴道瘘临床特征的手术治疗分析

目的基于放疗相关直肠阴道瘘(RI-RVF)的临床特点探讨手术治疗方法,以期为临床诊治提供参考。方法回顾性分析联勤保障部队第九○○医院2012年1月至2022年8月间收治的34例直肠阴道瘘患者的临床资料,其中RI-RVF组20例、非RI-RVF组14例,对两组患者的年龄、病程、瘘口、手术情况及术后情况等进行分析总结。结果10年期间收治的RI-RVF患者占比58.82%。两组相比RI-RVF患者年龄更大[(56.35±11.16)岁vs.(31.71±16.93)岁,t=5.123,P<0.001],瘘口直径更大[(3.18±0.64)cm vs.(1.74±0.77)cm,t=5.922,P<0.001],手术时间更长[110(91.25,120.00)min vs.85(60.00,98.75)min,Z=2.607,P=0.009],而术后住院天数较少[5.0(4.25,7.00)d vs.10.5(9.75,13.25)d,Z=-4.931,P<0.001]。RI-RVF组中16例行单纯肠造瘘,2例行预防性肠造瘘+直肠切除,1例行预防性肠造瘘+瘘修补,1例行单纯瘘修补;非RI-RVF组中6例行单纯肠造瘘,2例行预防性肠造瘘+瘘修补,6例行单纯瘘修补。两组的手术方式比较差异有统计学意义(P<0.05);在病程及术中出血量这两方面比较差异均无统计学意义(P>0.05);除1例RI-RVF术后20 d复发、4例RI-RVF因肿瘤复发导致愈后不良及1例非RI-RVF因术后瘘反复再发外,其余患者均恢复良好。结论RI-RVF具有炎症浸润、血管硬化及肠壁纤维化等特点,康复更加困难,需综合考虑放疗后局部条件及肿瘤进展情况等因素,选择个体化治疗方式。

舒适人文关怀护理对直肠阴道瘘患者负性情绪和生活质量的影响

目的探讨舒适人文关怀护理对直肠阴道瘘患者负性情绪和生活质量的影响。方法选取本院60例直肠阴道瘘患者为研究对象,随机分为两组,各30例。对照组采用常规护理,观察组采用舒适人文关怀护理,比较两组的护理效果、负性情绪、生活质量。结果观察组总有效率为96.67%,高于对照组的80.00%(P<0.05);护理后,观察组焦虑自评量表、抑郁自评量表评分低于对照组,生活质量量表评分高于对照组(P<0.05)。结论针对直肠阴道瘘患者,开展舒适人文关怀护理,可保证护理效果,减轻负性情绪,提高生活质量。

正确评估奶牛会阴裂伤并做好处置

会阴裂伤是奶牛和马自然分娩过程中比较复杂且普遍存在的问题。严重时会阴裂伤能够导致多种疾病。生产中存在许多因素会造成会阴裂伤,与其紧密相关的原因有胎儿过大、阴门过窄、母体体况过肥等。生产中选择合适的处置方法显得尤为必要,但是国内文献和书籍中却很少看到相关论述,该文参考国外研究数据进行总结,更好的指导生产工作。改良的单阶段手术方法非常适合奶牛三级会阴裂伤的处置且预后良好,不影响后续繁殖。

医源性直肠阴道瘘的成因分析和治疗方法探讨

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。