Management of a congenital H-type anorectal fistula by anterior sagittal anorectovaginoplasty (ASARVP)

Abstract

Dear Editor: Congenital H-type fistula between the anorectum and the genital tract without any variety of anal atresia is a very rare entity in the spectrum of anorectal malformations. The incidence of congenital cases of H-type fistulae in girls ranges from 3.2 to 14%. These malformations—in recent literature also termed as “double termination” of the alimentary tract—have been reported in Europe only sporadically, but in Asia, they are more common. According to the level of fistulous communication to the genital tract, they could divide into high-, intermediateand lowtype forms. High-type forms contain all cases in which the fistula lies between the rectum and the vagina (=rectovaginal fistula with normal anal canal). Intermediate-type forms describe all fistulas between rectum and vestibule (=rectovestibular fistula with normal anal canal). Low-type forms (=perianal canal) include all cases in which the fistula took its course between the anal canal and the vestibule of the vagina (=anovestibular fistula with normal anal canal). The perianal canal is the most common malformation among all types of double termination of alimentary tracts in girls. Various surgical techniques with or without protective colostomy have been described in literature but until today, there is no consensus regarding the operative technique. A 60-day-old girl with a left labium abscess was brought to our department. In physical examination, the anus was in normal localisation, was age-related in size and had a normal sphincter tone. A left labium abscess and a fistula were found between the left labium/vulva and the anus (anovestibular fistula = low-type form). Operative treatment was done in three sessions: First, a protective colostomy was performed for the management of the local infection, and the abscess was drained. Second, an anterior sagittal anorectovaginoplasty (ASARVP) was done 3 months later. Intraoperatively, the whole fistulous tract was excised, and the surrounding tissue was repaired in different layers. In the third step, the colostomy was closed. The second case described a 90-day-old girl with a passage of stool through the vestibulum as well as through the normal anal passage. She had been swelling and had tenderness on her left vulvar region for 2 weeks. Physical examination showed a normal anus in localisation and size and had also normal sphincter tone. A vestibular opening was found in the middle just below of the hymen, without any abscess in this region. The radiological examination showed a fistula between the left labium and the rectum (=intermediate type form). Reconstruction of this intermediate type was done by ASARVP as well, without a protective colostomy. Up to now, there were no relapses of fistula or abscess in these two cases. Since the first description of a recto-vestibular fistula with a normal anus by Bryndorf and Madsen, about 50 girls with H-type anorectal malformations have been described in the literature. Large series have been reported from Asian countries. This suggested that these anomalies are more common in individuals of Asian origin. In all of these cases, a fistula connected the rectum or the anus with the vestibulum or the vagina. The embryology of H-type fistula remains unclear and controversial. In our both cases, the abscess and the fistula were localized on the left side. Recently, van der Putte suggested that an interruption of the Int J Colorectal Dis (2006) 21:728–729 DOI 10.1007/s00384-006-0156-z