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FIGURE14-3Episioproctotomy:layingopenthefistula
tracttocreateacloacaldefect.
p.103
p.104
Dissectioncommencesinananterolateralfashionaimingto meticulouslyseparatetheanorectalmucosaandidentifythesphincter complexoneachside,usuallyperformingasharpdissection,makingsure toavoida“buttonhole”defect.Electrocauteryisjudiciouslyusedtotryto avoidthermalinjuries.Similarly,thevaginalsideisdissectedaswell,and dissectionplanisextendedabovethefistulaintherecto-vaginalseptum. Debridementofanyinfectedand/orgranulationtissuesisdonepriorto reconstruction.
Thesphinctercomplexisdissectedenmassoneachside,usuallythis mayrequireenteringtheischiorectalfossa,untilthereissufficient mobilitytoachieveoverlappingsphincterrepair.Afterproperhemostasis isassured,alayeredclosureisperformedstartingfromtherectum.Ifthis isnotdoneandifthesphincterisrepaired,firstvisualizationoftheapex oftherectumisimpeded,anditsreapproximationmayaddtothestrain onthesphincterrepairstitcheswithpotentialdisruption.Therectal mucosaisclosedwith2-0Vicrylpayingattentiontoalignthedentate line.Subsequently,thesphinctermuscleisclosedinanoverlapping fashionusing2-0PDSmattresssuture,typicallyusing2–4sutures. Eventually,thevaginalmucosaisapproximatedusing2-0Vicrylsuture, aligningthehymenline(Figs.14-4and14-5).Theperinealskinis partiallyclosedwithverticalmattressstitches,leavingasmalldefectfor drainagewithorwithoutadrainatthesurgeon’sdiscretion.Depending onthepreoperativetissuecondition,astomamaybeindicatedifthe
tissueswerefibrotic,especiallyaftermultiplepreviousrepairstodivert thefecalstream.
FIGURE14-4Episioproctotomy:layeredrepairstartingat
therectalmucosaandincludingthemusclelayers.
FIGURE14-5Episioproctotomy:closingthevaginal
mucosa.
Thisreconstructivelayeredrepairmayprovideeradicationofthe fistuloustrackbecauseitisamultilayerclosure,repairsthesphincter defect,providesanewbloodsupplytotheclosure,andlengthensthe perinealbody.
TissueTransferandInterposition
MartiusFlap
ThebulbocavernosusmuscleandfatthatcomprisetheMartiusflapmay beinterposedbetweentheanorectumandvaginatotreatacomplex fistula.
Theanovaginalseptumisdissectedandpreparedtoreceivetheflap. Theposteriorwallofthevaginaisinciseddistaltothefistulaandfull thicknessdissectionisundertakentoseparatethevaginafromthe underlyinganorectum.Thisdissectionisperformedincephalad,caudate, andlateraldirectionstocreateenoughspacetoaccommodatethe bulbocavernousfatpadandavoidcreatingdeadspace.Understanding theunderlyinganatomicallandmarksisakeyinharvestingtheflap.
Theflapisharvestedbyalongitudinalincisionoverthelabus majorum.Theflapisthendissectedofftheskinandthesurrounding tissue(Fig.14-6).Thebordersofdissectionarelaterallyboundbythe labiocruralfold,mediallybythelabiaminora,andposteriorlybythe Colles’fasciacoveringtheurogenitaldiaphragm.Theflapobtainsits bloodsupplybybranchesfromtheinternalpudendal,obturator,and externalpudendalarteries,inferiorly,laterally,andsuperiorly, respectively.Thelateralbranchesarescarifiedduringthedissection,and thesuperiorsupplyistakendownwhiletransectingattheuppermost extentofdissection,leavingtheflapbasedontheinferiorbloodsupply.A penrosedrainencirclestheflaptobeusedforgentletractiontoextend mobilizationsuperiorlyuntilenoughtissueisobtainedbeforeitis amputated.Therectalsideofthefistulaisclosedintwolayerswith absorbablesutures,andthevaginalsideistrimmed.Atunnelisthen createdbetweentheharvestandtherecipientsitesthroughwhichthe flapisdeliveredinanorientedfashion(Fig.14-7).Theflapisanchored gentlyoverlyingthefistulaclosuresite,separatingtheanorectumfrom thevagina,andobliteratingthedeadspace(Fig.14-8).Thelabialincision isclosedinlayerstominimizethedeadspace.Theskinincisionisclosed exceptforasmalldefectfordrainagewithasmallpenrosedrain.
FIGURE14-6Martiusflap.Tunnelingtheflapoverthesite
oftherepair.
p.104
p.105
FIGURE14-7Martiusflap:creatingthelabialflap.
Longitudinalincisionoverthelabiawithdissectionofthefat padkeepingthelowervascularpedicleintact.
FIGURE14-8Martiusflap.Positioningoftheflapoverthe
repair.
Thesiteofthefistularepairisclosedoverasphincterrepairoran anatomicalrepair.Theareaisdrainedtoavoidaseroma.
DivertingStoma
Temporaryfecaldiversiondoesnotguaranteesuccess.However,theneed fordiversionisasurrogateofseverityofsymptomsand/ortheextentof infectious/inflammatoryprocess;adiversionmaybeconsideredforthe tissuestobecomesoftandpliableagain.Considerationfordiversion includetheconditionofthesurroundingtissue,complexityofthefistula anatomy,etiology,and(numberof)priorattemptsarecrucialindeciding thetypeofstoma.Shouldarectalsleeveorcolonicpullthroughbe consideredasafuturestep,thenanileostomyisamoreappropriate option.
POSTOPERATIVEMANAGEMENT
Therearenoguidelinesorconsensusonpostoperativeinstructionsfor thesepatients.Themajorityofrecommendationsarefromanecdotal experienceandinheritancefromexperts.
Defecationcausesstretchintheanorectalareaimposingstrainonthe repair.Weprefertogivebowelpreparationforourpatientstominimize fecalcontaminationduringthefirstfewpostoperativedays.
Postoperativeantibiotics,hospitaladmission,bedrest,andoralintake areatsurgeon’sdiscretion,andallarebasedonindividualsurgeon experienceandpreference.
Patientsareusuallydischargedonoralantibioticsforatotalof7days andarerestrictedfromsoakinginaSitzbathtoavoidtissuesmaceration.

COMPLICATIONS

Infectionandseromaaremajorpostoperativeproblemsevenfollowing themostmeticuloustechnique.Patientsshouldbepreoperatively counseledaboutthispossibility.Perioperativeantibiotics,stoma,and bowelpreparationdonotguaranteeeliminatingtheriskofinfection.A lowindexofsuspicionisimportantandwarrantsatleastanexamination intheoffice.Anyconcernofinfectionpromptsexaminationunder anesthesiaifnecessaryandappropriatedrainageofanyinfection.A timelydrainagemaypreventrecurrence.Antibiotics,oralorintravenous, shouldbeconsideredasappropriate.Anotherriskfactorispostoperative stoolimpaction,whichmaypotentiallybeavoidedinnondiverted patients,withpreemptiveuseoflaxativeswiththefirstsignof constipation.Thisplanrequirespatienteducationinthepreoperative settingandondischargefromthehospital.
RESULTOFVARIOUSTHERAPIES
ObliterationofFistulaTract
Ellisetal.(2008)reportedaseriesof12patientstoevaluatethe effectivenessofthefistulaplugintreatingRVF.Afteratotalof20 procedures,3of5RVFand4of7pouchvaginalfistulaewerehealed, yielding35%proceduralsuccessrateandoverallsuccessrateof58%.A similarstudyreported44%successrate.However,repeatprocedures wereunsuccessful.
LocalAdvancementFlap
ThesuccessrateofRAFvariesfrom43%to88%(Table14-1).Although thehighestchanceofsuccessisatthefirstoperation,Lowryetal.showed thataredoRAFmayhaveasimilarsuccessrateof85%.However,after twofailedpriorrepairsthesuccessratedecreasedto55%.Therefore, tissueevaluationiscrucialandconsideringanalternativeoptioninthese patientsmaybereasonable.Thetechniquecanalsobeusedinaselected Crohn’sdiseasepatientpopulationwithquiescentornoactivedisease. Althoughshort-termsuccessratewasreportedtobeashighas75%,these casesaredoomedwithahigherrecurrencerateandoveralllowersuccess rate.
TABLE14-1 ASummaryoftheSuccessRatesofDifferent
Procedures
First author Year Procedure N
Success rate(%) Comments
Joo 1998 RAF 20 75 RVFinpatients
withCrohn’s
disease
Lowry 1998 RAF 81 83 Success:88%;85%
afteronerepair,
55%aftertwo
repairs
Marchesa 1998 SleeveFlap 13 61.5 Threerequired
additionalsurgery
Ellis 2008 Fistulaplug 12 58 3/5RVFand4/7
PVFhealed
Hull 2011 Episioproctotomy 50 78 Episioproctotomy
associatedwith
betterfecal
continenceand
sexualfunction
Pitel 2011 Martiusflap 20 65 Eightpatientshad
CD
RVF,rectovaginalfistula.
p.106
p.107
HullandFazioreportedon35patientswhounderwentthreedifferent typesofflaprepairs:curvilinear,linear,andsleeveadvancementflaps,for patientswithCrohn’sdiseaseandanRVF.Theinitialsuccessratewas 54%.Anadditionalprocedurewassuccessfulinfivepatientswithan overallsuccessrateof68%.
Marchesaetal.(1998)reportedon13patientswithCrohn’sdisease receivingarectalsleeve:includedfourpatientswithrecurrentRVF whereassevenhadconcurrentRVFandperianalfistulae.Eightof13 patientshealedtheirfistulae,leadingtheauthorstorecommendthis techniqueforselectedcases.
ReconstructiveandLayeredClosure
Whenlocaltissuesareinadequateforrepairwithaflap,areconstructive multilayeredrepairisofmerit.Tsangetal.(1998)foundthatpatients withclinicaloranatomicalsphincterdefectsbenefitedfromRVFrepair withanoverlappingsphincterrepairandhadan80%successrateas opposedto41%successinasimilargroupofpatientswhounderwent RAFonly.However,sphincterrepaircombinedwithRAFresultedina highersuccessrateof88%,whencomparedwitha78%successratefor patientswhounderwentRAFalone.
Hulletal.(2007)evaluatedepisioproctotomyin42patients.Ninehad cloacaldefectandtheresthadanRVFwithasphincterdefect.There were11recurrences,noneofwhichrecurredinpatientswithacloacal defect.Theyreportedanoverallsuccessrateof74%.
Hulletal.(2011)alsoreportedon50patientswhounderwentan episioproctotomyandwerecomparedwith37patientswhoreceivedRAF. Thesuccessrateswere78%and62%,respectively.Fecalcontinenceand sexualfunctionweresuperiorintheepisioproctotomygroupcompared
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