A late colon pouch vaginal fistula after low anterior resection – case report and discussion of aetiology

Spontaneous stercoral perforation resulting in rectovaginal fistula is uncommon. A patient is reported who developed a colon pouch vaginal fistula during an episode of severe constipation more than 3 years after successful surgery for rectal cancer. Patients with colon pouch to anus anastomosis may have an incresed lifelong risk of this complication and faecal impaction should be treated urgently. Colon pouch to anus anastomosis has become the standard reconstruction technique following low anterior resection and total mesorectal exision. Early vaginal fistula remains a well recognised complication whether a straight coloanal or a colon pouch to anal anastomosis is performed. No previous report has been found of a late colon pouch vaginal fistula in the absence of radiotherapy or recurrent disease. Received: 12 January 1999 / Accepted in revised form: 15 February 1999     

A Diverting Stoma Is Not Necessary when Performing a Handsewn Coloanal Anastomosis for Lower Rectal Cancer

Purpose Although a temporary diverting stoma is a frequent surgical procedure for the protection of anastomosis in a sphincter-preserving operation for lower rectal cancer, its impact on anastomotic leakage is not conclusive. This study was designed to evaluate anastomotic complications after ultralow anterior resection and handsewn coloanal anastomosis without a diverting stoma for lower rectal cancer patients. Methods Between January 1995 and December 2005, 96 patients were treated by ultralow anterior resection and handsewn coloanal anastomosis for lower rectal cancer. Fifty-one patients received preoperative concurrent chemoradiation, whereas 45 had no preoperative treatment. No diverting stoma was created in any of these cases. The anastomotic complications were evaluated between the groups. Results Six of 96 patients (6.1 percent) developed anastomotic complications: three anastomotic stenoses, one partial anastomotic dehiscence, one retrorectal abscess, and one rectovaginal fistula. All of the complications occurred in the preoperative radiation group, whereas none from the nonradiation group had an anastomotic complication (P = 0.017). The patients with stenosis and partial dehiscence were managed conservatively. The patient with retrorectal abscess was treated with debridement, irrigation and drainage, and seton procedure with a transanal approach. The patient with rectovaginal fistula underwent a second coloanal anastomosis. Conclusions The anastomotic complication rate was low even without a diverting stoma. This study suggests that a diverting stoma is not necessary when performing a handsewn coloanal anastomosis for lower rectal cancer however, an effort should be made for healthy anastomotic healing in patients with rectal cancer who are preoperatively radiated. Presented at the Congress of the International Society of University Colon and Rectal Surgeons, Istanbul, Turkey, June 25 to 28, 2006. Reprints are not available.     

Rektovaginale Fistel durch Mesh-Migration nach Sakrokolpopexie

The use of synthetic mesh for pelvic organ prolapse repair is associated with the risk of mesh erosion into hollow viscera. We report about a patient who developed a rectovaginal fistula 9 years after mesh sacrocolpopexy. The cause of this complication was related to mesh migration into the rectum. Laparoscopic rectal resection was performed to remove the mesh.     

Peritoneal mucinous carcinomatosis after laparoscopic-assisted anterior resection for early rectal cancer

Minimally invasive colon surgery has been shown to be both technically feasible and a safe alternative to laparotomy. Its efficacy for the curative resection of colorectal cancer, however, remains controversial. Of major concern are the increasing reports of port-site recurrence after use of laparoscopic techniques in malignant disease. In this article a heretofore unreported complication of peritoneal mucinous carcinomatosis after laparoscopic-assisted anterior resection for early stage rectal cancer is presented. Isolated peritoneal recurrence is rare after curative resection of Stage I rectal cancer. The effect of pneumoperitoneum on tumor dissemination is discussed.     

Rectovaginal fistula: Complication of low anterior resection

Three hundred of 990 active members (30 percent) of The American Society of Colon and Rectal Surgeons responded to a survey regarding the incidence of rectovaginal fistulas following low anterior resection. A total of 57 patients were reported to have had postoperative rectovaginal fistulas; of these, 53 had circular-stapled anastomoses. Patient characteristics, surgeon's experience, technical methods, pathology, and methods of treatment were surveyed. As lower resections for rectal sparing are attempted, this emerging complication must be recognized and avoided.     

Recto-cavernosal fistula after radiation for rectal cancer

Rectourethral fistula is a rare, but documented complication of rectal cancer. To our knowledge this is the first report of a recto- cavernosal fistula after chemo-radiotherapy for cancer of the rectum.     

Abdominoanterior sagittal approach for sphincter-saving low anterior resection for carcinoma of the rectum in females: a modified anatomical approach

Safe access to the lower rectum is of the utmost importance when performing sphincter-saving resection for rectal cancer. We describe an abdominoanterior sagittal approach for low anterior resection in females. The abdominal part of the procedure is similar to conventional low anterior resection. The perineal part includes making an anterior sagittal incision from the posterior fourchette to the anterior edge of the anus. The use of a muscle stimulator allows identification of the external sphincters. The rectum and both puborectal slings are identified. Lower margin division and completion of total mesorectal excision is done from below, under vision. The specimen is delivered and mobilized colon is brought down, a hand-sewn end-to-end colorectal anastomosis is formed, and a diverting colostomy is fashioned. Seven patients underwent low anterior resection via the abdominoanterior sagittal approach. Two patients (29%) developed anastomotic stricture, one in association with a rectovaginal fistula and still had a defunctioning stoma, while the other responded to dilatation. The six patients who underwent stoma closure achieved continence to solid stools with a mean Kelly score of 5. The abdominoanterior sagittal approach for low anterior resection is an alternative option for sphincter-saving resection in female patients as it defines the sphincteric anatomy, and minimizes the risk of sphincter injury.     

Surgical management of intestinal radiation injury

The management of 14 cases of radiation injury to the intestinal tract over a 4-year period is evaluated. The longest latent interval between radiation treatment and symptoms was 30 years. Eight patients were treated surgically; six were treated conservatively by laser therapy or application of formalin to the affected mucosa. The indications for surgery were rectovaginal fistula (four), rectal stricture (one), radiation proctitis (eight), and small bowel obstruction (one). Seven patients underwent large bowel resection. These consisted of four anastomoses with coloanal J-reservoirs, two low anterior resections, and one coloanal anastomosis without reservoir. There was no perioperative mortality. Morbidity occurred in one of the eight surgical cases. Radical resection of the radiation-damaged rectum has been shown to be a safe and reliable treatment for rectovaginal fistulas, rectal strictures, and proctitis unresponsive to medical measures. Coloanal J-reservoir is the procedure of choice to avoid urgency and frequency symptoms associated with coloanal sleeve anastomosis. Laser therapy for hemorrhagic proctitis can achieve an important place in the management of this problem without recourse to surgery.     

Postoperative Komplikationen nach Stapler-Hämorrhoidopexie (PPH) und STARR-Operationen

The procedure for prolapse and hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention, and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures, and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma, and perforation with pelvic sepsis, often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for 4th-degree hemorrhoids. Enterocele and anismus are contraindications to PPH and STARR, and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.     

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.     

Prevention of Anovaginal Fistula during Double-Stapling of Ileal Pouch-Anal Anastomosis

Abstract Recto- or anovaginal fistula is a troublesome complication of double-stapling technique in ultralow rectal anastomosis for rectal cancer or in ileal pouch-anal anastomosis for ulcerative colitis. In this study, a technique for preventing this problem by means of separation of the vaginal wall during the stapler firing is described using a flexible spatula introduced through the rectovaginal septum into the peritoneal cavity.     

Transanal advancement of the anterior rectal wall for vaginal fistulas involving the lower rectum

Experience from a personal series of nine patients with anovaginal or low rectovaginal fistula, operated upon by what is known as the Noble-Elting-Laird technique, is presented and added to the literature concerning the subject. Extensive preoperative mechanical bowel preparation including antibiotics was unnecessary as was a diverting colostomy. There were no operative deaths. Fistula did not recur in any of the nine patients followed six months, nor in any of eight of the nine patients followed over a period of two to 20 years. On comparing patients with anovaginal and rectovaginal fistula treated by transanal advancement of the anterior rectal wall with those patients treated by local layer closure, vaginally or anally, transanal advancement of the anterior rectal wall seems to be the better choice, particularly for the patient with a recurrent fistula. The data support the thesis that, since the anorectum is the primary source of such vaginal fistulas, the condition is best approached and treated accordingly. Read at the meeting of the Northwest Proctologic Society, Salishan, Oregon, September 9 to 12, 1979.     

Seminal vesicle fistula following abdominoperineal resection for recurrent adenocarcinoma of the rectum

PURPOSE: Fistula formation between the seminal vesicles and a pelvic abscess after abdominal perineal resection for recurrent rectal cancer is reported in a 32-year-old male previously treated with low anterior resection, chemotherapy, and radiation. METHODS: The case history was reviewed for clinical presentation, radiologic studies, and laboratory data. RESULTS: Successful management of this previously unreported complication included percutaneous abscess drainage, antimicrobial therapy, and oral administration of Proscar^® (Merck, Sharpe & Dohme, Rathway, NJ). CONCLUSION: Multiple factors predisposed this patient's development of a seminal vesicle fistula. These include extensive scarring from previous surgery, pelvic radiation, and an immunologically depressed status. The efficacy of Proscar^® in the successful management of this case remains unknown.     

Selective total mesorectal excision for rectal cancer

PURPOSE: Total mesorectal excision has been advocated for rectal cancer, but its use in upper rectal and rectosigmoid tumors remains a point of debate. METHODS: One hundred seventeen patients with rectal cancers were subjected to a prospective policy of total mesorectal excision for mid and low rectal cancers and a wide (5 cm) distal margin mesorectal excision for upper rectal and rectosigmoid cancers. RESULTS: Forty-one patients underwent ultralow anterior resection, 10 underwent abdominoperineal excision, 64 had anterior resection and 2 had Hartmann's procedure. The median follow-up was 39 months. Forty-three patients had a defunctioning ileostomy. Three patients (7.3 percent) had anastomotic leaks after ultralow anterior resection with total mesorectal excision. Ninety-three patients had palliative resections. There were four locoregional recurrences in this group, giving an actuarial locoregional recurrence rate of 9.3 percent at five years. The actuarial locoregional recurrence rate after anterior resection was 6.5 percent at five years. The actuarial five-year cancer-specific survival rate was 81.4 percent at five years. CONCLUSION: These results demonstrate that a policy of wide excision of the mesorectum for upper rectal and rectosigmoid cancer and total mesorectal excision for mid and low rectal cancer is associated with a low locoregional recurrence rate and may be as efficacious as routine total mesorectal excision for all rectal cancers.     

Transvaginal low anterior resection for rectal cancer

Adenocarcinoma of the lower rectum can be resected with a sphincter-sparing procedure but exposure of the lower pelvis may be difficult and sphincter function may be compromised. We have performed a low anterior resection for rectal cancer in a 69-year-old woman with mobilisation of the tumour and anastomosis performed transvaginally without a covering stoma. This way we could get good exposure of the lower rectum and anal sphincters. The patient made an uneventful recovery and was fully continent after surgery. Transvaginal low anterior resection is an alternative route which may be useful in cases of difficult exposure of low rectal cancer.     

Treatment of post-prostatectomy rectourethral fistula with fibrin sealant (Quixil™) injection: a novel application

Rectourethral fistulas in adults is a rare but potentially devastating postoperative condition requiring complex and demanding surgery. Fibrin glue treatment has been used with some success in anal and rectovaginal fistulas, and in the case we present here this indication has been extended to a postoperative rectourethral fistula following radical prostatectomy. For the first time, to our knowledge, a fibrin sealant (Quixil) was injected into the fistula tract, and a rectal mucosal flap was used to close the internal opening. The fistula healed in few weeks, and the patient is symptom free after 1 year of follow-up.     

Quality of Life after Low Anterior Resection and Temporary Loop Ileostomy

Purpose Low anterior resection has become the operation of choice for mid rectal or low rectal cancer. A defunctioning stoma is routinely created at some centers to decrease the risk of leakage requiring surgical intervention. This study was designed to evaluate the quality of life in patients undergoing low anterior resection with a temporary ileostomy. Methods A prospective longitudinal study was conducted in 22 patients with rectal cancer who underwent low anterior resection with a loop ileostomy. Quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires. Twenty-five patients who underwent high anterior resection for rectosigmoid cancer were studied concurrently to evaluate the impact of major colorectal resection without a stoma. Results Patients’ scores on the quality of life questionnaires generally improved after high anterior resection; however, for patients who underwent low anterior resection, the scores for physical and role functioning before ileostomy closure were worse than the preoperative values. The scores on the quality of life questionnaires generally improved after ileostomy closure. Ileostomy closure required a short hospital stay and was rarely associated with complications. Conclusion Patients who underwent low anterior resection with ileostomy had significant reductions in physical and role functioning, which apparently improved after ileostomy closure. Similar declines in these quality of life variables were not found in patients who underwent high anterior resection. A temporary ileostomy should be created in selected patients with the highest risk of anastomotic leakage. Increased resources for not only surgical care but also for stoma therapy are necessary for patients who undergo low anterior resection with a temporary ileostomy. Presented at the meeting of The Japan Society of Coloproctology, Tokyo, Japan, November 2 to 3, 2007.     

Rectovaginal septal repair: case presentations and introduction of a modified reconstruction technique

Abstract Rectovaginal fistula are a relatively rare kind of anorectal fistulas. Spontaneous healing is rare and the rectal advancement flap repair is the most popular procedure with success rates ranging between 60% and 80%. We present a new technique for repairing damage in the rectovaginal septum that consists of placing a folded polyglycolic acid mesh (Dexon) between the levator ani muscle closure area and the vaginal wall. This absorbable mesh separates the suture lines on the vaginal and rectal walls, and induces fibrosis and healing. The technique was performed in four women suffering from a rectovaginal fistula due to different causes. It was successful in all cases.     

Abscess in the inguinal hernial sac after peritonitis surgery： A case report

In this paper, we report an extremely rare case of an abscess that developed in the inguinal hernial sac after surgery for peritonitis. A 60-year-old man underwent laparoscopic low anterior resection for rectal cancer. One day after this operation, peritoneal drainage and ileostomy were performed for rectal anastomotic leakage. Five days after the second operation, computed tomography revealed an abscess in the left inguinal hernial sac. Subsequently, hernioplasty and resection of the inflamed sac were performed.     

Ultralow anterior resection and coloanal anastomosis for distal rectal cancer: functional and oncological results

We evaluated the functional and oncological outcome of ultralow anterior resection and coloanal anastomosis (CAA), which is a popular technique for preserving anal sphincter in patients with distal rectal cancer. Forty-eight patients were followed up for 6-100 months regarding fecal or gas incontinence, frequency of bowel movement, and local or systemic recurrence. The main operative techniques were total mesorectal excision with autonomic nerve preservation; the type of anastomosis was straight CAA, performed by the perianal hand sewn method in 38 cases and by the double-stapled method in 10. Postoperative complications included transient urinary retention (n=7), anastomotic stenosis (n=3), anastomotic leakage (n=3), rectovaginal fistula (n=2), and cancer positive margin (n=1; patient refused reoperation). Overall there were recurrences in seven patients (14.5%): one local and one systemic recurrence in stage B2; and one local, two systemic, and two combined local and systemic in C2. The mean frequency of bowel movements was 6.1 per day after 3 months, 4.4 after 1 year, and 3.1 after 2 years. The Kirwan grade for fecal incontinence was 2.7 after 3 months, 1.8 after 1 year, and 1.5 after 2 years. With careful selection of patients and good operative technique, CAA can be performed safely in distal rectal cancer. Normal continence and acceptable frequency of bowel movements can be obtained within 1 year after operation without compromising the rate of local recurrence.