Cases reported "Rectovaginal Fistula"

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1/24. Successful transvaginal repair of a rectovaginal fistula developing after double-stapled anastomosis in low anterior resection: report of four cases.

    The management of postoperative rectovaginal fistula (RVF) after low anterior resection for rectal cancer is difficult and the results are often unsatisfactory. Among 140 patients with rectal cancer who underwent low anterior resection with a double-stapled anastomosis at our hospital between 1986 and 1996, 4 (2.9%) developed RVF as a postoperative complication. The RVF developed gradually from 9 to 128 days after low anterior resection. We describe herein our technique of using a modified transvaginal approach for RVF repair with a diverting colostomy. In all four patients, the RVFs were completely eradicated with reestablishment of intestinal continuity and did not recur during the mean follow-up period of 29.5 months, ranging from 12 to 67 months. This report serves to demonstrate that emerging RVFs secondary to stapled anastomosis in low anterior resection for rectal cancer must be recognized, and that a modified transvaginal approach provides an effective method of repair.
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2/24. Recurrent rectoneovaginal fistula caused by an incidental squamous cell carcinoma of the neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome.

    OBJECTIVE: Mayer-Rokitansky-Kuster-Hauser syndrome is a congenital malformation characterized by an absence of the vagina associated with a variable abnormality of the uterus and the urinary tract but functional ovaries. Surgical correction requires the creation of a neovaginal canal by the performance of a neovaginoplasty and an accurate long-term application of an artificial phallus phantom to avoid secondary shrinkage of the canal. Due to the chronic alteration of the posterior neovaginal wall, ulcers and consecutive fistulae may occur. We report the clinical course of a female who required surgical intervention for a rectoneovaginal fistula and developed a recurrence of the fistula due to one of the extremely rare squamous cell carcinomas of the neovaginal epithelium in order to show potential diagnostic and therapeutic features. METHOD: The systematic report of a case is presented. RESULT: Almost 13 years following the initial construction of a neovagina the patient developed a single-tract rectoneovaginal fistula. After surgical repair she represented with a recurrence due to a vast squamous cell carcinoma of the former operation site. Tumor en bloc resection was performed and currently (follow-up: 4 months) she has no signs of new tumor progression. CONCLUSION: Creation of a neovagina is the standard procedure for treating vaginal atresia or aplasia. Because of the long clinical course postoperatively, complications may occur. This report of a case of a malignant transformation in neovaginal epithelium shows the potential risk of malignancy and underlines the necessity of a close follow-up.
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3/24. Gracilis transposition in complicated perianal fistula and unhealed perineal wounds in Crohn's disease.

    OBJECTIVE: To assess the efficacy of transposition of gracilis muscle in the treatment of chronic recurrent fistulas and unhealed perineal wounds after proctectomy in patients with Crohn's disease. DESIGN: Retrospective study. SETTING: Academic clinic, united states. SUBJECTS: 7 patients with Crohn's disease: 3 had unhealed perineal wounds and persistent sinuses; 2 had had several attempts to repair rectovaginal fistulas; 1 had a rectourethral fistula; and 1 a pouch vaginal fistula. INTERVENTION: Transposition of the gracilis muscle. MAIN OUTCOME MEASURE: Healing. RESULTS: Mean follow up was 18 months (range 3-30). All patients operated on for unhealed perineal wounds had healed completely within 3-6 months. The patients with a rectovaginal fistula and a rectourethral fistula had both healed by 1 month postoperatively. Two fistulas recurred, and the small pouch-vaginal fistula remained but was asymptomatic. CONCLUSIONS: Transposition of the gracilis is a viable option for the treatment of persistent sinus and unhealed perineal wound after proctectomy for Crohn's disease. It could also be an option before proctectomy for patients with other types of Crohn's-related or complicated fistulas for whom other treatments have failed. A larger series will be required before a definite conclusion can be drawn.
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4/24. Delayed presentation of a congenital recto-vaginal fistula associated with a recto-sigmoid tubular duplication and spinal cord and vertebral anomalies.

    Tubular duplication of the recto-sigmoid colon is a rare entity. Associated anomalies including fistulae to the genitourinary tract may be found. A baby girl was found to have duplication of the recto-sigmoid colon, anomalies of sacral vertebra from S1 to S5, and solitary right kidney. The septum of this duplication was divided using staplers. Because of a history of stool coming from the vagina, a meticulous examination perioperatively was performed, but no fistula could be found. Further extensive investigation failed to show any fistula. At the age of 10 she was operated on for a tethered cord. At age 14, she experienced passage of a small amount of liquid stool per vaginum. A recto-vaginal fistula was found. Via a posterior sagittal incision, the fistula was closed by a transrectal approach. She remained asymptomatic for 16 months until the fistula recurred. Using a perineal approach, a very short fistula between the vagina and the rectum was closed. The closure was reinforced by a vaginal flap. Four months later, she remains without signs of recurrence.
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5/24. Surgical treatment of the radiation injured bowel.

    Over the last 10 years, 9 patients treated by surgical procedure for radiation injuries of the bowel were studied with the following conclusions: The damage to the small intestine caused by external irradiation leads to adhesion of the bowel, perforation and postoperative anastomotic dehiscence if the irradiated bowel is used in the anastomosis. Surgical treatment for the small intestine is resection of the damaged loop. In order to determine the extent of the resection it is important that during the operation fibrosis and obstruction of vessels in the submucosa and subserosa is examined by biopsy. On the other hand, rectal ulcer and/or rectovaginal fistula is chiefly caused by intracavitary application plus external irradiation. For these lesion Hartmann operation or colostomy is performed, and the postoperative course is uneventful.
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6/24. Abdominosacral repair for a rectovaginal fistula with anastomotic stenosis after low anterior resection report of a case.

    The management of a postoperative rectovaginal fistula after low anterior resection for rectal cancer is difficult and requires reconstruction of the anastomotic site and fistula. The results of reconstructive operation are often unsatisfactory. Herein, we describe our reconstruction technique using the posterior approach through the vaginal lumen for a high rectovaginal fistula repair. This reconstructive operation is useful for postoperative rectovaginal fistulas accompanied by severe stenosis of the anastomotic site following low anterior resection for rectal cancer.
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7/24. Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds.

    Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation to treat advanced cervical cancer do not respond to conventional treatment because of the low vascularity in the irradiated area. We present the successful repair of these complications in a female patient, in whom several vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis and persisting fistulas. First, a synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap was used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. In a second approach, the persisting vesicovaginal fistula was closed by a right rectus abdominis myocutaneous flap while simultaneously reconstructing the anterior vaginal wall, closing the enterocutaneous stoma and performing an appendicovesicostomy as a continence channel for catheterization. Despite unfavorable local wound situations, including an enterocutaneous stoma through the rectus abdominis and various previous incision lines, the transfer of axially well-vascularized tissue can solve these problem wounds. Consecutive bilateral use of the rectus abdominis flap may be necessary to deal with extensive pelvic wounds. This technique should be considered as one repair modality in irradiated pelvic wounds with fistulas. Previous enterostomy is not a contraindication to the use of this flap.
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8/24. MURCS association and rectovestibular fistula: case report of a patient treated with one-stage posterior sagittal anorectoplasty and sigmoid loop vaginoplasty.

    MURCS association is rare, first described by Duncan in 1979, including nonrandom association of Mullerian duct aplasia or hypoplasia (MU), renal agenesis or ectopy (R), and cervicothoracic somite dysplasia. A 5-year-old girl was admitted to the clinic with a complaint of anteriorly located anus. Physical and radiologic examination of the patient found MURCS association with anorectal malformation (arm) of rectovestibular-type fistula. She had multiple vertebral anomalies, left renal agenesis, vaginal and uterine agenesia, with a normal female 46,XX karyotype. Posterior sagittal anorectoplasty (PSARP) and sigmoid loop vaginal reconstruction was performed as a one-stage operation for the treatment of vaginal agenesis and arm. There were no complications in the postoperative period. This combined one-stage operation can be used easily in the treatment of some components of the MURCS association such as vaginal agenesis and arm as an associated anomaly.
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9/24. Congenital H-type anovestibuler fistula.

    The congenital H-type fistula between the anorectum and genital tract besides a normal anus is a rare entity in the spectrum of anorectal anomalies. We described a girl with an anovestibuler H-type fistula and left vulvar abscess. A 40-day-old girl presented symptoms after her parents noted the presence of stool at the vestibulum. On the physical examination, anus was in normal location and size, and had normal sphincter tone. A vestibuler opening was seen in the midline just below of the hymen. A fistulous communication was found between the vestibuler opening and the anus, just above the dentate line. There was a vulvar abscess which had a left lateral vulvar drainage opening 15 mm left lateral to the perineum. After the management of local inflammation and abscess, the patient was operated for primary repair of the fistula. A protective colostomy wasn't performed prior the operation. A profuse diarrhea started after 5 hours of postoperation. After the diarrhea, a recurrent fistula was occurred on the second postoperative day. A divided sigmoid colostomy was performed. 2 months later, and anterior sagital anorectoplasty was reconstructed and colostomy was closed 1 month later. Various surgical techniques with or without protective colostomy have been described for double termination repair. But there is no consensus regarding surgical management of double termination.
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10/24. Severe intraoperative hypertension and opioid-resistant postoperative pain in a methadone-treated patient.

    patients who are treated with methadone present challenges for the anesthesiologist. We report the untoward effects of rapid preoperative methadone tapering on the operative and perioperative course of a patient who required emergency surgery. The patient's exaggerated stress response to surgery and severe intractable postoperative pain might have resulted from unrecognized methadone withdrawal. Continuation of methadone treatment in patients who have surgery may prevent exaggerated intraoperative hemodynamic responses to surgical stimuli and unnecessary postoperative suffering.
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