Anovestibular Fistula Research Articles

Anterior sagittal anorectoplasty for anovestibular fistula

Anterior sagittal anorectoplasty (ASARP) was used for the definitive correction in 107 cases of anovestibular fistula (AVF) between 1996 and 2005. These cases were subjected to three different types of treatment regimes during the same period. Majority of the cases (78) were operated in one stage where postoperatively an early oral feed was started (A). Cases were discharged in 2-4 days. In the second group (B), there were ten cases who were also operated in one stage but with prolonged fasting of 9-10 days postoperatively. Nineteen cases (C) were operated under cover of colostomy during the same period. In the immediate postoperative period, among the group A, one case had a major wound disruption requiring a colostomy and a redo surgery. Three cases had subcutaneous leak. In seven cases there was premature dehiscence of mucocutaneous or skin sutures. In groups B and C, there were no significant complications in the immediate postoperative period. In the follow-up period, out of 107 cases, 63 (58.8%) had constipation at the end of 3 months. However, at the end of one year, only 24.3% (26 cases) cases had constipation. Regarding fecal continence, 86 cases (90.5%) were totally continent. Seven had history of occasional soiling and in two cases, soiling was more frequent. As far as repair or correction of AVF or vestibular anus is concerned, we feel that anterior sagittal approach is more suitable as it requires less pelvic dissection. Separation of posterior vaginal wall from rectum, which is considered, is the most important step of the operation, takes place under direct vision. We also feel that AVF can be repaired in one stage with an early postoperative oral feed, provided we are meticulous in pre and postoperative bowel management. It reduces hospital stay and the cost of treatment. This provides a good option to cases who are not able to afford prolonged hospitalization (fasting) or are not willing for a colostomy.

P-125B A 2-year-old girl with anovestibular fistula presenting with a huge abdominal mass(Gastrointestinal, the 44th Annual Meeting of Japanese Society of Pediatric Surgeons)

P-125B A 2-year-old girl with anovestibular fistula presenting with a huge abdominal mass(Gastrointestinal, the 44th Annual Meeting of Japanese Society of Pediatric Surgeons)

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

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

Laparoscopically assisted anorectovaginoplasty for selected types of female anorectal malformations

Purpose: The aim of this study was to describe laparoscopically assisted anorectovaginoplasty (LAARVP) for the repair of selected types of female anorectal malformation. Methods: Five cases (case 1, rectovaginal fistula with a high rectum; case 2, rectovestibular fistula with double vagina; case 3, rectovestibular fistula with absent vagina; case 4, anovestibular fistula with absent vagina; case 5, cloaca) were reviewed. Results: Patient 4 had undergone a posterior sagittal anorectoplasty without vaginoplasty at another hospital after misdiagnosis of simple anovestibular fistula. Mean age at LAARVP was 15.4 months. At LAARVP, the fistula was divided in cases 1 through 4 and dissected as low as possible in case 5. In cases 3 and 4, the distal fistula was used to create the neovagina. In cases 1 through 3, the proximal rectum was mobilized and brought through the pelvic floor sphincter muscles using Georgeson’s laparoscopically assisted colon pull-through technique through a minimal perineal incision. A posterior sagittal incision was required in cases 4 and 5. However, the initial laparoscopic approach was very helpful in both cases. Currently, all patients are well after a mean follow-up period of 32.2 months. Mean current age is 4.0 years. Patients 1 through 3 are continent, patient 4 is incontinent with soiling, and patient 5 is too young to be evaluated. Conclusions: LAARVP helps to achieve low dissection of the fistula, gives optimal view of the pelvic organs, provides accurate placement of the anorectal pull-through, and minimizes abdominal perineal scars.

A Case of Anovestibular Fistula Accompanied by Human Tail

A Case of Anovestibular Fistula Accompanied by Human Tail

Analysis of 1,992 patients with anorectal malformations over the past two decades in Japan

Background/Purpose: This report describes the results of a group study of the Japanese Study Group of Anorectal Anomolies (JSGA) to determine the relative incidence of specific types of anorectal anomaly in Japan, and includes discussion of rectourethral fistula regarding the relationship between the levels of the fistula and blind end of the rectum, low type deformity, rare types, and associated anomalies. Methods: A total of 1,992 patients (1,183 boys and 809 girls) registered from 1976 to 1995 were analyzed. Results: High-type deformities accounted for 26.0% of cases, intermediate 10.7%, low 57.2%, miscellaneous 4.5% and unclassified 1.8%. The most frequent deformity was male anocutaneous fistula (n = 364), followed by male rectourethral fistula (n = 333), and female anovestibular fistula (n = 241). There were 42 rectovesical fistulas in boys and 93 rectocloacal fistulas in girls. Covered anus complete occurred at the same frequency (10.1% of low deformities) as covered anal stenosis. In rectourethral fistula, the blind end of the rectum lay at or above the level of the P-C line in 40.3% of cases, at or above the M line in 39.6% and at the vicinity of the I line in 20.2%, respectively. There was no parallel relationship between the site of the fistula opening and the level of the rectal pouch. The overall incidence of patients having one or more associated anomalies was 45.2%: 70.6% in high deformity, 60.7% in intermediate, and 31.3% in low. The rate of association of Down's syndrome with deformities without fistula (40.3%) was significantly higher than with deformities with fistula (0.3%). Conclusions: Rectovesical fistula and covered anus complete were not infrequent deformities in this series. We consider that at least 20% of rectourethral fistula should be categorized as intermediate or low deformity from the viewpoint of the position of there rectal pouch. A significant preponderance of Down's syndrome in the deformities without fistula suggests that further investigation of associated anomalies in comparison with other congenital diseases may provide insights into the pathogenesis of anorectal malformation in the field of molecular genetics.

Caudal regression syndrome: MR appearance

This article reports a case of caudal regression syndrome with hypoplasia of the sacrum, accompanied by an imperforate anus with anovestibular fistula. Magnetic resonance images showed a characteristic wedge-shaped cord terminus and the separation of anterior and posterior spinal roots at the level of the cauda equina.

Anorectal anomalies associated with Kabuki make-up syndrome

A case report of a 3-year-old girl with Kabuki make-up syndrome (KMS) associated with anovestibular fistula is presented. To our knowledge, 62 patients with KMS have been reported in the literature, three of whom were described as having an anorectal anomaly. Including the present patient, all four KMS patients were females with anovestibular fistula.

Congenital esophageal stenosis due to tracheobronchial remnants and its associated anomalies

Two cases of congenital esophageal stenosis due to tracheobronchial remnants are reported, one accompanied by anovestibular fistula and the other by microphthalmos with iris coloboma. A survey of congenital esophageal stenosis due to tracheobronchial remnants in Japan revealed that the incidence of associated anomalies in this lesion is 17.3% This value is significantly lower than that reported for esophageal atresia. Our analysis showed that esophageal atresia is the most frequently associated anomaly, followed by anorectal abnormalities. Cardiovascular anomalies are very uncommon. Embryology relating to this subject is discussed.

Congenital H-type Ano-vestibular Fistula, Presenting as Inflammation of the Bartholinian Gland

A two month old female infant presented with inflammation of the Bartholinian gland. A congenital ano-vestibular fistula was found without malformation of the anus. The possible pathoembryology is discussed. A protecting colostomy is advised to prevent recurrence of the fistula.