4.3 Bleeding and Dyspareunia

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Table 4.1 Surgical procedures for RVF and the most frequent postoperative complications, as reported in the literature (abdomi-

nal procedures are excluded)

Operation Author and year Reported complication

Transanal route

Rectal advancement flap Goldberg, 1990 Suture dehiscence

Hoexter, 1990 Sepsis and dehiscence

Lowry, 1992 Suture dehiscence

Marchesa, 1998 Sepsis and dehiscence

TEM plasty Darwood, 2008

Surgisis plug Gonsalves, 2009 Plug detachment

Perineal route

Lay-open Belt 1969, Anal incontinence

Francois, 1990 Anal incontinence

Fistulotomy and layered suture Hudson, 1977 Rectal bleeding

Puborectalis muscle interposition Oom, 2006 Local sepsis

Excision, suture, and sphincteroplasty Gagliardi, 2007 Suture dehiscence

Pinto, 2010 Dehiscence, bleeding

Bulbocavernosus muscle interposition Cui, 2009 Dyspareunia

Graciloplasty Lefèvre, 2009 Loss of libido

Gluteoplasty Lefèvre, 2009 Dyspareunia

Transvaginal route

Inversion and layered closure Given, 1970 Suture dehiscence

Episiotomy and layered closure Tancer, 1990 Bleeding, cellulitis

Vaginal advancement flap Ruffolo, 2009 Suture dehiscence

Transcoccygeal route

Rectal advancement flap Schouten, 2009

Only one case.

All complex RVF recurring after previous repair.

4 Rectovaginal Fistulae

Suture dehiscence

4.3 Bleeding and Dyspareunia

4.3.1 Bleeding

Bleeding rarely occurs after RVF repair (Tancer et al., 1990) but when it does it may be dramatic and require emergency re-intervention, as discussed at the end of the chapter. It is likely to be successfully managed by suturing the bleeding area, but may also require a diverting stoma. In a series of 184 patients treated at the Cleveland Clinic in Florida, Pinto et al. (2010) reported three cases of severe bleeding in which re-operation was required.

4.3.2 Dyspareunia

Dyspareunia may follow anterior levatorplasty or, more often, puborectalis muscle interposition. It is

due to the fact that the bulk of the muscle tissue sutured at the level of the rectovaginal septum can hinder sexual intercourse. Dyspareunia has been also reported in association with either a loss or a reduction of libido following graciloplasty for recurrent RVF (Lefèvre, 2009). This complication is prevented by a rectal flap advancement performed via the transcoccygeal route, as reported by Schouten and Oom (2009). Only one of the nine patients operated upon by Cui (2009) using bulbocavernosus muscle interposition complained of dyspareunia after surgery.

4.4 Local Sepsis and Suture Dehiscence

This complication has occurred in 10% of our patients after RVF repair (Gagliardi and Pescatori,

2007). Similar findings were reported by Pinto et

4.3 Bleeding and Dyspareunia

Fig. 4.2 Surgical procedure of reverse suturing after excision

of a transvaginal high rectovaginal fistula (black). The reversed stitches, translocated to the rectal side, prevent problems with the sutures and facilitate an effective plasty

al. (2010) in patients treated at the Cleveland Clinic in Florida, with sepsis and suture breakdown occurring in 13 out of 125 patients. When confined to the bowel, the dehiscence may either heal spontaneously following the application of local healing ointments/gels or in response to systemic antibiotics. Alternatively, treatment may require a diverting sigmoidostomy, with or without re-suture of the dehiscent wound, depending on its dimension and provided that the local infection has subsided.

A method to prevent (or minimize the risk of) anastomotic breakdown when performing complex procedures, e.g., a Martius flap or layered closure with sphincter reconstruction, is to prolong the administration of antibiotics beyond the typical antibiotic prophylaxis and to give the patient a course of intravenous feeding with enough calories to favor tissue healing. Alternatively, it may be preferable to perform a temporary diverting stoma, usually a sigmoidostomy, which does not increase the risk of RVF recurrence. The latter may be carried out to prevent fecal contamination in more complex repairs, such as the inverted layered closure with a rectal advancement flap (Fig. 4.2).

According to Wexner (in Pinto et al., 2010), heavy smokers, as previously reported by the Schouten group for anal fistula surgery (see Chap.

3), are at risk for anastomotic dehiscence, as smoke stimulates the production of catecholamines

and thus causes vasoconstriction, with the decreased blood supply in turn affecting the healing properties of the tissues. Crohn’s disease is another condition that increases the risk of suture breakdown after RVF repair, with a dehiscence rate of 60% reported in these patients by Lowry and Goldberg in 1992. Fry and Kodner (1989) reported a much lower dehiscence rate of 20% in their Crohn’s patients. Interestingly, Garcia Olmo et al. (2003) suggested the therapeutic use of stem cells in patients with RVF and Crohn’s diseases.

The construction of a flap offers several advantages for patients with anal continence, which is more often seen in patients with Crohn’s disease. These patients may have a less compliant, infla med rectum and a reduced stool consistency due to diarrheal episodes. By carrying out a flap, one may avoid the formation of a perineal wound, possibly affecting the sensory component of anal continence, and an anal deformity, which is likely to favor postoperative soiling. The question then becomes whether the surgical strategy should include a vaginal or a rectal flap. After reviewing the literature, Ruffolo et al. (2010) recommended the vaginal flap, the main reason being that the construction of a rectal flap requires a transanal procedure with stretching of the sphincter. Regarding the need for a stoma, Marchesa et al. (1998) preferred the use of a diverting colostomy

when dealing with Crohn’s RVF in patients treated at the Cleveland Clinic in Ohio.

Darwood and Borley (2008) successfully treated a patient with a rectovaginal fistula following an anterior resection of the rectum using TEM. As the latter technique is minimally invasive, it is less likely than conventional procedures to cause postoperative complications. However, this remains to be confirmed in larger series.

4.5 Re-interventions

A surgeon dealing with RVF patients should be prepared to re-operate, mostly due to dehiscences or recurrences. About one-third of RVF patients need more than one operation to be cured, underlining the importance of alternative procedures, as noted above.

The crucial point is that a patient who needs a re-intervention is at greater risk of complications and failures, namely, local sepsis, suture dehiscences, bleeding, and incontinence. In fact, the patient’s tissues are less vascularized, the anal sphincters are weaker, etc., due to the previous operation. This is true also for other proctological diseases, such as hemorrhoids (see Chap. 2). It is known that re-interventions for either complicated or recurrent hemorrhoids, namely, after procedures for prolapsing hemorrhoids, are more likely to cause postoperative bleeding (Brusciano et al.,

2004). Based on these considerations, surgically treated tissues are less vascularized and surgically treated sphincters are weaker and more prone to causing anal incontinence. Schouten and Oom (2009) recommended the avoidance of a perineal/transanal/transvaginal route in these cases, instead re-operating by another approach, through tissues with a good vascular supply and leaving intact the anal sphincters. They operated on a number of patients with recurrent RVF via a transsacral approach, with successful outcome. There was only one local infection in eight cases managed with a mucosal advancement flap. It should be noted, however, that most of the RVF in this Dutch series were post-obstetric, i.e., the patients with the best prognosis. The local sepsis rate was as high as 42% after another type of RVF repair, interposition of the puborectalis muscle, carried out by the same authors (Oom et al., 2006).

4 Rectovaginal Fistulae

4.6 Drains

Beck and Wexner (1992) recommend the use of a drain in repairs of high RVF with long tracts, in order to decrease the risk of sepsis and dehiscences. The Surgisis plug (Biodesign, Cook Medical, Bloomington, USA) has been used for the management of RVF, but it was displaced due to suture dehiscence in 42% of the patients in one series, with the fistula tract open within 4 weeks and requiring the implantation of another plug (Gonsalves et al., 2009). However, infection did not occur in any of the patients operated on by these surgeons.

4.7 Fecal Incontinence

Postoperative fecal incontinence was a complaint in 15% of the patients I operated upon for RVF (Gagliardi and Pescatori, 2007). When graded according to our validated system (Pescatori et al.,

1992), incontinence was due to liquid stool in all cases, occurring at least once a week (B2, score 4) in two-thirds and occasionally (B1, score 3) in one-third of the cases. However, some of these patients already suffered from incontinence prior to surgery, due to either diarhea or, more rarely, an inflamed rectal reservoir (in cases of Crohn’s disease) or an obstetric injury to the anal sphincters.

In an earlier report Belt (1969) found that fecal incontinence always occurred after laying open RVF. Francois et al. (1990) reported fecal incontinence in three out of nine surgically treated patients. I carried out a fistulotomy in a 35-yearold patient with Crohn’s disease. While she remained continent, the tract was very low, anovulvar rather than rectovaginal. The risk of postoperative incontinence may be minimized by using a tailored approach, i.e., avoiding transanal repair, which is likely to stretch the anal sphincters, in patients with weak pelvic floor. The use of a Martius flap, transposing the bulbocavernosus muscle, might be a good option in these patients (Cui, 2009). Alternatively, as suggested by Lowry in Beck and Wexner’s book (1993), anterior sphincter reconstruction may be required in case of injured anal sphincters. Annaway and Hull (2008) reported good results using this procedure, and a

4.7 Fecal Incontinence

qrs t uv

bc d ef g

ij k l

nop

Fig. 4.3 Sphincter-sparing procedure, aimed at preventing potoperative incontinence, in a patient with recurrent anal and rectovagi-

nal fistula a Patient in the lithotomy position. On the left: external opening of a vulvar fistula (images by N. Clemente); b probing of the fistulous track; c lay-open of a chronic abscess at the site of a Bartolini’s gland; d the cavity is completely laid-open after the partial division of both the bulbo-cavernosus and the superficial transverse muscle of the perineum; e the cavity is curetted with a Volkman spoon; f the underlying recto-vaginal fistula is probed; g a seton is inserted in the fistula; h the external orifice of a concomitant anal fistula is found and the small perianal abscess is curetted; i the horse-shoe anterior perianal fistula is probed; j the fistula is laid-open, dividing just a few fibers of the subcutaneous part of the external sphincter, anteriorly; k the fistulotomy has been carried out (arrow); l anal trimming; m the recto-vaginal fistula is excised; n it will be sent for histological examination; o a gauze soaked with Betadine is inserted in the vagina; p endoanal view: a Beak Sapimed anoscope has been inserted and a rectal mucosal advancement flap is prepared, injecting adrenaline and saline 1:200,000 under the submucosal layer; q vaginal aspect: the post-fistulectomy cavity is shown; r suture of the vaginal wall: 1) reconstruction of the bulbo-cavernosus muscle using 2/0 vicryl; s 2) the superficial layer of the vaginal wall has been sutured; t endoanal view: the rectal flap is sutured without tension to the subcutaneous part of the external sphincter, to cover the surgical defect in the lower rectum; u end of the surgical procedure; v two months later, the wounds are healed and the patient, in the Sims position, is fully continent

similar positive experience was obtained in our series, as noted above.

Anal and vaginal ultrasound (US) may be helpful to detect anterior occult lesions of the external sphincter in patients who do not present with clinically evident anal incontinence. When anal US and manometry are not available, a careful anamnesis and physical examination will allow surgeons to

easily identify patients at risk for postoperative incontinence, i.e., those who are multiparous, have a perineal descent and a short anal canal, suffer from irritable bowel syndrome, and have already undergone proctological surgery. However, an operation aimed at preserving anal sphincters may be carried out even when a fistula-in-ano is associated to RVF, as illustrated in Fig. 4.3.

4.8 An Unforgettable Complication

The patient is a friendly, smiling, but rather nervous 42-year-old woman who came to my office accompanied by her husband and daughter. One year before, in 2001, she had undergone a STARR procedure, performed for obstructed defecation, but she was still constipated, with the constant need to strain, unable to empty her bowel, and spending hours at the toilet, self-digitating. During digital exploration, when I asked her to strain, I clearly felt a paradoxical contraction of the puborectalis muscle. Pushing my finger towards the vagina, I also felt a modest rectocele. The patient had two vaginal deliveries, which had caused the rectocele. She then had undergone a stapled rectotomy, aimed at its correction, but, due to the repeated excessive straining against a contracted puborectalis, it had, not surprisingly, recurred. At proctoscopy, a prevalently anterior rectal internal mucosal prolapse was detectable that almost reached the anal verge on straining. At this point, the reader might ask how all this relates to RVF, but the answer will soon become clear. “Your main problem is the non-relaxing muscle,” I said to the anxious woman, showing her the contracted puborectalis on the screen of the US device. “You need a course of pelvic floor exercises.” A few months later, after seeing a physiotherapist, she returned for a follow-up exam, still constipated despite several sessions of biofeedback training. The muscle tended to relax but the rectocele and the prolapse of course persisted. The woman was even more distraught and agitated. She pleaded for a repair operation, to which I did not agree. But when I saw her again, 2 months later, she was still very upset and said that her obstructed defecation had worsened. I agreed that surgery was necessary and scheduled her for a Sarles mucosectomy to repair both the rectocele and the prolapse. Three weeks later, I performed the operation, which was technically demanding due to the fibrosis of the lower rectum caused by the previous operation. On postoperative day two, the patient had her first, albeit painful, bowel movement, with some pus discharge. Her temperature rose to 39°C and she was very uncomfortable. Two days later, at digital exploration, I felt a small gap in the rectoanal suture; moreover, the patients told me that she felt air coming out through the vagina. “The same feeling I had

4 Rectovaginal Fistulae

sometimes after the STARR operation” she added. “But you never reported this symptom to me before!” I said. “Well, doctor, you never asked me if I felt a loss of air through the vagina!” she replied. I discussed with her the need for re-intervention, explaining that in case of suture breakdown and RVF, a diverting stoma should have been carried out, but she strongly refused a possible stoma formation.

What did I find? What did I do in the operating theatre? Please provide your own hypotheses.

The patient was returned to the operating theatre, with the findings shown in Fig. 4.4. A Foley catheter was positioned in the bladder and the anal canal was gently stretched with a dilator. The rectoanal anastomosis of the Sarles (a type of anterior Delorme) appeared to be almost completely dehiscent. There was tissue ischemia, pus discharge, and a high fistula was clearly detectable, with a wide communication between the lower rectum and the vagina. After a complex perineal, transanal, and transvaginal repair, as a stoma could not be fashioned due to the patient’s refusal, a course of parenteral nutrition was started and the bowel confined to prevent fecal contamination of the sutures. One week later, the patient was doing well, with the wounds sutures apparently healed, but as she was not allowed to eat and had to stay in bed, she became increasingly agitated, until one afternoon she violently pulled out the Foley catheter, with the balloon inflated, causing bleeding from the perineum. Despite perineal compression with gauze, the hemorrhage did not stop. It was late in the evening, the patient was pale and tachycardic, and it was not possible to admit her to the operating room to administer anesthesia and suture the bleeding site; therefore, I had her transferred to a betterequipped, larger hospital, where an urgent reoperation was carried out, with suturing of the bleeding area, i.e., part of the surgical wound at the vaginal side. In addition, a diverting colostomy was performed. The patient was discharged one week later. The stoma was closed after a few months. After 8 years, she still suffers from obstructed defecation. In conclusion: postoperative bleeding is rare but may be dramatic after RVF repair. And never operate on a very anxious patient with anismus and obstructed defecation.

4.8 An Unforgettable Complication

Fig. 4.4 a “Unforgettable complication:” a mildly symptomatic

rectovaginal fistula, after STARR, that usually becomes clinically evident as a result of anastomotic dehiscence for local sepsis after Delorme prolapsectomy. At re-operation, a fistula excision with levatorplasty was performed. The patient refused a covering stoma and instead underwent peripheral total parenteral nutrition. A second operation became necessary because of an acute hemorrhage from the surgical wound, as a result of local trauma, i.e., forced removal of the Foley catheter by the patient, who suffered from high levels of anxiety

Fig. 4.4 b Transverse incision between the rectum and vagina.

The subcutaneous portion of the external sphincter is seen below and the superficial transverse perineal muscles (pink) above. The patient is in the lithotomy position

Fig. 4.4 c The posterior distal portion of the vagina is intact,

with the vaginal orifice of the fistula situated above

Fig. 4.4 d Vertical incision on the vaginal side

Fig. 4.4 e Traction stitches are placed to better view the opera-

tive field, which, from anus to vagina, includes the subcutaneous portion of the external sphincter, the transverse superficial and deep perineal muscles, and the bulbocavernosus muscle

4 Rectovaginal Fistulae

Fig. 4.4 f Clamp tips are inserted in the fistula orifice

Fig. 4.4 g Both lateral branches of the puborectal muscle are

placed on the medial side and sutured, performing an anterior levatorplasty, to interpose vital and well vascularized tissue between the rectum and vagina

Fig. 4.4 h Cutaneous plasty was performed to create more

space between the anus and the vulva

Summary

Fig. 4.4 i The surgical wound is incompletely sutured, to pre-

vent sepsis. The patient refused a covering stoma. Seven days later, bleeding from the depth of the surgical wound occurred, requiring an urgent hemostatic suture, followed by a diverting colostomy that was closed after a few months (from Pescatori,

2011)

Summary

The most feared complication after RVF repair is local sepsis, with suture dehiscence, which may occur in around 10% of patients. It may be prevented, or its consequences minimized, by performing a diverting stoma at the end of the fistula repair. Dehiscences are more prone to occur (up to 40%) in patients with Crohn’s disease or in those with recurrent RVF, who are operated on with a rectal advancement flap. Postoperative bleeding is rare, but may require re-intervention. Dyspareunia may follow levatorplasty and graciloplasty.

Fecal incontinence is more likely in patients operated upon via a transanal route, due to excessive stretching of the sphincters, but may be prevented by means of sphincter reconstruction following fistulectomy in patients with weak pelvic floor muscles. Alternatively, a transvaginal or a trans-sacral approach may be used.

The best clinical and functional results are achieved in low post-obstetric RVF, as the rectum is healthy and the patient is young. Patients with Crohn’s or post-radiation RVF have the worst prognosis.

The surgeon who deals with RVF should be a specialist able to perform more than one procedure, as approximately one-third of the patients require repeated interventions to achieve cure.

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