Penninckx F, Moneghini D, D'Hoore A, Wyndaele J, Coremans G, Rutgeerts P
Department of Abdominal Surgery, University Clinic Gasthuisberg, Catholic University Leuven, Belgium.
Colorectal Dis. 2001 Nov;3(6):406-11. doi: 10.1046/j.1463-1318.2001.00274.x.
To compare the healing rate after several types of surgical repair of rectovaginal fistula (RVF) in Crohn's disease, and to identify factors predicting a successful outcome.
A Medline review of the literature since 1980 and analysis of our results in 32 consecutive patients was done.
All types of repair (rectal, vaginal, anocutaneous advancement flap, or perineoproctotomy with fistula closure) seem to be equally effective. Healing after a first repair is observed in 58 (46-71)%. Healing can still be obtained at subsequent attempts in 62 (40-71)% of the patients. The reported overall healing rate is 75 (56-93)%. The need for proctectomy after an attempt to repair was 6 (0-27)% in these series. Using a tailored surgical approach, we observed primary healing in 57%, healing after one or more supplementary procedures in 71%, for a total 'definitive' closure rate of 75%. Anal continence was never compromised and all temporary stomas (12 patients) could be closed. Univariate analysis identified number of Crohn's sites, presence of extra-intestinal disease and previous Crohn's proctitis to be related with problematic healing after a surgical repair. A positive relation was found between extra-intestinal disease and the number of repairs needed to ultimately obtain healing, whereas the relation with previous right hemicolectomy was negative. Multivariate analysis revealed the number of Crohn's sites as the only factor predicting problematic healing. A defunctioning stoma was not related to the healing rate and had its intrinsic morbidity with supplementary hospitalization (9.6 days). After a median follow-up of 40.4 (range 8-87) months, we observed 4 late recurrences in 25 patients with healed RVF (16%).
Closure of a RVF in Crohn's disease should not be considered an easy undertaking, especially in patients with several Crohn's sites. In this very heterogeneous group of patients the technique is adapted to the nature and the extent of accompanying anorectal disease. Construction of a temporary stoma is not mandatory and can be limited to complex cases. Healing can be obtained in 75% of all patients, although a late recurrence might occur.
比较克罗恩病直肠阴道瘘（RVF）几种手术修复方式后的愈合率，并确定预测成功结局的因素。
对1980年以来的文献进行Medline检索，并分析我们连续32例患者的结果。
所有类型的修复（直肠、阴道、肛门皮瓣推进或瘘管闭合的会阴直肠切除术）似乎同样有效。首次修复后的愈合率为58%（46 - 71%）。在后续尝试中，62%（40 - 71%）的患者仍可实现愈合。报告的总体愈合率为75%（56 - 93%）。在这些系列中，尝试修复后需要行直肠切除术的比例为6%（0 - 27%）。采用定制的手术方法，我们观察到一期愈合率为57%，经过一次或多次补充手术后愈合率为71%，总的“确定性”闭合率为75%。肛门节制功能从未受到损害，所有临时造口（12例患者）均可关闭。单因素分析确定克罗恩病累及部位数量、肠外疾病的存在以及既往克罗恩病直肠炎与手术修复后愈合困难相关。发现肠外疾病与最终实现愈合所需的修复次数呈正相关，而与既往右半结肠切除术的关系为负相关。多因素分析显示克罗恩病累及部位数量是预测愈合困难的唯一因素。失功性造口与愈合率无关，且其本身存在补充住院（9.6天）的发病率。中位随访40.4个月（范围8 - 87个月）后，我们在25例愈合的RVF患者中观察到4例晚期复发（16%）。
克罗恩病RVF的闭合不应被视为一项简单的任务，尤其是在有多个克罗恩病累及部位的患者中。在这群非常异质性的患者中，手术技术应根据伴发的肛肠疾病的性质和程度进行调整。临时造口的构建并非必需，可仅限于复杂病例。所有患者中有75%可实现愈合，尽管可能会发生晚期复发。
