Treatment of Complex Rectovaginal Fistulas

Complex fistulas are high, large, or recurrent and are often secondary to cancer, IBD, or radiation. Consequently, the condition of surrounding tissues (involved with cancer, IBD, scar, or irradiation) may preclude repair with local procedure such as the advancement flap.3 These types of fistulas occur more often in older patients with numerous comorbid conditions, and therefore require more careful preoperative evaluation. In addition,the fistulas themselves require more intense evaluation by biopsy to ensure no recurrent cancer (in the case of irradiation) and to exclude the presence of IBD (in the case of recurrent fistulas). Radiologic and endoscopic assessment should be used judiciously to determine the extent of disease and associated involvement of adjacent organs. The presence of incontinence should be determined and addressed. Repairs for complex rectovaginal fistulas can be divided into two groups: perineal approaches with muscle transposition or abdominal procedures with bowel resection or fecal diversion. Fecal diversion is often used before repair of the fistula from radiation injury.

Repair of rectovaginal fistulas using tissue interposition techniques serves to introduce well-vascularized tissue to the area and to separate the two suture lines. Grafts of omentum, gracilis, sartorius, gluteus maximus, rectus, and bulbocavernosus muscle have been described. The bulbocavernosus muscle transposition is most frequently reported (Figure 13-2.5). The procedure is performed with the patient in the lithotomy position and a transperineal incision is made between the anus and vagina. The rectum is dissected from the vaginal wall, and both defects are sutured closed. A vertical incision is made over one of the labia majora, and skin flaps are created. The bulbocavernosus muscle and associated fat pad are mobilized and tunneled through a subcutaneous space to lie between the two closures. The vascular supply to this flap is the perineal branch of the pudendal artery.

The gracilis transposition is advocated at our institution because of the larger size, length, and bulk of this muscle and the ease of its mobilization (Figure 13-2.6). After undergoing mechanical and antibiotic bowel preparation, the patient is placed in the lithotomy position under general anesthesia. A transperineal incision is made, the walls of the rectum and vagina are separated, and the fistulous tract is divided [Figure 13-2.6(a)]. The fistulous openings in the rectal and vaginal walls are sutured closed with absorbable sutures. In the proximal leg, a small horizontal incision is made just below the edge of the palpable adductor muscles. The gracilis is identified and circumfer-

Figure 13-2.5. Bulbocavenosus muscle transposition. (Reprinted from Beck DE,Wexner SD, eds. Fundamentals of Anorectal Surgery. 2nd ed., p 178, Copyright 1996, with permission from Elsevier.)

entially dissected free, taking care to preserve the neu-rovascular bundle located in the proximal portion of the muscle. A second incision is used in the distal aspect of the leg to complete the circumferential dissection [Figure 13-2.6(b)]. The muscle is divided just proximal to its insertion at the knee and mobilized through a subcutaneous tunnel to the perineal incision. It is sutured into place on the rectal wall to prevent retraction after ensuring proper placement between the two fistulous closures [Figure 13-2.6(c)]. The perineal incision is closed from lateral to medial on each side leaving the central portion open for drainage. A closed external drainage system is left in the space previously occupied by the gracilis muscle and brought out through a separate stab wound. The leg wounds are then closed in layers. Adduction straps are placed around the patient's legs postoperatively to prevent any abduction and subsequent retraction of the flap. The patient is confined to bed rest with subcutaneous heparin and a urinary catheter for 3 days, after which the patient is allowed to ambulate and is discharged home.

The abdominal approach for the treatment of rectovagi-nal fistulas involves either resection of diseased bowel or associated organs, or fecal diversion. Fecal diversion is almost always used for radiation fistulas but may be used during repair of recurrent fistulas.

Figure 13-2.6. a,Through a perineal incision,the plane between the rectum and vagina is dissected to reveal both sides of the fistulous tract.b,The gracilis is mobilized through two incisions in the medial aspect of the leg.c,The gracilis is placed in the plane between the rectum and vagina separating the two ends of the fistula and reconstructing the perineal body.

Figure 13-2.6. a,Through a perineal incision,the plane between the rectum and vagina is dissected to reveal both sides of the fistulous tract.b,The gracilis is mobilized through two incisions in the medial aspect of the leg.c,The gracilis is placed in the plane between the rectum and vagina separating the two ends of the fistula and reconstructing the perineal body.

Parks and associates8 devised the sleeve (coloanal) anastomosis to treat postirradiation rectovaginal fistulas. The procedure is performed in stages with the first stage involving fecal diversion via a colostomy or loop ileostomy. This stage is followed by a waiting period of several months to allow resolution of inflammation of the bowel. The rectum is mobilized and divided at the point of the rectovaginal fistula. Through a perineal approach, an anorectal muco-sectomy is performed and the healthy bowel is threaded through the muscular sleeve covering the fistula. A hand-sewn or double-stapled anastomosis is then performed.

Bricker and Johnston9 devised an onlay patch for the treatment of radiation-induced fistulas. The rectum is mobilized and the fistula is exposed. The rectosigmoid is transected, with the proximal bowel made into an end colostomy. The distal line of transection is folded onto itself such that the open end may be anastomosed to the debrided edges of the fistula opening in the rectum. After healing is confirmed radiologically, the colostomy is taken down and the proximal sigmoid is anastomosed end-toside to the loop of rectosigmoid (Figure 13-2.7). This tech-

Onlay Patch Cardiac
Figure 13-2.7. Bricker and Johnston's onlay patch for the treatment of radiation-induced fistulas. (Reprinted from Beck DE,Wexner SD,eds.Fundamentals of Anorectal Surgery. 2nd ed., p 178, Copyright 1996, with permission from Elsevier.)

nique is much easier to perform because mobilization of the rectum in an irradiated pelvis is not undertaken. However, irradiated bowel is left in place, with a potential for bleeding, pain, and malignant degeneration.

At our institution, the procedure of choice for rectovaginal fistulas secondary to pelvic irradiation is a proctectomy with colonic J-pouch and double-stapled coloanal anastomosis with temporary diverting loop ileostomy. The rectum is mobilized circumferentially down to the level of the levators and resected. A 6-cm stapled J-pouch is created with the descending colon. A double-stapled anastomosis is performed involving the circular stapler inserted transanally to the colonic J-pouch. A diverting ileostomy is created until the anastomosis is healed and reversed approximately 6 weeks later.

The choice of operative repair for complex rectovaginal fistulas is primarily dependent on the etiology. High fistulas secondary to hysterectomy, diverticulitis, or previous surgery are amenable to proctectomy with anastomosis. Low, recurrent fistulas are most appropriately treated with the gracilis transposition or Martius bulbocavernosus graft. If the fistula is associated with cancer, resection appropriate for that specific cancer is undertaken. Abdominoperineal resection or pelvic exenteration may be needed for extensive disease, whereas diversion via a colostomy may be needed for palliation in unresectable disease. If the fistula is secondary to radiation, highly symptomatic patients that are otherwise healthy are candidates for repair once recurrent neoplasm has been excluded by multiple biopsies. Temporary diversion is usually undertaken in association with repair that may be accomplished with muscle transposition if low, and with low anterior resection with anastomosis if high. At Cleveland Clinic Florida, the preference is proctectomy with colonic J-pouch with double-stapled coloanal anastomosis and temporary loop ileostomy. An alternative is the Bricker onlay patch anastomosis, although this is not performed at our institution. Finally, if the complex fistula is secondary to IBD, assessment must be made of the type of IBD and the presence of proctitis. Medical management rarely results in closure. Proximal diversion may palliate symptoms but rarely results in closure. If proctitis is present, success is most likely with proctectomy. If no active proctitis is present, endorectal advancement flap may be attempted.

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