Surgical management of recto-vaginal fistula (about 6 cases).

INTRODUCTION: Recto-vaginal fistula (RVF) is defined as a pathological epithelialized communication between the posterior wall of the vagina and the anterior wall of the rectum through the recto-vaginal septum. RVFs are rare and represent less than 5% of rectal fistulas. Occurring after childbirth or during a proctological pathology, they create a deep distress for the patients. The aim of our work is to analyze the epidemiological particularities and the risk factors of occurrence of RVF as well as the modalities and results of our therapeutic management. MATERIALS AND METHODS: Our work is retrospective analytic and comparative concerning 6 cases operated in the department of general surgery 3 of the UHC Ibn Rochd of Casablanca for recto vaginal fistula or recidive over a period of 7 years from 2012 to 2018. RESULTS: The analysis of the results of our study allowed us to note: A frequency of occurrence of RVF of about 0.48%. The average age at diagnosis was 55 in our patients. The etiologies were dominated by post-radiation (33.33%) and post-operative (16.66%) RVFs. The predominant mode of delivery in our study was vaginal delivery (83.33%). The antecedents were dominated by pelvic irradiation in 50% of patients, and pelvic surgery for cervical cancer and/or rectal cancer (50%). The diagnosis was revealed by a vaginal stool output in all patients. Surgical treatment was performed in all our patients. The surgical technique of choice in our series was drainage by Stenon, in 83.33% of patients. A protective stoma was performed in all our patients studied, a colostomy in 66.66%, and an ileostomy in 33.33% of patients. The immediate postoperative evolution was excellent in all our patients, while the short- and medium-term evolution revealed the occurrence of recurrence in one third of the patients (33.33%). The treatment of choice for recurrence was the interposition of a pedicled fat flap of the labia majora, known as the modified Martius technique. The morbidity, represented mainly by recurrence, was 25%, with a mortality rate of 0%. DISCUSSION: The occurrence of RVF in all its etiologies seems to be infrequent. However, its real incidence remains poorly documented in the literature, it varies between 0.3% and 15.3%. RVFs are considered simple or complex depending on their size, location and etiology. The high or low location and the etiology of the RVF determine the choice of the approach during surgical management. The diagnosis is most often clinical. The examination will try to find the cause of the RVF and the associated lesions. RVF can be asymptomatic. The importance of the symptoms depends on the topography of the fistula, the diameter of the orifice, and the quality of the intestinal transit. No additional investigations are required to confirm the diagnosis of RVF, since the positive diagnosis is essentially clinical. However, in the case of a high or complex fistula, the clinician can support his or her pre-therapeutic assessment with the exploration of imaging data, especially those of the digestive opacification, MRI and pelvic CT. The causes of RVFs are multiple. However, their proportions are difficult to establish. Post-obstetrical RVFs, those due to Crohn's disease, and post-op are probably the most frequent. The literature describes a variety of surgical approaches and treatment options for RVF. However, there are no treatment recommendations. The available data are vague and do not define an optimal treatment. Medical treatment with antibiotics and sitz baths is often necessary to control the local infection. The surgical management of RVFs is complex and follows several principles. The therapeutic arsenal is very varied and constitutes a real "escalation", ranging from simple drainage by suture to the radical treatment represented by abdominal-pelvic amputation. The results of the treatment of simple VF are excellent in all studies. The healing rate varies from 75 to 100% depending on the authors. CONCLUSION: The results of this study confirm the low incidence of RVF, and show that vaginal delivery and a history of pelvic surgery (for rectal or cervical cancer) are the most frequent predictors of RVF. Thus, from a therapeutic point of view, medical treatment is always required, it allows the flow of the fistula to be reduced, which facilitates preparation for the surgical procedure.

Post-traumatic diaphragmatic rupture with pericardial denudation: A case report.

INTRODUCTION: Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. It can be associated with abdominal andthoracic lesions, particularly cardiac, which can be life-threatening. MATERIALS AND METHODS: Our work is a retrospective case report with a descriptive aim concerning a patient operated for a post-traumatic diaphragmatic rupture within the department of general surgery of CHU Ibn Rochd Casablanca. This work has been reported in line with the SCARE 2020 criteria (17). CASE PRESENTATION: A 60-year-old patient was admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration. The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility. The thoraco-abdomino-pelvic CT scan revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome. The decision was to directly send the patient to the operating room. Exploration found a large left diaphragmatic breach of 20 cm, a denudation of the pericardia, a medium-abundant hemoperitoneum and a hematoma of the right mesocolon. The procedure consisted of right hemicolectomy with ileocolic anastomosis, treatment of a diaphragmatic breach with a 2-silk raphia, thoracic drainage with a Joly drain, pericardial drainage with a Joly drain, pre-anastomotic drainage with 2 delbet slides, drainage of the Douglas and left subthreshold with 2 Salem catheters. The post-operative follow-up was simple. DISCUSSION: Diaphragmatic rupture is a rare and difficult to diagnose condition. Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% (1). Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% (9). The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain but it can be asymptomatic. Medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself. The chest X-ray is currently the first examination to be requested (4) and also helps in the diagnosis of injuries and diaphragm rupture (13). Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm. CONCLUSION: Diaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting. SUMMARY: Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. The lesions are more frequent in the left diaphragmatic dome compared to the right one, and exceptionally bilateral. Pericardial rupture following blunt chest trauma is rare and associated to a high mortality rate. It is often unrecognized and goes unnoticed in the acute phase. The most common clinical symptoms of diaphragmatic ruptures are respiratory distress and diffuse abdominal pain, as it can be asymptomatic. Its diagnosis is essentially radiological using CT scan, and requires emergency surgical treatment as soon as the diagnosis is suspected, in order to avoid the dreaded complications. Traumatic diaphragmatic rupture remains a diagnostic and therapeutic challenge. We report the case of a patient who presented a post-traumatic diaphragmatic rupture with pericardial damage operated in the visceral emergency department at the Ibn Rochd Hospital c in Casablanca, Morocco.