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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1199_Библиотеки_им_академика_М_И_Перельмана.pdf
82
F.Q . Parray
Obstetrical injuries are the most common cause
of RVFs, occurring in up to 88 % of published
series (Hibbard 1978 ; Lowry et al. 1988 ; Russell
and Gallagher 1977 ). The causative factor in these
fi stulas is either a failed recognition of 4th degree
tear or 7–10 days following an apparent normal
repair. Approximately 5 % of vaginal deliveries
result in 3rd or 4th degree tear which if repaired
promptly heals satisfactorily in 90–95 % of
patients (Venkatesh et al. 1989 ). Some fi stulas dur-
ing observation period may heal spontaneously.
Also it is very important to assess their degree of
incontinence, before embarking on a repair, which
may be seen in 27 % patients (Wise et al. 1991 ).
7.2.2.2 Diverticular Disease
Diverticular disease in the setting of previous
hysterectomy is the most common infectious
cause of a high fi stula.
7.2.2.3 Tuberculosis
and Lymphogranuloma
Venereum
Tuberculosis and lymphogranuloma venereum
have also been reported as a cause of RVF
(Greenwald and Hoexter 1978 ).
7.2.2.4 Malignancies
These are usually seen in the setting of rectal,
uterine, cervical, or vaginal malignancies that
have signifi cant local extension and have been
treated with radiation therapy.
7.2.2.5 Radiation Therapy
The patient may develop proctitis followed by
ulceration of the anterior rectal wall. Rectal ulcers
then progress to fi stula formation around 6 months
to 2 years post therapy. The incidence of rectovaginal fi stula is more with higher dose of radiation and
in patients with previous hysterectomy (Perez et al.
1984 ). If suspicion for an undiagnosed malignancy
is present, fi stula should be subjected to a biopsy.
incorporated in the stapler or if an anastomotic
leak leads to abscess, and that then drains into
the vagina.
• Pelvic procedures may result in high RVFs.
• Hysterectomy following radiation treatment
or with unrecognized intraoperative rectal
injury may result in fi stula development.
• Stapler hemorrhoidopexy: RVFs are being
increasingly reported after this procedure than
with conventional procedures. They are usually caused by errors in surgical technique,
where the posterior vaginal wall is also caught
in the stapler (Giordano et al. 2009 ; Giordano
et al. 2011 ; Angelone et al. 2006 ).
• Stapled transanal rectal resection (STARR) and
transanal stapled resection (TRANSTAR) are
among the other causes of rising incidence of
RVFs (Naldini 2011 ; Martellucci et al. 2011 ).
7.2.2.7 Infl ammatory Bowel Disease
Both ulcerative colitis and Crohn’s disease can be
associated with rectovaginal fi stula. Crohn’s disease is more frequently associated with rectovaginal fi stula because it causes transmural
infl ammation of the rectal wall. The incidence
may increase with the severity of a Crohn’s fl are up, with one study noting an increase in incidence
from 0.2 % with mild fl ares to 2.1 % with severe
attacks (De Dombal et al. 1966 ). In Crohn’s dis-
ease, rectovaginal fi stulas can precede intestinal
symptoms (Sher et al. 1991 ). Rectovaginal fi stula
may occur in patients with ulcerative colitis after
ideal pouch anal anastomosis with complications
like anastomotic leak or pelvic abscess.
Other rare causes of fi stulas have been reported
which include fecal impaction, vaginal dilatation
after radiation to the vaginal cuff, viral and bacterial infections in patients with human immunodefi ciency virus (HIV), and sexual assault (Schwartz
et al.
1992 ; Hoffman et al. 2003 ; Sharland et al.
1995 ; Parra and Kellogg 1995 ).
7.2.2.6 Operative Trauma
• Low fi stulas may be the result of anorectal and
vaginal operations.
• Low stapled colorectal anastomosis may
cause a fi stula if the vaginal wall becomes
7.3 Classifi cation
RVFS may be broadly classifi ed as simple or
complex on the basis of size, location, etiology,
and anatomy. Classifying the fi stulas is important
7 Rectovaginal Fistulas
83
Fig. 7.2 High RV fi stula
Fig. 7.1 Low RV fi stula
on clinical assessment in order to plan an appropriate surgical treatment.
7.3.1 Size
On the basis of size, fi stulas may be small or
large. Fistulas less than 2.5 cm in size are classifi ed as small, and more than 2.5 cm are described
as large fi stulas.
7.3.2 Location and Etiology
It can be described in relation to the rectum,
vagina, and rectovaginal septum (Corman
Rosenshein et al. 1980 ).
In low fi stulas, the rectal defect is at dentate
line and vaginal opening inside the vaginal fourchette (Fig. 7.1 ). In high fi stulas, the vaginal
opening is at the level of the cervix (Fig. 7.2 ).
Middle fi stulas are found between the two
(Fig. 7.3 ).
A perineal surgical approach is more suited
for low and middle rectal fi stulas, while high fi stulas are more easily repaired through a
laparotomy.
Simple rectovaginal fi stulas consist of small,
low fi stulas secondary to infection or trauma.
These fi stulas generally have healthy, wellvascularized surrounding tissue, which can be
repaired with local techniques.
1989 ;
Fig. 7.3 Mid-RV fi stula
Rectovaginal fi stulas are considered complex
if they are large (>2.5 cm), high, or caused by
infl ammatory bowel disease. Recurrent fi stulas
are also considered complex due to their association with tissue scarring and decreased blood
supply. To provide the best chance of successful
repair, healthy, well-vascularized tissue needs to
be introduced after resection of diseased tissue.
Complex fi stulas require more complicated surgical procedures for repair.
7.3.3 Anatomy
Based on anatomical considerations, the rectovaginal fi stula can be classifi ed into:
84
F.Q . Parray
7.3.3.1 Pelvic Enterovaginal Fistula
These are usually because of previous hysterectomy, Crohn’s disease, diverticular disease, cancer, or operation. The fi stula is usually from the
ileum, sigmoid, or anastomotic site with posterior fornix of the vagina.
7.3.3.2 High Rectovaginal Fistula
These follow radiotherapy or pelvic operations of
the rectum or uterus. The fi stula is usually
between the posterior fornix of the vagina with
middle third of the rectum.
7.3.3.3 Midzone Rectovaginal Fistula
They may be secondary to obstetric cause, rectal
neoplasia, or infl ammatory bowel disease. The
fi stula is between the lower third of the rectum
and midportion of the vagina.
7.3.3.4 Low Rectovaginal Fistula
These fi stulas are seen secondary to obstetric injury,
foreign bodies, and local trauma and pelvic repair
surgery. The fi stula lies at the level of anorectal ring.
7.3.3.5 Suprasphincteric and Transsphincteric Anovaginal Fistula
These are usually associated with anal gland
infection, perirectal abscess, Bartholin’s abscess,
Crohn’s disease, or previous anal surgery or anal
anastomosis. The transsphincteric variety is
becoming more common after ileoanal and coloanal anastomosis (Keighley et al.
2008 ).
The local examination should comprise of vaginal examination, rectal examination, and surrounding tissue examination. One should look for stained
undergarments; color, smell, and type of discharge;
surrounding skin color changes; eczema; excoriation; or any pitlike defects in the anterior midline.
Pinhole low fi stulas may be asymptomatic.
Vaginal examination with a speculum may
reveal darker mucosa in the fi stula track, contrasting
with the light vaginal mucosa. There may be visible
stool in the vagina or one may encounter signs of
vaginitis. Probing the tract should be avoided.
In rectal examination and proctoscopy, try to
assess the integrity of sphincters, perineal body,
the muscles, and tissues between the rectum and
vagina. Try to locate the opening in the rectum by
direct visual examination during proctoscopy or
by bi-digital examination with one fi nger in the
rectum and other in the vagina. In case of big
defects, the two fi ngers meet each other at the site
of defect. This method of examination can also
give you the assessment of the strength of intervening tissue and mainly the thickness of the
perineal body. A colonoscopic examination after
bowel preparation should be an important part of
the assessment in case of any suspicion of infl ammatory bowel disease or malignancy. During the
physical examination, an assessment of anal
sphincter integrity will assist in surgical planning. There is often a coexisting fecal incontinence due to pelvic fl oor neuropathy and
sphincter defi ciency (Snooks et al. 1986 ).
7.4 Clinical Presentation
Patients usually report to doctor with the
complaints of passage of fl atus or liquid stools
per vagina. In third world countries, many a times
the females may report quite late because of
social inhibitions. Some patients may complain
of foul smelling vaginal discharge and frequent
infections of the vagina and passive incontinence
if the fi stula is above the sphincter. In evaluation,
always try to rule out infl ammatory bowel disease
and any pelvic malignancy. It is also quite important to know about any history of previous surgery
or irradiation to pelvis or genitalia which may be
the predisposing factor for the causation.
7.5 Diagnosis
Many a times the confusion may still be there about
the exact anatomic location and nature of sphincter
damage on the basis of clinical evaluation. It is very
important for the surgeon to know the exact anatomic location and the status of sphincteric strength
to plan the best modality of treatment.
7.5.1 Examination Under
Anesthesia (EUA)
This may prove to be one of the most effective
diagnostic tools in uncooperative patients and
may even reveal better details in most of the
7 Rectovaginal Fistulas
85
patients and help to plan the most suited surgery.
This will also allow you to take multiple biopsies
to rule out an infl ammatory bowel disease and
malignancies.
7.5.2 Anorectal Manometry
It may provide some useful information in fi stulas secondary to radiation or infl ammatory bowel
disease. These conditions will usually alter the
resting anal pressure, squeeze pressure of sphincter, and compliance of the rectum to function as a
reservoir.
7.5.3 Neurophysiologic Testing
Neurophysiologic testing with pudendal nerve
terminal motor latency can be performed in
selected instances, but it hardly has any prognostic signifi cance, hence not performed in most of
the centers (Saclarides 2002 ).
Fig. 7.4 Transrectal ultrasound image demonstrating a
fi stula highlighted with hydrogen peroxide. Arrow is
showing the site of fi stula
7.5.4 Vaginography
This contrast study is one of the time-tested
investigations performed in many centers with a
water-soluble contrast medium which has a sensitivity of 79–100 % (Arnold et al. 1990 ; Bird
et al. 1993 ; Giordano et al. 1996 ).
7.5.5 Barium Enema
This investigation can give general information
about the health of the colon and rectum. This
investigation, however, may fail to identify fi stula
in many patients, hence at present not practiced
in most of the centers.
7.5.6 Computed Tomography (CT) Scan
A CT scan of the abdomen and pelvis with oral
contrast may help to pick up the phlegmon or a
neoplastic mass and detect the position of the gut
responsible for a fi stula.
Fig. 7.5 Endoanal ultrasound 2 arrows show the area
with a breach in sphincter
7.5.7 Endoanal Ultrasonography (EAUS)
It is a very good investigative tool in patients who
complain of incontinence along with complaints
suggestive of an RVF (Figs. 7.4 and 7.5 ).
Ultrasound can identify internal anal sphincter as
a uniform hypoechoic circle under the submucosa. Defects can be easily picked up in the internal anal sphincter with the use of EUAS, but
defects in the external sphincter are diffi cult to
appreciate. The reason being that external
sphincter fi bers are hyperechoic, striated, and
more loosely arranged in circular pattern.
The normal thickness of the perineal body
as measured from anal mucosa to posterior
86
a
Fig. 7.6 ( a , b) 3D endoanal ultrasound demonstrating fi stula
F.Q . Parray
b
vaginal wall is 12 mm, and obstetric injuries
usually cause thinning of the muscle within
perineal body and shortening of the height of
the high- pressure zone of the anus. EAUS is a
good investigation to pick up these changes
(Saclarides 2002 ). However, some studies
report that initial evaluation with EAUS is not
satisfactory (Choen et al. 1991 ), but its diag-
nostic accuracy has improved with technical
advances in ultrasonography including the use
of hydrogen peroxide (H 2 O 2 ) as a contrast
agent and 3D reconstruction (Cheong et al.
1993 ; West et al. 2004 ). The image is no longer
limited to axial phone in 3D-EAUS, but it is
possible to cut across any part of the data in the
coronal, sagittal, or oblique plane (Fig.
7.6a,
b ). The H 2 O 2 -enhanced 3D-EAUS is expected
to diagnose anal fi stula with high accuracy.
Kim and Park ( 2009 ) concluded in their study
on 3D-EAUS assessment of an anal fi stula with
and without H 2 O 2 enhancement on 61 patients
that 3D-EAUS is highly reliable in the preoperative evaluation of anal fi stula. The use of
H 2 O 2 for enhancement offers some benefi ts,
although it did not signifi cantly improve the
diagnostic accuracy in this study. The selective
use of H 2 O 2 may be economical and reliable in
diffi cult cases.
7.5.8 Magnetic Resonance Imaging (MRI)
The test creates images of soft tissues in a
patient’s body. MRI can show the location of a
fi stula, as well as involvement of pelvic organs or
the presence of a tumor (Fig. 7.7a, b ). Comparative
studies of endoluminal ultrasonography and
endoluminal MR imaging have comparable positive predictive values in revealing the location of
anovaginal and rectovaginal fi stulas (Stroker
et al. 2002 ).
7.5.9 Endoanal MRI
Endoanal MRI provides high-resolution multiplanar images of the anal canal, the rectum, and
the vagina. The T2-weighted sequences can
depict lesions with high signal intensity such as
fi stulas and fl uid collection. Studies have shown
that endoanal MRI is an excellent modality for
the assessment of simple as well as complicated
anovaginal fi stulas and allows evaluation of anovaginal fi stulas and additional abnormalities such
as abscesses within the rectovaginal septum secondary perianal fi stula tracts and sphincter damage (Dwarkasing et al. 2004 ).
7 Rectovaginal Fistulas
ab
Fig. 7.7 ( a , b) MRI demonstrating RVF. Arrow shows the fi stula tract
87
7.6 Management
It is important to give a trial of conservative management to fi stulas with a low discharge, small
opening, and healthy perineum. Many such fi stulas may close spontaneously. The surgical
approaches for such patients are numerous. The
options are determined by the etiology of the fi stula, location, size, quality of the surrounding tissue, and previous attempted repairs. Most surgical
approaches can be classifi ed as either local or
abdominal. Local repairs are most useful for low
to middle rectovaginal fi stulas and include transanal, vaginal, and perineal approaches. Abdominal
operations are most useful for high rectovaginal
fi stulas. Either approach may require the use of
healthy muscle or tissue for transposition.
7.6.1 Medical Management
This is helpful in RVFs secondary to obstetric or
operative trauma or fi stulas complicated by
secondary infection. Use local wound care,
drainage of infectious material, and antibiotics
till the infection settles. Allow tissues to heal for
6–12 weeks. Many fi stulas may heal completely
and require no further treatment. Fistulas which
persist can be repaired at a later date when the
tissue is supple and infection is completely
controlled.
In patients with IBD, appropriate medical
therapy should be started. Repair of RVF can be
carried out even when the patient is on steroids
but with the understanding that chances of
recurrence are high. Some patients can maintain
RVF repair while on antimetabolites like
6- mercaptopurine or azothioprine. Some fi stulas
heal completely on infl iximab but most improve
symptomatically. If the patient presents with signifi cant colonic involvement and anal stricture,
then a fecal diversion should accompany the fi stula repair.
7.6.2 Surgical Treatment
RVFs which do not settle with conservative
management will fi nally need one or the other
types of surgery for the long-term cure. It is
important to know that RVFs originating from
radiation therapy, IBD, and stapling procedures
88
F.Q . Parray
are quite diffi cult to treat surgically. A proper
evaluation, an appropriate selection of surgical
procedure, and an experienced hand to tackle
with the problem would be worthwhile to save
the patient from the misery of repeated surgeries.
Broadly surgical approaches may be perineal or
abdominal as described under.
Planning
A proper planning of the procedure based on
evaluation would be invaluable. Decide
beforehand what approach you are going to
adopt after assessing the anatomy, physiology,
physical examination, and radiology of the
patient. Discuss in detail with the patient and
the attendants about the chances of recurrence, stoma, and complications of the operative procedures. Lack of planning will
invariably lead to many confusions regarding
positioning and type of anesthesia.
Optimization and preoperative preparation
Try to optimize patient’s nutritional status and
anemia before contemplating any repair. Make
sure the disease is under control in patients
with IBD, and steroids and immunosuppres-
sants have been weaned to minimal possible
dose. Ensure that you have waited enough for
the trial of conservative management. The gut
is cleaned with mechanical bowel preparation
before planning any surgery. Give a third-
generation cephalosporin as an intravenous
prophylactic antibiotic at the time of induction
after test dose or within an hour before sur-
gery. In case there is any history of irradiation
to the pelvis, preferably use ureteral catheters
to aid in dissection. Vaginal lumen is cleaned
with an antiseptic solution and urinary bladder
is catheterized.
Positioning
The most popular position used by the surgeons
all over the world still continues to be a
lithotomy position. Various modifi cations
can be made as per the requirement or the
approach used. However, if one plans to go
for transanal repair, then a prone jackknife
position with the buttocks stripped apart will
make the procedure more comfortable and
surgeon friendly.
Anesthesia
General anesthesia for abdominal approach and
spinal anesthesia for perineal approach would
be appropriate. Remember always to repeat
your digital rectal examination under anesthesia and fi nalize your plan. Many times you
may get the most important information by
EUA which you missed otherwise.
7.6.2.1 Transanal Approaches
7.6.2.1.1 Mucosal Advancement Flap Repair
This procedure was originally described for
repair of fi stula in ano. It is a fl ap composed of
mucosa, submucosa, and a portion of internal
sphincter muscle used to cover the fi stula defect.
This is one of the commonly employed procedures for a low RVF. Patient is catheterized and
placed in prone jackknife position. Infi ltration
with adrenaline has become controversial as
some believe that it may make the tissue soggy
and more prone to ischemia (Keighley et al.
2008 ). In this procedure, a trapezoid-like fl ap for
4 cm cephalad is mobilized (Fig. 7.8a ). The base
of the fl ap should be twice the width of the apex.
This helps to keep the fl ap well vascularized. The
distal end of the fl ap with the fi stula is then
excised (Fig. 7.8b ) and the fi stula dissected
through the septum into the vaginal opening and
sent for histological examination. The defect in
the vagina is closed in two layers or may be left
open for drainage (Fig.
7.8c, d ).
If levators can be mobilized and closed over
vaginal defect, the risk of ischemic breakdown
decreases. The rectal advancement fl ap is then
used to cover levatoroplasty and is sutured to the
distal part of incision in the anus with an absorbable suture.
The literature reports different success rates
with this approach. The reasons are multifactorial
like previous operations, Crohn’s disease,
preexisting sphincter status, and type of fi stula.
The success rates are reported in the range of
63–96 % in various studies (Sonoda et al. 2002 ;
Kodner et al. 1993 ; Tsang et al. 1998 ). The stud-
ies have also proven beyond doubt that adding
7 Rectovaginal Fistulas
a
c
89
b
d
Fig. 7.8 ( a – d) Mucosal advancement fl ap repair
sphincteroplasty to this repair in patients with
sphincter disruption, the success rates may go up
to 95 % (Khanduja et al. 1999 ).
The proponents of this procedure propagate
that intrarectal pressure increases at the time of
defecation, so this type of repair addresses rectal defect in a more appropriate way, so chances
of repair to last are better than transvaginal
repairs.
7.6.2.1.2 Transanal Sleeve Advancement Flap (TSAF)
This procedure is ideally suited for patients with
RVFs secondary to Crohn’s disease but with
disease- free rectum. This is also considered to be
a better approach for recurrent fi stula complicated by anorectal stenosis. This procedure is
done in lithotomy with a lone star retractor
applied. The coring of fi stula is done from the
90
a
Fig. 7.9 ( a , b) Transanal sleeve advancement fl ap (TSAF)
F.Q . Parray
b
vaginal site. In the anal canal, a circumferential
incision is made at the level of dentate line just
below the fi stula. One more circumferential incision is made approximately 3 cm above toward
the rectum. Upper end-cut edges are held with
series of sutures (Fig. 7.9a ). The dissected cylin-
drical rim is sent for histology. The anorectum is
mobilized circumferentially to mid-sacral level
to avoid any tension on the anastomosis. A coloanal anastomosis is made (Fig. 7.9b ) and a drain
is put through excised fi stula site. Some surgeons
may prefer to remove a sleeve of mucosa and
submucosa only instead of whole thickness of
anorectum.
This procedure was fi rst reported by Hull and
Fazio in
1977 . They subsequently updated it, and
in their experience at Cleveland clinic, 12 patients
with RV fi stula with severe Crohn’s disease were
operated, and 1 year after surgery, 8 patients
showed full recovery. The authors are of the opinion that this procedure can be offered to some
patients with severe Crohn’s fi stula with a relatively normal rectum particularly when the only
alternative left is total proctocolectomy and a
permanent stoma.
7.6.2.1.3 Transanal Endoscopic
Microsurgery (TEM)
The proponents of this approach believe that
TEM is an ideal surgical approach to remove
the fi stula and the surrounding scar tissue. In
this approach, you don’t make any incision in
the perineum, so the chances of damaging
sphincter are completely avoided, and the
vision inside the rectum is magnifi ed; thus,
chances of identifying the fi stula comfortably
are more.
• In prone position, RVF is identifi ed after introducing a proctoscope, with a soft tube of small
caliber introduced through the vagina or with
the use of methylene blue. The vagina is then
packed with gauze to avoid carbon dioxide
(CO2) leakage.
The fi stula tissue is widely excised till healthy
margins are seen under three-dimensional vision
of TEM. When dissection of the septum is complete, the TEM instrumentation is temporarily
removed.
• Use fi nger dissection to complete the dissection of the aboral part of the septum until the
sphincter fi bers are reached. For technical reasons, this part of the operation cannot be
performed by TEM. The dissection of this part
of the septum is easy once the correct plane is
identifi ed.
• Proctoscope is introduced again, and the vaginal edges are held in 3–4 stitches in vertical
orientation for closure to be tied at the end of
procedure. The rectum is closed transversely.
The patient is placed in the supine position,
and a vaginal retractor is introduced. The
vagina defect is sutured with introversion of
edges.
7 Rectovaginal Fistulas
a
c
91
b
Fig. 7.10 ( a – d) Transvaginal inversion repair
D’Ambrioso et al. in 2014 reported their
experience of TEM on 13 patients of RV fi stula
who were referred to them with failed repairs
and with diversions. TEM was performed on all
these patients between 2001 and 2008.
Radiologic evaluation performed on postoperative day 10 showed no fi stulas. In two cases, the
procedure was complicated by hematoma of the
septum and abscess of the septum, treated with
antibiotic therapy. In two cases, night soiling
was observed, and anorectal manometry showed
a moderate sphincter hypotonia. This functional
problem resolved in 3 months with sphincter
reeducation.
7.6.2.2 Transvaginal Approaches
7.6.2.2.1 Transvaginal Inversion Repair
This procedure is conveniently carried out in
lithotomy position under spinal anesthesia.
Patient is catheterized and the operation site is
prepared with antiseptic solution. This approach
is quite popular with gynecologists. The fi stula
tract is identifi ed. An incision is made in a U
d
fashion around the fi stula site on posterior
vaginal wall (Fig.
7.10a ). The vaginal mucosa is
now elevated from the underlying rectovaginal
septum (Fig. 7.10b ). Adrenaline infi ltration
(1:200,000 dilution) may ease the fl ap lift, but
some surgeons will avoid it because of the threat
of ischemia. The fi stula tract is excised up to
rectal vault and sent for histology A series of
concentric purse string sutures are placed transvaginally into the rectovaginal septum to imbricate the fi stula opening into the rectal vault.
Levatoroplasty can be performed simultaneously with this approach (Fig.
7.10c ). This
ensures the interposition of healthy tissue
between the repairs. Finally, close the vaginal
mucosal fl ap after cutting the lower part which
bears the opening of the fi stula (Fig. 7.10d ).
Proponents of this approach prefer this
repair because of the improved exposure compared with transanal approaches. This approach
as per some studies has shown encouraging
results, and some have even reported the success rate up to 100 % (Rahman et al. 2003 ). In
patients with Crohn’s disease, some surgeons