Beijing Pinggu District Traditional Chinese Medicine Hospital Zhang Shuling Hebei Xianghe County Hospital Li Deqing Li Shuwei
The Third Hospital of Wulanchabu League, Inner Mongolia Wu Enzhen, Zhan Jiuyun, Zhao Hu, Jun County, Hebi City, Henan
Rectovaginal fistula is the communication between the rectum and the vagina, which causes gas, secretions or feces in the intestine to come out of the vagina. It belongs to the categories of "Yin Blow" , "Erosion"   , etc. in Chinese medicine surgery. Rectovaginal fistula is a more difficult problem in the treatment of anorectal surgery.
There are many treatment methods for rectovaginal fistula, some are too complicated, difficult to care for, and the treatment cost is high, which is difficult for patients to accept. In the past 10 years, we have used transperineal repair to treat middle and low rectal-vaginal fistulas with good results. The introduction is as follows:
1. Materials and methods
1. normal information
2. Indications: Simple medium and low rectal-vaginal fistula.
3. Contraindications: Acute inflammation in the local area or storage bag; rectal-vaginal fistula caused by radiotherapy, neoplasm or rectal Crohn's disease.
Repair rectovaginal fistula via perineum. ①Preoperative routine bowel preparation (same as rectal cancer preparation), using continuous epidural anesthesia, taking the lithotomy position, routinely disinfecting the drape, placing iodophor gauze three times in the vagina and rectum, and leaving it for 3 minutes each time. ②1% lidocaine or normal saline and adrenaline are configured as a 1:5000 solution for infiltration around the fistula and submucosa of the rectum and vagina to reduce bleeding. ③ Use a knife to make an arc-shaped incision between the anus and the anterior vulva, and separate the rectum and vagina until the rectum and vaginal fistula, and remove all the epithelialized tube wall tissue. ④The rectal defect was sutured intermittently with No. 0 silk thread before intermittent inversion suture. ⑤ Intermittently suture the levator ani muscle with No. 1 silk thread for reinforcement. ⑥ Intermittently suture the posterior wall of the vagina with 3-0 EthiconVicryl absorbable sutures. ⑦If there is a storage bag, peel off its wall and suture the entire cavity to close it. ⑧ After placing a skin sheet between the rectum and vagina for drainage and fixation, use iodophor gauze to apply externally on the perineal wound 3 to 5 times, leave it for 3 minutes each time, and then intermittently suture the perineal wound with No. 4 silk thread and cover and fix it with external gauze. ⑨Dry gauze is placed in the vagina, and a rubber tube is placed in the rectum to connect to a sterile bag for drainage, and pay attention to fixation. ⑩Daily decoction with traditional Chinese medicine Qudu Decoction and then sit bath, twice a day, to clear heat and detoxify, promote blood circulation and remove blood stasis, reduce swelling and relieve pain; change the vaginal gauze 1 or 2 times to keep dry as much as possible; place diarrhea in the rectum Tai Hemorrhoid Suppository 1 capsule per day; fasting for 5-7 days, and give supportive therapy and effective antibiotic treatment; control stool for 7-10 days; the skin is usually removed after 24 hours, and the rubber tube placed in the rectum is generally 3 to 5 After days, it was removed, the perineal wound was changed daily until healed, and the sutures were removed for one week.
In this group of patients, except for tumors, radiotherapy and Crohn's disease, the rest healed by first intention. The average hospital stay was 9 days (7-13 days), and the average follow-up was 24 months (12-30 months). During the follow-up period, no recurrence cases were found, and the success rate was 73%. According to the Parks anal incontinence grading system, the postoperative anal function of this group of recovered patients was evaluated, and no anal incontinence occurred. Satisfaction of cured patients after operation was 100% . The gastrointestinal quality of life index improved significantly after surgery .
According to statistics abroad, the incidence of rectal-vaginal fistula accounts for less than 5% of anal fistulas. The pathogenic factors are congenital and acquired. Congenital factors are mostly caused by anorectal hypoplasia and abnormal opening of the rectum in the vagina. Congenital rectovaginal fistulas have been reported to account for about 12%. Acquired factors include ① infection (Crohn’s disease, perianal abscess, Bartholin’s gland infection, diverticulitis, lymphogranuloma venereum, HIV ulcer, tuberculosis, etc.); ② trauma (reported birth injury caused by rectal vaginal fistula accounted for 11~ 20%, the perineum vulvectomy or tear during childbirth is the most common cause of rectovaginal fistula, followed by violence, rough intercourse, trauma, etc.); ③tumor invasion (including rectal and gynecology); ④complication during treatment Symptoms such as hysterectomy, low anterior resection, anorectal surgery and pelvic radiotherapy.
In terms of diagnosis, anyone who has gas or stool discharged from the vagina should suspect the existence of a fistula. ①Determine the cause: detailed medical history can help to find the cause, and the patient's stool control status should be recorded. ②Determine the existence of fistula: low and large fistulas can be found during physical examination. Small fistulas need to be checked by other tests. For example, methylene blue staining can confirm the existence of fistula. The method is to take the stone cut position and put it in the vagina After the tampon, inject 1ml of methylene blue plus 39ml of 1% hydrogen peroxide solution into the rectum, and then take out the tampon to observe its staining; vaginal angiography can be helpful for finding high fistulas.③Defecation angiography can determine the location of the large fistula and the function of the anal sphincter; ④Sphincter examination should be a necessary step in the diagnosis of every patient with enterovaginal fistula, especially for patients with rectovaginal fistula caused by birth injury, defecation incontinence may be caused by sphincter damage cause. Furthermore, symptoms of incontinence can be masked by fistulas. Therefore, physical examination and anorectal physiological examination (including intrarectal ultrasound, rectal pressure measurement and pudendal nerve potential) are very important for revealing hidden injuries and formulating surgical repair programs. ⑤ Proctoscopy can not only confirm the rectal-vaginal fistula but also observe the rectal mucosa. Biopsy was performed on the marginal mucosa of the fistula with and without disease to determine the cause of the rectovaginal fistula.
According to the cause, size and location of the fistula, the rectal-vaginal fistula is divided into low and high, simple and complicated. The rectal side opening of the low rectal-vaginal fistula is located at or slightly above the dentinal line, and the vaginal side opening is in the labia frenulum; the high-position fistula refers to the vaginal opening of the rectal-vaginal fistula close to or behind the cervix. The median fistula is between the low and high fistulas. Simple fistulas are those that are low and are caused by trauma and infection; complex fistulas are high, large in diameter, and are caused by radiotherapy, tumors, inflammatory bowel disease, or recurrent fistulas.
There are many surgical approaches for the treatment of low-to-medium rectal-vaginal fistulas, including transanal repair, transvaginal repair, transperineal repair, transsphincter repair (York and Mason), transanal flap repair, transabdominal repair, and tissue transplantation and repair. Film and other methods. In general, it is believed that simple fistula resection or incision should not be performed for rectal-vaginal fistulas, and vaginal incision will cause a certain degree of anal incontinence; many surgeons and all gynecologists tend to treat rectal-vaginal fistulas through vaginal repair. However, due to the high pressure area on the rectal side, if the opening of the fistula in the rectum is not completely closed, then no matter how careful the operation in the vagina, failure is inevitable; transsphincter repair, transanal valve repair, transabdominal repair and Methods such as tissue transplantation and patching are difficult to operate, require high conditions, have many complications, and have high expenditures. Patients, especially rural patients, have low acceptance.
Based on many years of clinical experience, we believe that the treatment of rectal-vaginal fistula via perineal repair has low requirements on infrastructure, and is less traumatic, fast recovery, low cost, and more suitable for promotion in rural primary hospitals. ②When repairing through the perineum, the levator ani muscle can be pulled together, which reduces local tension and improves local blood circulation, thereby improving the healing ability of repaired wounds. ③ No need to cut the sphincter, avoid keyhole deformity, anal incontinence, and no need to make a protective stoma. ④Perineal repair can repair the defective sphincter at the same time, reducing the complications caused by multiple incisions. ⑤ Transperineal repair can completely separate the rectum and vaginal fistula, and at the same time repair the rectum and vagina separately, eliminating the tediousness of turning the patient over during the operation. ⑥The rubber tube placed in the rectum after operation can drain the gas and liquid in the intestine to the body, thereby reducing the impact of high pressure in the rectum on the healing of the repaired wound. However, there is acute inflammation in the local area or the storage bag; the success rate of repairing the rectal-vaginal fistula caused by radiotherapy, neoplasm or rectal Crohn's disease is low, and the reason is worthy of further investigation.
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