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.

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.

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.

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.

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.