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14. Benign Anorectal: Rectovaginal Fistulas 317
• The rectum is pulled through the anal canal, the diseased portion
excised, and healthy tissue sutured to anoderm below the dentate
line. This technique is reported in patients with a rectovaginal fi stula
and infl amed anal canal and distal rectum from Crohn’s disease.
• This technique is useful for someone with a rectovaginal fi stula
and a stricture because both problems will be corrected with
the procedure.
Excision of Fistula with Layered Closure
• Another option is excision of the fi stula tract and layered closure.
• Layered closure may actually be performed through the rectum,
vagina, or perineum.
• The fi stula tract is excised. Vaginal mucosa, rectovaginal septum,
rectal muscle, and rectal mucosa are closed in succession.
• Using layered closure, successful repair is reported in 88–100%
of patients in the small series published.
Perineo-proctotomy
• Perineo-proctotomy is conversion to a fourth-degree laceration
(Fig. 14.2 ).
• This approach begins with the identifi cation of the fi stula and
division of the bridge of skin, subcutaneous tissue, sphincter
muscle, rectal and vaginal walls overlying the fi stula. The tract
is excised and both the rectal and vaginal walls are dissected
away from the muscle. After repair of both the rectal and vaginal
defects, the external sphincter muscle is reapproximated.
• Success rates for fi stula closure range from 87 to 100% in small
series.
Inversion of Fistula
• The vaginal mucosa is mobilized circumferentially around the
fi stula. The tract is excised and a pursestring suture used to
invert the fi stula into the rectum.
• One small series reports success in 8 of 11 patients; a more
recent series reports a 100% success rate in 47 women.
Complex Repairs
• The complex repairs involve the interposition of well-vascularized
tissue between the rectum and the vagina; that tissue may be
muscle, omentum, or healthy bowel.
318 The ASCRS Manual of Colon and Rectal Surgery
Fig. 14.2 . Perineo-proctotomy.
14. Benign Anorectal: Rectovaginal Fistulas 319
Table 14.2 . Results of sphincteroplasty for rectovaginal fi stula.
Author Year No. of patients Success (%)
Russell and Gallagher 1977 9 96
Lowry 1991 29 93
Wise et al. 1991 15 100
Khanduja et al. 1994 11 100
MacRae et al. 1995 7 86
Tsang et al. 1998 35 80
Yee et al. 1999 22 91
Halverson et al. 2001 14 65
Tissue Interposition: Muscle
• The most common tissue interposition technique is a sphincteroplasty utilized when a defect in the external sphincter is
present with the rectovaginal fi stula. In that situation, an
overlapping sphincteroplasty will correct the fi stula and the
incontinence.
• Successful closure of rectovaginal fi stulas with this operation
is reported in 65–100% of patients (Table 14.2 ).
• When the sphincter muscle is intact or the fi stula is above the
sphincter muscles, rectus, bulbocavernous, gracilis, gluteus,
and sartorius muscles have been used to repair rectovaginal
fi stulas.
Tissue Interposition: Bowel
• Healthy bowel may be interposed in one of two ways. An
extended low anterior resection may be done with excision of
the rectum containing the fi stula and an anastomosis below.
The vaginal defect is closed and if possible separated from the
new anastomosis with omentum.
• Parks and associates described a sleeve coloanal technique
when the fi stula is very low.
Choice of Treatment
• For any patient with a rectovaginal fi stula, conservative
management is an option if the symptoms are tolerable.
320 The ASCRS Manual of Colon and Rectal Surgery
Rectovaginal Fistulas Secondary to Obstetric Injury
• Rectovaginal fi stulas may close spontaneously in the early
postpartum period; all others require surgery to close.
• It is important that the surrounding tissue be free of infection and
induration before proceeding with surgery. For most patients,
treatment of infection and time will allow the surrounding tissue to soften.
• An important part of the evaluation of women with rectovaginal
fi stulas caused by obstetric injury is assessment of anal sphincter anatomy and function. In multiple studies, the incidence of
associated sphincter defect is close to 100% in this subset of
patients. Therefore, both closure of the fi stula and continence
should be considered important outcome measures.
• For women with intact sphincters and a rectovaginal fi stula
after childbirth, a simple local repair is recommended.
– In most practices, these women represent only a small
portion of the patients with rectovaginal fi stulas because
the majority will have a concomitant sphincter defect.
• For women with sphincter defects, sphincteroplasty closes the
fi stula and repairs the sphincter defect. A perineo-proctotomy
is also appropriate. The advantage of this technique is the
excellent exposure it provides; the disadvantage is the risk of
incontinence if intact sphincter muscle is divided.
Rectovaginal Fistulas Secondary to
Cryptoglandular Disease
• When rectovaginal fi stulas secondary to cryptoglandular disease
are reported, they represent only a small portion of most series.
• Evaluation must include a search and treatment of associated
local sepsis with the possible use of a seton.
• Endoanal ultrasound should be performed to exclude an occult
sphincter defect. If none is found, an endorectal advancement
fl ap is the most frequently used procedure.
Rectovaginal Fistulas Secondary to Crohn’s Disease
• Given the nature of Crohn’s disease, control of symptoms
becomes the primary goal as opposed to elimination of the fi stula
14. Benign Anorectal: Rectovaginal Fistulas 321
in this subset of patients. In addition, the treatment is in more
fl ux than any other subset of patients.
• Medical management with antibiotics and immunosuppressive
medication is able to control symptoms but rarely closes fi stulas.
• Surgical therapy often required proctectomy because of associated proctitis and was not uniformly successful even in the
absence of infl ammation.
• A randomized, controlled trial found that infl iximab was signifi cantly better than placebo in healing fi stulas in Crohn’s
disease. Subsequent studies have confi rmed a 24–55% healing
rate by assessment of clinical symptoms.
– Although this therapy is promising for perianal fi stulas, it
is not clear that rectovaginal fi stulas respond as well.
• Surgical therapy often requires proctectomy because of associated proctitis. If there is no active proctitis, various advancement fl ap techniques have been reported; while successful
repairs are possible they are not uniformly successful even in
the absence of infl ammation.
• At the present time, the following treatment program seems
reasonable:
– Each patient should be assessed to determine the pres-
ence of associated proctitis and undrained local sepsis.
– Patients with associated proctitis require appropriate
medical or surgical management for that condition. In
either case, any local sepsis should be drained, all tracts
identifi ed, and setons placed if appropriate.
– Until more defi nitive data are available, a trial of infl ixi-
mab should be considered.
– Setons should be removed before the last infusion. If
symptoms resolve or are minimal, then conservative
therapy is appropriate.
– No clear recommendation regarding maintenance infl ixi-
mab or immunosuppressive medication is possible at this
time.
• If a persistent fi stula results in signifi cant symptoms and any associated proctitis resolves, then surgical intervention is appropriate.
• The necessity of diversion is controversial but it is often performed in this subset of patients.
• Whether the use of infl iximab or other new medications will
result in improved outcomes remains to be seen.
322 The ASCRS Manual of Colon and Rectal Surgery
Rectovaginal Fistulas Secondary to Malignancy
• The treatment of these fi stulas is dictated by the type of underlying malignancy.
• For rectal cancer invading the vagina, resection with or without
reconstruction is required. If preoperative adjuvant therapy is
given, diversion before initiation of treatment may be necessary
for the patient’s comfort.
• For squamous cell carcinoma of the anus, a preexisting fi stula
or one that develops during chemoradiation often requires
diversion for symptom control.
• If the treatment eliminates the tumor, muscle interposition may
be considered after resolution of acute radiation effects.
• If tumor persists after chemoradiation, an abdominal perineal
resection is necessary.
Rectovaginal Fistulas Secondary to Radiation Therapy
• The evaluation of patients with fi stulas secondary to radiation must be more intensive than most other patients with rectovaginal fi stulas. Because of their usual age, they are more
likely to have signifi cant medical conditions. In addition, it is
paramount that the fi stula site be biopsied to exclude recurrent
cancer.
• Diversion for a minimum of 6 months is recommended to allow
infl ammation in the surrounding tissue to resolve.
• Decisions about surgical intervention center on the patient’s
overall medical condition, the degree of symptoms caused by
the fi stula and any associated abnormalities, and the risk of
a proposed corrective procedure. Not uncommonly, the combination of those factors makes a colostomy alone the most
reasonable choice. This is particularly appropriate if the patient
is experiencing signifi cant fecal incontinence.
Iatrogenic Rectovaginal Fistulas
• The choice of treatment for an iatrogenic fi stula is based on the
causative operation.
• Once a fi stula occurs, temporary diversion is often necessary to
control pelvic sepsis.
14. Benign Anorectal: Rectovaginal Fistulas 323
• Some fi stulas will close spontaneously although this is less
likely if the patient has received pelvic radiation.
• Repair is determined by the level of the fi stula. High fi stulas
usually require repeat resection with anastomosis or interposition of omentum or muscle. Low fi stulas may be amenable to
rectal or vaginal advancement fl aps. Large fi stulas or one failing initial attempts at repair will require tissue interposition.
Persistent Rectovaginal Fistulas
• Repeat repairs after one attempt seem to have a reasonable success rate. However, several studies report a higher failure rate
after two or more procedures so subsequent options should be
chosen carefully.
• From the data available, it seems that a reasonable approach
to recurrent rectovaginal fi stulas would begin with a planned
waiting period of a minimum of 3 months. In the interval, the
status of the sphincter muscle and surrounding tissue should be
evaluated. Any areas of sepsis must be drained.
• For low fi stulas, the treatment choice depends on the status of
the sphincter and the number of prior repairs.
• If there is a defect in the sphincter muscle, sphincteroplasty is
the appropriate choice.
• The role of diversion is not established but seems to be primarily control of symptoms except perhaps in patients with
Crohn’s disease.
• Recurrent fi stulas involving the middle of the vagina almost
always require tissue interposition.
• High fi stulas require resection or tissue interposition through
an abdominal approach.
15. Pilonidal Disease and Hidradenitis
Suppurativa*
A. Pilonidal Disease
Background and Incidence
• “Pilonidal disease” refers to a subcutaneous infection occurring
in the upper half of the gluteal cleft. It may present as an acute
“pilonidal abscess,” or as an indolent wound, resistant to
spontaneous healing, and causing drainage and discomfort.
• It typically presents in the second decade of life, but also occurs
in teenagers and in patients in their thirties.
• It affl icts men more often than women at a ratio of three or four
to one, and is more common in individuals with more body hair.
• Patients typically present initially with pain, redness, and
swelling in the midline gluteal cleft region overlying the sacrum
and coccyx.
• Many patients will spontaneously drain their abscesses, which
will temporarily relieve the symptoms. This may set up a chronic
cycle of drainage and recrudescence of the abscess before the
patient eventually seeks medical attention. Thus, some patients
may already have a chronic condition at the time of their initial
presentation.
• Patients may also present with a history of having had many
different surgical procedures performed in the past for their
disease. They may have a persistent wound from a midline
* The opinions or assertions contained herein are the private views of the authors and
are not to be construed as offi cial or as refl ecting the views of the Department of the
Army or the Department of Defense.
D.E. Beck et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery, 325
DOI: 10.1007/978-0-387-73440-8_20, © Springer Science + Business Media, LLC 2009
326 The ASCRS Manual of Colon and Rectal Surgery
excision or a failed fl ap procedure. Those patients with
long-standing disease typically have multiple sinuses that usually
extend cephalad from where the midline pits lie.
• The term “pilonidal,” means “hair nest.”
• The term pilonidal “cyst” is a misnomer, because no epithelialized
wall exists in the cavities this disease creates.
• Pilonidal “sinus” or “disease” are the more accurate terms.
Pathogenesis
• Empiric data currently support the theory that pilonidal disease
is an acquired condition. Pilonidal disease has been observed
in the hands of barbers and sheep shearers, implying that shed
hairs may initiate the condition.
• In addition, pilonidal lesions appear to have the pathologic
characteristics of a foreign body reaction, presumably from
burrowed hair and debris.
• Pilonidal disease likely results from problems that attack
epidermis in the gluteal cleft, rather than from a problem in the
deep tissues, or problems with midline skin itself.
• John Bascom believes that the skin in the natal cleft is perfectly
normal, but that conditions that exist there may predispose a
patient to pilonidal disease.
– Bascom theorizes that vacuum forces and negative suction
in the natal cleft draws hair and debris into the midline
pits, which are stretched and ruptured hair follicles, resulting in obstruction. These stretched follicles, he believes,
stretch and eventually rupture into the subcutaneous
tissue, causing the classic pilonidal abscess. The midline
“pits” communicate with chronic abscesses containing
trapped hair and debris via sinus tracts.
– Presently, the ideas of Bascom and others about the patho-
genesis of pilonidal disease are based on empiric evidence.
• No published experiments exist that directly prove or refute the
current theories about how pilonidal disease occurs.
Initial Presentations: Pilonidal Abscess
• The presenting symptoms for many patients include pain,
swelling, and erythema near the top of the natal cleft, with or
without spontaneous drainage.
15. Pilonidal Disease and Hidradenitis Suppurativa 327
• An acute pilonidal abscess is no different from an acute
abscess in any other location on the body. It requires incision
and drainage before considering any other defi nitive therapy.
• A chronic abscess is really an established pilonidal sinus cavity,
which chronically drains and fails to heal because of retained
hair and foreign material.
• A recurrent abscess is an acute abscess, which occurs after
apparent complete healing of pilonidal disease in the past.
• Excision in a patient in the presence of acute infl ammation and
swelling is ill advised. Many times the midline pits will not be
visible until after the infl ammation subsides. Abscesses should
be drained with an incision parallel to the midline and at least
1 cm lateral to it (if possible) to facilitate healing of the wound
(Fig. 15.1 ).
• Packing of such wounds serves no good purpose, is painful,
and potentially interferes with drainage and healing.
• Antibiotics are only necessary in the patient with signifi cant
cellulitis.
Incision
Abscess
At least one cm
Fig. 15.1. Incision placement for acute pilonidal abscess.
Midline
Anus
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