Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 4  |  Page : 813-817

Primary versus multistage repair of congenital rectovestibular fistula


Department of General Surgery, Faculty of Medicine, Menoufia University, Menofia Governorate; Department of Pediatric Surgery, Ministry of Health, Kafr ELzayat, Gharbia, Egypt

Date of Submission24-Jan-2015
Date of Acceptance12-Mar-2015
Date of Web Publication12-Jan-2016

Correspondence Address:
Wael Omar Zeina
Kafr ELzayat, Gharbia, 31611
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.173597

Rights and Permissions
  Abstract 

Objective
The aim of this study was to evaluate the feasibility, safety, and outcome of one-stage posterior sagittal anorectoplasty in cases of rectovestibular fistula.
Background
Rectovestibular fistula is the most common type of anorectal malformation in the female population. The standard treatment for rectovestibular fistula is the staged approach. In recent times, posterior sagittal anorectoplasty has revolutionized the management of anorectal malformation (ARMs).
Materials and methods
This study was conducted on 24 female patients with rectovestibular fistula who were divided into two groups:
Group 1: This group comprised patients who underwent primary repair without colostomy (14 cases) prospectively.
Group 2: This group comprised patients who underwent multistage repair (10 cases) retrospectively (the last 10 cases were operated upon in our hospital).
Results
A total of 24 patients were included in our study. All patients were more than 1 month old. Intraoperative complications included opening the posterior wall of the vagina (n = 2). Postoperative complications included the following: anal excoriations in seven patients in group 1 only; superficial wound inflammation in four patients in group 1 but only in one patient in group 2; partial dehiscence of the perineal skin in three patients in group 1 but only in one patient in group 2; anal stenosis in one patient in each group; and mucosal prolapse in one patient in group 1 only.
Conclusion
Primary repair of rectovestibular fistula is technically feasible and safe. It avoids the risk of complications related to colostomy and the risks of multiple anesthesia, and reduces the economic and psychological burden on the family.

Keywords: primary repair, rectovestibular fistula, multistage repair


How to cite this article:
Loulah MA, Sultan TA, Zeina WO. Primary versus multistage repair of congenital rectovestibular fistula. Menoufia Med J 2015;28:813-7

How to cite this URL:
Loulah MA, Sultan TA, Zeina WO. Primary versus multistage repair of congenital rectovestibular fistula. Menoufia Med J [serial online] 2015 [cited 2020 Feb 16];28:813-7. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/813/173597


  Introduction Top


Anorectal malformations represent a large group of diseases that can affect children, and involve the distal anus and rectum as well as the urinary and genital tract [1] . The average incidence worldwide is one in 5000 live births and it can also occur in association with several syndromes. Rectovestibular fistula is the most common type of anorectal malformation in the female population [2] and it was reported by Bryndorf and Madsen [3] .

The standard treatment for rectovestibular fistula is the staged approach. Many trials were carried out for rectovestibular fistula, including old surgical techniques such as cutback and V-Y plasty. In recent times, posterior sagittal anorectoplasty (PSARP) described by Peña and DeVries [4] has revolutionized the management of ARMs by providing complete exposure of the anatomy of the anorectal region during surgery. This is the most widely used method and provides exact visualization of the fistula between the rectum and the female genital tract and places the rectum within the striated muscle complex, giving the best chance to achieve continence [5] .

Primary repair will avoid the comorbidity associated with a colostomy [6] .

The aim of this study was to evaluate the feasibility, safety, and outcome of one-stage PSARP in cases of rectovestibular fistula.


  Materials and methods Top


This study was conducted on 24 female patients with rectovestibular fistula from January 2013 to July 2014 with approval from Ethics Committee of Scientific Research. The patients were divided into two groups:

Group 1: This group comprised patients who underwent primary repair without colostomy (14 cases) prospectively.

Group 2: This group comprised patients who underwent multistage repair (10 cases) retrospectively (the last 10 cases were operated upon in our hospital).

Exclusion criteria

The exclusion criteria included associated major congenital anomalies, poor general condition, and previous trial of repair. All patients were subjected to detailed perinatal history evaluation, full physical examination (for evaluation of the buttock contour, examination of the perineum, contraction of the anal dimple, exact site of the fistula and its relation to the hymen, and presence of other major congenital anomalies), necessary laboratory investigations, and imaging study (plain radiography, abdominal ultrasonography, and echocardiography). The patients' parents underwent full counseling.

Preoperative preparation

Patients were admitted 1 or 2 days before the operation for bowel preparation: only clear fluids were allowed until 4 h preoperatively, rectal washouts with saline were done at 6 hourly intervals until the enema became clear, and antibiotics - a combination of co-amoxiclav, amikacin, and metronidazole - were started 1 h before the operation and continued postoperatively for 5 days.

Surgical technique

Following induction of general anesthesia with endotracheal intubation, a urinary catheter was inserted and the patient was placed in the prone position. Following the approach described by Levitt and Peña [7] , a midline incision was made. The midline incision continues around the fistula into the vestibule and multiple 5-0 sutures are placed circumferentially at the fistula site. Traction is placed on these sutures, and the rectum is dissected circumferentially. The posterior rectal wall can thus be easily identified. The dissection starts from the posterior aspect and extends laterally.

The last step, separation of the rectum from the vagina, is the most delicate part of the dissection. Once fully separated, an areolar plane between the two structures is created. At this point, branches of the hemorrhoidal vessels found on the lateral aspects of the rectum can be ligated with cautery, thereby mobilizing the rectum to gain enough length to perform a tension-free bowel-to-skin anastomosis.

The limits of the sphincteric mechanism are electrically determined and marked with temporary silk sutures. The perineal body is then reconstructed by bringing together the anterior limit of the sphincter complex.

The anterior edge of the muscle complex is reapproximated taking bites of rectal wall. The levator muscle is not usually exposed and thus does not need to be reconstructed. Anoplasty and wound closure are then performed.

Defunctioning or loop sigmoid colostomy was carried out at admission in group 2 patients, followed by definitive surgery after 1-3 months and then closure of the colostomy after complete healing.

Patients were kept nil per oral for the next 3 days. They were kept on intravenous fluids and triple antibiotics. The urinary catheter was removed on the fifth postoperative day. Wound care for the perineum and neoanus included the use of betadine solution and amikacin spray and the patients were discharged once they could tolerate feeding with no signs of infection. The children were followed up in the outpatient department after discharge at 1 week for assessment of wound healing and for any wound complication. They were followed up for a minimum period of 6 months. The perineal area was inspected for any excoriation, wound infection, wound dehiscence, and anal stenosis, retraction, or recurrence of fistula.


  Results Top


A total of 24 patients with rectovestibular fistula were studied and divided into two groups:

Group 1: This group included patients who underwent primary repair without colostomy (14 cases) prospectively.

Group 2: This group included patients who underwent multistage repair (10 cases) retrospectively (the last 10 cases were operated upon in our hospital).

The age of the patients in group 1 at the time of surgery ranged from 3 to 11 months, with a mean age of 5.679 months. The treatment of one patient was delayed until the age of 9 months because of marked hydronephrosis and this patient underwent pyeloplasty first. The age of the patients in group 2 ranged from 2.5 to 10 months, with a mean age of 6.5 months ([Table 1]).
Table 1 Comparison between group I and group II as regard age (months)


Click here to view


The weight of the patients at time of surgery ranged from 5 to 9 kg. The operative time ranged from 60 to 95 min. The posterior wall of the vagina was injured in two cases in both groups; these minor openings were repaired without any postoperative consequences ([Table 2]). No injury to the hymen or major bleeding occurred.
Table 2 Comparison between group I and group II as regards operative complications


Click here to view


The duration of postoperative hospital stay ranged from 3 to 5 days, with a mean time of 5.143 days. Only three patients from group 1 stayed for 10 days postoperatively because of wound disruption, whereas in group 2 all patients were discharged after 3 days, except for one patient who was discharged after 10 days ([Table 3]).
Table 3 Comparison between group I and group II as regard postoperative hospital stay (days)


Click here to view


Oral feeding started after 3 days in group 1 and on the first day in group 2.

Postoperative follow-up

The patients were followed up postoperatively for a period that varied between 3 and 9 months. The incidence of complications was recorded and compared between the two groups ([Table 4]).
Table 4 Comparison between group I and group II as regards postoperative complications


Click here to view


Anal excoriations occurred in seven patients only in group 1 because of soiling. All of them were treated with zinc oxide cream ([Figure 1]).
Figure 1 Anal excoriation.



Click here to view


Superficial wound inflammation was reported in four cases in group 1 but only in one case in group 2.

Partial dehiscence of the perineal skin occurred in three patients in group 1 but in only one patient in group 2, which required extension of hospital stay and frequent dressing ([Figure 2]).
Figure 2 Partial dehiscence.



Click here to view


No complete dehiscence of the perineal wound or disruption of the perineal body was reported in either group.

Anal stenosis occurred in three patients in group 1 but in only one patient in group 2. The degree of stenosis was mild in both groups, and responded to regular anal dilatation with decreasing frequency.

Mucosal prolapse occurred in one case in group 1, whereas anal retraction was not recorded in either group.

In addition to the above complications, complications from the colostomy and its closure were seen only in group 2. These complications have been summarized in [Table 5] and [Table 6].
Table 5 Complication of colostomy in group 2


Click here to view
Table 6 Complication of closure of colostomy in group 2


Click here to view



  Discussion Top


Rectovestibular fistula is the most common type of anorectal malformation in the female population [2],[8]. These anomalies usually have very good prognosis when properly treated. It is estimated that 93% of patients with vestibular fistula will develop voluntary bowel movement by the age of 3 years [9] .

The procedure of PSARP reported by Peña and DeVries in early 1980 was introduced for the treatment of high and intermediate anorectal anomalies [4] . Since then, it has become the procedure of choice because of fewer complications and good functional outcome. Further, it is a less traumatic approach with good anatomical exposure as it is unnecessary to cut the levator ani muscle.

Three-stage operations are of immense disadvantage to the patients and their parents. The cost is significant and the incidence of complications is considerable.

A single-stage operation will reduce the total cost of treatment and the duration of hospital stay with obvious benefits to both parents and children, with comparable results [10].

A variety of complications related to colostomy performed during infancy have been reported in the literature. Common complications include colostomy prolapse or retraction, skin dehiscence and excoriation, intestinal obstruction, and stomal ulceration and bleeding.

In addition, the complications after closure of colostomy are also significant.

A significant incidence of wound infection, incisional hernia, and adhesive intestinal obstruction has been reported after colostomy takedown [11],[12] . The advantages of bypassing the colostomy stage are many. First, the above-mentioned colostomy complications are eliminated completely, which is specifically important in developing countries where the idea of colostomy is socially unacceptable, besides the shortage of stoma nurses and deficient parent's knowledge about colostomy care [6].

A colostomy offers the advantage of decreasing the soiling of the wound after the definitive procedure.

The age of the patients in group 1 at the time of surgery ranged from 3 to 11 months, with a mean age of 5.679 months, whereas the ages ranged from 2.5 to 10 months with a mean of 6.5 months in group 2. In the study by Wakhlu and colleagues the age at surgery was 3-6 months [6] , whereas in the study by Kuijper and Aronson [13] the age at surgery ranged from 0 to 73 months and in the study by Kumar et al. [14] the age ranged from 28 days to 10 years.

In our study the operative time ranged from 60 to 95 min, with a mean time of 73.571 min, whereas in the study by Upadhyaya et al. [15] the mean operative time was 110 min.

In our study, vaginal injury occurred in two patients in each group (14.29% in group 1 and 20% in group 2.

No injury to the hymen or major bleeding occurred in any patient of the study.

In our study the duration of postoperative hospital stay ranged from 3 to 5 days with a mean of 5.143 days. Three patients in group 1 stayed for 10 days postoperatively because of wound disruption, whereas in group 2 all patients were discharged after 3 days, except for one patient who was discharged after 10 days because of wound care. In the study by Upadhyaya et al. [15] the average duration of hospital stay was 5-6 days, whereas in the study by Javid et al. [16] the average duration of hospital stay was 3.7 days.

Oral feeding was started after 3 days in group 1 and on the first day in group 2. In the study by Upadhyaya et al. [15] feeding started after 3 days.

Our patients were followed up postoperatively immediately and for a period that varied between 3 and 9 months. The incidence of complications was recorded and compared between the two groups.

In our study, there was significant difference between group I and group II as regards anal excoriation: anal excoriation occurred in seven patients (50%) only in group 1 because of the presence of soiling. All of them were treated with zinc oxide cream. In the study by Menon and Rao [17] mild anal excoriation was seen initially in 60% of the infants, which subsided within 2-3 weeks.

In our study, superficial wound inflammation was reported in four cases (28.57%) in group 1 but only in one case (10.00%) in group 2. In the study by Menon and Rao [17] mild wound infection was seen in five patients in the early postoperative period, which responded to conservative management, whereas in the study by Kuijper and Aronson [13] 3/19 children (15.8%) had superficial wound infections.

In our study, partial dehiscence of the perineal skin was seen in three cases (21.43%) in group 1 but in only one patient (10.00%) in group 2, which required extension of hospital stay and frequent dressing; in the study by Kumar et al. [14] superficial wound dehiscence occurred in 10.57% of patients.

No complete dehiscence of the perineal wound or disruption of the perineal body was reported in either group in our study, similar to the results of Menon and Rao [17] and Upadhyaya et al. [15] . Kumar et al. [14] however, reported total wound dehiscence in two patients (1.63%), which was managed successfully with redo operation after 6 weeks.

In our study, anal stenosis occurred in three patients (21.43%) of group 1 but in only one patient (10.00%) of group 2. The degree of stenosis was mild in both groups and responded to regular anal dilatation with decreasing frequency. Upadhyaya et al. [15] reported anal stenosis in 2 (5%) patients, Kumar et al. [14] reported it in 5 (6.76%) patients, whereas Menon and Rao [17] reported no incidence of anal stenosis.

In our study, mucosal prolapse occurred in 1 (7.14%) patient in group 1 and required mucosectomy. Upadhyaya et al. [15] reported mucosal prolapse in 3 (7.5%) patients and Kumar et al. [14] reported it in 2 (2.7%) patients, whereas Menon and Rao [17] reported that there was no incidence of mucosal prolapse.

Anal retraction was not recorded in either group in our study, similar to the study by Menon and Rao [17] . In follow-up, all the patients were subjected to anal dilatation.

The complications resulting from the colostomy and its closure had a high incidence, varying from mild complications such as skin excoriation to severe complications necessitating secondary surgical interference, such as incisional hernia.

In our study, complications of colostomy such as postoperative wound infection was recorded in 3 (30%) cases, partial wound dehiscence in 2 (20%) cases, severe skin excoriation in 5 (50%) cases, stomal prolapse in 2 (20%) cases, stomal retraction in 1 (10%) case, and incisional hernia in 1 (10%) case.

Also, complications after closure of colostomy were significant: wound infection in four (40%) cases, leakage in 1 (10%) case, and incisional hernia in 1 (10%) case.


  Conclusion Top


The one-stage approach is technically feasible through the posterior sagittal approach.

It avoids the risk of complications related to colostomy and the risks of multiple anesthesia, and reduces the economic and psychological burden on the family.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Peña A, Levitt M. Imperforate anus: surgical prospective. J Pediatr Surg 2006; 4 :221-235.  Back to cited text no. 1
    
2.
Wakhlu A, Pandey A, Prasad A, Kureel SN, Tandon RK, Wakhlu AK. Anterior sagittal anorectoplasty for anorectal malformations and perineal trauma in the female child. J Pediatr Surg 1996; 31 : 1236-1240.  Back to cited text no. 2
    
3.
Bryndorf J, Madsen CM. Ectopic anus in the female. Acta Chir Scand 1960; 118 :466-478.  Back to cited text no. 3
    
4.
Peña A, Devries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982; 17 :796-811.  Back to cited text no. 4
    
5.
Peña A. Surgical treatment of high imperforate anus. J World Surg 1985; 9 :236-243.  Back to cited text no. 5
    
6.
Adeniran JO. One-stage correction of imperforate anus and rectovestibular fistula in girls: preliminary results. J Pediatr Surg 2002; 37 :E16.  Back to cited text no. 6
    
7.
Levitt M, Peña A. Anorectal malformations. In: Coran A, ed. Pediatric surgery. 7th ed. Philadelphia: Elsevier; 2012. 1289-1309.  Back to cited text no. 7
    
8.
Peña A. Imperforate anus and cloacal malformations. In: Ashcraft K, ed. Pediatric surgery. 3rd ed. Philadelphia: Elsevier; 2000. 473-492.  Back to cited text no. 8
    
9.
Peña A, Hong A. Advances in the management of anorectal malformations. Am J Surg 2000; 180 :370-376.  Back to cited text no. 9
    
10.
Davies MC, Creighton SM, Wilcox DTLong-term outcomes of anorectal malformation. Pediatr Surg Int 2004; 20 :567-572.  Back to cited text no. 10
    
11.
Patwardhan N, Kiely EM, Drake DP, Spitz L, Pierro A. Colostomy for anorectal anomalies: high incidence of complications. J Pediatr Surg 2001; 36 :795-798.  Back to cited text no. 11
    
12.
Nour S, Beck J, Stringer MD. Colostomy complications in infants and children. Ann R Coll Surg Engl 1996; 78 :526-530.  Back to cited text no. 12
    
13.
Kuijper CF, Aronson DC. Anterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?. J Pediatr Surg 2010; 45 :1505-1508.  Back to cited text no. 13
    
14.
Kumar B, Kandpal DK, Sharma SB, Agrawal LD, Jhamariya VN. Single-stage repair of vestibular and perineal fistulae without colostomy. J Pediatr Surg 2008; 43 :1848-1852.  Back to cited text no. 14
    
15.
Upadhyaya VD, Gopal SC, Gupta DK, Gangopadhyaya AN, Sharma SP, Kumar V Single stage repair of anovestibular fistula in neonate. Pediatr Surg Int 2007; 23 :737-740.  Back to cited text no. 15
    
16.
Javid PJ, Barnhart DC, Hirschl RB, Coran AG, Harmon CM. Immediate and long-term results of surgical management of low imperforate anus in girls. J Pediatr Surg 1998; 33 :198-203.  Back to cited text no. 16
    
17.
Menon P, Rao KL. Primary anorectoplasty in females with common anorectal malformations without colostomy. J Pediatr Surg 2007; 42 :1103-1106.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
Acknowledgements
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1608    
    Printed6    
    Emailed0    
    PDF Downloaded120    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]