Recto Vaginal Fistula Clinical Trial
Official title:
Transperineal Repair of Primary Obstetric Rectovaginal Fistulas With Fecal Incontinence Using Fistulectomy, Sphincteroplasty and With or Without Bulbocavernosus Muscle Flap:Surgical Pitfalls and Prevention of Recurrence
Introduction: A rectovaginal fistula (RVF) is an epithelium-lined abnormal tract between the
rectum and the vagina and is often a challenging problem for both the patients and to the
surgeons. In literature, there is still debate regarding the best treatment options for
rectovaginal fistulas.
Aim: To assess the results of the treatment of rectovaginal fistulas with incontinence and
impaired anal tonus using fistulectomy, sphincteroplasty with or without bulbocavernosus
muscle (Martius) flap.
Materials and Methods: A total of 22 consecutive patients with simple RVFs were included and
assigned to transperineal repair. The patients were divided into two groups , group1: with
Martius flap; group2: without Martius flap .Postoperatively, patients were followed up for
one year at the outpatient clinic or through telephone interviews with specific questionnaires
to collect information on the status of fecal control, flatus, or fecal leakage from the
vagina.
Introduction:
Rectovaginal fistulas represent an often devastating condition in patients and a challenge for
surgeons because of their irritating and embarrassing symptoms and high failure rate after
repair.Patients with rectovaginal fistulas typically present with complaints of passage of
flatus or feces from the vagina with painful skin excoriation.
(1) The most common etiological cause of rectovaginal fistulas is obstetrical trauma. When
obstructed labor is unrelieved, the presenting fetal part is impacted against the soft
tissues of the pelvis leading to ischemic vascular injury and subsequent tissue necrosis and
fistula formation. Other predisposing factors include forceps delivery, midline episiotomy,
and third or fourth-degree perineal lacerations.( 2).
Evaluation of a patient with rectovaginal fistula includes a detailed history, examination of
the rectum, vagina, and perineal body. The perineal body is often thin or nearly nonexistent
in patients with sphincter injuries secondary to obstetrical trauma. Endoanal ultrasonography
and pelvic Magnetic Resonance Imaging (MRI) to confirm sphincter injury and may provide
valuable information before a planned repair. MR is the modality of choice for disease
staging (sensitivity 91%) (3).
( Sagittal T2 MR imaging shows communication between the rectum tumor and the vagina) The
experience of the surgeon and the previous attempts at repair are also important factors of
the success rate of the operations [4)
There are various operative procedures, such as the advancement flap, sphincteroplasty and
fistulectomy, coloanal anastomosis,and gracilis muscle repair to manage rectovaginal fistulas
[5].
The choice of the operative technique greatly depends on the status of the fistula and the
etiological rationale behind this medical complication [6.].
In this study, we have compared the outcomes of the fistulectomy and sphincteroplasty
procedures with or without concomitant bulbocavernosus flap. All patients were incontinent
and felt to have impaired anal tonus.
Patients and method:
Study design:
This prospective study involved 22 patients diagnosed with simple rectovaginal fistula from
January 2018 to January 2019 at the General surgical department, faculty of medicine Zagazig
University, Egypt. This study was approved by the institutional ethics board of our hospital.
All patients who participated in the study provided informed consent.
rectovaginal examination, endoanal ultrasonography, and pelvic MRI findings were collected to
assess the extension of the fistula. Colonoscopy was performed in selected patients with
severe bowel symptoms such as bloody diarrhea to exclude inflammatory bowel disease.
Decisions regarding operations were made cautiously and involved the whole medical team. All
cases underwent fistulectomy, sphincteroplasty and with or without bulbocavernosus flap
technique.All patients were evaluated for incontinence using Wexner Incontinence Score (WIS)
[7) Method of randomization: simple randomization with a balance.
Patient selection:
Inclusion criteria:
1. Rectovaginal fistula caused by obstetric problems
2. Female >20 years
Exclusion criteria:
1. other causes of rectovaginal fistula as Crohn's disease or malignant fistula
2. complex and recurrent fistula
Three patients did not undergo surgery. One because of patient's choice, one because of
minimal symptoms and one because fistula healed after medical therapy.
Methods:
Patients were given a mechanical bowel preparation the day before surgery and an enema on the
morning of the operation. The patient was placed in the lithotomy position under spinal
anesthesia. Antibiotics in the form of third generation cephalosporin and 500 mg of
Metronidazole were given.
Sub mucosal lidocain 5% in adrenalized saline at a ratio of 1: 100 000 was injected around
the fistula. Surgical excision of the fistula using scalpel was performed. Biopsies of rectal
mucosa and the fistula margin were also obtained for pathological evaluation to exclude an
underlying Crohn's disease or malignancy. A transverse perineal incision was done. Dissection
of the internal sphincter fibers away from the external sphincter fibers was performed,
allowing a tension free rectal closure at the fistulous site (Dissection of internal
sphincter fi bers from external sphincter fi ber s.). Closure of the fistulous opening at the
rectal side was done using Vicryl 3/0 sutures. This was followed by suturing of the
rectovaginal septum to the internal sphincteric fibers using Vicryl 3/0 sutures (Suturing of
internal sphincter fi bers to the rectovaginal septu m.). The bulbocavernosus muscle flap was
harvested from the left side in all patients at its anterior part, preserving the
posteroexternal vascular pedicle (Posterior muscle repair), through the same incision, and
sutured across the rectum to its counterpart on the other side (Vaginal advancement fl a p.&
Fig. 1 a The fistulae are indicated by the two forceps passing through them; b The finger
demonstrates the large recto-vaginal orifice) using 2/0 Vicryl sutures. The vaginal flap was
advanced at the fistula site and sutured to the perineal skin using Vicryl 3/0 sutures
(Preparation of the bulbocavernosus fl a p.& Fig. 3 a, b After a right labial incision, the
bulbocavernous muscle and the surrounding fibroadipose tissue were carefully mobilized,
avoiding possible damage of the postero-external vascular pedicle& Fig. 4 A subcutaneous
tunnel connecting the two incisions was created after transecting superior to the
bulbocavernous muscle& Fig. 5 The final set-up with the interrupted absorbable sutures over
the vaginal closure after sectioning of the longitudinal vaginal septum. The bulbocavernous
muscle is clearly visible after the lay open of the perineovaginal tract).
No suction drain was used. No covering stoma was done. Postoperatively, Soft, stool was
provided in the postoperative period at least for two weeks with the help of clear liquid
diet, plenty fluid intake, and the use of stool softeners. Oral broad-spectrum antibiotic
therapy was given for 3-5 days postoperatively. Sexual activity or any physical activities
more strenuous than a slow walk were avoided by the patients for three weeks after the
surgery. Follow up period up to one year.
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