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.

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.

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.

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.

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.

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.

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.

Review of Denonvilliers’fascia:the controversies and consensuses

The Denonvilliers’fascia(DVF)plays an important role in rectal surgery because of its anatomic position and its relationship to the surrounding organs.It affects the surgical plane anterior to the rectum in the procedure of total mesorectal excision(TME).Anatomical and embryological studies have helped us to understand this structure to some extent,but many controversies remain.In terms of its embryonical origin,there are three mainstream hypotheses:peritoneal fusion of the embryonic cul-de-sac,condensation of embryonic mesenchyme,and mechanical pressure.Regarding its architecture,the DVF may be a single,two,or multiple layers,or a composite single-layer structure.In women,most authors deem that this structure does exist but they are willing to call it the rectovaginal septum rather than the DVF.Operating behind the DVF is supported by most surgeons.This article will review those mainstreamstudies and opinions on the DVF and combine them with what we have observed during surgery to discuss those controversies and consensuses mentioned above.We hope this review may help young colorectal surgeons to have a better understanding of the DVF and provide a platform from which to guide future scientific research.