Correspondence
Comment on Tozer et al.: Surgical management of rectovaginal fistula in a tertiary referral centre – many techniques are needed
view does the gracilis muscle interposition form a useful technique for RVF repair and where should it be placed in the proposed treatment algorithm?
A. Hotouras, J. B. Haddow and C. L. Chan doi:10.1111/codi.12470
Academic Surgical Unit, National Centre for Bowel Research and Surgical Innovation, Barts Health NHS Trust, London, UK E-mail: [email protected]
Dear Editor, We greatly enjoyed the article by Tozer et al. [1] on the surgical management of rectovaginal fistula (RVF), one of the most challenging anorectal conditions. The authors are to be congratulated on their systematic, thorough approach and for proposing a clinically relevant treatment-based algorithm dependent on the level of the internal opening, the integrity of the anal sphincter complex and the presence of perineal descent. In our clinical practice we have encountered an increasing number of patients who are referred to our tertiary unit with RVF following transanal stapling procedures (e.g. STARR, PPH) performed in the UK and abroad for obstructed defaecation syndrome or haemorrhoids. The reported incidence of this catastrophic complication is approximately 1% and may occur even when the procedure is performed according to the standardized operative steps [2–4]. Tozer et al. reported treating four patients with an iatrogenic RVF. Unfortunately, further details as to the nature of the injury were not presented and a detailed tabulation was not offered to allow derivation of the outcomes for this subgroup. We would be interested to hear if these cases were similar to ours and how they were managed collectively. In our experience, such cases appear extremely difficult to treat, perhaps even more so than patients with Crohn’s disease, and are refractory or recurrent despite several surgical revisions. We wonder whether this may be due to the presence of staples inducing a foreign body reaction and/or devascularization of the rectovaginal septum. In our multidisciplinary approach, we have observed that the most successful surgical strategy for these iatrogenic RVFs is similar to the authors’ ‘sphincter intact with low internal opening and no perineal descent’ strategy, but with one key difference: employing an adjunct lotus cutaneous or gracilis muscle interposition flap. This approach brings healthy, well-vascularized tissue into the affected area and is associated with a good success rate and acceptable, albeit reduced, quality of life and sexual activity [5,6]. We have found this to be superior to the other suggested alternative therapies, for example Martius flap and omentoplasty. In the authors’
144
Received 3 September 2013; accepted 4 September 2013; Accepted Article online 25 October 2013
References 1 Tozer PJ, Balmforth D, Kayani B, Rahbour G, Hart AL, Phillips RKS. Surgical management of rectovaginal fistula in a tertiary referral centre: many techniques are needed. Colorectal Dis 2013; 15: 871–7. 2 Bassi R, Rademacher J, Savoia A. Rectovaginal fistula after STARR procedure complicated by haematoma of the posterior vaginal wall: report of a case. Tech Coloproctol 2006; 10: 361–3. 3 Naldini G. Serious unconventional complications of surgery with stapler for haemorrhoidal prolapse and obstructed defaecation because of rectocoele and rectal intussusception. Colorectal Dis 2011; 13: 323–7. 4 Jayne DG, Schwandner O, Stuto A. Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry. Dis Colon Rectum 2009; 52: 1205–12. discussion 12–14. 5 Lefevre JH, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y. Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis Colon Rectum 2009; 52: 1290–5. 6 Furst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, Agha A. Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease. Int J Colorectal Dis 2008; 23: 349–53.
Re: Fluid administration in bowel surgery doi:10.1111/codi.12486
Dear Sir, We read with interest the study by Zakhaleva et al. [1] which investigated the role of goal-directed fluid therapy (GDFT) in bowel surgery and would like to make the following observations. The authors comment on the impact of GDFT on complications, but the study was in fact powered to detect a 1.5 day difference in length of stay. Although this required 99 patients, only
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 144–146
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Comment on Tozer et al.: Surgical management of rectovaginal fistula in a tertiary referral centre – many techniques are needed
view does the gracilis muscle interposition form a useful technique for RVF repair and where should it be placed in the proposed treatment algorithm?
A. Hotouras, J. B. Haddow and C. L. Chan doi:10.1111/codi.12470
Academic Surgical Unit, National Centre for Bowel Research and Surgical Innovation, Barts Health NHS Trust, London, UK E-mail: [email protected]
Dear Editor, We greatly enjoyed the article by Tozer et al. [1] on the surgical management of rectovaginal fistula (RVF), one of the most challenging anorectal conditions. The authors are to be congratulated on their systematic, thorough approach and for proposing a clinically relevant treatment-based algorithm dependent on the level of the internal opening, the integrity of the anal sphincter complex and the presence of perineal descent. In our clinical practice we have encountered an increasing number of patients who are referred to our tertiary unit with RVF following transanal stapling procedures (e.g. STARR, PPH) performed in the UK and abroad for obstructed defaecation syndrome or haemorrhoids. The reported incidence of this catastrophic complication is approximately 1% and may occur even when the procedure is performed according to the standardized operative steps [2–4]. Tozer et al. reported treating four patients with an iatrogenic RVF. Unfortunately, further details as to the nature of the injury were not presented and a detailed tabulation was not offered to allow derivation of the outcomes for this subgroup. We would be interested to hear if these cases were similar to ours and how they were managed collectively. In our experience, such cases appear extremely difficult to treat, perhaps even more so than patients with Crohn’s disease, and are refractory or recurrent despite several surgical revisions. We wonder whether this may be due to the presence of staples inducing a foreign body reaction and/or devascularization of the rectovaginal septum. In our multidisciplinary approach, we have observed that the most successful surgical strategy for these iatrogenic RVFs is similar to the authors’ ‘sphincter intact with low internal opening and no perineal descent’ strategy, but with one key difference: employing an adjunct lotus cutaneous or gracilis muscle interposition flap. This approach brings healthy, well-vascularized tissue into the affected area and is associated with a good success rate and acceptable, albeit reduced, quality of life and sexual activity [5,6]. We have found this to be superior to the other suggested alternative therapies, for example Martius flap and omentoplasty. In the authors’
144
Received 3 September 2013; accepted 4 September 2013; Accepted Article online 25 October 2013
References 1 Tozer PJ, Balmforth D, Kayani B, Rahbour G, Hart AL, Phillips RKS. Surgical management of rectovaginal fistula in a tertiary referral centre: many techniques are needed. Colorectal Dis 2013; 15: 871–7. 2 Bassi R, Rademacher J, Savoia A. Rectovaginal fistula after STARR procedure complicated by haematoma of the posterior vaginal wall: report of a case. Tech Coloproctol 2006; 10: 361–3. 3 Naldini G. Serious unconventional complications of surgery with stapler for haemorrhoidal prolapse and obstructed defaecation because of rectocoele and rectal intussusception. Colorectal Dis 2011; 13: 323–7. 4 Jayne DG, Schwandner O, Stuto A. Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry. Dis Colon Rectum 2009; 52: 1205–12. discussion 12–14. 5 Lefevre JH, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y. Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis Colon Rectum 2009; 52: 1290–5. 6 Furst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, Agha A. Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease. Int J Colorectal Dis 2008; 23: 349–53.
Re: Fluid administration in bowel surgery doi:10.1111/codi.12486
Dear Sir, We read with interest the study by Zakhaleva et al. [1] which investigated the role of goal-directed fluid therapy (GDFT) in bowel surgery and would like to make the following observations. The authors comment on the impact of GDFT on complications, but the study was in fact powered to detect a 1.5 day difference in length of stay. Although this required 99 patients, only
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 144–146
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
