复发性直肠阴道瘘的治疗

目的 探讨对反复多次修补失败的直肠阴道瘘的临床治疗对策. 方法 采用带血管蒂的全层肠片以及直肠推进瓣的方法 ,治疗经多次修补失败的直肠阴道瘘3例.结果 采用全层肠片修补术1例,采用直肠推进瓣术治疗2例.患者因复发性直肠阴道瘘而行手术治疗的次数为2～9次,平均为(4.3±3.3)次.手术时间为3.3～6.8 h,平均为(4.8±1.5)h,3例复发性直肠阴道瘘术后均获痊愈,大便1～2次/d,排便功能良好;随访4～20个月无复发.结论 选择恰当的术式和手术时机是手术成功的关键.采用带血管蒂的全层肠片以及直肠推进瓣技术可明显提高手术成功率.     

直肠移动瓣修补先天性直肠阴道瘘

目的 探讨直肠移动瓣修补先天性直肠阴道瘘的临床治疗效果.方法 设计直肠移动瓣,充分游离移动瓣直肠粘膜,无张力修补直肠瘘口,且直肠壁缺损与阴道壁缺损分别关闭,缝合不在同一水平面上.结果 12例患者经手术治疗均治愈,随访1年～9年,无复发、肛门失禁并发症.结论 对于低位先天性直肠阴道瘘,直肠移动瓣修补术疗效确切,值得推广,术前充分肠道准备、术中规范操作对保证手术成功至关重要.     

直肠阴道瘘经阴道手术治疗探讨

目的探讨直肠阴道瘘（rectovaginal fistula,RVF）经阴道手术修补的方法及手术成功的关键。方法2007年2月～2013年4月,对13例RVF经阴道修补。其中4例为RVF二次修补术,3例有2个瘘孔。均于瘘口形成半年后手术,术中不切除瘘管,采用“向心性”分离,充分利用瘘口周围的组织填补加固创面。结果13例瘘口均顺利愈合,无须行结肠造瘘术。手术时间25～55rain,（35±15）min。随访0．5～7年,平均2．5年,无复发。结论直肠阴道瘘经阴道修补简单易行,术中无需切除瘘管,手术时机、术前准备、术式的选择、术后管理是直肠阴道瘘治疗成功的关键。     

弧形直肠推移瓣治疗低位直肠阴道瘘的体会(附11例报告)

目的探讨弧形直肠推移瓣修补低位直肠阴道瘘的临床治疗效果。方法对11例直肠阴道瘘患者采用弧形直肠推移瓣治疗的临床资料作回顾性分析。结果 11例患者经肛门手术修补均一次成功,随访1～3年,无复发及肛门失禁等并发症。结论对于低位的直肠阴道瘘,弧形直肠推移瓣修补术疗效确切,成功率高,对肛门功能影响小,可以作为首次低位直肠阴道瘘手术修补的首选方式。     

直肠阴道瘘的病因与治疗

直肠阴道瘘（rectovaginal fistula，RVF）是连接直肠前壁和阴道后壁之间的异常病理性管道，内衬上皮细胞。RVF治疗困难，初次手术修补成功率为70％～100％，再次或多次修补成功率为40％～85％。[第一段]     

直肠阴道瘘的手术治疗经验

目的　探讨直肠阴道瘘的手术治疗经验。方法　采用会阴部弧形切口 ,在切除瘘口四周瘢痕组织后分别缝合修复直肠和阴道的缺损。结果　 1 0例患者均获痊愈 ,无需结肠造瘘。随访 1～ 9年 ,无复发。结论　充分游离并切除瘘口四周的瘢痕组织 ,分别缝合直肠和阴道壁缺损对成功修复直肠阴道瘘至关重要 ;选择恰当的手术时机、术前充分的肠道准备、术后适当的营养支持对保证手术的成功也很重要。     

经阴道修补直肠阴道瘘的临床分析

为探讨经阴道修补治疗直肠阴道瘘的临床效果，回顾分析于我院经阴道修补治疗的5例直肠阴道瘘患者的病例资料。结果显示，5例患者均成功完成手术，其中1例术后1个月内有少量阴道排气，2个月后痊愈。随访6个月至5年，均无复发。结果表明，准确把握手术时机、适应症及全面的围手术期护理，是经阴道修补直肠阴道瘘手术成功的关键。     

Musset术治疗直肠阴道瘘20例临床分析

直肠阴道瘘是阴道后壁与直肠前壁之间一种非正常的连接,瘘管表面以上皮覆盖。临床表现以经阴道溢气、溢粪、性生活受限为主。主要原因为产伤,亦可继发于感染、创伤及肿瘤等,或医源性因素造成。2010年9月至2013年3月期间,吉林大学中日联谊医院结直肠肛门外科对收治的20例直肠阴道瘘患者行Musset术,效果满意,现报道如下。     

22例直肠阴道瘘的个体化手术方式选择的治疗经验

目的 探讨直肠阴道瘘的手术治疗经验。方法 将22例直肠阴道瘘分为高位瘘、中低位瘘和复发瘘,而分别采用经肛门结肠拖下术,直肠粘膜游离瓣修补术和经会阴体瘘管切除直肠阴道修复术。结果 22例患者均获痊愈。无需结肠造瘘。随访1～11年,无复发。结论 直肠阴道瘘形式复杂,个体化手术方式的正确选择、恰当的手术时机、充分的术前准备以及加强术后管理是手术成败的关键。     

直肠阴道瘘临床研究进展

直肠阴道瘘临床治疗棘手,术后易复发,严重影响患者生活质量。目前治疗直肠阴道瘘的手术方法很多,但尚无治疗各类直肠阴道瘘最佳手术方式,仍需个体化选择。目前,对于直肠阴道瘘的治疗,缺乏基于高级别证据的专家共识或临床治疗指南。本文旨在从直肠阴道瘘病因、分类、诊断、手术方式、手术入路、微创技术应用以及围手术期管理几方面进行详细综述,以全面认识直肠阴道瘘的治疗现状。     

Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair

Aim Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique. Method Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn’s disease with proctitis, malignant or radiation‐related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure‐of‐eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days. Results Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28–78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn’s disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow‐up of 14 (2–67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre‐ and postoperatively were 1.3 (0–15) and 0.6 (0–6), respectively. Conclusion The success rate was promising with no deterioration of anal continence.     

Gracilis transposition flap for repair of an acquired rectovaginal fistula in a pediatric patient

Acquired rectovaginal fistulas in the pediatric population are relatively rare but are often difficult to treat. We describe a young girl who acquired a neorectovaginal fistula after a repeat pull-through procedure for Hirschsprung's disease. Durable repair of the fistula was accomplished with a gracilis transposition flap, providing a well-vascularized muscle buttress between the neorectum and vagina. To our knowledge, this is the first report of a gracilis flap in a pediatric patient with an acquired fistula and should be considered for this complication after pull-through for Hirschsprung's as well as for other perineal fistulas such as those acquired after trauma, infection, or in the setting of inflammatory bowel disease.     

Refinements in closure of radiation induced rectovaginal fistula

A two stage procedure for closure of a large rectovaginal fistula is presented. The gracilis muscle with full thickness skin patches is used for this purpose. In the first operation full thickness skin grafts, corresponding to the size of the mucosal defects, are applied to either side of the muscle for closure in the second stage. In the second operation the temporary extradermal exposed muscle pedicle, covered with healed skin grafts, is placed into the defect. All structures are reconstructed, rectal mucosa, rectovaginal space and vaginal mucosa.     

Martius flap: an adjunct for repair of complex, low rectovaginal fistula

Background

Complex, rectovaginal fistula (RVF) are uncommon but difficult therapeutic problems. Local repair and flap advancement techniques have a high incidence of recurrence with poor functional outcomes. Transperineal repair with anal sphincter reconstruction, when indicated, and placement of a Martius flap (bulbocavernosus pedicled transplant) result in improved rates of repair and better functional outcomes.

Methods

A consecutive series of patients were retrospectively reviewed from a prospective database between 2002 and 2006. Data were gathered from 2 colon- and rectal-specialty practices. Patient demographics and operative and functional outcomes were documented.

Results

Sixteen patients with a mean age of 39.5 years (17-62) were treated. Etiology of the fistula was obstetric (9), cryptoglandular (5), and Crohn’s disease (2). They had undergone a mean of 1.5 (0-4) prior repairs, and 6 had a preexisting diverting stoma before repair. Preoperatively, anal sphincter disruption was identified in 11 patients, and fecal incontinence was identified in 5 patients all with anal sphincter disruption. Dyspareunia was identified in 1 of 13 sexually active patients preoperatively. At a mean follow-up of 75 weeks (24-190), 1 recurrent fistula was identified (6.2%). Stomas were reversed in all patients. Two patients complained of fecal incontinence postoperatively. Five patients had dyspareunia postoperatively (5/16, 31%). One patient had a labial wound complication requiring local wound care.

Conclusion

Selected complex RVF can be reliably repaired with good functional outcomes using the Martius flap with anal sphincter reconstruction. Persistent or recurrent fecal incontinence and dyspareunia are common sequela of the underlying perineal injury and repair. No acute or delayed morbidity related to the Martius flap was identified.     

股薄肌转移修补复杂直肠阴道（尿道）瘘的前瞻陛研究

目的评估股薄肌转移修补治疗复杂直肠阴道（尿道）瘘的临床疗效。方法前瞻性收集2009年5月至2011年11月间在北京世纪坛医院接受股薄肌转移修补治疗的19例复杂直肠阴道（尿道）瘘患者的临床资料。记录修补成功率和手术并发症,并于术前及术后6个月分别进行SF-36生活质量评分、Wexner肛门失禁评分及女性性功能评分。结果19例患者中男性8例（直肠尿道瘘）,女性11例（直肠阴道瘘）。术前修补0-3（平均1．0）次,瘘口直径0．5～2．5（平均1．6）cm,均位于肛门括约肌上方。手术时间145。400（中位240）min,术后住院时间10。39（中位21）d。术后近期出现大腿麻木疼痛2例,小腿麻木2例;无远期并发症出现。术后随访6-35（中位18）个月,修补成功率94．7％（18／19）。术后6个月时。19例患者的Wexner评分由术前10．0±8．8降为2．9±5．8,控粪功能显著改善（P=0．002）;11例女性患者的性功能评分由术前的1．0±1．8升高至4．0±4．0。性功能显著改善（P=0．022）;SF-36生活质量评分显著提高（P〈0．001）。结论股薄肌转移修补治疗复杂直肠阴道（尿道）瘘成功率高,并发症少而轻微,疗效确切。     

Martius advancement flap for low rectovaginal fistula: short‐ and long‐term results

Aim Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short‐ and long‐term results of the Martius flap procedure. Method Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF‐12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined. Results Crohn’s disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn’s disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2–31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right‐sided flap was associated with a higher success rate (P = 0.0442). Conclusion The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.     

Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas

Aim Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery. Method A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig‐Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome. Results Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn’s disease had no ileostomy raised. At a median follow‐up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re‐operation and bovine plug repair combined with a mucosa flap. Conclusions Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.     

闭孔动、静脉前皮支阴股沟岛状皮瓣修复阴道直肠瘘

目的　介绍一种修复阴道直肠瘘的新方法。方法　在解剖学研究的基础上 ,设计并应用以闭孔动、静脉前皮支为蒂的阴股沟岛状皮瓣修复阴道直肠瘘。结果　本组 4例 ,皮瓣全部成活 ,手术成功。结论　该岛状皮瓣具有血运可靠、薄而无毛、供区隐蔽等优点 ,是一种较好的阴道直肠瘘修复术式。