Use of endoanal ultrasound in patients with rectovaginal fistulas

PURPOSE: The purpose of our study was to define the role of endoanal ultrasound in the evaluation and management of patients with rectovaginal fistula. METHODS: A retrospective review was performed of all patients with rectovaginal fistula who were evaluated by endoanal ultrasound at Barnes-Jewish Hospital at Washington University from 1992 to 1997. RESULTS: Twenty-five females underwent endoanal ultrasound before rectovaginal fistula repair. Mean age was 34 years. Rectovaginal fistulas were caused by obstetric trauma (19 patients; 76 percent), cryptoglandular disease (5 patients; 20 percent), and Crohn's disease (1 patient; 4 percent). Previous rectovaginal fistula repair had been performed in ten patients (40 percent). A history of anal incontinence was present in ten patients (40 percent). Rectovaginal fistula location was above (15 patients), at (7 patients), or below (3 patients) the dentate line. Rectovaginal fistula size was <5 mm (19 patients; 76 percent) or >5 mm (6 patients; 24 percent). Anal manometry revealed decreased sphincter pressures (resting or squeeze) in 12 patients (48 percent). Pudendal nerve latency was abnormal in three patients (9 percent). Endoanal ultrasound identified the rectovaginal fistula in 7 patients (28 percent) and an anterior sphincter defect in 23 patients (92 percent). At surgery sphincter injuries were identified in 23 patients (92 percent). Treatment was either sliding flap repair with anal sphincter reconstruction (22 patients; 88 percent) or sliding flap repair alone (3 patients; 12 percent). Repair of the rectovaginal fistula was successful in 23 patients (92 percent). Complications occurred in 11 patients (44 percent): two recurrent rectovaginal fistulas, five infections, two skin separations, one ectropion, and one hematoma. The two patients with recurrent rectovaginal fistula had prior repairs, and both were subsequently repaired successfully. Of the 11 patients with preoperative anal incontinence, 6 patients (54 percent) were continent and 2 (18 percent) improved after surgery. Cause, size, location, and previous repair of fistula had no effect on final outcome. CONCLUSIONS: Noncontrast endoanal ultrasound was not useful in imaging rectovaginal fistulas and cannot be recommended as a diagnostic or screening tool for the identification of a rectovaginal fistula. However, we recommend that endoanal ultrasound be performed preoperatively in all patients with known rectovaginal fistulas to identify and map occult sphincter defects. Concomitant anal sphincter reconstruction should be considered strongly in patients with rectovaginal fistula and an endoanal ultrasound-documented sphincter defect.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty

PURPOSE: This study evaluated the effectiveness of combining advancement flap with sphincteroplasty in patients symptomatic with rectovaginal fistula and anal sphincter disruption. METHODS: Twenty patients with rectovaginal fistulas and anal sphincter disruptions after vaginal deliveries underwent combined rectal mucosal advancement flap and anal sphincteroplasty between July 1986 and July 1993. The mean age of the patients was 30 (range, 18–40) years and the mean duration of symptoms was 54.8 weeks (range, 7 weeks to 6 years). In addition to mucosal advancement flap repair, 13 patients underwent two-layer repair of anal sphincters (with reapproximation of the puborectalis in 8 of the patients); 6 patients underwent one-layer overlap repair of anal sphincters (with reapproximation of the puborectalis in 2 of the patients); and 1 patient underwent reapproximation of internal anal sphincter alone because squeeze pressures were adequate, as determined by anal manometry. RESULTS: Postoperatively, vaginal discharge of stool and flatus was eliminated entirely in all 20 patients. Perfect anal continence of stool and flatus was restored in 14 patients (70 percent). Incontinence was improved but not eliminated in six patients (4 incontinent to liquid stool and 2 to flatus), and two patients required perineal pads. Subjectively, 19 patients (95 percent) reported the result as excellent or good. There were no complications. CONCLUSION: The combination of mucosal advancement flap and anal sphincteroplasty is a safe and highly effective procedure for correcting rectovaginal fistula with sphincter disruption after obstetrical injuries.Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Anal sphincter integrity and function influences outcome in rectovaginal fistula repair

PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defect on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preoperative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry studies. Follow-up was by mailed questionnaire in 36 patients (69 percent) and by telephone interview in 12 (23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18–70) years, and median follow-up was 15 (range, 0.5–123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before surgery. There were 27 endorectal advancement flaps and 35 sphincteroplasties (28 with and 8 without levatoroplasty). RESULTS: Success rates were 41 percent with endorectal advancement flaps and 80 percent with sphincteroplasties (96 percent success with and 33 percent without levatoroplasty;P=0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function(P=not significant). For sphincteroplasties, success rates were 73vs. 84 percent for normal and abnormal sphincter function, respectively (P=not significant). Results were better after sphincteroplastiesvs. endorectal advancement flaps in patients with sphincter defects identified by endoanal ultrasound (88vs. 33 percent;P=not significant) and by manometry (86vs. 33 percent;P = not significant). Poor results correlated with prior surgery in patients undergoing endorectal advancement flaps (45 percentvs. 25 percent;P = not significant) but not sphincteroplasties (80vs. 75 percent;P = not significant). CONCLUSIONS: All patients with rectovaginal fistula should undergo preoperative evaluation for occult sphincter defects by endoanal ultrasound or anal manometry or both procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of previous repairs. Patients with clinical or anatomic sphincter defects should be treated by sphincteroplasty with levatoroplasty.Read at the Minnesota Surgical Society, May 3, 1996, at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996, and at the Tripartite Meeting, July 8 to 10, 1996.     

Surgical treatment of low rectovaginal fistulas

Forty women with low rectovaginal fistulas were operated upon over a 9-year period. The etiology of the fistula in the majority was obstetric. Nine women had prior attempts to repair the fistula. All 40 women were managed with endorectal advancement flap with the addition of sphincteroplasty or perineal body reconstruction in 15 patients and rectocele repair in six patients. Postoperative complications included urinary difficulties (two patients) and wound complications (three patients). There were two recurrences. All women treated with sphincteroplasty or perineal body reconstruction were continent. Seven women complained of varying degrees of incontinence postoperatively; none had undergone sphincter or perineal body reconstruction. Endorectal advancement flap is a safe and effective operation for women with rectovaginal fistulas. Concomitant sphincteroplasty or perineal body reconstruction should be performed in women with historical, physical, or manometric evidence of incontinence.     

Operative repair of anovaginal and rectovaginal fistulas

PURPOSE: Operative repair of low rectovaginal fistulas should be tailored to the specific anatomic defect. Endoanal flap repair frequently provides successful fistula closure; however, if substantial injury to the perineal body, anal sphincter, or rectovaginal septum exists, a more extensive repair is required. We present our experience with 95 consecutive patients, operated for rectovaginal fistulas via septal repair after conversion to a fourth degree perineal laceration, endoanal flap, or anoperineorrhaphy. METHODS: A retrospective chart review was performed. Data collected included etiology, location, size, repair type, and degree of anal continence. All patients received standard mechanical and antibiotic bowel preparation and parenteral antibiotics. No covering stomas were used. RESULTS: Fistula etiology included obstetric injury (N=77), perianal cryptoglandular infection (N=15), and other (N=3). Thirty-one patients had previous unsuccessful repairs. Types of repairs were fourth degree perineal laceration (38), endoanal flap (19), and anoperineorrhaphy (38). Excellent or good functional results occurred in 92 patients (97 percent). Similar success occurred in patients with previous failed repairs (90 percent excellent or good). The recurrence rate was 3 percent. There were no outcome differences between techniques. CONCLUSION: We believe that all three types of repair for rectovaginal fistulas result in a high cure rate, thereby allowing operative technique to be tailored to the anatomic defects present. This approach should allow for optimal functional outcome.Funded by a grant from the Ferguson-Blodgett Research Foundation, Grand Rapids, Michigan.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Treatment of rectovaginal fistulas that has failed previous repair attempts

PURPOSE: The purpose of this study was to assess results of treatment of rectovaginal fistulas (excluding pouch vaginal fistulas) that have failed previous attempts at repair. METHOD: A retrospective chart review of all patients presenting with nonhealing rectovaginal fistula was performed. RESULTS: Twenty eight patients with persistent fistulas were identified. In 18 patients the fistula was classified as simple, and in 10 the fistula was complex. Fourteen fistulas were secondary to obstetric injury, five were caused by Crohn's disease, and nine patients had miscellaneous etiologies for their fistulas. Of patients with persistent simple fistulas, 13 (72 percent) of the fistulas healed, 5 after advancement flaps, 5 following sphincteroplasty, and 3 after coloanal anastomoses. Of persistent complex fistulas, only four of ten (40 percent) healed, one following sphincteroplasty, one with coloanal anastomosis, and two after gracilis transposition. A total of 23 advancement flaps were done in 17 patients with five fistulas healing (29 percent). Sphincteroplasty and fistulectomy was successful in six of seven patients (86 percent). Coloanal anastomosis resulted in healing of four of six patients (67 percent) in whom it was attempted. Gracilis muscle transfer was successful in two of two patients (100 percent). CONCLUSION: Persistent rectovaginal fistula presents a difficult management problem. Choice of operation must be tailored to the underlying pathology and type of repair previously done. Advancement flap repair is generally not recommended for persistent complex fistulas or for simple fistulas that have failed a previous advancement flap repair.Dr. MacRae was supported in part by the Wigston Foundation, Toronto, Ontario, Canada.Read at the meeting of The American Society of Colon and Rectal Surgeons, in Montreal, Quebec, Canada, May 7 to 12, 1995.     

The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition

Transanal advancement flap repair (TAFR) has been advoated as the treatment of choice for patients with low rectovaginal fistulas. Recently, several studies have reported a significantly lower healing rate. We also encountered low healing rates after TAFR. In an attempt to improve our results, we added labial fat flap transposition (LFFT) to the TAFR of rectovaginal fistulas. The aim of the present study was to evaluate the outcome after TAFR and to investigate the impact of an additional LFFT. Between 1991 and 1997, 21 consecutive patients of median age 33 years underwent TAFR. The etiology of the fistulas was: obstetric injury (n=9), cryptoglandular abscess (n=8) and wound infection after anterior anal repair (n=4). The first 9 patients underwent TAFT with (n=3) or without (n=6) anterior anal repair. In the following 12 patients, LFFT was added to the advancement flap. In 4 of these a concomitant anterior anal repair was performed. The median follow-up was 15 months. The overall healing rate was 48%. In the first 9 patients, in whom no additional LFFT was performed, the rectovaginal fistula healed in 4 cases (44%). In the following 12 patients in whom an additional LFFT was performed, a similar healing rate was observed (50%). In conclusion, the outcome of transanal advancement flap repair of rectovaginal fistulas is poor. Addition of a labial fat flap transposition does not improve this outcome. Received: 25 January 2002 / Accepted in revised form: 6 February 2002     

Effect of Tobacco Smoking on Advancement Flap Repair of Complex Anal Fistulas

Purpose Options for the management of complex anal fistulas include fistulotomy, setons, fibrin sealant, and advancement flaps. This study was performed to evaluate our results with advancement flap repair of anal fistulas and to identify factors associated with failure. Methods A retrospective analysis was performed for all patients treated with an anal fistula between June 2000 and May 2003. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, smoking history, procedure performed, and fistula recurrence. Results There were 95 patients (43 males and 52 females) with a mean age of 42 years. Transsphincteric fistulas were present in 51 patients and 44 females had rectovaginal fistulas. A mucosal flap repair was performed for 68 patients and 27 patients had an anodermal flap repair. The median length of follow-up was ten months. The fistula recurred in 31 patients (32.6 percent). Subset analysis showed an association between a history of previous attempts at repair or tobacco smoking and an increased rate of fistula recurrence, but did not reveal any increased risk of recurrence for patients over age 40 years, for those with rectovaginal fistula, or for males. Conclusion A history of previous attempts at repair of an anal fistula or tobacco smoking is associated with an increased risk of fistula recurrence; while age over 40 years, male gender, or a rectovaginal fistula are not. Presented at the Tripartite Meeting, Dublin, Ireland, July 4 to 8, 2005.     

New option for recurrent rectovaginal fistulas

PURPOSE: To describe an operative technique for repair of recurrent rectovaginal fistulas. METHODS: A diamondshaped cutaneous flap advancement into the vagina and a standard endoanal advancement flap are described for use as an alternative option in treatment of recurrent rectovaginal fistulas. RESULTS: Complete healing of fistula was achieved with no impairment of continence. CONCLUSION: This technique is suitable in treatment of recurrent rectovaginal fistulas especially in frail and elderly patients.     

Recovery rates and functional results after repair for rectovaginal fistula in Crohn’s disease: a comparison of different techniques

Background and objectives Rectovaginal fistulas (RVF) in Crohn’s disease continue to be a challenging problem. Several operations are often necessary to attain definitive healing of the disease process. There are no guidelines concerning optimal therapeutic approaches. Endoanal mobilization techniques such as the advancement flap technique were considered the therapy of choice for many years, but are now regarded ever more critically. We have implemented several less aggressive closure techniques that take account of the anatomy and morphology of the anorectum. The long-term results are presented in this paper. Materials and methods The method used was observational analysis with a standard protocol of all patients with RVF and Crohn’s disease treated surgically at a single institution. Results/Findings Between January 1985 and December 2002, we treated 72 patients with low rectovaginal fistulas. The operations comprised 56 procedures performed in 37 women presenting with RVF. The patients’ median age was 34.6 ± 10 years; the follow-up period was 7.15 years (10 months–18 years). Several techniques were performed: transverse transperineal repair (n = 20), endoanal direct closure multilayer without flap (n = 15), anocutaneous flap (n = 14), and advancement mucosal or full-thickness flap (n = 7). Diverting ileostomies were created in 28 patients (76%). Recovery was achieved with the initial repair in 19 patients (51.4%). An additional 12 patients underwent repeat procedures (2–5), with an overall success rate of 27:37 (73%). The rate of recurrence was 30% during a follow-up period of 7.1 years. The rate of proctectomy was 13.5%. The success rates for each of the techniques in the above group were 70, 73, 86, and 29%, respectively. They were significantly higher with the direct closure and anocutaneous flap technique than with the advancement flap technique. However, the transperineal repair led to decreased postoperative resting pressures. In the advancement flap technique, the resting and squeezing pressure decreased significantly. The risk of developing a suture line dehiscence leading to a persisting fistula was higher in the advancement flap procedure with 43%. Interpretation/conclusion Techniques with a low degree of tissue mobilization such as the direct closure and anocutaneous flap show higher success rates without significant postoperative changes in continence and manometric outcome. Impaired continence was observed only in the advancement flap group, resulting in significant changes in manometric values and recovery rates. The authors prefer to apply the direct multilayer closure technique without flap.     

Relationship between sphincter morphology on endoanal MRI and histopathological aspects of the external anal sphincter

Atrophy of the external anal sphincter can be shown only on endoanal magnetic resonance imaging (MRI). Until now no study has compared the morphological endoanal MRI findings with histopathological aspects of the external anal sphincter. The aim of this study was to validate the MRI interpretation of the external anal sphincter using histology as a ”gold standard.” In this prospective study 25 consecutive unselected women (median age 48 years, range 27–72) with fecal incontinence due to obstetric trauma were assessed preoperatively with endoanal MRI. All patients underwent anterior sphincteroplasty within 6 months of the preoperative assessment. During sphincter repair, a biopsy specimen was taken both from the left and right lateral parts of the external anal sphincter. Interpretation of MRI was performed by one of the radiologists (J.S.), and biopsy specimens were evaluated by the pathologist (W.J.M.). Both were blinded to the interpretation of the other. MRI revealed external anal sphincter atrophy in 9 of the 25 patients (36%). Histopathological investigation confirmed these findings in all but one. In one additional patient atrophy was detected on histological investigation while the morphology of the external anal sphincter was classified as normal on MRI. In detecting sphincter atrophy endoanal MRI showed 89% sensitivity, 94% specificity, 89% positive predictive value, and 94% negative predictive value. MRI correctly identified sphincter morphology in 23 of 25 cases (92%). This study demonstrates that endoanal MRI accurately identifies normal and abnormal external anal sphincter morphology. Endoanal MRI is therefore a valuable preoperative diagnostic tool. Accepted: 29 December 1999     

Delayed repair of obstetric injuries of the anorectum and vagina

PURPOSE: We categorized the various types of postobstetric injuries of the anorectum and vagina encountered in a five-year period. The operative procedures used to repair these injuries and the functional outcome after surgery were assessed. METHODS: Between 1986 and 1991, 52 patients were surgically treated for obstetric injuries of the anorectum and vagina; 48 patients were available for follow-up study. Four clinical injury types were identified: Type I, incontinent anal sphincter (11 patients); Type II, rectovaginal fistula (16 patients); Type III, rectovaginal fistula and incontinent anal sphincter (11 patients); and Type IV, cloaca-like defect (10 patients). The mean age of the patients was 30 years, the mean duration of symptoms before surgery was 13 months, and the mean follow-up period was 16 months. The major component of surgical repair for each injury type was: Type I, overlap repair of external anal sphincter; Type II, rectal mucosal advancement flap; Type III, overlap repair of external anal sphincter and rectal mucosal advancement flap; and Type IV, overlap repair of external anal sphincter, anterior levatorplasty, and anal and vaginal mucosal reconstruction. Fecal diversion was not performed in any patient. Specific questions were asked at the most recent follow-up assessment to determine results. RESULTS: Continence status postoperatively was classified as perfect, impaired, or poor; poor was defined as no improvement or worse. Postoperative continence (perfect, impaired, or poor) was, respectively: Type I (11 patients), 64 percent, 36 percent, and 0 percent; Type II (16 patients), 56 percent, 0 percent, and 44 percent; Type III (11 patients), 64 percent, 36 percent, and 0 percent; and Type IV (10 patients), 90 percent, 10 percent, and 0 percent. Vaginal discharge of stool was eliminated in all patients with a rectovaginal fistula. Subjectively, 92 percent of the patients had excellent or good results. Complications included wound hematoma (n=2), fecal impaction (n=2), urinary retention (n=1), and urinary tract infection (n=1). CONCLUSION: Patients with Type II injuries had the worst results (P < 0.001). These patients should be evaluated for anal incontinence before surgery to assess the need for a concomitant sphincteroplasty.     

Is routine endoanal ultrasound useful in anal fistulas?

OBJECTIVE: To evaluate the effectiveness of endoanal ultrasound with hydrogen peroxide enhancement in the assessment of anal fistula (tract and internal opening), and to value the utility of this examination for anal or perianal suppuration when performed by a colorectal surgeon trained in this technique. PATIENTS: Endoanal ultrasound was performed in 103 patients with anal or perianal suppuration. Twenty patients were excluded: 9 had the external opening closed, and 11 had cryptoglandular abscesses. All ultrasound scans were performed by the same explorer using a BK Diagnostic Ultrasound System with a 7 MHz endoprobe. The examination was based on the identification of the three anal planes, then hydrogen peroxide was infused and the procedure was repeated. RESULTS: Out of 83 patients included, 11 had a perianal sinus and 72 an anal fistula. In all fistulas the main tract was found: 24 were inter-sphinteric (33.33%), 33 trans-sphincteric (45.83%), 3 supra-sphincteric (4.17%), and 12 extra-sphincteric (16.67%). An internal opening was identified in 69 (95.83%). CONCLUSIONS: Endoanal ultrasound with hydrogen peroxide enhancement is an effective examination to visualize fistulous tracts and internal openings. We think it is highly useful for anal or perianal suppuration to identify abscesses, to recognize a perianal sinus, to check the sphincteric condition, and to plan subsequent surgery.     

Outcomes After Repair of Rectovaginal Fistulas Using Bioprosthetics

Purpose  The purpose of this study was to report the outcomes with the use of advancement flaps and bioprosthetic grafts for the management of rectovaginal fistulas. Methods  A retrospective analysis of prospectively collected data was performed for all patients treated with a rectovaginal fistula. Results  There were 44 patients in the advancement flap group. A mucosal flap repair was performed for 29 patients, and 15 patients had an anodermal flap repair. The mean follow-up was 10 (range, 6–22) months. There were 34 patients in the bioprosthetic repair group. A bioprosthetic interposition graft was used to repair the fistula in 27 patients with a mean follow-up of 12 (range, 6–22) months, and 7 patients had a bioprosthetic plug repair of their fistula with a mean follow-up of 6 (range, 3–12) months. The fistula recurred in 15 patients (34 percent) who were managed by a flap repair, 5 patients (19 percent) who were managed by a bioprosthetic sheet, and 1 patient (14 percent) who was treated with a bioprosthetic plug. Conclusions  Use of bioprosthetics for the management of rectovaginal fistulas is a new technique, which, based on early experience, seems to yield results equal to advancement flap repair. Dr. Ellis serves as a paid consultant for Cook Surgical. He has a Research Grant from Cook Surgical to study the long-term efficacy of Cook’s Anal Fistula Plug for treatment of anal fistulas.     

Repair of simple rectovaginal fistulas

The results of 81 endorectal flap advancements for simple rectovaginal fistulas are reported. Simple fistulas are defined as <2.5 cm in diameter, low or mid vaginal septum in location, and infectious or traumatic in origin. Essentially, the technique is advancement of a flap of mucosa, submucosa, and circular muscle over midline approximation of internal sphincter muscle. The mean patient age was 34 years old (range, 18 to 76 years). The causes were obstetrical injury (74 percent), perineal infection (10 percent), operative trauma (7 percent), and unknown (8 percent). Overall, the repair was successful in 83 percent of patients. Success correlated with the number of previous repairs,i.e., none: 88 percent success; one: 85 percent success; two: 55 percent success. There were 25 concomitant overlapping sphincteroplasty procedures. Only minor complications ensued, with no mortality. This repair is recommended for patients with no or one previous repair because of its lack of mortality, minimal morbidity, ease of concomitant sphincteroplasty, and avoidance of a colostomy. For patients with two or more earlier repairs, a muscle interposition should be considered. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.     

Long-term seton drainage for high anal fistulas in Crohn's disease—A sphincter-saving operation?

METHODS: Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place. RESULTS: Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two. CONCLUSION: Long-term seton drainage for high anal fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.     

Transperineal ultrasound in the detection of perianal and rectovaginal fistulae in Crohn's disease

OBJECTIVES: Perianal and rectovaginal fistulae are common complications in Crohn's disease. Magnetic resonance imaging (MRI) and endoanal ultrasound are used for imaging perianal fistulae and abscesses, but both methods require expensive equipment and experienced investigators. Transperineal ultrasound may represent another method of detecting perianal complications in Crohn's disease. We investigated Crohn's disease perianal and rectovaginal fistulae using transperineal ultrasound and compared the findings with results of endoanal ultrasound as reference standard. METHODS: A total of 46 patients with Crohn's disease and perianal and/or rectovaginal or anovulvar fistulae underwent, transperineal and endoanal ultrasound, on the same day. Transperineal ultrasound was performed using regular convex and high-resolution linear probes. Endoanal ultrasound was performed using an ultrasound system with a 7 MHz rotating endoanal probe. Fistulae were classified according to Parks' classification in intrasphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Rectovaginal or anovulvar fistulae were described separately. Presence of abscesses was also reported. RESULTS: Fifty-two fistulae (3 intra-sphincteric, 28 transsphincteric, 8 suprasphincteric, 2 extrasphincteric, 9 rectovaginal, and 2 anovulvar) were detected by transperineal ultrasound. Endoanal ultrasound confirmed the correct classification of 45 fistulae (predictive positive value: 86.5%). Of the 53 fistulae detected by endoanal ultrasound, 45 were correctly classified by transperineal ultrasound (sensitivity 84.9%). Transperineal ultrasound showed 10 perianal abscesses: 2 horseshoe, 4 deep, and 4 superficial. Endoanal ultrasound confirmed all horseshoe, 3 deep, and 2 superficial abscesses and did not find further abscesses. CONCLUSIONS: Transperineal ultrasound is a simple, painless, real-time method to detect and classify perianal and rectovaginal fistulae and/or abscesses in Crohn's disease.     

Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn’s disease

Background  Due to the considerable variety in the clinical presentation of anorectal and rectovaginal fistulas in Crohn’s disease, data on treatment results for each type of fistula are limited. The aim of this study was to summarize the results after surgical treatment of such fistulas in a large consecutive series of patients. Patients and methods  All patients with anorectal or rectovaginal fistula due to Crohn’s disease requiring surgery in our institution between 1991 and 2001 were extracted from a prospective database. A standardized telephone interview was conducted and patients were followed in our outpatient clinic, the department of internal medicine, or at their gastroenterologist. Type of fistula and interventions were classified and analyzed. Recurrence-free time intervals were estimated for each type of fistula and for the different surgical procedures. The influence of the surgical procedure, the number of operations performed, and the correlation to other localizations of the disease were analyzed in regard to the recurrence rate. Results  From 777 patients with Crohn’s disease undergoing surgery between 1991 and 2001, 147 had anorectal or rectovaginal fistula (292 operations). Ninety-eight percent of them also had Crohn’s disease in the colon or rectum compared to only 21% of patients without a fistula (p value <0.001). Over long-term follow-up, 29 patients (20%) required proctectomy. Submucosal fistulas needed major surgery in only 14% of cases compared to 56% of cases with rectovaginal fistulas. After 5 years, complex fistulas showed a strong trend towards a higher recurrence rate after surgery than simple submucosal fistulas (45.6% vs. 18.8%, p = 0.079). Whereas recurrences occurred over the whole observation period in the group of patients with complex fistulas, there was no further recurrence in patients with submucosal fistulas 13 months after surgery. In rectovaginal fistulas, additional levatorplasty showed no advantage over standard endorectal advancement flap. Conclusions  Long-term follow-up demonstrates that recurrence rates after repair of complex fistulas for Crohn’s disease are high and continuously increase over time. Submucosal fistulas have the best outcome; after 13 months without recurrence, definite cure can be expected.     

Gracilis muscle repair of rectovaginal fistula after restorative proctocolectomy

Gracilis muscle interposition flaps have been used to treat two patients with rectovaginal fistulas. The fistulas occurred following restorative proctocolectomy with a J-shaped ileal reservoir and ileoanal anastomosis. Attempts at local repair of the fistulas had failed. A diverting loop ileostomy was constructed simultaneously. Anterior sphincteroplasty was performed in one patient for associated incontinence. Excellent results were achieved in both patients. The fistulas have healed, and intestinal continuity has been re-established. This procedure can be useful to salvage a pelvic pouch complicated by a rectovaginal fistula.     

Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap

PURPOSE: The endorectal advancement flap is a surgical procedure used in the treatment of anorectal and rectovaginal fistulas. There is a wide range of success rates published in the literature. This study was undertaken to examine the success rate of primary endorectal advancement flap in our own institution. We attempted to identify factors that influence the rate of healing. METHODS: A retrospective review was performed on 105 patients (43 males) who underwent their first endorectal advancement flap at our institution between January 1, 1994, and June 30, 1999. Ninety-nine patients were available for follow-up. Sixty-two patients had anorectal and 37 had rectovaginal fistulas. The causes of fistula included cryptoglandular (48 patients), Crohns disease (44), obstetric injury (5), trauma (1), and other (1). RESULTS: The median follow-up was 17.1 (range, 0.4–66.9) months. The median age was 42 (range, 16–78) years. Recurrence was seen in 36 patients (36.4 percent); thus, the primary rate of healing was 63.6 percent. Factors that were associated with higher rates of success were increased age (P = 0.011), greater body surface area (P = 0.012), history of incision and drainage of a perianal abscess preceding advancement flap (P = 0.010), previous placement of a seton drain (P = 0.025), and short duration of fistula (P = 0.003). Factors that negatively influenced the healing rate of the flap were the diagnoses of Crohns disease (P = 0.027) and rectovaginal fistula (P = 0.002). Length of hospitalization, discharge on oral antibiotics, and the presence of a diverting stoma did not influence the rate of healing. Prednisone was associated with a distinct trend toward failure, with none of the patients on high-dose prednisone (greater than 20 mg/day) having achieved long-term healing. No fistulas recurred after a period of 15 months. CONCLUSION: The endorectal advancement flap is an effective method of repair for both anorectal and rectovaginal fistulas, even though the success rate may not be as optimistic as in some other published studies. Patient selection is imperative, realizing that a higher rate of failure may be present in Crohns disease and rectovaginal fistulas. Control of sepsis before endorectal advancement flap with drainage of a perianal abscess and/or seton placement, whenever possible, is indicated.