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►Содержание►
POSTOPERATIVEMANAGEMENT
Patientsareobservedintherecoveryareawithclosehemodynamic monitoringuntiltheyareawakeandabletoambulatefreely.Patientsare expectedtovoidspontaneouslybeforetheyareallowedtogohome.The authorstypicallyuseacombinationofnarcoticandNSAIDsfor postoperativepaincontrol,andallpatientsareplacedonstoolsofteners duringthefirst3weeksfollowingthesurgery.Postoperativefollow-up typicallyoccurs3–4weeksaftersurgery.Asmanytreatmentfailuresafter theLIFTproceduretendtopresentlate,werecommendfollow-upforat least6monthsafterthesurgery.

COMPLICATIONS

Severalreportshavesuggestedthedevelopmentofpersistentsinusinthe interspicntericgroove.Wefeelthatthiscomplicationcanbeminimized byleavingtheskinincisionopenandallowingittogranulate.A modificationofthissurgicaltechniqueinvolvingthedivisionofthe internalsphincteratthetimeoftheLIFThasalsobeendescribed.

RESULTS

Whereastheoriginaldescriptionofthistechniquereportedasuccessrate upwardsof90%,subsequentreportshavesuggestedsuccessrates comparablewithmucosaladvancementflapbetween60%and70%.In ourexperience,themajorityofpatientswithrecurrencepresentwith muchmorebenignintersphinctericfistulae,theso-called“medialization” oftheexternalopening,aconditioneasilymanagedwithinternal sphincterotomywithoutasignificantriskoffecalincontinence.
Tothebestoftheauthors’knowledge,noneofthereportshave documentedpostoperativefecalincontinenceaftertheLIFTsurgery.

CONCLUSIONS

LIFTisaneffectivetreatmentforintersphinctericfistulae.Reported successratesappeartobecomparablewithmucosaladvancementflaps andfavorabletofistulapluginsertion.Theobviousbenefitofthis procedureisthepreservationoftheexternalsphincter,minimizingthe riskoffecalincontinence.Possibledisadvantagesincludethepossibility ofintersphinctericfistulaafterLIFT,necessitatinganadditionalsurgical procedure.However,giventhehighsuccessratesandpreservationof fecalcontinence,LIFThasbecometheprocedureofchoicefor intersphinctericfistulaeoverthelastdecade.
RECOMMENDEDREFERENCESAND READINGS
BastawrousA,HawkinsM,KratzR,etal.Resultsfromanovelmodificationtotheligation
intersphinctericfistulatract.AmJSurg2015;209(5):793–8;discussion798. BleierJI,MolooH,GoldbergSM.Ligationoftheintersphinctericfistulatract:aneffectivenew
techniqueforcomplexfistulas.DisColonRectum2010;53(1):43–6. LangeEO,FerrariL,KraneM,FicheraA.Ligationofintersphinctericfistulatract:asphincter-
sparingoptionforcomplexfistula-in-ano.JGastrointestSurg2016;20(2):439–44. LiuWY,AboulianA,KajiAH,KumarRR.Long-termresultsofligationofintersphinctericfistula
tract(LIFT)forfistula-in-ano.DisColonRectum2013;56(3):343–7. MushayaC,BartlettL,SchulzeB,HoYH.Ligationofintersphinctericfistulatractcomparedwith
advancementflapforcomplexanorectalfistulasrequiringinitialsetondrainage.AmJSurg
2012;204(3):283–9. RojanasakulA,PattanaarunJ,SahakitrungruangC,TantiphlachivaK.Totalanalsphinctersaving
techniqueforfistula-in-ano;theligationofintersphinctericfistulatract.JMedAssocThai
2007;90(3):581–6. RojanasakulA.LIFTprocedure:asimplifiedtechniqueforfistula-in-ano.TechColoproctol
2009;13(3):237–40.doi:10.1007/s10151-009-0522-2. ShanwaniA,NorAM,AmriN.Ligationoftheintersphinctericfistulatract(LIFT):asphincter-
savingtechniqueforfistula-in-ano.DisColonRectum2010;53(1):39–42. TanKK,TanIJ,LimFS,KohDC,TsangCB.Theanatomyoffailuresfollowingtheligationof
intersphincterictracttechniqueforanalfistula:areviewof93patientsover4years.DisColon
Rectum2011;54(11):1368–72.
PARTIII
RECTOVAGINALFISTULA
Chapter11
TransperinealApproach
G.WillyDavila
Asuccessfulrepairofarectovaginalfistula(RVF)canbearemarkable challengeforthereconstructivepelvicsurgeon.Becausethefemale perineumandperinealbodyrepresentsacoalescenceofsofttissue (muscleandcollagen)thatisdirectlytraumatizedbythevaginaldelivery process,theresultantscartissuecannegativelyaffectitsintegrity, primarilybyimpairedvasculatureandinnervationofthoserelatively poorlysupportedtissues.Similarly,ifaffectedbyaninflammatory processsuchasCrohn’sdisease,themultiplecomponentsoftheperineal bodycanbeaffectednegatively.Astissueplanesarenotspecifically definedinthispartofthebody,fistuloustractsarenotpredictableand canbequitetortuous.Theselectedapproachshouldthusbe individualized,andmultiplefactorstakenintoaccount.Thefactors involvethelocationoftheRVFrelativetotheperineum,analsphincter unit,andrectovaginalseptum,aswellasanypriorattemptedrepairand underlyinginflammatoryconditions.Thereareotherindividualaspects tobeconsideredincludingphysicalactivitylevel,sexualfunction,and anestheticriskfactors.
Whenselectingamongatransvaginal,atransrectal,oraperineal approach,thelocationoftheRVFandthequalityofthesurrounding tissuesaretheprimaryconsiderations.Forexample,inawomanwhohad aninfection-relatedbreakdownofafourth-degreeepisiotomyrepair,a wideperineoplastyisrequiredtocorrecttheresultantlargeperineal cloaca,andatransperinealapproachpreferred.Itisalsoevidentthat gynecologicsurgeons(whoarecomfortablewithobstetricalperineal lacerationrepairsandtypicallyoperatetransvaginallywiththepatientin lithotomy)andcolorectalsurgeons(whomaypreferatransanalapproach inpronejackknifeposition)mayelectdifferentapproachestorepairan RVF.Regardlessofthepreferredapproachandthepatientposition,the transperinealapproachtotherepairofanRVFisprimarilyindicatedfor low,infrasphincteric(distaltotheanalsphincter)andcomplexmultitract diseaseRVFs.AsuprasphinctericRVF(proximaltotheanalsphincter) wouldrequiretransectionoftheanalsphinctertoattemptatransperineal
repair—atechniquethatisstronglydiscouragedifthesphincterisintact.
Ifthesphincterisalsodisrupted,suchaswithatransphinctericRVF, therepairoftheRVFshouldbebasedonhowthesurgeonwishesto approachtherepairofthesphinctermusclecomplex.RVFrepairisalso discussedinotherchapters,andthereadershouldreviewthosechapters aswellforothermanagementoptions.Acombinedapproach,withthe colorectalsurgeonperformingthesphincterrepair(withthepatientin hisorherpreferredposition)andtheurogynecologicsurgeonperforming thefistulaandperinealrepairs(posteriorcolporrhaphywith perineoplasty),allowsthepatienttobenefitfromtheoptimalapproaches tosphincterdisruptionrepairaswellasperinealreconstruction.Inthe absenceofatrainedurogynecologist,thecolorectalsurgeonmaywishto consultanobstetrician-gynecologistclinicianastheyalsohave experienceintheperformanceofposteriorcolporrhaphyand perineoplasty.

INDICATIONS/CONTRAINDICATIONS

Indications
Inflammatory,infectious,traumatic(suchasobstetrical),orradiation injuriescanresultintheformationofRVF.Giventhepsychosocial,self­image,andsexualmorbidityassociatedwiththesefistulas,surgical managementisindicatedforanypatientwhoismedicallyabletoundergo asurgicalprocedure.AlthoughsomeRVFsmaycloseontheirown, spontaneousclosureisuncommon,andasurgicalapproachshouldbe planned.
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SelectionoftheProcedure
Thereisnoonetechniquethatisconsideredthe“goldstandard”forthe managementofRVFs.Instead,thechosensurgicaltechniquedependson thetrainingandexperienceofthesurgeon,theetiologyandanatomyof thefistula,theintegrityoftheperinealbody,andthepresenceorabsence ofasphincterdefectandofincontinence.Optionsinclude:
AnanalmucosalflapcanbeusedforthemanagementofanRVF. Theseflapscanbecreatedandusedtocovertherectal(high-pressure) sideofthefistula.Possiblecomplicationsoftheseflapsincludeflap retractionandfistulapersistence,creationofamucosalectropionwith resultantmucusleakageandrectalbleeding(mucosalflap).This approachisfavoredbymanycolorectalsurgeonsastheirprimary approachduetoitsminimalinvasiveness,buthasahighrecurrencerate inCrohn’sdiseaseandradiatedpatients.
Fistulotomywithperineoproctotomycreatesafourth-degreeperineal lacerationandprovidesfortheidentificationandexcisionofthefistula tractwithlayeredclosureoftheanalsphinctercomplex,vaginaland rectalwalls,andtheperinealbody.Thisapproachismostusefulfor womenwithanRVFassociatedwithasphincterdefectwithincontinence, asitcombinestheclosureofthefistulawithoverlappingorend-to-end sphincterrepairs.Transectinganintactsphinctercomplexmayleadto subsequentfecalincontinence—anditsassociatednegativequality-of-life impact.Thus,thisapproachisnotthepreferredmethodunderthese circumstances.
TransvaginalrepairofRVFand/orEASdefectisthepreferred approachbygynecologicsurgeonswhooperatewiththepatientinthe lithotomyposition.Exposureisexcellentandthemultiplelayersofthe vaginalwallcanbeapproximatedtoclosethefistuladefect.Thisaccessis bestsuitedforsupra-ortransphinctericRVFs,wherethetractislocated atadistanceabovetheperineum.Owingtotheabilitytoclosethetractin multiple(3+,mucosa,rectalmuscularis,levatormusculature,vaginal fibromuscularis,andvaginalepithelium)layers,highsuccessratesare reported.
TransperinealrepairofRVFallowsfortheclosureoflarger,complex, andrecurrentfistulae,aswellassimpleprimaryrepairs.Exposureis excellent,allowingformeticulousdissectionandclosureoftissuelayers. Avariantoftheligationoftheintersphinctericfistulatract(LIFT) techniqueaddsabioprostheticgrafttocovertheclosureofthefistula tract.Typically,however,abiologicimplantisnotnecessaryunlessthere hasbeenpriorradiation,multiplepreviousrepairattempts,orahistory ofinflammatorylocaldisease.ManywomenwithRVFhaveareduced perinealbodyvolumeandnarrowrectovaginalseptumbecauseofthe previouslocaltrauma.Atransperinealapproachallowsforperineal reconstructionatthetimeoffistularepair.Thischapterreviewsthe transperinealapproachtoRVFclosure,associatedtechniques,andpre­andpostoperativecare.
Contraindications
MostwomencansafelyundergotransperinealclosureofRVF.Therepair canbeperformedundergeneral,regional,orevenlocalanesthesia. Relativecontraindicationsincludeanacute,inflamedfistularesulting fromobstetrictraumaorfistulasassociatedwithacuteinflammationsuch asCrohn’sdisease.Onceinflammationresolves,therepaircanbe performed.
ActiveanorectalCrohn’sisacontraindicationtothesurgicalrepairof anRVF.Forthesepatients,medicalmanagementshouldbedirectedat stabilizingthediseaseprocessbeforesurgicalrepaircanbeconsidered.
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