Multimedia article. Success of episioproctotomy for cloaca and rectovaginal fistula.

PURPOSE: Surgical repair of rectovaginal fistula with an advancement flap has had suboptimal results. The existing literature documenting episioproctotomy as a surgical option in females with rectovaginal fistula or cloaca is limited. This study was designed to examine our experience with episioproctotomy in this group. Additionally we were interested in risk factors, which might predict failure. METHODS: All females who had repair of a rectovaginal fistula or cloaca with episioproctotomy from 1998 to 2004 were studied. Data were collected from chart review and telephone contact. This included demographics, body mass index, tobacco use, Crohn's disease, previous surgery, and diverting stoma. RESULTS: Data were obtained from 42 females (mean age, 39.2 (range, 25-70) years). The mean follow-up was 37 (range, 2-84) months. Nine females had a cloaca and the rest had a rectovaginal fistula with an anterior sphincter defect. Eleven (all with anterior tissue) had recurrence of fistula. None with cloaca had recurrence. Eight of 11 recurrences occurred in females who had failed at least one previous repair. No variables that were studied significantly affected recurrence. Median (25th, 75th percentiles) postoperative Wexner incontinence scores for those with and without recurrence were 8 (7, 12) and 5 (2, 6) respectively. CONCLUSIONS: Episioproctotomy is a successful technique for repair of rectovaginal fistula and cloaca. Incontinence score postoperatively were acceptable. It should be considered a first line of surgical treatment in those with a fistula that includes compromise of the anterior sphincter complex.

Repair of recurrent rectovaginal fistulas.

BACKGROUND: Recurrent rectovaginal fistulas (RRVFs) pose a challenging problem, which can be treated by different surgical procedures. We performed this study to determine the ultimate success rate of various repair techniques. METHODS: Using a standard data collection form, we retrospectively reviewed charts of patients treated for RRVF. RESULTS: Between 1991 and 2000, 57 procedures were performed in 35 women who presented with RRVF. Median follow-up was 4 months (interquartile range, 1,25). The causes of RRVF included obstetrical injury (n = 15), Crohn's disease (n = 12), fistula occurring after proctocolectomy with ileal pouch-anal anastomosis (for ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial polyposis, n = 1), cryptoglandular disease (n = 2), and fistula occurring immediately after low anterior resection for rectal cancer (n = 1). The methods of repair used included mucosal advancement flap (n = 30), fistulotomy with overlapping sphincter repair (n = 14), rectal sleeve advancement (n = 3), fibrin glue (n = 1), proctectomy with colonic pull-through (n = 2), and ileal pouch revision (n = 6). Twenty-seven of 34 (79%) patients with adequate follow-up eventually healed after a median of 2 operations. Logistic regression was used to analyze outcome according to etiology of fistula, patient age, number of prior repairs, time interval between last repair and current repair, and presence of fecal diversion. Crohn's disease, the presence of a diverting stoma, and decreased time interval since prior repair were associated with a poorer outcome. CONCLUSIONS: Most RRVFs can be successfully repaired, although repeated operations may be necessary. Delaying repair may improve outcome.

Outcome of sphincteroplasty combined with surgery for urinary incontinence and pelvic organ prolapse.

PURPOSE: This is the first reported prospective study comparing outcome and cost in patients undergoing sphincteroplasty for anal incontinence vs. sphincteroplasty performed in combination with one or more procedures for urinary incontinence and/or pelvic organ prolapse. METHODS: We analyzed 44 patients with fecal incontinence who underwent anal sphincter repair alone (20 patients) or in combination with procedures for urinary incontinence or pelvic organ prolapse (24 patients). Information regarding risk factors for fecal incontinence, the degree of incontinence, and the extent that incontinence limited social, physical, and sexual activity was prospectively obtained from questionnaires. Clinic chart reviews and follow-up telephone interviews provided additional data. A cohort of case-matched patients who underwent only urogynecologic procedures was compared retrospectively for operative time, hospital cost, length of stay, and postoperative complications. RESULTS: There were no major complications in any group. The functional outcomes, physical, social, and sexual activity were similar in all three groups. Twenty-two of 24 patients who underwent the combined procedures were glad that they had both procedures concomitantly. CONCLUSION: Combination pelvic floor surgery provides good outcomes and is cost effective. This approach should be offered to women with concurrent problems of fecal and urinary incontinence and/or pelvic organ prolapse.

Preliminary results of an outcome tool used for evaluation of surgical treatment for fecal incontinence.

PURPOSE: The lack of an outcome tool to evaluate the outcome of surgical and medical treatment for fecal incontinence makes interpretation of success difficult. The purpose of this study was to evaluate a preliminary outcome tool for fecal incontinence. METHOD: Since 1994 an extensive database has prospectively been collected on all females undergoing an overlapping sphincter repair for fecal incontinence by a single surgeon. A simple incontinence form designed to examine outcome, developed by colon and rectal surgeons, was filled out preoperatively and postoperatively. RESULTS: Of 206 females evaluated for surgical treatment of their fecal incontinence, 65 underwent surgical treatment from January 1994 until July 1999. The mean age was 49 (range, 23-80) years, and the mean follow-up was 10 (range, 1-50) months. When comparing each variable (problems holding gas, staining of undergarments, accidental bowel movements, and need to wear pads) and lifestyle issue (physical, social, and sexual activities) preoperatively and postoperatively, there was significant improvement in all areas. Three parameters were chosen (change in accidental bowel movements, improvement in two of three lifestyle areas, and improvement in one of three lifestyle areas) to examine individual items from the database and to determine if they affected outcome. No single variable has a significant effect on the outcome. A scoring system was devised from the questionnaire. From preoperatively to postoperatively, there was a median 14-point improvement that was statistically significant. CONCLUSIONS: This preliminary tool to examine outcome for fecal incontinence measures parameters that are significantly improved by overlapping sphincteroplasty. More work is needed to refine and validate this tool because a standard outcome tool is needed for reporting the results of surgical treatment of fecal incontinence.

Dietary choices of people with ostomies.

OBJECTIVE: The objective was to collect data related to individual dietary recommendations and restrictions for people with ostomies. DESIGN: A descriptive survey was used that asked people about food choices/avoidances that occurred because of their ostomy. SUBJECTS: Subjects were members of the United Ostomy Association who had an ostomy and were living at home. METHODS: A 14-item questionnaire was mailed to the United Ostomy Association membership (approximately 40,000 current members) in their quarterly newsletter. RESULTS: Six hundred and four questionnaires were returned. The most frequent reason for ostomy surgery among the respondents was colon cancer (71%; n = 424), and the most common type of ostomy was a colostomy. The majority of respondents (88.4%) stated that they were not following a special diet because of the ostomy; 11.8% (n = 69) stated that they had modified their diet. Of the people who had modified their diet, 55% stated that they were using the special diet indefinitely and were adhering to it very well. More than half of the participants had received dietary instructions, provided mainly by a WOC nurse, at the time of surgery. The foods avoided because of the ostomy included fresh fruits, nuts, coconut, and vegetables such as corn, popcorn, cabbage, beans, and onions. The major problems reported were blockage and increased gas. CONCLUSION: Many respondents reported problems with certain foods. Preoperative teaching and postoperative follow-up must include anticipatory guidance on food selection.