Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
J Pediatr Surg. 2011 Jun;46(6):1226-30. doi: 10.1016/j.jpedsurg.2011.03.058.
H-type rectovestibular or rectovaginal fistulas are rare entities in the spectrum of anorectal malformations seen in North America. Management options described in the literature have included perineal repair, anterior perineal anorectoplasty, vestibuloanal pull-through, and limited or formal posterior sagittal anorectoplasty, with a reported recurrence rate of 5% to 30%. We describe our approach and outcome in the management of these patients.
In a series of 1170 females with anorectal malformation, we cared for 8 patients who had an H-type rectovestibular or rectovaginal fistula and reviewed their clinical presentation, diagnosis, operative technique, and postoperative course.
The patients' presenting symptoms included passage of stool per vagina (6), constipation (3), labial abscess (1), and recurrent urinary tract infection (1). There was associated anorectal stenosis in 3 patients. The remaining 5 patients had normal anal openings. Endoscopy was not helpful in locating the fistulas, but the fistulas were all demonstrated on direct inspection under anesthesia. The fistula was located in the vestibule (4), vagina (3), or labia (1). One patient had an associated presacral mass. Two patients had been operated on twice previously using a perineal repair and a protective colostomy and presented with third recurrences. In 5 cases, a posterior sagittal approach was used, placing sutures circumferentially around the fistulous opening on the rectal side, ligating the fistula, and pulling down a normal segment of rectum to be placed in front of the repaired vaginal wall. In our last 3 cases, we performed a transanal mobilization of the anterior rectal wall, leaving the perineal body intact. After our repairs, the patients have been followed up for 3 months to 15 years with a median of 15 months, and we have seen no recurrences.
In addition to vaginal passage of stool, an H-type fistula should be suspected when there is a labial abscess in an infant, and an associated anal stenosis or presacral mass must be checked for. Direct inspection is the key, with a careful look in the vestibule, because endoscopy may miss the fistula. The essential technical point for repair is to get healthy anterior rectal wall to cover the area of fistula on the posterior vagina. A transanal approach, leaving the perineal body intact, is an excellent option for this repair.
H 型直肠前庭或直肠阴道瘘在北美所见的肛门直肠畸形谱中较为罕见。文献中描述的治疗选择包括会阴修复、前会阴肛门成形术、前庭肛门拖出术以及有限或正式的后矢状位肛门直肠成形术，其复发率为 5%至 30%。我们介绍了我们在治疗这些患者中的方法和结果。
在一系列 1170 名女性肛门直肠畸形患者中，我们治疗了 8 名患有 H 型直肠前庭或直肠阴道瘘的患者，回顾了他们的临床表现、诊断、手术技术和术后过程。
患者的主要症状包括阴道排便（6 例）、便秘（3 例）、阴唇脓肿（1 例）和复发性尿路感染（1 例）。3 例患者存在直肠肛门狭窄。其余 5 例患者的肛门开口正常。内镜检查对定位瘘管没有帮助，但在麻醉下直接检查时均显示瘘管。瘘管位于前庭（4 例）、阴道（3 例）或阴唇（1 例）。1 例患者伴有直肠前肿块。2 例患者曾两次接受会阴修复和保护性结肠造口术治疗，出现第三次复发。在 5 例患者中，采用后路矢状位入路，在直肠侧围绕瘘口环形缝合，结扎瘘管，并将正常的直肠段拉下放置在修复后的阴道壁前方。在我们的最后 3 例患者中，我们进行了经肛门的前直肠壁游离，保持会阴体完整。我们的修复后，对患者进行了 3 个月至 15 年的随访，中位随访时间为 15 个月，未发现复发。
除阴道排便外，当婴儿出现阴唇脓肿时，应怀疑为 H 型瘘管，并且必须检查是否存在肛门狭窄或直肠前肿块。直接检查是关键，要仔细观察前庭，因为内镜检查可能会遗漏瘘管。修复的关键技术要点是使健康的前直肠壁覆盖阴道后部的瘘管区域。经肛门入路，保持会阴体完整，是这种修复的极佳选择。
