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212
G. A. Santoro and M. A. Abbas
– A 400 micron radial-emitting disposable
laser ber is inserted into the catheter with
its tip emerging at the internal orice. The
ber delivers laser energy homogenously
at 360°, and by applying continuous energy,
the tract is closed while withdrawing it at a
speed of 1mm per second.
– The procedure includes the closure of the
internal opening by means of an anorectal
ap. When some scar tissue prevents that,
either a mucosal or anodermal ap is used
for closure of the internal opening.
• Application of autologous expanded adiposederived stem cells (ASCs) represents a novel
approach for enhancing regeneration of damaged tissues.
– ASCs are obtained from subcutaneous fat
by liposuction, and this process yields 100
times more stem cells than bone marrow
aspirates.
– Following curettage of the stula tract and
suture closure of the internal opening, ASC
solution is injected into the tract and into
the walls of the stula.
– The tract is subsequently sealed with brin
glue.
Outcomes
• Complex stulous disease challenges even the
most experienced surgeons.
• Success rate in patients with complex or recurrent anorectal stulas is lower than in patients
with simple anal stulas.
• Often more than one procedure is needed to
eradicate the stula.
• Risk for incontinence is usually higher due to
the complexity of the stula, recurrent or persistent disease, and/or prior failed interventions.
Seton
• Non-cutting seton is usually used as a bridge
to additional surgical intervention and typically is not curative.
• A high rate of incontinence (38%) has been
reported with cutting seton.
– Typically reserved for patients with high
complex stulas who failed multiple prior
interventions or in stulas not amenable to
other techniques such as high posteriorbased stulas in patients with deep buttock
cleft.
– Overall the fecal incontinence was 5.6%
when the internal anal sphincter was
preserved compared to 25.2% when it was
divided.
– Women with prior vaginal deliveries expe-
rienced signicant incontinence leading
the authors to advice against the use of cutting seton in this subgroup of patients
especially in the setting of an anterior
stula.
– Frequent gas incontinence developed post-
operatively in 9.5% of the patients, and
21.4% developed occasional gas
incontinence.
Advancement Flap
• Endorectal ap has demonstrated a success
rate of between 60% and 93%, and it has been
advocated as the treatment of choice for complex stula-in-ano.
• It can be technically challenging especially in
posterior-based stula in males and in patients
with deep buttock cleft.
• Postoperative incontinence rate has been
reported between 7% and 38%.
• Prior drainage with a non-cutting seton is
believed to increase success rate.
• Patients who fail an initial ap can be considered for a repeat procedure.
– Primary healing occurred in 72% of
patients, and secondary healing (following
a second ap after initial failure) occurred
in 57% of cases yielding an overall healing
rate 93%.
• The ap technique can impact success rate.
– Overall recurrence rate was 24% and was
much lower in the full thickness subgroup
(5%) compared to the mucosal subgroup
(35.3%).
• Smoking has been associated with a lower
success rate.
15 Complex Anorectal Fistulas
213
– During a median time of 14months, heal-
ing rate was 60% in smokers compared to
79% in nonsmokers.
Ligation oftheIntersphincteric
Fistula Tract
• LIFT procedure appears to be an effective
sphincter-conserving approach for the treatment of complex stula-in-ano. The initial
reported success rate of the LIFT procedure
was 94%.
• Subsequent studies with longer follow-up
have shown a wider range of success rate from
40% to 95%, mean 76% (Table15.1).
• In those patients with recurrence, the LIFT
technique can transform a complex stula into
a simple intersphincteric stula that could be
effectively treated by subsequent intersphincteric stulotomy.
• Minor continence disturbance was observed
in 0–6% of cases.
• A recent prospective randomized trial comparing the LIFT procedure with mucosal
advancement ap in patients with high transsphincteric stula found similar long-term
healing rate, recurrence rate, continence, and
quality of life.
• BioLIFT procedure success rate is 63–94%.
• LIFT-PLUS procedure success rate is 85%.
Anal Fistula Plug
• Several studies have reported variable results
with this minimally invasive procedure; success rate in various studies have ranged from
13.9% to 87% (Table15.2).
• The postoperative abscess/sepsis rate has
ranged from 4% to 29%.
• Failures have been related to technical issues,
plug extrusion, and infection.
• In a systematic review (22 studies included,
488 patients) of the anal stula plug, stula
closure was achieved in 54% of cases.
• Tract length and number of tracts are predictors of outcome with longer stula tracts carrying higher success rate.
• Ortiz and colleagues conducted a randomized
clinic trial comparing the Surgisis® AFP with
the endorectal advancement ap in patients
with high cryptoglandular stula-in-ano.
– The trial was closed prematurely due to a
high failure rate of the plug (80%) compared to the ap (12.5%).
• The GORE® BIO-A® Fistula Plug was the second plug introduced in the eld of stula surgery but is no longer commercially available.
Fibrin Glue
• The use of brin sealant injection initially
demonstrated promising results with high success rates between 60% and 80%.
Table 15.1 Results of LIFT procedure
Year No. of patients Follow-up (months) Success (%) Incontinence (%)
Rojanaskul etal. 2007 18 6.5 94 0
Ellis (24) 2010 31 15 94 0
Shanwani etal. 2010 45 9 82 0
Aboulian etal. 2011 25 6 68 0
Tan etal. 2011 93 5.8 85 0
Abcarian etal. 2012 40 4.5 74 0
Mushaya etal. 2012 39 16 92 0
Ooi etal. 2012 25 5.5 68 0
Wallin etal. 2012 93 19 40 31
Han etal. 2013 21 14 95 5
van Onkelen etal. 2013 22 19.5 82 0
Lehmann etal. 2013 17 13.5 65 0
Sirikurnpiboon etal. 2013 41 4.8 83 0
Sileri etal. 2014 26 16 73 0
214
Table 15.2 Results of the anal stula plug
Year No. of patients Follow-up (months) Success (%) Extrusion (%)
Johnson etal. 2006 15 3.5 87 N.R.
Champagne etal. 2006 46 12 83 4
Schwandner etal. 2008 18 9 61 2
Christoforidis etal. 2008 47 5 38 14
Theckkinkattil etal. 2008 36 11 50 10
Starck etal. 2008 32 12 59 N.R.
Lawes etal. 2008 20 7.4 24 N.R.
Safar etal. 2009 35 4.2 13.9 9.7
Ortiz etal. 2009 15 12 20 15
Wang etal 2009 29 9 34 N.R.
McGee etal. 2010 41 24 44 5
Anyadike etal. 2010 33 14 73 N.R.
Van Koperen etal. 2011 31 11 29 13
Ommer etal. 2012 40 12 57.5 N.R.
O’Riordan etal. 2012 488 3–24.5 54 8.7
Table 15.3 Results of stulotomy with sphincter reconstruction
Year No. of patients Follow-up (months) Success (%) Incontinence (%)
Parkash etal. 1985 120 6–60 83.3 3.7
Christiansen and Ronholt 1995 14 12–48 85.7 21.4
Perez etal. 2006 35 32 92.9 12.5
Roig etal. 2010 75 13 89.4 18.3
Kraemer and Picke 2011 38 N.R. 97.4 9.4
Arroyo etal. 2012 70 81 91.4 16.6
Ratto etal. 2013 72 29.4 95.8 11.6
G. A. Santoro and M. A. Abbas
• Subsequent studies with longer follow-up have
reported lower success rates of 32% to 54%.
• The high failure rate associated with brin
glue injection has been attributed to the difculty in ensuring the glue remains in the stula tract, failure of closure of the internal
opening, and lack of autologous tissue
ingrowth to seal the tract.
• A Cochrane database systematic review analyzed ten randomized controlled trials.
– There was no signicant difference in
recurrence rate or incontinence rate in any
of the studied operation except in the case
of advancement ap which carried higher
success rate.
– A higher recurrence rate was noted when
brin glue injection was added to an
endorectal advancement ap, favoring a
ap-only technique.
– Both brin glue injection and advancement
ap had low incontinence.
Fistulotomy withSphincter
Reconstruction
• Patients with baseline incontinence, those at
risk for incontinence (such as patients with
previous childbirth, anterior stula in females,
existing sphincter defect from prior anal surgery), and patients with recurrent disease can
be suitable candidates for this technique.
• Overall healing rates range from 83.3% to
97.4%, and the incontinence rates between
3.7% and 21.4% (Table15.3).
Newer andEvolving Technologies:
VAAFT, FiLaC™, andStem Cell
• Using the VAAFT procedure:
– Meinero and Mori achieved an overall suc-
cess rate of 73.5% in 136 patients with
non-Crohn’s disease-related anal stula,
and recurrence rate was 26.5% within
2–3months of follow-up.
15 Complex Anorectal Fistulas
215
– Kochhar and colleagues found the recur-
rence rate to be 15.8%.
– Due to the limited data on VAAFT, it is pre-
mature to draw any rm conclusion about
its long-term efcacy, additional benets,
and limitations compared to the existing
surgical options.
FiLaC™ procedure:
• The FiLaC™ procedure remains investigational at this stage, and additional data is
needed prior to making rm recommendations
for its use.
• Recommend the placement of a draining seton
prior to the procedure to help create a more
homogenous tract caliber and may contribute
to the closure of secondary tracts.
• So far it appears not to impact continence
level; however long-term success rate is
unknown.
• Autologous adipose-derived stem cells:
– Novel approach for the management of
complex anal stula, limited data.
– A phase III multicenter, randomized, sin-
gle-blind, add-on clinical trial was performed to investigate the safety and
efcacy.
– In treatment of complex anal stula, a dose
of 20 or 60 million adipose-derived stem
cells alone or in combination with brin
glue was considered a safe treatment,
achieving healing rates of approximately
40% at 6months and of more than 50% at
1-year follow-up.
Rectourethral Fistulas
Denition, Classication,
andPathophysiology
• In the Western world, the most common
mechanism of RUF is a multimodality treatment for prostate cancer, including surgery,
external beam radiation therapy (EBRT), or
brachytherapy, with an incidence of 0.1–3% in
patients who received these therapies.
• Fifty percent of patients with RUF have a history of irradiation, leading to microvascular
injuries and mucosal ischemia.
• The mean time from the last radiotherapy session and the diagnosis of RUF ranged from
14months to as long as 14years.
• Rectal injury during radical prostatectomy is
uncommon with a reported overall incidence
ranging from 0.12% to 9% (0.47–2% of laparoscopic cases).
Clinical Assessment andDiagnostic
Evaluation
• Symptoms of RUF include fecaluria, pneumaturia, hematuria, recturia, rectal bleeding, urinary tract infection, and severe rectal or pelvic
pain.
• Physical examination (inspection, palpation,
digital rectal examination) is performed to
determine the size and location of the stula in
relationship to anal verge.
• Diagnostic modalities include cystoscopy
(Fig.15.13), colonoscopy or exible sigmoidoscopy (Fig.15.14), voiding cystography, retrograde urethrography, gastrogran enema
(Fig.15.15), computed tomography scan, and
magnetic resonance imaging.
• If feasible, urodynamic evaluation can be performed for the preoperative assessment of urinary function as those with total urinary
incontinence or severe voiding dysfunction
may be treated with a permanent urinary
diversion.
• Rectourethral stula (RUF) is uncommon and
can be congenital or acquired, resulting from
surgery, radiation, inammatory bowel
disease, malignant neoplasm, pelvic infections, or trauma.
Surgical Treatment
• A multidisciplinary team approach involving
a colorectal surgeon, a urologist, and in some
216
Fig. 15.13 Cystoscopic view of external beam radiationinduced rectourethral stula
G. A. Santoro and M. A. Abbas
BLADDER
Fig. 15.15 Gastrogran enema reveals a rectourethral
stula secondary to laparoscopic radical prostatectomy.
Note the contrast ow into the bladder [white arrow]
Fig. 15.14 Reex view during exible sigmoidoscopy
demonstrates post-radical prostatectomy rectourethral stula. Note the urethral catheter on the bladder side
instances a reconstructive surgeon is needed
for optimal management.
• The management of RUF has not been standardized, and large variations in treatment
approaches exist.
• Figure 15.16 provides the carepath
algorithm.
• Small, minimally symptomatic, non-irradiated
RUF can be managed initially with a urethral
catheter and if needed suprapubic catheter
drainage.
• Cases do sometimes heal spontaneously without fecal diversion (60%).
• If RUF remains unhealed for 2 or more
months, surgical intervention is usually
warranted.
• Local transanal ap repair is a good option for
small non-irradiated RUF.
• If RUF remains unhealed following local ap
repair, a diverting stoma followed by additional local ap repair or transperineal repair
with gracilis interposition ap or dartos ap
would be the next step.
• Patients with large RUF (> 1cm), prior radiation or cryotherapy, signicant symptoms,
severe urethral stricture, or prior failed repair
require fecal diversion with suprapubic catheter drainage.
• After 3 months of fecal diversion, the RUF
should be reassessed.
– If healed, the patient can then undergo
stoma closure.
– It is important to reassess the patient with a
minimum of two diagnostic studies [endoscopic or imaging] from the bladder and
rectal side to conrm complete healing
prior to closing the stoma.
15 Complex Anorectal Fistulas
INITIAL
MULTIDISCIPLINARY
CLINICAL ASSESSMENT
• History
• Physical exam
• Anoscopy
SECONDARY
ASSESSMENT
• Cystoscopy
• Voiding cystourethogram/
Retrograde urethography
CONSIDER
• CT scan to exclude
abscess
∗Drain if present
• Pelvic MRI
• Urodynamics
• Colonoscopy if indicated
CONDITION SPECIFIC
ASSESSMENT AND
MANAGEMENT
(Refer to appropriate
section)
• Colorectal Cancer
• Prostate Cancer
• Crohn’s Disease
COMPLEX RUF
(Meets ≥ 1criteria)
• Large (> 1 cm)
• High fistula
• Severe radiation or
cryotherapy damage
• Very symptomatic
• Pelvic sepsis
• Severe urethral
stricture
• Prior failed repair
SIMPLE RUF
• Small, non-
irradiated
• Minimal
symptoms
CLOSE STOMA Healed
STOMA
± Suprapubic
catheter
± Abscess
drainage
KEEP
URETHRAL
CATHETER
(± Suprapubic
catheter)
Unhealed
UNHEALED
UNHEALED
(within 2
months)
HEALED
(within 2
months)
HEALED
(within 3 months)
UNHEALED
HEALED
(within 3
months)
(within 3
months)
LOCAL FLAP
TRANSPERINEAL
INTERPOSITION
CLOSE
STOMA
MEETS CRITERIA
• Positive
oncologic margin
• Non functioning
bladder
• Severe urethral
stricture
• High fistula
LOCAL FLAP
REPAIR
REMOVE
URETHRAL
CATHETER
REPAIR
FLAP
ABDOMINAL
SURGERY
• Pelvic
exenteration
• Cystectomy with
urinary diversion
Yes
• Abdominal
perineal resection
•Proctectomy with
coloanal
No
FISTULA
CHARACTERISTICS
• Large (> 1 cm)
• Severe radiation or
cryotherapy damage
•Prior failed repair
No
217
Yes
Fig. 15.16 An algorithm-based approach to the management of rectourethral stula
• Patients who desire denitive repair can be
approached via a transabdominal [proctectomy with coloanal with or without omental
ap, pelvic exenteration with or without
sphincter preservation], transanal, transperineal [gracilis ap interposition or dartos ap],
transsphincteric, or trans-sacral technique.
• Urethral reconstruction can be achieved with a
buccal mucosal ap or biologic mesh.
Posterior Approach
• High RUF can be approached via a posterior
approach either through a York-Mason transsphincteric dissection or a Kraske approach.
– York-Mason technique involves posterior
sagittal division of the anal sphincter and
levator muscles as well as the posterior wall
of the rectum to gain access to the stula.
– Kraske approach entails resection of the coc-
cyx and division of the tissues between the
Transanal Approach
• For a non-irradiated small RUF, a transanal
approach with rectal advancement ap is a
good option in patients without anal stricture.
• The addition of biologic material can be helpful in a patient with larger defect and good
coccyx and the sphincters to provide access
to the posterior wall of the rectum, which is
then opened to provide access to the stula.
• The use of a transsphincteric approach has
decreased signicantly over the past years,
because of the risk of fecal incontinence.
vascularized tissue which can facilitate tissue
ingrowth.
• A urethral catheter is kept for 4–6weeks postoperatively before assessing stula healing.
Transperineal Approach
• The transperineal approach is the preferred
method for most mid to low RUFs that require
218
Table 15.4 Outcome of patients with rectourethral stula in various series
Year No. of patients Procedure Follow-up Closure (%)
Youssef etal 1999 12 Dartos ap 9–42months 69
Garofalo etal 2003 14 Rectal ap 31months 68
Lane etal. 2006 22 Transabdominal (68%) 29months 88
Wexner etal. 2008 36 Gracilis ap N.R. 78
Ghoneim etal. 2008 25 Gracilis ap 28months 100
Gupta etal. 2008 10 Gracilis ap 24months 100
Ulrich etal. 2009 26 Gracilis ap 22months 100
Kasraeian etal. 2009 12 Transsphincteric 22months 75
Vanni etal. 2010 74 Gracilis ap+tissue rectal ap 20months 92
Samplaski etal. 2011 13 Gracilis ap 2.5months 92
Hechenbleikner etal. 2013 416 Gracilis ap (72%) N.R. 87.5
Keller etal.
a
43% required denitive stula repair
a
2015 30 Transperineal (54%)
Transanal (31%)
Transabdominal (15%)
G. A. Santoro and M. A. Abbas
72months 90
interposition of healthy and well-vascularized
tissue.
• Tissue interposition can be provided with a
dartos ap or gracilis muscle.
Transabdominal Approach
• Patients with postoperative RUF following
prostate or rectal surgery and positive
oncologic margins can be offered a transabdominal approach.
• Additional indications include:
– High RUF not accessible to a transanal or
transperineal approach
– Patients with nonfunctioning irradiated
bladder or severely stricture urethra which
requires excision with urinary diversion
– Patients with prior failed repairs
• The type of abdominal operation include:
– Cystectomy with urinary diversion
– Proctectomy with coloanal anastomosis
– Abdominoperineal resection
– Pelvic exenteration
• An omental ap or rectus abdominis ap
interposition can be used if needed.
• Signicant heterogeneity exists in the various
reports due to differences in patient populations and operative techniques.
• Table 15.4 summarizes the results of several
large series.
• The reported success rate following denitive
operative intervention ranges from 68% to
100%. A spontaneous closure rate of 14%–
46.5% has been reported after fecal diversion,
and some patients can heal small RUF with
urethral catheter drainage alone.
• The overall permanent urinary diversion rate
was 8.3% and was signicantly higher in
irradiated patients (42.5%) compared to nonirradiated patients (4%).
• The transanal approach with rectal advancement ap is safe and effective in the absence
of prior radiation therapy with reported 85%
closure rate.
• The gracilis muscle interposition is currently the
most commonly used method for treating complex, large, recurrent, and/or irradiated RUF.
Postoperative Fistulas
Outcome
• The outcome of RUF treatment is difcult to
evaluate because published studies with large
number of patients are scarce.
Denition, Classication,
andPathophysiology
• Ileal-pouch stula can be classied as pouchanal, pouch-vaginal, and pouch-perineal.
15 Complex Anorectal Fistulas
219
– Fistula is dened as complex if there are
multiple tracts and/or the internal opening
is at or above the IPAA (high stula).
• Perianal stula may occur as a postoperative
complication after ultralow anterior resection,
coloanal anastomosis, Hartmann reversal procedure, abdominoperineal resection, or
transanal endoscopic microsurgery for distal
rectal cancer.
• Major risk factors associated with development of postoperative stulas include
elderly age, diabetes, vasculopathy, smoking, preoperative/postoperative radiotherapy, operative technique, and postoperative
pelvic sepsis.
Clinical Assessment andDiagnostic
Evaluation
• Fistulas often present with pelvic and perianal
sepsis or drainage and pain.
• Patients with an inadequate clinical assessment should undergo examination under
anesthesia.
• Preoperative imaging to evaluate the anatomy
of the stula tract includes endoanal ultrasound, pelvic MR imaging, CT scan, pouchography, and stulography.
Surgical Treatment
• The guiding principles are to control pelvic
and perianal sepsis and eliminate the stulous
tract.
• An acute abscess should be drained, and when
necessary, a non-cutting seton may be placed
to control anorectal infection.
• Operative techniques include gracilis muscle
interposition, lay-open stulotomy, collagen
plug insertion, ileal advancement ap, transvaginal advancement ap, brin glue, transperineal repair, Martius (i.e., bulbocavernosus)
ap, pouch excision, or redo pouch.
• Simple procedures should be attempted rst,
if there is a chance of success, before more
complex procedures are considered.
• Temporary diverting ileostomy, permanent
end ileostomy with/without pouch excision,
and redo-RPC should be considered in patients
with ileal-pouch stulas.
• Temporary diverting colostomy with/without
coloanal/colorectal anastomoses or permanent
end colostomy with/without anastomoses
removal or completion proctectomy should be
considered in rectal cancer patients.
• Complex perineal stula occurring after APR
or pelvic exenteration can be treated by the
use of an omentoplasty or rectus abdominis
musculocutaneous ap to ll the dead space of
the pelvis with well-vascularized tissue.
• Medical treatment including anti-TNF agents
should be the rst-line therapy for patients
who present delayed onset of pouch stula
and a suspicion for Crohn’s stula.
Outcome
• Mallick and colleagues reviewed the Cleveland
Clinic Experience with pouch-vaginal stulas.
– Fistula occurred in 102 females: 59 at
≤12 months (early stula) and 43 at
>12months (late-onset stula).
– Local repair was performed in 77.3% of
patients (ileal pouch advancement ap in
49.5% of cases and transvaginal repair in
27.8% of cases).
• The healing rate after ileal pouch
advancement ap was 42% when performed as a primary procedure and 66%
when performed secondarily after a different procedure.
• The healing rate for transvaginal repair
was 55% when done as a primary procedure and 40% when performed
secondarily.
– Nineteen patients underwent redo ileal
pouch construction, with an overall pouch
retention rate of 40%.
– At median follow-up of 83months, 57.7%
of the 102 patients had healed the pouchvaginal stula; pouch failure occurred in
34 women (35%, 12 early onset and 22 late
onset).
Rectovaginal Fistula
JamieA.Cannon
16
Key Concepts
• Rectovaginal stulas (RVFs) are abnormal
communications between the anus or rectum
and the vagina.
• Repair of rectovaginal stulas should be tailored to the individual patient based on the
anatomy of the stula and associated
conditions.
• Perianal sepsis must be controlled prior to
attempting a denitive repair.
• Patients with RVFs from obstetric trauma
should be evaluated for concomitant sphincter
defects.
• Patients who have a Crohn’s-related RVF
should have their disease medically optimized
prior to repair of the stula.
• Introduction of healthy, well-vascularized tissue such as a Martius ap or gracilis interposi-
tion should be considered in patients who
have attenuated tissues or have undergone
multiple previous unsuccessful repairs.
• Patients may present with stool per vagina
resulting in frank incontinence or gas or drainage per vagina.
• Anatomically, there is little muscle in the thin
rectovaginal septum, which may make it more
difcult for this region to heal.
• Fistulotomy, the most successful surgery for
managing perianal stulas, is contraindicated
as it invariably results in some degree of
incontinence.
• There is not an ideal operation with a uniformly high success rate.
• Preoperative fecal diversion has not been
shown consistently to lead to better outcomes,
but this may represent selection bias in those
patients chosen for diversion.
J. A. Cannon (*)
Division of Gastrointestinal Surgery, Department
of Surgery, University of Alabama at Birmingham,
Birmingham, AL, USA
e-mail: jacannon@uab.edu
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_16
221
222
J. A. Cannon
Etiology ofRectovaginal Fistulas
• Rectovaginal stulas can be the result of
obstetric injuries, cryptoglandular disease, or
Crohn’s disease, malignancy, radiation therapy, or leaks from a colorectal, coloanal, or
ileal pouch-anal anastomosis.
Obstetric Injury
• Obstetric injury is the most common cause of
RVFs.
• Rectovaginal stulas are reported to occur following 0.1–0.5% of all vaginal deliveries.
• Obstetric stulas can arise from a fourthdegree tear in which the repair has broken
down.
– This type of stula will generally become
clinically apparent 1–2 weeks after delivery and is most often located at the level of
the anal sphincters.
• Prolonged labor resulting in compression of
the rectovaginal septum by the infant’s head
can lead to necrosis of the RV septum and
cause a rectovaginal stula that presents in a
more delayed fashion.
• Traumatic injury from an instrumented delivery may result in an immediately apparent
stula.
• Repairs of RVFs caused by obstetric injury
tend to be more successful than repairs of stulas from other causes.
• Halverson etal. reported on 15 patients with
obstetric-related RVFs; all stulas were eventually able to be repaired for an overall success rate of 100% but required a total of 23
procedures for a per-procedure success rate of
65%.
Cryptoglandular Disease
• This occurs when an anteriorly located anal
gland or its associated duct becomes occluded;
the resulting abscess may form in the rectovaginal septum and decompress into the
vagina.
• Generally located at the level of the dentate
line on the rectal side and course through the
anal sphincters to the low vagina or introitus.
Crohn’s Disease
• They are the result of transmural inammation
from the anorectum; they are frequently associated with perianal sepsis, branching stula
tracts, additional rectocutaneous stulas, and
scarring and stricturing of the anorectum.
• Approximately 10% of women with Crohn’s
disease will develop a rectovaginal stula, and
they are more common in those who suffer
from colonic Crohn’s disease.
• Surgical repair of rectovaginal stulas caused
by Crohn’s disease is not as successful as
repair of stulas of obstetric or cryptoglandular origin.
• Prior to attempting any repair, control of perianal sepsis is required by abscess drainage and
seton placement.
• A discrete, epithelialized tract should be present before attempting repair, which is best
achieved with initial seton placement.
• Multiple stula tracts, a watering can
perineum, or active inammation of the rectal
mucosa are contraindications to repair,
Fig.16.1.
• Repair should not be undertaken in the presence of active inammation of the rectum as
the repair is unlikely to heal.
– Should be managed either medically, with
a seton, or with a proctectomy
• The use of iniximab has been shown to lead
to spontaneous healing of stulas in Crohn’s
disease.
– Kraemer et al. reported healing of symp-
tomatic stulas in 8 of 19 patients with
Crohn’s-associated anorectal stulas
treated with iniximab prior to surgery.
– If the stula does not close spontaneously,
reducing the amount of associated inammation will likely improve the chance of
success with surgical repair.
– ACCENT II trial studied iniximab in
patients with stulizing Crohn’s disease;