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14 Anal Conditions: Rectovaginal Fistula
117
e
f
g
Fig. 14.3 (continued)
118
J. E. Hrabe and T. L. Hull
a
b
cd
e
Fig. 14.4 Rectal sleeve advancement. (a, b) Full thick-
ness circumferential ap is raised starting at the dentate
line, heading cephalad until sufcient mobilization is
attained. (c) The stula tract is debrided, closed on the
rectal side while vaginal mucosa is left open. (d, e) The
distal ap is sutured to the new dentate line with interrupted absorbable suture (Reprinted with permission,
Cleveland Clinic Center for Medical Art and Photography
© 2008–2016. All rights reserved)
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14 Anal Conditions: Rectovaginal Fistula
119
thickness ileal pouch advancement aps are a
reasonable choice. For higher stulas, or where
there is accompanying stricture, mobilization
of the ileal pouch anastomosis and pouch
advancement, sometimes accompanied by
abdominal mobilization, is recommended
(Fig. 14.5). This approach starts with anal
eversion sutures to provide exposure. A circumferential incision is made at the dentate
line, distal to the stula and any accompanying
stricture. The pouch is dissected circumferentially and cephalad, excising the mucosa from
the internal sphincter into the supralevator
space. The pouch is mobilized circumferentially to the extent that a healthy portion of
pouch reaches beyond the anal verge to allow
for a tension-free anastomosis. The distal
pouch segment is excised of the stula- and
stricture-containing portion. A neoileoanal
anastomosis is created with interrupted absorbable sutures. As stated previously, there can be
difculty mobilizing the pouch from a transanal approach and further mobilization through
an abdominal incision may be required. In a
last resort, a pouch excision with redo of the
ileoanal pouch may be needed.
Fig. 14.5 Pouch advancement and neoileoanal anastomosis for pouch vaginal stula. (a) Anal eversion sutures
(or Lone Star retractor, neither shown) provide exposure.
A circumferential incision is made at the dentate line, distal to the stula and any stricture. (b) The dissection is
carried circumferentially and cephalad into the supralevator space excising remaining mucosa and mobilizing the
pouch-anal anastomosis. (c) The pouch is mobilized such
that normal distal pouch reaches beyond the anal verge,
and the stula-containing portion is excised. (d) A
tension- free neoileoanal anastomosis is created with interrupted absorbable sutures; if there is concern with reach,
an abdominal mobilization is performed (Reprinted with
permission, Cleveland Clinic Center for Medical Art and
Photography © 2008–2016. All rights reserved)
120
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J. E. Hrabe and T. L. Hull
Vaginal Approaches
Because the anorectum is the higher pressure side
of the stula, most in colorectal surgery prefer transrectal procedures. However, in settings where the
rectum is inamed or scarred, vaginal approaches
have the benet of the repair being done with
healthy, pliable, and well vascularized tissue.
Vaginal advancement aps entail raising a ap
around the stula from the vaginal side. The rectal
stula opening is closed with absorbable suture.
The levator ani muscles are approximated to form a
barrier between rectum and vaginal walls, though
this approximation may be difcult in very low stulas and contribute to dyspareunia. The vaginal
ap is trimmed to excise the portion containing the
stula opening, and the ap is then sewn to perineal
skin with absorbable sutures. Another vaginal
approach is stula inversion, which can be used for
low and small stulas. A ap of vaginal mucosa is
raised around the vaginal side of the stula opening.
A few concentric purse string sutures are placed,
which invert the stula into the rectum. The opening
in the vaginal mucosa is then closed.
K.Tissue Interposition
In instances of multiple prior failed repairs or other
etiologies leading to inadequate healthy tissue available for aps, interposition of a ap of well vascularized tissue should be considered. Two of the
more common procedures are gracilis interposition
and bulbocavernosus (“Martius”) aps (Fig.14.6).
They offer the benet of a perineal approach,
thereby avoiding the morbidity that can accompany
Fig. 14.6 Bulbocavernosus (Martius) graft. (a) (Not
shown) Through a transverse perineal incision the posterior vagina is dissected from the rectum and the stula is
divided. The rectal stula os is closed with absorbable
suture. A longitudinal incision over either labia major is
made. The fat pad and bulbocavernosus muscle are mobilized, preserving the vascular pedicle. The proximal
attachments are divided. (b) A subcutaneous tunnel from
labial to perineal wound is created and the graft is pulled
through the tunnel ensuring appropriate orientation (no
twist). The graft is loosely afxed above the rectal closure. The labial and perineal incisions are closed with
interrupted absorbable suture, and a drain is typically used
to prevent seroma (Reprinted with permission, Cleveland
Clinic Center for Medical Art and Photography © 2008–
2016. All rights reserved)
14 Anal Conditions: Rectovaginal Fistula
121
abdominal incisions, but are typically done with a
diverting stoma in place. The procedural details will
not be fully described here, but the approach
requires complete muscle mobilization, division of
the distal tendon near the knee, preservation of the
proximal vascular pedicle, tunneling of the muscle
into a space dissected between anorectum and
vagina, and securing the ap in place. The rectal
side of the stula os should be repaired after debriding the edges, while the vaginal side can be left open
to drain. The gracilis ap is useful since disruption
of the muscle leads to little functional decit, though
morbidity from the leg incision can be a problem
after this surgery. For any tissue interposition
approach, an important portion of the perineal dissection is adequate dissection superior to the stula.
One should dissect at least 3–5cm cephalad in the
rectovaginal septum to separate the vaginal and
anorectal openings.
Martius aps (Fig.14.6) require a transverse
perineal incision through which the posterior
vagina is dissected from the rectum and the stula is divided. The rectal stula os is closed with
absorbable suture. Next, a longitudinal incision is
made over either labia major. The fat pad and bulbocavernosus muscle are mobilized, with careful
attention to preserving the vascular pedicle. The
attachments proximally are divided. A subcutaneous tunnel from the labial incision to perineal
incision is created and the graft is pulled through
the tunnel ensuring the graft is not twisted. The
graft is loosely sutured in place to separate the
vaginal and anorectal opening. The labial and
perineal incisions are closed with interrupted
absorbable suture.
ple and/or low enough that they would be near
the neodentate line. For these difcult cases, a
Turnbull-Cutait procedure, or two stage coloanal anastomosis, should be performed
(Fig.14.7). Via an abdominal incision, mobilization of the colon is performed from the
splenic exure down to the rectum. Dissection
is carried down to the levator ani muscles. The
rectum is divided. From the perineum, anal
eversion sutures are placed for exposure and a
mucosectomy is performed. A total of eight
interrupted sutures are placed around the anal
canal and the needles left on for the second
stage anastomosis. These should be evenly
spaced and incorporating a bit of internal
sphincter. Using a Babcock, the colon is pulled
through the anus. The distal edge of the exteriorized colon is transected to ensure adequate
blood supply as conrmed by active bleeding.
The colon is wrapped in gauze, the eight
sutures and needles are carefully wrapped
around this gauze and then covered with an
additional gauze wrap to protect against inadvertent needle stick injury. The gauze is secured
in place. If the patient is not already diverted, a
loop ileostomy is created and the abdomen
closed. At the second stage, generally performed ve to seven days later to allow time
for the bowel to adhere, the exteriorized segment is excised and the anastomosis is completed with full thickness sutures through the
colon wall. Special care is taken to avoid anal
canal mobilization, which would disrupt the
adhesions between bowel and raw surface of
stula repair.
L.Redo Colo-anal Anastomosis,
Immediate andDelayed
When local aps and perineal approaches are
no longer an option and in settings of severe
circumferential disease, resection and anastomosis with an abdominal approach may be
required. This can be done in one procedure if
the dissection and anastomosis is far enough
distal to the stulous tracts, and is similar to
the rectal sleeve advancement ap though with
intra-abdominal mobilization as necessary. In
some instances, though, the stulas are multi-
Conclusion
RVF are challenging both for the patient and the
surgeon. As with most surgical conditions, the
best opportunity for a successful outcome is with
the rst repair. A careful evaluation to understand
the stula etiology and anatomy, adequate control of sepsis, and a deliberate plan for surgical
repair which considers the health of the surrounding tissue optimize chances for complete healing.
Surgeons familiar with a range of techniques will
be best suited to offer the procedure most likely
to yield success.
122
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J. E. Hrabe and T. L. Hull
Fig. 14.7 Turnbull-Cutait abdominoperineal pull
through. (a) After mucosectomy and mobilization with
complete pelvic dissection to the levator ani, the colon is
amputated and pulled through the anal canal. (b) Anal
anastomotic sutures are placed (not shown) and wrapped
around the exteriorized portion which is wrapped in
Vaseline-moistened gauze. The entire colon with sutures
is wrapped in a gauze and secured to keep the gauze from
Suggested Reading
Fazio VW, Tjandra JJ. Pouch advancement and neo-
ileoanal anastomosis for anastomotic stricture and
anovaginal stula complicating restorative procto-
colectomy. Br J Surg. 1992;79(7):694–6.
Hull TL, El-Gazzaz G, Gurland B, Church J, Zutshi
M. Surgeons should not hesitate to perform episio-
proctotomy for rectovaginal stula secondary to cryp-
toglandular or obstetrical origin. Dis Colon Rectum.
2011;54(1):54–9.
unwrapping. (c) Second stage, gauze is carefully
unwrapped and the sutures laid out. The exteriorized segment is excised. (d) Using previously placed sutures, the
anastomosis is completed through bowel wall, with care
not to disrupt adhesions between the colon and anal canal
(Reprinted with permission, Cleveland Clinic Center for
Medical Art and Photography © 2008–2016. All rights
reserved)
Jarrar A, Church J. Advancement ap repair: a good
option for complex anorectal stulas. Dis Colon
Rectum. 2011;54(12):1537–41.
Lowry AC, Thorson AG, Rothenberger DA, Goldberg
SM.Repair of simple rectovaginal stulas. Inuence of
previous repairs. Dis Colon Rectum. 1988;31(9):676–8.
Mallick IH, Hull TL, Remzi FH, Kiran RP.Management
and outcome of pouch-vaginal stulas after IPAA surgery. Dis Colon Rectum. 2014;57(4):490–6.
Marchesa P, Hull TL, Fazio VW. Advancement sleeve
aps for treatment of severe perianal Crohn's disease.
Br J Surg. 1998;85(12):1695–8.
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McNevin MS, Lee PY, Bax TW.Martius ap: an adjunct
for repair of complex, low rectovaginal stula. Am J
Surg. 2007;193(5):597–9; discussion 9
Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L,
van Hogezand RA, etal. Iniximab for the treatment
of stulas in patients with Crohn’s disease. N Engl J
Med. 1999;340(18):1398–405.
Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio
VW. Outcomes following Turnbull-Cutait abdomino-
perineal pull-through compared with coloanal anasto-
mosis. Br J Surg. 2009;96(4):424–9.
Shah NS, Remzi F, Massmann A, Baixauli J, Fazio
VW. Management and treatment outcome of pouch-
vaginal stulas following restorative proctocolectomy.
Dis Colon Rectum. 2003;46(7):911–7.
Valente MA, Hull TL. Contemporary surgical manage-
ment of rectovaginal stula in Crohn's disease. World
J Gastrointest Pathophysiol. 2014;5(4):487–95.
Wexner SD, Ruiz DE, Genua J, Nogueras JJ, Weiss
EG, Zmora O. Gracilis muscle interposition for the
treatment of rectourethral, rectovaginal, and pouchvaginal stulas: results in 53 patients. Ann Surg.
2008;248(1):39–43.
Anal Conditions: Anorectal Crohn’s Disease—Fistula
AndrewT.Schlussel andKarimAlavi
15
Introduction
Anorectal Crohn’s disease (CD) may be observed
in up to 90% of patients, with manifestations
including skin tags, hemorrhoids, abscesses, and
stulas. The majority of these patients will
require an operation. The degree of perianal disease often coincides with the patient’s luminal
disease, and inammation located distally is
often associated with a greater risk of perianal
complications. The most common presentation
of perianal CD, and often most challenging to
treat, are anorectal stulae and abscesses, which
occur in approximately 50% and 42% of patients,
respectively. The primary focus in the management of anorectal stulae, regardless of the etiology is to prevent ongoing tissue destruction, and
preserve sphincter integrity in efforts to maintain
continence.
A cryptoglandular abscess or stula may
occur in CD, and should be treated as it would in
a patient without CD.However, determining the
underlying pathophysiology may often be a challenge. A true Crohn’s disease associated stula
typically arises from a penetrating rectal ulcer or
cryptitis that spreads into the intersphincteric
planes. This results in an upregulated immune
response in the stula tract resulting in chronic
recurring inammation and remodeling. These
factors alter the natural repair mechanisms of the
body, and make the treatment of a Crohn’s related
stula far more complex.
A single perianal stula could be the index
presentation of Crohn’s disease, and this must be
a differential diagnosis for all treating surgeons.
A high index of suspicion is required for all complex or recurrent stulas, those that fail to heal
from a previous operation, ones with multiple
tracts, or patients with associated symptoms secondary to proctitis. A thorough history and physical, which includes an endoscopic evaluation, is
necessary prior to implementing an operative
plan. Ultimately determining the diagnosis will
be a multidisciplinary approach between the surgeon and gastroenterologist; however, it is on the
surgeon to provide the safest operation with optimal means of sphincter preservation especially
when the diagnosis is unclear.
A. T. Schlussel
Department ofGeneral Surgery, Madigan Army
Medical Center, Tacoma, WA, USA
K. Alavi (*)
Division ofColon andRectal Surgery, University
ofMassachusetts Medical School,
Worcester, MA, USA
e-mail: Karim.Alavi@umassmemorial.org
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_15
Refer to Algorithm in Fig. 15.1
A. Septic presentations are the most common
indication for surgical intervention in CD.
These include an abscess or undrained stula, and must be managed in an urgent
125
126
ab
Fig. 15.1 Algorithm for management of an anorectal stula in Crohn’s disease. EUA examination under anesthesia,
EUS endorectal ultrasound
A. T. Schlussel and K. Alavi
Fig. 15.2 Example of seton placement. (a) Penrose drain for large stula tract. (b) Silastic vessel loop for narrow tract
fashion to prevent systemic complications.
Special considerations should be made for a
CD patient when performing an incision and
drainage for a perianal abscess. The incision
should be as close to the anal verge as possible, but still provide appropriate drainage.
This may minimize the length of a stula
tract if one is to develop in the future. In
addition, a drainage catheter may also be
placed in a large cavity, allowing it to close
around the tube over time, and if there is a
concomitant stula at the time of presentation a draining seton should be placed using
either a silastic vessel loop or Penrose drain
(Fig.15.2).
B. Successful management of a stula is depen-
dent on accurately dening its anatomy and
characterizing the degree of sphincter
involvement. The epithelialized tract of an
anorectal stula connects the anal crypts at
the dentate line to an external opening on the
perianal skin, and typically corresponds to a
previous abscess drainage site. Classication
of an anorectal stula is dened based on its
relationship to the sphincter complex and
includes: intersphincteric, transsphincteric
(low or high), suprasphincteric, or
extrasphincteric (Fig.15.3). To simplify the
management of perianal stulizing disease,
the American Gastroenterology Association
BD
15 Anal Conditions: Anorectal Crohn’s Disease—Fistula
EC
anal sphincter
AExternal
External
anal sphincter
127
Fig. 15.4 Complex anorectal stula with multiple external opening. Metallic probe localizes external stula
openings
A. Superficial fistula tract
B. Intersphincteric fistula tract
C. Transsphincteric fistula tract
D. Suprasphincteric fistula tract
E. Extrasphincteric fistula tract
Fig. 15.3 Classication of anal stulae (AGA Technical
Review on Perianal Crohn’s disease)
(AGA) dichotomized the disease into two
groups, “simple” and “complex,” stulas.
Simple stulas are distal, below the dentate
line, with a single external opening and no
associated uid collections or perianal complications. These stulas may be termed
supercial or low intersphincteric, or low
transsphincteric. Complex stulas are proximal to the dentate line, there may be multiple
external openings (Fig.15.4), and an associated abscess or other perianal disease may be
present. These stulas can be classied as
high intersphincteric, high transsphincteric,
extrasphincteric or suprasphincteric. From
another perspective, all stulas in patients
with CD are complex due to the underlying
immune suppression associated with CD. A
perianal Crohn’s disease score can also be
used to help make therapeutic decisions and
to monitor disease status.
An exam under anesthesia (EUA) is usually required to fully characterize the extent
of disease (Fig. 15.5). Additionally, an
endoanal ultrasound (EUS) or magnetic resonance image (MRI) may be used to aid in
operative planning. EUS has been associated with a sensitivity and specicity of
87% and 43%, respectively, in the detection
of a stula tract. The instillation of hydrogen peroxide in the stula will also enhance
the tract and improve identication.
However, tenderness may preclude interanal
ultrasonography. Pelvic MRI has recently
been reported as the gold standard in the
diagnosis of perianal CD. Soc and colleagues demonstrated that MRI had an
accuracy of 100% when discriminating
between intersphincteric, transsphincteric,
suprasphincteric and extrasphincteric stula
tracts. In addition, MRI has a sensitivity and
specicity of 87% and 69%, respectively, in
its ability to characterize the anatomy of the
stula tract through each muscle layer of the
sphincter complex. MRI will also aid in the
identication of any undrained uid collections and differentiate active inammation
from chronic brosis. In a direct comparison of EUS and MRI, Schwartz etal. demonstrated that when either imaging