Coloplastia vaginal, una opción en el tratamiento de la fístula rectovaginal grande / Vaginal coloplasty, an option in the treatment of large rectovaginal fistula

Objetivo: Presentar un tratamiento alternativo para una fistula recto vaginal grande producida por la radiación en una mujer joven tratada por cáncer de cuello uterino, basado en las sigmoideoplastias vaginales en pacientes con agenesia de vagina. Paciente y método: Paciente de sexo Femenino de 36 años que el año 2010 concurre al consultorio de proctología por presentar proctorragia asociada a la defecación de dos semanas de evolución. Antecedentes de conización en el año 2008 por carcinoma epidermoide de cuello uterino y en 2009 irradiada con braquiterapia y radioterapia por presentar recidiva en vagina de cáncer de cuello uterino. Se decide la internación y al día siguiente es llevada a quirófano donde se observa a nivel de recto inferior y medio, fístula con tercio medio e inferior de vagina de unos 4 a 5 cm de diámetro. Dada las características de la misma, el grado de incontinencia de la paciente, su retracción inmediata de sus actividades laborales y sociales, se le plantea la posibilidad de desfuncionalizarla resecado el recto medio e inferior, completar la cirugía oncológica de su cáncer y en un segundo acto reconstruir tanto el tránsito intestinal como su vagina con un segmento vascularizado de colon. Discusión: Existen varias formas de clasificar una fistula rectovaginal, en base a su ubicación, según su diámetro, por último se pueden clasificar según su complejidad en simples y complejas. Dentro de los tratamientos hallamos los perineales, rectales o vaginales, indicados en las fistulas bajas o medias y los abdominales en las fistulas altas. Existen algunas que no responde a los tratamientos habituales o que desde un principio no se pueden tratar por las técnicas habituales, llevando en contadas ocasiones a tratamientos más agresivos como la desfuncionalización, colgajos miocutáneos o la técnica de Simonsen.

Purpose: to present an alternative treatment for rectovaginal fistula secondary to radiation in a young female patient treated for cervical cancer, based on a vaginal sigmoideoplasty. Patient and Method: 36 years old female patient with a 2-week history of rectal bleeding. Personal history of conization in 2008 for cervical squamous carcinoma and postoperative treatment in 2009 with brachytherapy and radiaton therapy for local cancer recurrence. On surgical perineal exploration a recto-vaginal defect of 4-5 cm was identified in the middle-lower vagina. Proctectomy was performed based in surgical principles. During reconstructive surgery the vagina was replaced with a colonic segment. Results: there are several ways to classify a rectovaginal fistula, based on location, diameter and according to their complexity into simple and complex. Rectal, perineal and vaginal approaches have been described. In some cases, more aggressive techniques could be performed such as myocutaneous flaps and Simonsen technique.

Ressecção anterior ultrabaixa e interesfinctérica do reto com anastomose coloanal por videolaparoscopia / Laparoscopic very low anterior resection with coloanal anastomosis and intersphincteric resection

O autor apresenta, detalhadamente, a técnica de ressecção anterior ultrabaixa e interesfinctérica com anastomose coloanal por videolaparoscopia para tratamento do câncer do reto distal. São descritos os principais passos da operação: 1 - Posição do Paciente; 2 - Posicionamento do Equipamento e Equipe; 3 - Posicionamento dos Trocartes e Exploração da Cavidade Abdominal; 4 - Exposição do Campo Operatório; 5 - Ligadura dos Vasos Mesentéricos Inferiores pelo acesso medial; 6 - Mobilização do Ângulo Esplênico e do Colon Sigmóide; 7 - Excisão total do mesorreto, preservação dos nervos pélvicos e mobilização do reto pela técnica de Rullier; 8- Secção do reto distal e anastomose coloanal;9-Ressecção interesfinctérica (RI) e anastomose coloanal com coloplastia transversa, bolsa colónica em J ou anastomose latero-terminal. A utilização desta técnica, apesar de ser um procedimento complexo, mostrou-se viável e segura, pois apresentou baixo índice de complicação pós-operatória e mortalidade.

The author present the laparoscopic coloanal anastomosis and intersphincteric resection technique to treat patients with very low rectal cancer. The operative steps are: 1 - Patient positioning; 2 - Instruments and equip positioning; 3 - Insertion of the ports; 4 - Preparation of the operative field; 5 - Difining and dividing the inferior mesenteric artery and vein by the medial approach; 6 - Mobilization of splenic flexure and sigmoid colon; 7 - rectal mobilization and total mesorectum excision by Rullier technique; 8 - Rectal division and coloanal anastomosis; 9 - intersphincteric resection and coloanal anastomosis by coloplasty, J pouch or latero-to-end techniques. The technique employed is safe and have presented low rate of complication and no mortality.

Application of sigmoid coloplasty after resection of middle or low rectal cancer / 中华消化外科杂志

Objective To investigate the feasibility of sigrnoid coloplasty for patients after resection of middle or low rectal carcinoma, and to evaluate the defecation function after the operation. Methods Forty-three patients with middle or low rectal cancer who had been admitted to the cancer Hospital of the Chinese Academy of Medical Sciences from January 2007 to January 2008 received sigrnoid coloplasty after rectal carcinoma resection (treatment group), and another 43 patients who had been admitted during the same period received colonic J pouch reconstruction (control group). The feasibility and safety of the 2 surgical procedures and postoperative defecation function were assessed. All data were processed by t test, chi-square test or Fisher exact probability. Results The sigmoid coloplasty was successfully performed in all patients in treatment group, while the reconstruction of the J pouch failed in 4 patients in the control group. Three patients in each group underwent temporary transverse colostomy. The incidences of postoperative complications in treatment group and control group were 7% (3/43) and 9% (4/43), respectively, with no statistical difference between the 2 groups (X2 =0. 282, P > 0.05). The median frequency of defecation in treatment group was 2.0 ± 1.5 per 24 hours, which was significantly less than 2.5 ± 1.0 in control group (X2 = 1. 242, P > 0.05). The fecal incontinence scores in treatment group and control group were 1.7 ± 0. 7 and 1.6 ± 0.8, respectively, with no statistical difference between the 2 groups (t = 0. 285, P > 0. 05). Conclusion Sigmoid coloplasty has similar benefits to colonic J pouch reconstruction, while sigmoid eoloplasty is relatively feasible, effective and safe for low colorectal or coloanal anastomosis.

Comparison of a Straight, a Coloplasty, and a Colonic J-pouch Anastomosis after a Proctectomy for Rectal Cancer

PURPOSE: Colonic pouches have been used to improve the reservoir function of the neorectrum after a ultra-low anterior resection for treatment of rectal cancer. The purpose of this study was to compare the safety and the functional outcome between a straight anastomosis, an anastomosis using coloplasty, and that using a colonic J-pouch in patients who had undergone an ultralow anterior resection. METHODS: From 2004 through 2006, 60 patients underwent a coloanal straight (straight group: n=23), coloplasty (coloplasty group: n=19), or colonic J-pouch (J-pouch group: n=18) anastomosis to the anal canal after a total mesorectal excision of the rectal cancer. We retrospectively reviewed the medical records of those patients for clinical outcomes according to the reservoir type. The median follow-up interval was 23.7 (4.4-40.9) mo. RESULTS: The anastomotic leakage rate was higher in the coloplasty group (21.1%) than in the straight group (8.7%) or in the J-pouch group (0%), but the difference was not significant (P=0.1). The mean number of bowel movements per day was significantly lower in the coloplasty group (3.6) and in the pouch group (3.1) than in the straight group (6.2) (P=0.015). No statistically significant differences were found among the three groups regarding other functional outcomes, including use of antidiarrheal drugs (P=0.971), gas incontinence (P=0.256), fecal incontinence (P=0.544), use of pads (P=0.782), difficulty of evacuation (P=0.496), and use of enemas (P=0.712). CONCLUSION: Reconstruction with a coloplasty or a colonic J-pouch in patients undergoing a low colorectal or coloanal anastomosis after rectal cancer surgery seems to decrease the number of daily bowel movements compared to a straight anastomosis. However, the anastomotic leakage rate of coloplasty group was higher than that of the straight-anastomosis group.