Rectovaginal Fistula

About 2% of women with CD will develop a rectovaginal fistula (RVF). Surgical as well as medical treatment may be unnecessary as many of these fistulas are very low and have no associated symptoms. Surgical treatment is reserved for those patients with an unacceptable quality of life in whom medical treatment has failed. Unfortunately, the development of a RVF is a poor prognostic sign and may require proximal diversion to decrease local sepsis and/or eventual proctectomy. In patients undergoing RVF repair, the disease should be quiescent and the rectum distensible. In general, for low RVF (< 15% of the sphincter involved) and normal sphincter function, simple fistulotomy is a viable option. However, some surgeons advocate use of an endorectal advancement flap as an alternative to fistulo-tomy or noncutting Setons in patients with a simple fistula who do not have active rectal inflammation (Joo et al, 1998; Makowiec et al, 1995). An advancement flap involves creating a flap of tissue around the internal opening of a fistula (Hobbiss and Schofield, 1982) (Figure 82-6). Reports of its efficacy vary widely; in our experience, this approach yields unpredictable results.

Joo and colleagues (1998) reported sustained closure in 74% of 26 patients with fistulizing CD treated with endorectal advancement flap. Hull and Fazio (1997) reported that, among 35 patients with an advancement flap for low anovaginal fistulas, the initial healing rate was 54%, and an ultimate healing rate after > 1 procedure was 68%, but few others have such outcomes. Even more aggressive options can be considered in a few selective patients (Radcliffe et al, 1988; Halverson et al, 2001). Procedures such as an advancement sleeve flap can be used for larger perianal fistula dis-

Endorectale Flap Fistula

FIGURE 82-6. Endorectal advancement flap. A, The fistula tract is probed to identify the internal opening of the fistula. B, The internal opening of the fistula tract is incised. C, A flap of tissue (including mucosa, submucosa, and circular muscle) around the site of the resected internal opening of the fistula is incised. D, The flap is pulled down to cover the site of the resected internal opening of the fistula.

FIGURE 82-6. Endorectal advancement flap. A, The fistula tract is probed to identify the internal opening of the fistula. B, The internal opening of the fistula tract is incised. C, A flap of tissue (including mucosa, submucosa, and circular muscle) around the site of the resected internal opening of the fistula is incised. D, The flap is pulled down to cover the site of the resected internal opening of the fistula.

ease, as long as the rectum is spared. A report from Hull and Fazio (1997) looked at five patients with CD vaginal fistulas where four of the five have had resolution of their fistulas. Another 13 with complex fistulas have been treated in this manner, with 61% having resolution of symptoms. Although these results seem reasonable, we are unable to achieve anything near these outcomes and do not perform flap advancement for patients with RVF caused by CD.*

*Editor's Note: The role of aggressive medical therapy and of fecal diversion will have to be considered in the future, as mentioned below.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment