Annals of Coloproctology

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Original Article

Benign proctology,Surgical technique

Endorectal Advancement Flap With Muscular Plication in Anovaginal and Anterior Perineal Fistulas: Axel Egal, Isabelle Etienney, Patrick Atienza; Ann Coloproctol. 2021;37(3):141-145. Published online May 15, 2020; DOI: https://doi.org/10.3393/ac.2020.04.10.1

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Purpose
Endorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas.
Methods
This retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms.
Results
Thirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%).
Conclusion
This study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.

Citations

Citations to this article as recorded by

Failure rates and complications of four sphincter-sparing techniques for the treatment of fistula-in-ano: a systematic review and network meta-analysis
G. Fuschillo, F. Pata, M. D’Ambrosio, L. Selvaggi, M. Pescatori, F. Selvaggi, G. Pellino
Techniques in Coloproctology.2025;[Epub] CrossRef
Mesenchymal Stem Cells for the Treatment of Complex Anovaginal and Rectovaginal Fistulas in Crohn's Disease: A Systematic Review
Kleuber Arias Meireles Martins, Isabela Coutinho Faria, Leonardo Januário Campos Cardoso, Pedro Henrique Gibram Gontijo, Ana Júlia da Silva Oliveira Bittarães, Mariana Menezes Corcinio, Bárbara Nogueira Braga, Mariana Lisboa de Jesus
Journal of Coloproctology.2025; 45(02): e1. CrossRef
Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas
Pankaj Garg, Laxmikant Ladukar, Vipul Yagnik, Kaushik Bhattacharya, Gurleen Kaur
Clinical and Experimental Gastroenterology.2024; Volume 17: 97. CrossRef
Initial Clinical Outcomes Using Umbilical Cord–Derived Tissue Grafts to Repair Anovaginal Fistula
Gala M. Godoy-Brewer, Oluwafemi P. Owodunni, Alyssa M. Parian, Leonardo C. Duraes, Florin M. Selaru, Susan L. Gearhart
Diseases of the Colon & Rectum.2023; 66(2): 299. CrossRef
Modern opportunities for treatment of patients with rectovaginal fistulas: literature review
P. N. Myshentsev, S. E. Katorkin, A. I. Kuzmina
Meditsinskiy sovet = Medical Council.2023; (13): 184. CrossRef
Is It a Refractory Disease?- Fecal Incontinence; beyond Medication
Chungyeop Lee, Jong Lyul Lee
The Ewha Medical Journal.2022;[Epub] CrossRef
A case report: Trans-Anal mucosal trapezoid flap for repair of Ano-vaginal fistula
Ratna Chopra, Yadav Pramod, Garg Ankit, Pandey Shruti
Indian Journal of Colo-Rectal Surgery.2020; 3(3): 71. CrossRef

Case Report

Benign proctology

Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition: Saket Kumar, Noushif Medappil, Sunil Kumar Singh, Abhijit Chandra; Ann Coloproctol. 2020;36(1):58-61. Published online February 29, 2020; DOI: https://doi.org/10.3393/ac.2018.08.21

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1 Web of Science
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Abstract PDF

Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient’s neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark’s incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.

Citations

Citations to this article as recorded by

Is It a Refractory Disease?- Fecal Incontinence; beyond Medication
Chungyeop Lee, Jong Lyul Lee
The Ewha Medical Journal.2022;[Epub] CrossRef

Original Article

Clinical Outcome of a Rectovaginal Fistula in Crohn's Disease.: Chung, Choon Sik , Lee, Dong Keun , George, Bruce D , Mortensen, Neil J; J Korean Soc Coloproctol. 2007;23(1):10-15.; DOI: https://doi.org/10.3393/jksc.2007.23.1.10

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3 Citations

Abstract PDF

PURPOSE
The aim of this study is to analyze the outcome of a variety of treatments, including local surgical treatments, diverting stoma, and combined medical therapy, for patients with a rectovaginal fistula complicating Crohn's disease.
METHODS
Between 1994 and 2003, twenty-one patients with a rectovaginal fistula complicating Crohn's disease from a prospectively compiled 422-patient Crohn's disease database were reviewed.
RESULTS
All three patients treated by seton and fibrin glue recurred despite having relatively long tracts. Of six patients with infliximab treatment combined with a seton procedure, five patients had an improvement of their symptoms, but were not cured. Of eight patients with a transanal or endovaginal advancement flap techniques, three had successful closure, three eventually required a proctectomy, and two had a recurrent fistula without symptoms. Four (2 without any local treatments, and 2 with seton placement) of 16 patients who had a diverting stoma during treatment had successful closure. All proctectomy patients (n=8) had rectal involvement of Crohn's disease. Two patients who underwent a proctectomy with a presumptive diagnosis of ulcerative colitis and indeterminate colitis turned out to have Crohn's disease. Overall, except for the proctectomy patients, seven patients (54%) had successful closure, but six (four without symptoms, and two with symptoms) following a wide spectrum of treatments had recurrence after a mean follow-up of 44 months.
CONCLUSIONS
Combining different treatments for a rectovaginal fistula in Crohn's disease can be successful in a reasonable number of cases. The presence of uncontrolled perianal sepsis and/or complicated anorectal problems is likely to lead to a proctectomy.

Citations

Citations to this article as recorded by

Guidelines for the Management of Crohn's Disease
Byong Duk Ye, Suk-Kyun Yang, Sung Jae Shin, Kang Moon Lee, Byung Ik Jang, Jae Hee Cheon, Chang Hwan Choi, Young-Ho Kim, Heeyoung Lee
Intestinal Research.2012; 10(1): 26. CrossRef
Guidelines for the Management of Crohn's Disease
Byong Duk Ye, Suk-Kyun Yang, Sung Jae Shin, Kang Moon Lee, Byung Ik Jang, Jae Hee Cheon, Chang Hwan Choi, Young-Ho Kim, Heeyoung Lee
The Korean Journal of Gastroenterology.2012; 59(2): 141. CrossRef
Long-term results in the treatment of fistula-in-ano with fibrin glue: a prospective study
Göktürk Maralcan, İlyas Başkonuş, Avni Gökalp, Ersin Borazan, Ahmet Balk
Journal of the Korean Surgical Society.2011; 81(3): 169. CrossRef

Case Report

A Case Report of Rectal Herniation through Rectovaginal Fistula Associated with Uterine Prolapse.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2003;19(1):45-47.

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Abstract PDF: A rectovaginal fistula, associated with a uterine prolapse, is a very rare entity. The case presented here is that of an elderly woman with a uterine prolapse, associated with an anterior rectal wall herniation through a rectovaginal fistula just above the anorectal ring. It was thought the uterine prolapse had caused the weakness, and long diastasis, of the posterior vaginal wall and the rectovaginal fistula, and then the anterior rectal wall became herniated, with eversion through the rectovaginal fistula. A total abdominal hysterectomy, with bilateral salpingo-oophorectomy, was performed. The rectum was mobilized just beyond the level of the rectovaginal fistula, and resected at that point. Then, from a perineal approach, a coloanal anastomosis was performed using the Parks' sleeve anastomosis technique. After the repair of the long diastasis of the posterior vaginal wall, with inclusion of the fistula opening, a portion of the omentum was interposed between the posterior vaginal wall and the coloanal anastomosis site.

Original Articles

Clinical Results of Coloanal Anastomosis in Radiation-induced Rectovaginal Fistula.: Lee, Il Kyun , Hah, Hyun Su , Sohn, Seung Kook , Lee, Kang Young , Kim, Nam Kyu; J Korean Soc Coloproctol. 2002;18(5):300-304.

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Abstract PDF: PURPOSE
Generally speaking, permanent colostomy has been frequently used as a treatment for radiation-induced rectovaginal fistula. In order to administer an operation accurately, at least two-staged operations have been performed. If anastomosis were to be performed between normal, healthy tissues after removal of irradiation-damaged tissues definite operation could be performed in one stage. We reviewed clinical records to evaluate postoperative recurrence and anal functions in patients who underwent coloanal anastomosis without diverting colostomy as one step due to radiation-induced rectovaginal fistula.
METHOD
From Sep. 1994 to Jun. 2000 we did a retrospective study with clinical data of 8 patients who underwent operations due to radiation-induced rectovaginal fistula in Yongdong Severance Hospital.
RESULTS
The mean age was 49 years (range 31-61). All patients concurrently received irradiation and induction chemotherapy due to primary, gynecologic malignancies. The total dosage of exposure to radiation was 8,400 cGy in 6 of 8 cases and 8,940 cGy in the remaining 2 cases. TAH with BSO had been undergone before concurrent chemoradiation in 2 cases. The median duration from diagnosis to operation was 29 months (range 16-131) in cases without previous colostomy (n=7) and 7 months in cases with colostom y (n=1). Before the operation, previous surgery had been undergone in 2 cases due to rectovaginal fistula. No recurrences were noted for gynecologic malignancies. The mean distance of fistula opening from anal verge was 3.9 cm (range 2.0-7.0). For 7 out of 8 cases, patients underwent LAR with handsewn coloanal anstomosis and the remaining patient underwent anterior resection. No diverting colostomy was performed for all cases. During the median follow-up period of 25 months (range 7-71), two patients developed anal stenosis. One patient experienced postoperative recurrence for the follow-up period. In terms of sphincter function (n=6) (f/u period>12 months), there were 1 urgency, 1 gas incontinence and 1 night staining.
CONCLUSIONS
Although this study is a small scale research in terms of the number of subjects involved, one-staged, handsewn coloanal anastomosis after LAR without colostomy may be proved to be helpful for the patients with radiation-induced rectovaginal fistula. If case selection performed properly, unnecessary operation can be avoided and psychologic resistance can be reduced by this procedure.

Repair of Rectovaginal Fistulas.: Park, Weon Kap , Hwang, Do Yeon , Kim, Khun Uk; J Korean Soc Coloproctol. 1999;15(1):65-71.

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Abstract PDF: Thirteen women with rectovaginal fistulas unrelated to inflammatory bowel disease or previous radiotherapy were operated on during Jan. 1993 - Jul. 1997 at Song-Do Colorectal Hospital. The mean age was 36.9 (range, 25~56) years. The mean follow-up after operation was 33 (range, 8~62) months. The etiology of the fistula in the majority of patients was obstetric injury and operative trauma (10/13). Seven patients were referred after attempts at repair elsewhere. Eleven patients were managed with a mucosal flap advancement and a 3-layered repair of the rectovaginal septum: 4 without and 7 with a perineal body reconstruction or sphincter repair. Two patients were managed with a mucosal flap advancement only without a repair of rectovaginal septum. In all cases, a concomitant colostomy was not performed. Postoperative complications were noticed in 3 of the patients managed by a mucosal flap advancement and 3-layered repair of the rectovaginal septum with perineal body reconstruction or sphincter repair and all were perineal wound infections. All of these infections were cured, without recurrence, by simple rubber seton drainage. Recurrence occurred in one case managed by a mucosal flap advancement only. Three patients with liquid incontinence became continent after a sphincter reconstruction. We conclude that most rectovaginal fistulas unrelated to inflammatory bowel disease or previous radiotherapy can be managed with a mucosal flap advancement and 3-layered reconstruction of the rectovaginal septum. If any signs or symptoms of sphincter injury are noticed preoperatively while taking the patient's history or during manometry and endorectal ultrasonography, a perineal body reconstruction or sphincter repair should be performed.

Clinical Analysis of 62 patients with Rectovaginal Fistula.: kang, Seung Hyun , Kim, Nam Kyu , Lim, Dae Jin , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 1998;14(1):109-114.

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Abstract PDF: Rectovagianl fistula(RVF) is a congenital or acquired communication between the two epithelial-lined surface of the rectum and the vagina. We present our experience with 62 patients with RVF. There were various etiologies and repair methods of rectovaginal fistula. The purpose of this study was to retospectively review the clinical course of the patients we treated and to evaluate the efficacy of various treatment options. The mean age was 40.5 yr, The type of RVF was classified to one of two(simple and complex), according to their location, size and etiology. RVF was developed most commonly after radiotherapy due to cervical cancer(n=17), then after pelvic surgery due to malignancy(n=16), obstetric trauma after episiotomy at delivery(n=7), congenital malformation(n=4), inflammatory bowel disease(n=1), Bechet's disease(n=1), infections such as perianal fistula or abscess(n=2), direct invasion of carcinoma(n=3), after chemotherapy(n=1), and idiopathic(n=6). Three cases of them associated with rectovesicovaginal fistula. Surgical therapeutic option was divided to local repair, abdominal approach and tissue transposition by the type of RVF. Most simple RVFs were repaired with local approach through the vagina or rectum. Most complex RVFs were repaired through abdominal approach or tissue transposition. With an average follow up of 20 months, the treatment results were as follows: completely healed(n=36, 58.1%), persistent symptom(n=6, 9.7%), recurrence after repair(n=5, 8.1%), loss of search or death(n=15, 24.1%). Therefore we assist that the management of RVF depends on size, location, and cause. anal sphincter function and overall health status of the patient. Careful preoperative assessment of the fistula, surrounding tissues, and anal sphincter and exclusion of associated disease are essential. With through evaluation, thoughtful consideration of treatment options, and meticulous operative technique, patient can be assured of an optimal outcome.

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