Management of H-type rectovestibular and rectovaginal fistulas

Introduction

H-type rectovestibular or rectovaginal fistulas are rare entities in the spectrum of anorectal malformations seen in North America. Management options described in the literature have included perineal repair, anterior perineal anorectoplasty, vestibuloanal pull-through, and limited or formal posterior sagittal anorectoplasty, with a reported recurrence rate of 5% to 30%. We describe our approach and outcome in the management of these patients.

Methods

In a series of 1170 females with anorectal malformation, we cared for 8 patients who had an H-type rectovestibular or rectovaginal fistula and reviewed their clinical presentation, diagnosis, operative technique, and postoperative course.

Results

The patients' presenting symptoms included passage of stool per vagina (6), constipation (3), labial abscess (1), and recurrent urinary tract infection (1). There was associated anorectal stenosis in 3 patients. The remaining 5 patients had normal anal openings. Endoscopy was not helpful in locating the fistulas, but the fistulas were all demonstrated on direct inspection under anesthesia. The fistula was located in the vestibule (4), vagina (3), or labia (1). One patient had an associated presacral mass. Two patients had been operated on twice previously using a perineal repair and a protective colostomy and presented with third recurrences. In 5 cases, a posterior sagittal approach was used, placing sutures circumferentially around the fistulous opening on the rectal side, ligating the fistula, and pulling down a normal segment of rectum to be placed in front of the repaired vaginal wall. In our last 3 cases, we performed a transanal mobilization of the anterior rectal wall, leaving the perineal body intact. After our repairs, the patients have been followed up for 3 months to 15 years with a median of 15 months, and we have seen no recurrences.

Conclusions

In addition to vaginal passage of stool, an H-type fistula should be suspected when there is a labial abscess in an infant, and an associated anal stenosis or presacral mass must be checked for. Direct inspection is the key, with a careful look in the vestibule, because endoscopy may miss the fistula. The essential technical point for repair is to get healthy anterior rectal wall to cover the area of fistula on the posterior vagina. A transanal approach, leaving the perineal body intact, is an excellent option for this repair.     

Endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula

Background/purpose: Rectourethral (RUF) or rectovaginal fistula (RVF) is a troublesome complication after anorectal surgery because of dense adhesions around the fistula. The authors applied a new technique for the redo surgery.Methods: Case 1 is Hirschsprung’s disease in a 1-year-old boy who underwent modified Duhamel’s procedure and had RUF. Case 2 is rectovestibular fistula in an 11-year-old girl who had anterior sagittal anorectoplasty complicated by RVF. Case 3 is multiple urogenital anomalies including rectovesical fistula in a 4-year-old boy in whom transvesical repair was unsuccessful. The colon was mobilized as far as possible at laparotomy. The rectum was opened via a posterior sagittal approach leaving 1 cm of the anal canal. Extended endorectal mucosectomy was performed to the dentate line, and the fistula was closed from inside of the rectum. The remaining mucosal cuff was everted out of the anus and the intact colon was pulled through the rectum and anastomosed to the cuff extraanally.Results: The postoperative contrast enema showed no recurrent fistula, and defecation was not impaired.Conclusions: Endorectal pull-through of the intact colon can spare troublesome mobilization of the fistula and can prevent the recurrence of fistula. Rectal incision via a posterior sagittal approach provides a direct view of the fistula.     

Outcome of patients after single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification

Purpose

The aim of the study is to assess the characteristics and outcome of anorectal malformation (ARM) patients who underwent single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification.

Methods

From 2002 to 2013, twenty-eight males and four females with perineal fistula who underwent single-stage repair without colostomy in our institute were included in this study. Patients with perineal fistula who underwent staged repair were excluded. Demographics, associated anomalies, and operative complications were recorded. The type of surgical procedures and functional outcome were assessed using the Krickenbeck classification.

Results

Six patients had associated anomalies, including two patients with renal, two with cardiac, one with vertebral, and one with limb abnormalities. Thirteen patients underwent perineal operation, and fourteen patients underwent anterior sagittal approach in the neonatal period. One patient underwent anterior sagittal approach, and four patients underwent PSARP beyond the neonatal period. One patient had an intra-operative urethral injury and one a vaginal injury. Complications were not associated with the type of surgical procedure (p = 0.345). All perineal wounds healed without infection. By using the Krickenbeck assessment score, all sixteen children older than five years of age had voluntary control. One patient had grade 1 soiling, and no patient had constipation.

Conclusions

Single-stage operation without colostomy was safe with good outcomes in patients with perineal fistula. The use of Krickenbeck classification allows standardization in assessment on the surgical approach and on functional outcome in ARM patients.     

Robotic-assisted anorectal pull-through for anorectal malformations

Background/purpose

Many reports have addressed the feasibility and safety of using robotic surgery in children. To our knowledge, no published report has described the use of a surgical robot in the repair of anorectal malformations (ARMs).

Methods

Included children underwent robotic-assisted repair of ARMs with rectourethral fistula between April 2006 and March 2010 at King Khalid University Hospital, Riyadh, Saudi Arabia, using the da Vinci Surgical System. Their medical records were reviewed with respect to demographic data, associated anomalies, techniques and operative procedures, complications, outcomes, and follow-up.

Results

Five male infants (mean age, 6.6 months) underwent robotic-assisted repair of ARMs with rectourethral fistula using the Georgeson technique. The fistulae were divided and ligated in 4 patients and was left open in 1. All procedures were successfully completed without conversion to an open technique. One patient developed left-sided epididymo-orchitis postoperatively. All the patients had their colostomy closed. The follow-up ranged from 6 to 36 months. Fecal continence was difficult to assess in 2 patients. Two patients have voluntary bowel movements without soiling. One infant has fecal soiling and is on a laxative/enema for constipation.

Conclusions

Robotically assisted repair of ARMs with rectourethral fistula is feasible and safe. It offers a good alternative to the criterion standard, posterior sagittal anorectoplasty (PSARP), for repair of ARMs with rectourethral fistula. More patients and a longer follow-up period are needed for further evaluation of this novel approach.     

Single-stage repair for rectovestibular fistula without opening the fourchette

Background

Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach.

Method

All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence.

Result

A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse.

Conclusion

Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.     

Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition

INTRODUCTION

Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures.

PRESENTATION OF CASE

We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient''s quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures.

DISCUSSION

This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum.

CONCLUSION

In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.Abbreviations: RVF, rectovaginal fistula; STARR, stapled trans anal rectal resection; TRANSTAR, transanal stapled resection     

Transanal endoscopic-assisted proctoplasty--a novel surgical approach for individual management of patients with imperforate anus without fistula

Background/Aim

Imperforate anus without fistula consists of a spectrum of defects with variable distance between the rectal pouch and the perineum. We have developed a novel surgical approach for individual management of these patients based on precise knowledge of the level of the anomaly.

Methods

All consecutive patients with imperforate anus without fistula between 2002 and 2004 had sigmoidostomy performed after having failed to pass meconium in the first 24 hours. The upper pouch was intraluminally visualized using retrograde endoscopy through the sigmoid mucous fistula. The distal termination of the rectum was clearly identified as by convergence of the anal columns. Bright translumination of the endoscope light from the rectum to the anal dimple within the external sphincter indicated a low malformation amenable to transanal proctoplasty. The rectum was incised from below under endoscopic visual control. Poor translumination indicated a higher defect, in which case, the operation was converted to standard posterior sagittal anorectoplasty.

Results

Seven patients (6 boys) were identified. Four patients (3 boys) completed transanal endoscopic-assisted proctoplasty. In all cases, the convergence of anal columns indicating rectal termination was right above the anal pit at the site of the maximal external sphincter squeeze. In 3 patients, the operation was converted to posterior sagittal anorectoplasty after verification of a higher anomaly by endoscopy. There were no operative complications. The median follow-up was 3 months (range, 1-26 months). All patients have an appropriate size anus and regular bowel actions.

Conclusions

Transanal endoscopic-assisted proctoplasty allows safe and anatomical reconstruction of the anorectum, as well as contemporaneous closure of the sigmoidostomy in a significant proportion of patients with imperforate anus without fistula, avoiding the potential complications associated with the open posterior sagittal approach.     

Laparoscopy and its use in the repair of anorectal malformations

Introduction

Laparoscopy has been used for the treatment of anorectal malformations (ARMs) in an attempt to be less invasive and with the hope that it would result in a better functional outcome. There remains a significant debate about whether these expectations have been fulfilled.

Methods

Seventeen patients with ARM for whom laparoscopy was used were retrospectively reviewed. Six were operated on primarily by the authors, and 11 cases were referred after a laparoscopic repair performed elsewhere. In addition, a literature review was performed looking for evidence of less invasiveness and improved functional results in patients operated on laparoscopically.

Results

The diagnosis was imperforate anus with a rectobladder neck fistula in our 6 cases with the fistula ligated laparoscopically in each case. In 1 patient, the malformation was repaired entirely using laparoscopic technique. The other 5 patients had a laparoscopically assisted repair because we had to open the abdomen to taper a dilated rectum in 2, mobilize a very high rectum in 2, and take down a distal colostomy stoma in 1. Eleven patients were referred with a variety of problems after a laparoscopic repair done elsewhere for rectal stricture (5), rectal prolapse (4), recurrent rectourethral fistula (3), rectal mislocation (3), failed attempted repair leading to fecal incontinence (1), and a posterior urethral diverticulum (1). Our literature review included 47 references (involving 323 patients) published between 1998 and 2010. All studies showed that laparoscopic repair of ARMs is feasible. The review, however, did not provide evidence of less invasiveness or improved functional results.

Conclusions

Laparoscopy for ARM is a less invasive procedure when compared with those operations that would have previously required a laparotomy (rectobladder neck fistula). In cases of rectoprostatic fistulae, the laparoscopic approach is feasible and avoids a lengthy posterior sagittal incision. There is no evidence that the laparoscopic approach is a less invasive procedure for other types of ARMs. In cases of rectobulbar fistula, congenital anal stenosis, perineal fistula, ARM without fistula, the evidence suggests that it may be lead to more complications. There is no evidence in the literature demonstrating better functional results in cases of ARM operated on laparoscopically.     

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts

Background

Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field.

Methods

A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011.

Results

The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae.

Conclusions

With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.     

Rectovaginal Fistula Repair Utilizing a Cadaveric Dermal Allograft

Rectovaginal fistula repair is commonly performed through the vagina. When recurrent fistulae occur, healthy tissue such as a muscle or fat pad may be interposed to facilitate healing and prevent recurrence. A woman developed a postpartum rectovaginal fistula after her third-degree perineal laceration failed to heal completely. Two subsequent fistula repairs were performed, with recurrence following each procedure. The fistula was ultimately repaired by performing a layered closure and interposing a cadaveric dermal allograft between the rectovaginal septum and vaginal epithelium. Allogenic cadaveric graft may be a viable alternative to traditional autologous flaps for the repair of recurrent or complicated rectovaginal fistulae.     

Reoperations in Hirschsprung disease

Background

We sought to identify causes of preventable complications related to operations for Hirschsprung disease.

Methods

We reviewed the cases of 51 patients with Hirschsprung disease who underwent a primary procedure elsewhere, had a complication, and were referred for reoperation.

Results

Thirty-five patients had 1 failed operation, 10 had 2, and 6 had 3. Initial operations were Soave (20), Duhamel (15), Swenson (5), transanal endorectal (4), myectomy (3), unknown (3), and laparoscopic Swenson (1). Thirty-one patients presented with a stoma. Patients without a stoma (20) had fecal impaction (8), recurrent enterocolitis (6), and fecal incontinence (6). None had both enterocolitis and incontinence. Reoperation was performed posterior sagittally (40) or transanally (5). Indications included stricture (21), megarectal Duhamel pouches (12), fistulae (11 [8 rectocutaneous, 2 rectourethral, and 1 rectovaginal]), pouchitis (2), and retained aganglionic bowel (8). After reoperation, 14 were continent, 11 had a stoma (8 permanent), 6 had voluntary bowel movements but soiled occasionally, 6 received rectal irrigations to avoid enterocolitis, 6 were incontinent but clean with bowel management, and 2 were lost to follow-up.

Conclusion

Stricture, megarectal pouch, fistula, and retained aganglionic bowel are preventable complications. Enterocolitis is partially preventable but can occur after a technically correct procedure. Fecal incontinence is a preventable complication likely because of anal canal damage.     

Single-stage repair of vestibular and perineal fistulae without colostomy

Purpose

This retrospective study was undertaken to evaluate the feasibility of primary anorectoplasty without a covering colostomy using the anterior sagittal anorectoplasty (ASARP) or posterior sagittal anorectoplasty (PSARP) technique in patients having vestibular and perineal fistulae, its complications, results, and remote outcome in our institute.

Methods

From January 2000 to June 2007, patients with vestibular and perineal fistulae subjected to single-stage surgical correction at our institute were reviewed retrospectively from the data available in hospital records and follow-up complaints of patients and their parents in the outpatient department. Patients who had undergone a staged repair were excluded from the study. All patients were assessed for immediate and delayed complications including continence of the neorectum.

Results

From January 2000 to June 2007, 123 patients having vestibular (94) and perineal fistulae (29), age range from 28 days to 10 years, were subjected to primary repair either by the ASARP (34) or PSARP (89) technique. Follow-up period ranged from 3 months to 7 years. Mortality was nil. Constipation (25.68%) was the major long-term problem. Incontinence occurred in 1 patient (1.85%), who also had associated sacral agenesis. A total of 98.15% of patients were continent with stool frequency of 1 to 4 per day. Recurrence of fistula (0.81%), anal stenosis (6.76%), mucosal prolapse (2.70%), and anterior migration of the neoanus (1.35%) were the other major problems. Other minor problems like wound infection, superficial wound dehiscence, transient constipation, and diarrhea, etc, were successfully managed by local wound care, antibiotics, laxatives, enema, anal dilatation, and dietary changes.

Conclusion

Primary anorectoplasty either by PSARP or ASARP is feasible in vestibular and perineal fistulae without covering colostomy. Associated sacral agenesis/hypoplasia, redundant rectosigmoid or pouch colon, and wound infections with dehiscence are the major confounding factors affecting overall outcome. Better outcome in terms of continence can be achieved by careful surgical technique and follow-up along with proper toilet training. Complication rate was greater in cases of vestibular fistula than of perineal fistula, regardless of technique used. Some sort of laxatives and enema are often required. Dilatation of the neoanus for varying periods is also needed.     

Repair of Rectourinary Fistulas Using a Posterior Sagittal Transanal Transrectal (Modified York-Mason) Approach: An Update

Purpose

We report our experience with posterior sagittal, transanal, transrectal repair of rectourinary fistulas.

Materials and Methods

A total of 16 fistula repairs was done in 15 patients.

Results

Of the fistulas 13 occurred after a variety of prostatic procedures, 1 after Y-V plasty and 1 after pelvic trauma (2 repairs were attempted in the latter case). Six patients underwent repair without colostomy. No patient experienced fecal or anal complications and all repairs were successful.

Conclusions

Our surgical approach for repair of rectourinary fistulas is simple, effective, associated with minimal morbidity and cost-effective.     

Transvaginal primary repair of a suprasphincteric rectovaginal fistula

Introduction and hypothesis

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

Methods

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

Results

Anatomy restoration was completed without complications.

Conclusion

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

     

Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn’s disease a risk factor for failure? A prospective cohort study

Background

The surgical management of rectovaginal fistulae associated with Crohn’s disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn’s-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn’s disease patients and in a control group.

Materials and methods

All patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005–2016). The primary study outcome was the comparison of the success rate of GMT in Crohn’s disease and control group patients.

Results

Twenty-one patients with a rectovaginal fistula due to Crohn’s disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57 months (p 0.34), the success rate of GMT was 75% in patients with Crohn’s disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5 months (1–12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1).

Conclusion

GMT is associated with a high success rate, especially in Crohn’s disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae.

     

Diagnosis and management of congenital rectourethral fistula in a child with long tubular duplication of the colon and Klippel-Feil syndrome

We describe a unique association of congenital rectourethral fistula with long tubular duplication of the colon in a boy with Klippel-Feil syndrome and Sprengel deformity. He presented with a rectourethral fistula after surgical repair of a tubular duplication of the terminal ileum, colon, and proximal rectum. Preoperative identification of the fistula was challenging and was only achieved after cystoscopy with injection of methylene blue under pressure through Foley catheters placed into the anus and distal stoma of a colostomy. Surgical repair was performed through the posterior sagittal approach. The patient is doing well after 4 years of follow-up.     

Single-stage repair of rectoperineal and rectovestibular fistulae can be safely delayed beyond the neonatal period

Purpose

We sought to examine the short-term outcomes following single-stage repair of rectoperineal and rectovestibular fistulae in infants and identify risk factors for wound complication.

10-Year outcome of children born with anorectal malformation, treated by posterior sagittal anorectoplasty, assessed according to the Krickenbeck classification

Background

Anorectal malformations (ARMs) affect 1 in 4000 to 5000 births. The Krickenbeck conference developed a classification based on anatomical and functional criteria to better compare treatment outcome.

Aim

The aim of this study is to evaluate the functional outcome in patients 10 years following standardized surgical treatment of ARM related to the Krickenbeck classification. .

Methods

Anatomical anomalies were classified as above. Children and carers were followed closely in a multidisciplinary clinic. Data were collected using a functional outcome questionnaire for a minimum of 10 years after surgical reconstruction. Outcome measurements were related to the Krickenbeck classification.

Results

There were 53 children in the study group (29 male, 24 female). Krickenbeck anatomy: perineal fistula, 36%; vestibular fistula, 26%; rectourethral fistula, 36%; rectovesical fistula, 2%.All children were treated by posterior sagittal anorectoplasty.In children with perineal fistula, continence was achieved in 90%. Grade 2 constipation was noted in 21%. One child had a Malone antegrade continence enema (MACE) procedure.In children with vestibular fistula, continence was achieved in 57%. Grade 3 constipation was noted in 28%. One child had grade 1, and one child had grade 2 soiling. Two children had a MACE procedure.In children with rectourethral fistula, continence was achieved in 58%. One child had grade 3 soiling. Grade 3 constipation was found in 42% of children and grade 2 constipation in 1 child. A MACE procedure was performed in 36%.The only child with a bladder neck fistula had a MACE procedure for intractable soiling.

Conclusions

The outcome for patients with ARM is related to the severity of the anomaly. The uniform application of the Krickenbeck classification should allow rational comparison of treatment outcome.     

Rectourethral fistula after radical prostatectomy: Transperineal repair in jack-knife position

Background: Rectourethral fistula is a rare complication of radical prostatectomy. Risk factors include history of pelvic irradiation, cryotherapy, intraoperative rectal injury or transurethral resection of the prostate. Diagnosis of rectourethral fistula requires a high index of suspicion, and complete work-up with endoscopy and imaging studies. The majority of patients require operative intervention, with approaches ranging from transabdominal, transrectal, transanal, and transperineal routes. Method: We report two patients with rectourethral fistula after radical prostatectomy. The first patient was a 59-year-old man who underwent an uncomplicated laparoscopic radical prostatectomy for early prostate cancer in another hospital. The second patient was a 64-year-old man who had local recurrence after cryotherapy for prostate cancer. He underwent salvage radical prostatectomy in a private hospital, which was complicated by intraoperative rectal injury. Results: In both patients, the rectourethral fistulae were successfully repaired with a transperineal approach in the prone jack-knife position. Conclusion: We found that the transperineal approach in the prone jack-knife position offered excellent exposure, allowed versatile surgical manoeuvres and produced successful repair with good continence outcomes.