FÍSTULAS RECTO – VAGINALES
Dra. Angelita Habr- Gama
Rectovaginal fistulas (RVFs) account for approximately 5 percent of all
anorectal fistulas. Many of these fistulas arise in the anal canal and should be
more correctly described as anovaginal fistulas. They can cause physical
morbidity and significant psychological problem leading to social and sexual
isolation of the patient.
Rectovaginal fistulas may be congenital and acquired. Congenital RVFs are
usually associated to imperforate anal abnormalities. Acquired RVFs may be of
traumatic origin (operative, obstetric, violence, foreign bodies, etc.) consequent
to infection, inflammatory bowel disease (IBD), radiation, carcinoma, sexually
transmitted or hematological disease (Table 1).
The incidence of each etiology depends on the referral pattern of the authors of
the different studies. Obstetric injury due to vaginal delivery is a common cause
of traumatic RVF, however, the occurrence of this complication is rare.
Venkatesh et al. reported that of 20,500 women undergoing vaginal deliveries,
1,040 had episiotomies with third or fourth degree tears; only 25 (0.1%) required
repair of a RVF. Development of such fistulas are more commonly result of
dehiscence of the repaired laceration or due to an unrecognized injury.
Postoperative RVFs may be secondary to surgical procedures involving the
posterior vaginal wall, anus and rectum. With the increased use of surgical
staplers and a growing number of low colorectal, coloanal, ileorectal or ileoanal
anastomosis being performed, RFVs are becoming more frequent. Among
gynecological operations, difficult hysterectomy is the most common cause of
fistulas, particularly when indicated for treatment of endometriosis.
Infection of the anal glands or Bartholin’s abscess may produce low RVF.
Crohn’s disease (CD) is a common cause of RVF which may preceed the
appearance of intestinal symptoms or may be associated to an active or severe
phase of the disease. Ulcerative colitis, although less frequently than CD, may
also cause RVF. Diverticular disease of the colon associated to pelvic abscess
particularly in a hysterectomized woman may cause RVF.
Radiation used to treat gynecological or anorectal tumors may also be a cause;
higher doses of radiation and previous hysterectomy facilitate its occurrence.
The fistula may appear after radiotherapy in an interval from one to 12 months
or even after several years. The process begins as a proctitis, followed by
ulceration of the anterior vaginal wall, generally located at 4 to 5 cm above the
dentate line. One third to one-half of such ulcers will progress to a RVF.
Advanced carcinoma of the anus, rectum, vagina or uterus and other rare
causes including endometriosis, leukemia, aplastic anemia, agranulocytosis,
systemic lupus erythematosus, tuberculosis and lymphogranuloma venereum
may also originate RVF.
INVESTIGATION
A small RVF may be entirely asymptomatic. A slight leakage of gas and fecal
seepage may be noted in the vaginal discharge. When the fistula is large, the
predominant symptom is the uncontrolled elimination of gas through the vagina
and associated fecal odor in the vaginal secretion. When the fistula is even
larger, the entire rectal content may be eliminated through the vagina.
Tenesmus, recurrent vaginitis, and anal incontinence are common associated
complaints.
Careful questioning regarding stool habits and anal continence, previous bowel
habit, consistency of feces, number of pregnancies, vaginal deliveries,
associated episiotomies, previous operations help to clarify the etiology of the
fistula.
Physical examination begins with careful visual inspection of the perineum, anal
verge and introitus. Digital rectal and vaginal examination is next performed to
detect the presence of fistula, to assess the anal sphincter tone, strenght of
sphincter contraction and to assess the rectovagina septum and fistula tract. If
the fistula tract is not identified on clinical examination, a pack may be placed in
the vagina followed by transanally injection of methylene blue or of hydrogen
peroxidase to help the diagnosis.
For high RVF, contrast bowel X-ray and colonoscopic examination with biopsy
are helpful in ruling out associated pathologies or to determine the presence,
activity and distribution of IBD, radiation injury or carcinoma.
When anal sphincter dysfunction is suspected, assessment of anal function is
indicated before the operation. Investigation may include anal sonografy,
anorectal manometry and electromyography for assessment of the resting.
CLASSIFICATION
Classification of RVF is important for selection of the appropriate treatment.
There are many classifications and the following landmarks are generally taken
into account: location, size, etiology. According to location, RVFs may be
classified as Low when the rectal opening is at or just above the dentate line
and the vaginal opening is just inside the vaginal fourchette. This type of fistula
is more precisely an anovaginal fistula, but is generally considered a RVF. High
RVF´s when the vaginal opening is behind or near the cervix. Mid RVFs are
those located between low and high. Fistulas less than 2.5 cm in diameter are
considerede Small and those greater than this are considered Large.
Combining these landmarks with the etiology of the fistula, Rothenberger et al.
classified RVFs as Simple or Complex; simple if they are small, low and
secondary to trauma or infection; complex, if they are high, large and caused by
IBD, diverticulitis, irradiation, carcinoma or are the result of multiple failed
repairs regardless the location, size and etiology. This is an useful classification
to facilitate selection of appropriate treatment and better interpretation of the
results reported by different authors.
TREATMENT
Few RVFs may heal spontaneously. Small ones of traumatic origin are more
prone to heal than those caused by IBD, radiation or infectious process. Non
surgical option are indicated for malignant fistula or recurrent ones.
There are many surgical techiques and each one must be carefully selected
according to the patient’s performance, characteristics of the fistula and
sphincter function. Operation may be very simple, consisting only in a local
repair or may require complex procedures. It may be performed as a single
procedure or it may demand staged operations.
Patients with local sepsis require adequate drainage. Chronic disease must be
treated with conservative measures before surgery. Staged management is also
required for patients with associated cryptoglandular abscess. Careful drainage
must be done to avoid sphincter injury.
RVF caused by cancer, radiation, or previous major pelvic operations must be
treated by more complex procedures which may be performed by different
approaches:
abdominal,
abdominotransanal,
abdominoperineal,
abdominotransacral. Some complex fistulas also require for its cure
interposition of other tissues (Table 2).
As important as the choice of the technique is the adherence to some surgical
principles: timing for the surgery, precise definition of the fistula, adequate
mobilization of tissue; excision of the entire fistula tract, meticulous closure of
the rectal orifice, interposition of healthy tissue between rectum and vagina,
absence of tension along suture lines, choice of sutures, careful hemostasia
and the addition of sphincter or levatorplasty. Timing for operation must be
considered when resolution of surrounding inflammation and infection should be
expected which usually occures within three months or even more for some
RVFs associated to IBD or to irradiation.
Preoperative preparation for surgery includes a full mechanical bowel
preparation and antibiotics. A diverting stoma is indicated only in selected
patients, particularly those with radiation proctitis, or some with associated CD.
When malignancy is present, treatment is directioned primarily to this condition.
Local repair
Local repair is suitable for all simple RVFs, for some complex RVFs related to
IBD and for recurrent fistulas of traumatic etiology. It may be performed by
transanal, transvaginal, transperineal or transacral approach. All techniques
may produce good results if the procedure is well indicated and correctly
performed. For simple fistulas most colorectal surgeons prefer the transanal
while gynecologists prefer the transvaginal approach.
Excision of the fistula and transanal or transvaginal closure is successful in 72
to 100% of the patients. Transanal repair may be performed by the techniques
of sliding advancement flap, sleeve advancement flap or by layered closure.
Sliding advancement flap was firs described by Noble in 1902. The operation
consisted of splitting the rectovaginal septum, dissecting the lower end of the
rectum from the vagina and drawing the anterior wall down through and external
to the anus. Numerous modifications of this technique were reported (Laird et
al.; Belt and Belt). This sliding flap advancement technique has the advantage
of being a simple and rapid procedure, and easy to be learned; there is no
incision in the skin and therefore it is associated with a fast recovery. It provides
a better exposing of the high pressure side of the fistula, avoids anal and
perineal deformity and sphincter injury.
As result of data obtained in Minnesota, Rothenberger et al. suggest the use of
isolated transanal advancement flap as first procedure only for women with
intact sphincter muscle and without or with only one prior repair. For patients
with an anterior gap detected at the sphincter or with previous two failed repairs,
they recommend a transperineal overlapping sphincteroplasty to correct both
the fistula and sphincter disruption.
Sucess rate with this technique vary from 43 to 100%. We performed this type
of sliding advancement flap technique in 18 patients. Recurrences occurred in
two, one with obstetric fistula and the other with CD. The first underwent a
perineoproctotomy with success and the other was submitted to a total
proctocolectomy.
Sleeve advancement flap is also a valuable operation for treatment of RVFs
when previous attempts of endorectal flap advancement failed. The operation
consists in a circumferencial dissection of the rectal mucosa starting above the
dentate line and below the fistula orifice. A sleeve of mucosa, submucosa and
circular muscle is dissected proximally until sufficient length is achieved to allow
advancement of the entire ring after the excision of the diseased distal portion.
We used this technique in 3 patients, a bad result was observed in one patient
with CD.
Transvaginal approach
Majority of RVFs in the past were repaired transvaginally either by local sutures
or with approxination of the muscle. The potential limitation is that adequate
mobilization of tissue necessary for a successful repair may be difficult and
vaginal constriction may result. High rates of recurrence and anal incontinence
were also described. More recently, Bauer et al. used this approach associating
an endovaginal flap and levatorplasty for treatment of RVFs associated with CD
in 13 patients. They consider as advantages of this technique the use of non
diseased, pliable and intact vaginal tissue for the flap, with minimal manipulation
of the diseased rectum and the interposition of the levator ani muscles between
the rectal and vaginal mucosal wall. This would provide support to the septum
and by separating the rectal and vaginal suture lines, it would be possible to
minimize recurrence. In their series they had recurrence in only one patient
(7.7%) with this method, a result which is considered good when compared to
rates of failures up to 40% obtained in series with endorectal flap for RVFs in
CD.
Transperineal repair
Low RVF were commonly treated by simple fistolotomy, drainage and laying
open the entire track. This procedure is associated to a high rate of failure and
partial or total anal incontinence; its indication has been almost abandoned
limited to minor low RVF caused by infection process. We had the opportunity
to use this technique in only one case of low cryptoglandular RVF.
Fistulotomy and perineoproctotomy is the technique commonly used by
gynecologists. It may be a good indication for large and low fistula, with
incontinence and damage of sphincter muscle. In this technique, the perineal
bridge between the vaginal fourchette and the fistula orifice is cut, converting
the fistula into a fourth degree perineal laceration. The fistula track is excised
and each layer — vaginal wall, sphincter muscle and rectal mucosa — are
identified, mobilized and repaired and the perineal body is reconstructed. An
intact anal sphincter may be the main disadvantage of this procedure. As it has
to be cut, this may result in improper healing and scaring with consequent
function impairment. Success rates reported range from 87.5 to 100%. We
performed this technique in 4 patients of our series without failures. One patient
developed anal incontinence.
Lawson Tait in 1886, described the transverse transperineal repair. This
technique was very popular at the beginning of the century with success, but
has been almost forgotten for many years. More recently, interest was renewed
and it has been the technique of our choice for patients with low, large RVF,
with compromise of the perineal body and associated fecal incontinence. We
used in 9 patients, with success in 7. A diverting stoma was not necessary. In
two patients, a minor degree of wound infection was observed but not
compromising the final results (Table 3).
Abdominal repair
Local repair techniques are unsuitable for treatment of high RVF of any cause
and also for the low ones whenever the rectum is severely compromised.
Abdominal procedures allow excision of all diseased tissue with sphincter
preserving being possible in the majority of cases. The technique may consists
of direct repair of both rectal and vaginal defects after mobilization of the
rectovaginal septum or it may be associated to interposition of a pedicled graft
such as omentum between the rectum and vagina.
Postoperative RVFs are usually treated by low anterior resection while large
congenital or radiation RVFs are often treated by coloanal anastomosis or even
more complex procedures.
Total proctocolectomy is the operation of choice for RVFs due to CD resistent to
medical approach. Abdominoperineal excision with vaginectomy is necessary in
patients with carcinomas.
Several other techniques have been suggested for management of large RVFs.
They include primary closure and omentopexy to reinforce suture line,
bulbocavernous fatty tissue graft (Martiu’s operation), seromuscular intestinal
patch graft (Bricker-Johnston sigmoid colon graft) and layered closure
associated to Sartorius and gracilis muscle interposition. However, most of
these techniques are too cumbersome to perform, requiring large mobilization
of tissues or resections or include anastomosis of healthy and diseased tissues.
Results are frequently poor and permanent colostomy is not an infrequent
outcome. To avoid these drawbacks we prefer to use in the most difficult cases
the technique proposed by Simonsen et al. This technique is a combination of
delayed coloanal anastomosis Habr-Gama and Duhamel procedure with the
Haddad’s modification, as it was largely used in Brazil for treatment of both
acquired megacolon and rectal cancer. This technique eliminates the need of
wide rectovaginal disection, avoids difficult mobilization of diseased and
hardened tissue, and prevents the use of abdominal diverting colostomy.
Moreover, it provides a strong, healthy, and well-vascularized natural patch for
the posterior vaginal wall (i.e. neovagina). A potential disadvantage of this
technique, when used for treatment of radiation RVF is the maintenance of the
injured rectum in situ with the consequent risk of malignant transformation. For
this reason, patients treated by this method need to be monitored constantly by
conventional gynecologic and proctologic propedeutic methods, aided by
imaging techniques. We used this technique in 19 patients. There were no
operative mortality and low morbidity. No recurrence or malignancy in the
operated area were seen during up to 20 years of follow-up (Table 4).
Table 1
RECTOVAGINAL FISTULAS – ETIOLOGY
CAUSE
Congenital defect
Traumatic
NUMBER
7
41
obstetric
postoperative
trauma RT
violence
19
15
6
1
Inflammatory bowel disease
19
Crohn’s disease 14
Ulcerative colitis 5
Diverticulitis
Radiation
Infection
Sexually transmitted disease
Carcinoma
TOTAL
4
13
5
1
11
101
Table 2
RECTOVAGINAL FISTULAS
SURGICAL OPTIONS
LOCAL REPAIR
Transanal
advancement flap
sleeve advancement
layered closure
Vaginal approach
inversion of fistula
layered closure
Perineal approach
fistulotomy
perineoproctomy
transverse repair
Tissue transposition
Omentum – gracilis – Sartorius
ABDOMINAL
ABDOMINOTRANSANAL
ABDOMINOTRANSPERINEAL
Local closure
Low anterior resection
Coloanal anastomosis
Abdominoperineal resection
Onlay patch anastomosis
Abdominoretroendoanal
(Simonsen technique)
Colostomy
/
Gluteus maximus - Bulbocavernous
Table 3
LOCAL REPAIR FOR RECTOVAGINAL FISTULA
TYPE OF APPROACH
Transanal approach
NUMBER
23
Sliding advancement flap
Sleeve advancement
Layered closure
18
3
2
Vaginal approach
3
Inversion of fistula
Layered closure
0
3
Perineal Approach
14
Fistulotomy
Perineoproctotomy
Transverse repair
TOTAL
1
4
9
40
Table 4
RECTOVAGINAL FISTULAS
TRANSABDOMINAL PROCEDURES
TYPE OF PROCEDURE
Local closure
Low anterior resection
Abdominal endorectal coloanal anastomosis
Abdominoperineal excision of the rectum
Total proctocolectomy
Simonsen technique
Colostomy
TOTAL
NUMBER
2
9
10
5
7
19
10
59
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