SURGICAL TREATMENT OF RECTOVAGINAL FISTULAS

Transcription

1 POLSKI PRZEGLĄD CHIRURGICZNY 007, 79, 8, /v x SURGICAL TREATMENT OF RECTOVAGINAL FISTULAS TOMASZ KOŚCIŃSKI, MARTA SĘKOWSKA Department of General, Gastrointestinal and Endocrine Surgery, K. Marcinkowski Medical University in Poznań Kierownik: prof. dr hab. M. Drews Rectovaginal fistulas account for less than 5% of all anorectal fistulas. They may occur as a result of obstetrical injuries, inflammatory bowel diseases, or pelvic cancer irradiation. The aim of the study was to describe the results of different methods of surgical treatment according to the etiology and localization of rectovaginal fistulas. Material and methods. The study included 3 female patients who underwent operations for rectovaginal fistulas within the period of 995 to 006. The age of patients ranged from 8 to 64 years, with an average age of 4 years. 4 patients received radical treatment according to the etiology and localization of the fistulas: four were treated with abdominal approach, six with a local excision of the rectovaginal fistula involving layer closure of rectal and vaginal openings and interposition of musculomucosal flaps, and four with a simple fistulectomy involving the removal of inflamed tissue and the reconstruction of the perineal body, anal sphincters, and all layers of the rectal and vaginal walls. In nine cases, patients received a palliative surgical treatment to address extensive tissue destruction resulting from radiotherapy for uterine cervix cancer or advanced rectal cancer. Results. Complete recovery occurred in patients who underwent laparotomy for rectovaginal fistulas following inflammatory bowel disease or complicating anterior resection of the rectum. Patients operated on using rectal and vaginal approaches displayed positive results, as did those who underwent. fistulectomy with perineal body and anal sphincter reconstruction. Conclusions. Various surgical techniques are available for the management of rectovaginal fistulas depending on their etiology, size, and location. The best results of low rectovaginal fistula treatment occurred using fistulectomy with layer closure and both-sided covering of the tissue defect with advancement vaginal and rectal flaps. Key words: rectovaginal fistula, causes, surgical treatment Rectovaginal fistulas account for less than 5% of all anorectal fistulas (). In obstetrics they may be secondary to perineal tears that occur during delivery or episiotomy. Rectovaginal fistulas localized at a different distance from the vestibule of the vagina and the cutaneous anal margin may result as a complication of posterior vaginal wall, rectal and anal surgery. There is a reported risk of this complication following low anterior resection of the rectum when creating an intestinal anastomosis during gastrointestinal tract reconstruction (, 3). Inflammatory bowel diseases (Crohn s and ulcerative colitis) are causative of a separate therapeutic group of fistulas. To successfully treat these fistulas and minimize their recurrence rate, problematic portions of the gastrointestinal tract should be found and removed. However, an alternative opinion states that primary intestinal resection has no significant influence on the healing of rectovaginal fistulas and does not improve a chance for successful treatment (4). The most difficult cases to treat are fistulas resulting from cancer irradiation therapy on

2 534 T. Kościński, M. Sękowska the pelvic organs. These fistulas are frequently large and accompanied by extensive tissue destruction, intensive inflammation, and necrosis. The aim of this study is to present the results of different surgical treatments according to the etiology and localization of the rectovaginal fistulas. MATERIAL AND METHODS The study included 3 female patients who underwent operations for rectovaginal fistulas within the period of 995 to 006 in the Department of General, Gastrointestinal and Endocrinal Surgery. The patients were 8 to 64 years old, with an average age of 4 years. Etiology of rectovaginal fistulas are reflected in tab.. The location and size of the fistulas were determined using both-handed gynecological and anorectal examinations, rectoscopy, and colposcopy. Routine procedures included a preoperative cleansing enema, perioperative antibiotic prophylaxis, disinfection of the vagina, and vesical catheterization. 4 patients had surgical removal of fistulas depending on the etiology and localization of the fistulas. The above-mentioned are shown in tab.. Four patients were treated using an abdominal approach; in two of them, the fistulas were a complication after anterior resection of the rectum. In one 8-year old girl treated for ulcerative colitis, the fistula was caused by an improperly performed stapled J-pouch anastomosis with posterior vaginal fornix after proctocolectomy. The above-mentioned anastomosis was separated, and the gap in the vaginal wall was sutured. Using an EEA stapling device, the J-pouch was anastomosed with her rectal stump, which was impossible to make shorter because of inflammation that had been left too long during the primary operation. A patient (P.L. 48) had a fistula following ulcerative colitis, so a proctocolectomy with anal excision and removal of fistulous canal was performed. Six patients were operated on using conservative local excision of rectovaginal fistula with layer closure of rectal and vaginal openings and interposition of musculomucosal flaps. In one of the above-mentioned patients (P.A. 35), this kind of surgery was performed to treat a recurrent fistula arising from an ineffective layer closure that used only the vaginal approach, decompressed with transversostomy. All four cases underwent a simple fistulectomy with the removal of inflamed tissue and the reconstruction of the perineal body, sphincters and all layers of rectal and vaginal walls. This surgical technique is presented in fig. -5. In patient M.M. (age 46), the above-mentioned operation was the third in a four-month period after two ineffective attempts of layer closure, also decompressed with stomy. These surgical interventions were performed in such a short period of time in response to persistent bleeding from granulation and suppurative tissues of fistulous canal in the HCV(+) patient. In nine patients, a palliative surgical treatment was performed to alleviate nagging rectovaginal symptoms (tab. 3). In patients who had undergone curietherapy for uterine Table. Etiology of rectovaginal fistulas Causes of rectovaginal fistulas Obstetrical trauma Complications after surgical/gynecological operations resection of the rectum reconstructive operations of rectal and vaginal congenital disorders excision of vaginal papilloma incorrect J-pouch vaginal anastomosis Perineal abscess Crohn s disease Ulcerative colitis Cervix cancer curietherapy Rectal cancer Number of patients n = * X-ray-therapy

3 Surgical treatment of rectovaginal fistulas 535 Table. Radical treatment of rectovaginal fistulas Patients/age Cause of rectovaginal fistula Type of surgery M.N., 6 injury after forceps delivery perineal body reconstruction, perineum and sphincters reconstruction P.A., 35 complication after perineal suturing transversostomy layer closure using vaginal approach double advancement sliding flap K.E., 6 complication after low anterior repairing of colo-rectal anastomotic leackage resection of the rectum suturing of the defect of vaginal wall S.M., 8 incorrect J-pouch vaginal anastomosis anastomosis was separated, suturing of the defect in the vaginal wall, J-pouch rectal stomosis R.K., 37 M.M., 46 ow anterior resection of the rectum complication, after rtg therapy perineal abscess HCV(+) renal insufficiency resection of the rectum using Hartmann s procedure suturing of the defect of vaginal wall transversostomy suturing of the defect of vaginal wall setonage of the ramificated fistula fistulectomy layer closure fistulotomy perineal body, perineum and sphincters reconstruction T.M.M., 6 Crohn s disease fistulectomy layer closure K..L, 43 surgery of atresic anus fistulectomy R.H., 36 perineal tear after labour fistulectomy P.L., 48 ulcerative colitis total proctocolectomy, terminal ileostomy S.J., reconstruction of the vagina fistulectomy J.H., 56 complication after vaginal papilloma excision fistulectomy F.M., 6 complication after perineal sutures fistulectomy perineal body, perineum and sphincters reconstruction S.S.A., 46 complication after perineal tear fistulectomy perineal body, perineum and sphincters reconstruction Fig.. Identification of fistulous canal Fig.. Fistulectomy. X-shaped incision of perineal skin

4 536 T. Kościński, M. Sękowska Fig. 3. Dissection and identification of all structures of the perineal body and the sphincters Fig. 4. Reconstruction of all muscular structures of perineum, vestibule of the vagina and sphincters RESULTS Fig. 5. X and Z perineoplasty cervix cancer, advanced rectal cancer, or Crohn s disease, elimination of rectovaginal fistulas was impossible due to extensive tissue destruction. Patients who underwent laparotomy experienced complete recovery from their rectovaginal fistulas arising from inflammatory bowel disease or complicating anterior resection of the rectum. After jatrogenic J-pouch-vaginal anastomosis, one patient experienced periodic openings of a microfistula that let through gases without visible inflammation. In her rectal stump that was left too long, the mucosa showed obvious inflammation symptoms. All patients operated on using rectal and vaginal approach with layer closure after the fistula excision and interposition of musculomucosal flaps were durably cured. Similarly, positive results were obtained in patients who had fistulectomy and the reconstruction of the perineal body and sphincters. Fistula s excision and layer closure outcome in patient T.M.M. 6, cured for Crohn s disease is unknown as she did not call for a control examination. After the disconnection of the gastrointestinal passage from the rectum, patients with extensive pelvic tissue destruction from radiotherapy or carcinoma displayed significant improvement. There was a significant reduc-

5 Surgical treatment of rectovaginal fistulas 537 Table 3. Palliative procedures Patients/age Causes of fistula Type of surgery B.., 5 recurrence of rectal cancer ileostomy P.H., 54 rtg-therapy of cervix cancer Hartmann s sigmoidostomy T.J., 53 rectal cancer ileostomy K.A., 45 rtg-therapy of cervix cancer sigmoidostomy M.S., 46 rtg-therapy of cervix cancer transversostomy P.B., 5 rtg-therapy of cervix cancer sigmoidostomy P.S., 45 rtg-therapy of cervix cancer sigmoidostomy K.W., 48 Crohn s disease ileostomy W.H., 43 rtg-therapy of cervix cancer resection of the rectum using Hartmann s procedure * rtg-therapy tion in odorous discharge and a decrease in persistent inflammation. DISCUSSION Surgical management of rectovaginal fistulas depends on the patient s general health, sphincter function, and on the etiology, size, and location of the fistulas (5, 6). High fistulas are localized above one third of the rectum and should be treated using abdominal approach. Many surgical techniques have been described. In the case of simple fistulas with no large surrounding inflammation, both organs are divided and the orifices are sutured separately. Laparoscopic operations offer another alternative in the treatment of rectovaginal fistulas (5, 7). If the patient has post-irradiation fistulas, accompanying inflammatory bowel diseases (Crohn s or complications of diverticulosis), or pelvic carcinoma, it is necessary to remove the opening within the changed bowel segment. An unchanged proximal bowel and the need to distance the anastomose from a vaginal fistulous opening conditions the reestablishment of gastrointestinal tract continuity (8). Surgical techniques for the management of anorectal fistulas include simultaneous low colorectal and anal anastomoses, or the pull-through technique with hand made transanal anastomosis (3, 9). These anastomoses usually need to be protected by a proximal stomy (0). Interposition of tissues with a good blood supply improves the chance of achieving good results and prevents recurrences. This is applicable to the greater omentum, thigh muscles, and the straight muscle of the abdomen. If there is carcinoma or a wide inflammation area, reconstructing the continuity of gastrointestinal tract is risky. In such cases, Hartmann s procedure is the best option and continuity reconstruction should be postponed until the inflammatory process and infection recede, or in cancer cases, until a minimum period of 8 months has passed (, 8). If there is advanced carcinoma or extensive inflammation with Crohn s disease that spreads toward the anal canal, preserving therapy of rectovaginal fistula becomes impossible. In such cases it is necessary to make an abdomino-perineal resection of the rectum, or a proctocolectomy with ileostomy (8, 0). Low fistulas, localized between the lower one third of the rectum and lower half of the vagina, are treated using transvaginal, transperineal, or transanal approaches. A simple circular fistulectomy with layer closure is carried out using both-sided vaginal and rectal approaches. The disadvantages of this procedure are insufficient tissue mobilization andexcessive tension where the suture line and direct sutures meet in the vaginal and rectal walls. A recurrence rate ranges from 30% to 84% (, ). Advancement flap repair lacks most of the disadvantages present in the above-mentioned surgeries (, 3, 4). It involves the mobilization of a mucosal flap that includes the submucosal membrane. Next, the rectovaginal septum is reconstructed by a simultaneous suturing of muscular rectal and vaginal layers. The base of the flap should be twice the width of the apex. Obtained in this way, a part of the rectal wall will cover the fistulous opening. Similarly, the vaginal mucosal flap should cover the excised opening in a tight manner. Willis, Rau and Schumpelick used only the advancement rectal flap and left the vaginal

6 538 T. Kościński, M. Sękowska orifice open; they achieved primary healing in 8% of their patients (5). Casadeus et al. report a 75% success rate in surgeries performed from the vaginal approach using the advanced flap of its wall. Wide vaginal access also enabled approaching levator muscles to midline, creating distance between the sutured openings in the rectal and vaginal walls. The relevant literature frequently stresses the importance of suturing the rectal hole and covering it with healthy mucosa, for the following reasons: the orifice of the fistula must be resected, the point of higher pressure then in the vagina should be secured, the mucosal sutures should be distanced from the fistulous canal (4). In patients with destroyed sphincteric complex of the anterior quadrant, simultaneous reconstruction is recommended (6, 7). In order to do so, wide perineal access is necessary;, the fistulous canal is removed and all damaged structures should be found. Reconstructions are performed on the following: the mucosa of the rectum, the anal canal, the internal and external sphincters, the perineal muscles, and the muscles and mucosa of the vaginal vestibulum. Primarily shortened perineum is reconstructed using skin perineoplasty, using mostly X en Z technique. Durable distancing of the rectum and vagina can be achieved using a total excision of fistulous tract and introducing musculofibrous tissue between them. This treatment is estimated to be close to 00% effective (8). CONCLUSIONS Various surgical techniques are available for the management of rectovaginal fistulas according to their etiology, size, location. For the treatment of low fistulas, best results were achieved using conservative fistulectomy, layer closure, and both-sided covering of the tissue defect with advancement vaginal and rectal flaps. In patients with destroyed sphincters, successful treatment involved a fistulotomy, the reconstruction of all structures in the perineal body, sphincters, vaginal and rectal mucosa, and an anoplasty. High rectovaginal fistulas should be treated transabdominally. Simple division of both organs is performed and the openings are sutured separately. In patients with surrounding inflammation and carcinoma of the rectal wall, a part of the gut should be removed. Wide carcinoma spreading in the pelvis and irradiation injury are indications for excluding the rectum from the gastrointestinal passage. REFERENCES. Bernstein M: Rectovaginal fistula. In: John L. Cameron, ed.: Current Surgical Therapy. 6 th ed., St. Louis, Mosby, 998: Antonsen HK, Kronborg O: Early complications after low anterior resection for rectal cancer using the EEA stapling device. Dis Colon Rectum 987; 30: Rex JC Jr, Khubchandani JT: Rectovaginal fistula: complication of low anterior resection. Dis Colon Rectum 99; 35: Radcliff AG, Ritchie JK, Hawley MS et al.: Anovaginal and rectovaginal fistulas in Crohn s disease. Dis Colon Rectum 988; 3: Kumaran SS, Palanivelu C, Kavalakat AJ et al.: Laparoscopic repair of high rectovaginal fistula. Is it technically feasible? BMC Surgery 005; 5: Casadeus D, Villasana L, Sanchez JM et al.: Treatment of rectovaginal fistula: A 5-year review. Aust NZJ Obst Gynecol 006: 46: Schwenk W, Bohm B, Grundel K et al.: Laparoscopic resection of rectovaginal fistula with intracorporeal colorectal anastomosis omentoplasty. Surg Endosc 997; : Keighley MRB: Intestinal fistulas. In : Surgery of the anus, rectum and colon. Keighley MRB and Williams NS (eds). Sannders Co Ltd. London 993; Bannura GC, Contreras JP, Melo CL et al.: Espectro clinico de la fistula rectovaginal: analysis de 38 patientes. Rev Chil Obst Ginecol 00; 67: Cohen JL, Stricker JW, Schoetz DJJr et al.: Rectovaginal fistula in Crohn s disease. Dis Colon Rectum 989; 3: Mazier WP, Senagore AJ, Schiesel EC: Operative repair of anovaginal and rectovaginal fistulas. Dis Colon Rectum 995; 39: Naru T, Rizvi JH, Talati J: Surgical repair of genital fistulae. J Obst Gynaecol Res 004; 30: Watson SJ, Phillips RKS: Non-inflammatory rectovaginal fistula. Br J Surg 995; 8: Tsang CBS, Madoff RD, Wong WD: Anal sphincter integrity and function influences outcome in rectovaginal fistula repair. Dis Colon Rectum 998; 4: Willis S, Rau M, Schumpelick V: Surgical treatment of high anorectal and rectovaginal fistulas with

7 Surgical treatment of rectovaginal fistulas 539 the use of transanal endorectal advancement flaps. Chirurg 000; 7: Rahman MS, Al-Suleiman SA, El-Yahia AR et al.: Surgical treatment of rectovaginal fistula of obstetric origin: a review of 5 year s experience in a teaching hospital. J Obst Gynecol 003; 3: Wiskind AK, Thomson JD: Transverse transperineal repair of rectovaginal fistulas in the lower vagina. Am J Obst Gynecol 99; 67: Chew SSB, Rieger NA: Transperineal repair of obstetric-related anovaginal fistula. Aust NZJ Obst Gynecol 004; 44: Received: r. Adress correspondence: Poznań, ul. Przybyszewskiego 9