Gracilis Flap Repair for Reoperative Rectovaginal Fistula.

BACKGROUND: Surgical treatment of recurrent rectovaginal fistulas is notoriously difficult. Placement of the gracilis muscle between the vagina and anus is an advanced technique used to close persistent fistulas. We have utilized this procedure for recalcitrant fistulas and hypothesized that a gracilis interposition would offer a good treatment option for patients with refractory rectovaginal fistulas, regardless of underlying etiology. OBJECTIVE: The purpose of this study was to investigate healing rates of gracilis interposition in patients with refractory rectovaginal fistulas. DESIGN: Following institutional review board approval, a retrospective review of all adult female patients with a diagnosis of rectovaginal fistula between January 2009 and August 2020 was performed; those who underwent gracilis interposition for definitive fistula closure were included for analysis. SETTINGS: The study was conducted at a colorectal surgery department at a tertiary center in the United States. PATIENTS: All patients were adult females with a diagnosis of a rectovaginal fistula who underwent gracilis interposition for definitive closure. MAIN OUTCOME MEASURES: Patient demographics, etiology of rectovaginal fistula, previous surgical intervention, presence of intestinal diversion, operative details, 30-day morbidity, recurrence of fistula, and time to recurrence. Fistula closure was defined as lack of clinical symptoms following stoma closure, negative fistula detection on gastrograffin enema' and absence of an internal opening at examination under anesthesia. RESULTS: Twenty-two patients were included who had a median age of 43 years (range, 19-64 years) and median body mass index of 31 kg/m 2 (range, 22-51). Median time between prior attempted surgical repair and gracilis surgery was 7 months (range, 3-17). The number of previously attempted repairs were 1-2 (n = 8), 3-4 (n = 9), and > 4 (n = 5). The most recent attempted surgical repair was rectal advancement flap (n = 7), transperineal +/- Martius flap (n = 4), episioproctotomy (n = 3), transvaginal repair (n = 2), and other (n = 6). All patients had fecal diversion at the time of gracilis surgery. Thirty-day postoperative surgical site infection at the graft/donor site was 32% (n = 7). At a median follow-up of 22 months (range 2-62), fistula closure was 59% (n = 13). Gracilis interposition was successful in all inflammatory bowel disease patients. LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: Gracilis interposition is an effective operative technique for reoperative rectovaginal fistula closure. Patients should be counseled regarding the possibility of graft/donor site infection. See Video Abstract at http://links.lww.com/DCR/B763 . REPARACIN CON COLGAJO DE GRACILIS PARA LA FSTULA RECTOVAGINAL REOPERATORIA: ANTECEDENTES:El tratamiento quirúrgico de las fístulas rectovaginales recurrentes es muy difícil. La colocación del músculo gracilis entre la vagina y el ano es una técnica avanzada que se utiliza para cerrar las fístulas persistentes. Hemos utilizado este procedimiento para las fístulas recalcitrantes y planteamos la hipótesis de que una interposición del gracilis ofrecería una buena opción de tratamiento para pacientes con fístulas rectovaginales refractarias, independientemente de la etiología subyacente.OBJETIVO:Investigar las tasas de curación de la interposición del gracilis en pacientes con fístulas rectovaginales refractarias.DISEÑO:Tras la aprobación de la junta de revisión institucional, se realizó una revisión retrospectiva de todas las pacientes adultas con un diagnóstico de fístula rectovaginal entre enero de 2009 y agosto de 2020; los que se sometieron a interposición de gracilis para el cierre definitivo de la fístula se incluyeron para el análisis.AJUSTE:Departamento de cirugía colorrectal de un centro terciario en Estados Unidos.PACIENTES:Todas las pacientes adultas con diagnóstico de fístula rectovaginal que se sometieron a interposición de gracilis para cierre definitivo.PRINCIPALES MEDIDAS DE RESULTADO:datos demográficos del paciente, etiología de la fístula rectovaginal, intervención quirúrgica previa, presencia de derivación intestinal, detalles quirúrgicos, morbilidad a los 30 días, recurrencia de la fístula y tiempo hasta la recurrencia. El cierre de la fístula se definió como la ausencia de síntomas clínicos después del cierre del estoma, la detección negativa de la fístula en el enema de gastrograffin y la ausencia de una abertura interna en el examen bajo anestesia.RESULTADOS:Se incluyeron 22 pacientes que tenían una mediana de edad de 43 años (rango 19-64 años) y una mediana de índice de masa corporal de 31 kg / m2 (rango 22-51). La mediana de tiempo entre el intento previo de reparación quirúrgica y la cirugía del gracilis fue de 7 meses (rango 3-17). El número de reparaciones previamente intentadas fue: 1-2 (n = 8), 3-4 (n = 9), y >4 (n = 5). El intento de reparación quirúrgica más reciente fue el colgajo de avance rectal (n = 7), el colgajo transperineal +/- Martius (n = 4), la episioproctotomía (n = 3), la reparación transvaginal (n = 2) y otros (n = 6). Todos los pacientes tenían derivación fecal en el momento de la cirugía gracilis. La infección del sitio quirúrgico posoperatorio a los 30 días en el sitio del injerto / donante fue del 32% (n = 7). Con una mediana de seguimiento de 22 meses (rango 2-62), el cierre de la fístula fue del 59% (n = 13). La interposición de Gracilis fue exitosa en todos los pacientes con enfermedad inflamatoria intestinal.LIMITACIONES:Carácter retrospectivo de los datos.CONCLUSIONES:La interposición de Gracilis es una técnica quirúrgica eficaz para el cierre reoperatorio de la fístula rectovaginal. Se debe asesorar a los pacientes sobre la posibilidad de infección del sitio del injerto / donante. Consulte Video Resumen en http://links.lww.com/DCR/B763 . (Traducción-Dr. Ingrid Melo ).

Treatment of Rectovaginal Fistula Using Fractionate CO2 Vaginal Laser: A Case Series.

Background: Rectovaginal fistulas (RVFs) are abnormal tracts that connect the lower gastrointestinal tract with the vagina. They can result from obstetric trauma, infection, local surgeries, cancer, radiation damage, and Crohn's disease. Despite the advances in surgical and clinical treatment, there is no consensus regarding the best line of treatment. Objective: To report five cases of patients with RVF submitted to intravaginal CO2 fractional laser treatment, as a complementary and additional therapeutic option in this scenery. Materials and methods: Five laser sessions with monthly intervals followed by complete evaluation through clinical examination and magnetic resonance imaging of the pelvis were performed for all patients. Results: Three patients had complete resolution of symptoms after the end of planned vaginal laser sessions, whereas two patients reported significant improvement in symptoms. Four patients who had stopped having sex due to their condition admitted to resuming regular sexual activity. In addition, all five patients had closure of the fistulous track confirmed by pelvic MRI. No adverse events from vaginal laser therapy were reported by any of the patients. Conclusions: We believe this method to be a complementary, promising, and safe therapeutic alternative for the management of RVF. It may potentially enable return to regular sexual activity. Future studies using this therapeutic strategy are needed to confirm the efficacy and safety of this method in this clinical setting. Clinical trial registration no.: CAAE 93673618.4.0000.5133.

Systemic lupus erythematosus complicated by Crohn's disease with rectovaginal fistula.

BACKGROUND: Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, and few cases combine with Crohn's disease. We present the first SLE patient concurrent with Crohn's disease and rectovaginal fistula. She was successfully treated with vedolizumab and surgical intervention. Besides, she also had a rare opportunistic infection, cryptococcal pneumonia, in previous adalimumab treatment course. CASE: A 57 year-old female had SLE in disease remission for 27 years. She suffered from progressive rectal ulcers with anal pain and bloody stool, and Crohn's disease was diagnosed. She received adalimumab, but the lesion still progressed to a rectovaginal fistula. Besides, she suffered from an episode of cryptococcal pneumonia under adalimumab treatment course. Therefore, we changed the biologics to vedolizumab, and arrange a transverse colostomy for stool diversion. She had clinical remission without active inflammation, but the fistula still persisted. Then, she received a restorative proctectomy with colo-anal anastomosis and vaginal repair. Follow-up endoscopy showed no more rectal ulcers or fistula tracts, and contrast enema also noted no residual rectovaginal fistula. CONCLUSION: When a SLE patient had unusual rectal ulcers, Crohn's disease should be considered. Biologics combined with surgical intervention is an optimal solution for Crohn's disease with rectovaginal fistula. Although cryptococcal pneumonia is a rare opportunistic infection in the biological treatment, we should always keep it in mind.

Hyperbaric oxygen therapy for the treatment of rectovaginal fistulas in patients with Crohn's disease: results of the HOT-REVA pilot study.

BACKGROUND: Positive effects of hyperbaric oxygen (HBO) on perianal fistulas in Crohn's disease (CD) have been described, but the effect on rectovaginal fistulas (RVFs) has not yet been studied. The aim was to investigate the efficacy, safety and feasibility of HBO in patients with RVF in CD. METHODS: In this prospective study, consecutive CD patients between November 2018 and February 2020 presenting with RVF at the outpatient fistula clinic of the Amsterdam University Medical Centre were included and selected to receive treatment with 30 daily HBO sessions, if fistulas were actively draining and any concomitant treatment regimen was stable at least 6 weeks prior to start of HBO. Patients with a stoma were excluded. The primary endpoint was clinical closure at 3-month follow-up, defined as cessation of complaints and/or closure of the external orifice if visible at baseline. Secondary outcomes were improvement of concomitant perianal fistulas as measured by the perianal disease activity index (PDAI) and fistula drainage assessment (FDA), as well as improvement in patient-reported outcomes (visual analogue scale (VAS), inflammatory bowel disease questionnaire (IBDQ), faecal incontinence quality of life scale (FIQL) and female sexual functioning index (FSFI)) at 3-month follow-up. RESULTS: Out of 14 eligible patients, nine patients (median age 50 years) were treated, all of whom had previously had one or more unsuccessful medical and/or surgical treatments for their RVF. Clinical closure occurred in none of the patients at 3-month follow-up. There was no improvement in PDAI and patient-reported outcomes (VAS, IBDQ, FIQL and FSFI). Two patients had concomitant perianal fistulas; using FDA, one patient had a clinical response and one patient was in clinical remission 3 months after HBO. There were two treatment-related adverse events during HBO concerning claustrophobia and fatigue. Furthermore, two patients had a surgical intervention due to RVF and two patients were treated with antibiotics for a urinary tract infection during follow-up. One patient had a dose reduction of ustekinumab because of decreased luminal complaints. CONCLUSION: Treatment with HBO was feasible, but in this therapy-refractory cohort without deviating ostomy no clinical closure of RVF or improvement in quality of life was seen 3 months after HBO. Treatment with HBO alone in this specific group of patients therefore appears to be ineffective.

Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease. / Recomendaciones del Grupo Español de Trabajo de Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) para el tratamiento de las fístulas perianales de la enfermedad de Crohn.

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.

Surgical Strategy for Rectovaginal Fistula After Colorectal Anastomosis at a High-volume Cancer Center According to Image Type and Colonoscopy Findings.

BACKGROUND/AIM: The reported incidence of rectovaginal fistula is very low. Although some case reports have described surgical procedures, no systematic approach to the treatment of rectovaginal fistula according to diagnostic image and colonoscopy findings has been proposed. We present a comprehensive surgical strategy for rectovaginal fistula after colorectal anastomosis according to diagnostic image and colonoscopy findings. PATIENTS AND METHODS: This retrospective study included 11 patients who developed rectovaginal fistula after colorectal anastomosis. Rectovaginal fistula was classified into 4 types according to contrast enema images and colonoscopy findings, i.e., "Alone type", "Dead space type", "Anastomotic stricture type", and "Dead space and Anastomotic stricture type". The surgical strategies were "Diversion (Stoma)", "Percutaneous drainage", "Anastomotic stricture type", "Endoscopic balloon dilation", "Curettage of foreign bodies", "Simple full-thickness closure", "Split-thickness closure", "Pedicled flaps packing", and "Reanastomosis". The surgical strategy appropriate for each rectovaginal fistula type was investigated. RESULTS: Among "Alone type" cases, 5 (71.4%) healed with "only Diversion (Stoma)". "Alone type" cases (n=11) and all other cases (n=4) healed with "only Diversion (Stoma)" (n=5) or any other method (n=6) (p=0.022). CONCLUSION: For treatment of rectovaginal fistula after colorectal anastomosis, less invasive treatment approaches should be attempted first.

Case Report: Treatment for Rectovaginal Fistula in Crohn's Disease Using Fractionate CO2 Vaginal Laser with Anti-TNF Therapy.

Background: Rectovaginal fistulas (RVFs) are defined as any connection between the anorectum and the vagina. They can have several causes, being Crohn's disease, the second leading cause of RVFs, responsible for ∼10% of the RVFs. Despite the advances in surgical and clinical treatment, there is no consensus regarding the best line of treatment. Objective: To report another therapeutic option, we describe the case of a patient with Crohn's disease and RVF refractory to anti-tumor necrosis factor (TNF) therapy, submitted to intravaginal CO2 fractional laser treatment. Materials and methods: Three laser sessions with monthly interval and analysis by clinical examination, sexual evaluation questionnaire, and magnetic resonance of the pelvis were performed. Results: We obtained an important improvement of the symptoms and of the dimension of the fistulous path. Conclusions: We believe this method to be a complementary, promising, and safe therapeutic alternative for the management of vaginal fistula. Future studies using this therapeutic strategy are needed to confirm the efficacy of this method in this clinical setting.

Social Experiences of Women with Obstetric Fistula Seeking Treatment in Kampala, Uganda.

BACKGROUND: Obstetric fistula is a preventable and treatable condition predominately affecting women in low-income countries. Understanding the social context of obstetric fistula may lead to improved prevention and treatment. OBJECTIVES: This study investigated social experiences of women with obstetric fistula seeking treatment at Mulago Hospital in Kampala, Uganda. METHODS: A descriptive study was conducted among women seeking treatment for obstetric fistula during a surgical camp in July 2011 using a structured questionnaire. Descriptive statistics were computed regarding sociodemographics, obstetric history, and social experience. FINDINGS: Fifty-three women participated; 39 (73.58%) leaked urine only. Median age was 29 years (range: 17-58), and most were married or separated. About half (28, 47.9%) experienced a change in their relationship since acquiring obstetric fistula. More than half (27, 50.94%) acquired obstetric fistula during their first delivery, despite almost everyone (50, 94.3%) receiving antenatal care. The median years suffering from obstetric fistula was 1.25. Nearly every participant's social participation changed in at least one setting (51, 96.23%). Most women thought that a baby being too big or having kicked their bladder was the cause of obstetric fistula. Other participants thought health care providers caused the fistula (15, 32.61%; n = 46), with 8 specifying that the bladder was cut during the operation (cesarean section). Knowing someone with obstetric fistula was influential in pursuing treatment. The majority of participants planned to return to family (40, 78.43%; n = 51) and get pregnant after repair (35, 66.04%; n = 53). CONCLUSION: Study participants experienced substantial changes in their social lives as a result of obstetric fistula, and there were a variety of beliefs regarding the cause. The complex social context is an important component to understanding how to prevent and treat obstetric fistula. Further elucidation of these factors may bolster current efforts in prevention and holistic treatment.

[Treatment of complications after laparoscopic intersphincteric resection for low rectal cancer].

OBJECTIVE: To summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management. METHODS: An observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital. The clinicopathological parameters, perioperative and postoperative complications, and clinical outcomes were collected from a prospectively maintained database. Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation, respectively. RESULTS: Forty-nine(67.1%) cases were male and 24(32.9%) were female with a median age of 61(25 to 79) years. The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm. The median operative time was 195 (120 to 360) min, median intra operative blood loss was 100 (20 to 300) ml, median number of harvested lymph nodes was 14(3 to 31) per case. All the patients underwent preventive terminal ileum loop stoma. No conversion or hospital mortality was presented. The R0 resection rate was 98.6% with totally negative distal resection margin. A total of 34 complication episodes were recorded in 21(28.8%) patients during perioperative period, and among which 20.6%(7/34) was grade III(-IIII( according to Dindo system. Anastomosis-associated morbidity (16.4%,12/73) was the most common after LapISR, including mucosa ischemia in 9 cases(12.3%), stricture in 7 cases (9.6%, 4 cases secondary to mucosa necrosis receiving anal dilation), grade A fistula in 3 cases (4.1%) receiving conservative treatment and necrosis in 1 case (1.4%) receiving permanent stoma. After a median follow up of 21(3 to 60) months, postoperative complications were recorded in 12 patients (16.4%) with 16 episodes, including anastomotic stenosis (8.2%), rectum segmental stricture (5.5%), ileus (2.7%), partial anastomotic dehiscence (1.4%), anastomotic fistula (1.4%), rectovaginal fistula (1.4%) and mucosal prolapse (1.4%). These patients received corresponding treatments, such as endoscopic transanal resection, anal dilation, enema, purgative, permanent stoma, etc. according to the lesions. Six patients (8.2%) required re-operation intervention due to postoperative complications. CONCLUSION: Anastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods, which must be strictly managed with suitable methods.

Time trends in the epidemiology and outcome of perianal fistulizing Crohn's disease in a population-based cohort.

OBJECTIVE: Perianal disease is a debilitating condition that frequently occurs in Crohn's disease (CD) patients. It is currently unknown whether its incidence has changed in the era of frequent immunomodulator use and biological availability. We studied the incidence and outcome of perianal and rectovaginal fistulas over the past two decades in our population-based Inflammatory Bowel Disease South-Limburg cohort. PATIENTS AND METHODS: All 1162 CD patients registered in the Inflammatory Bowel Disease South-Limburg registry were included. The cumulative probabilities of developing a perianal and rectovaginal fistula were compared between three eras distinguished by the year of CD diagnosis: 1991-1998, 1999-2005 and 2006-2011. Second, clinical risk factors and the risk of fistula recurrence were determined. RESULTS: The cumulative 5-year perianal fistula rate was 14.1% in the 1991-1998 era, 10.4% in the 1999-2005 era and 10.3% in the 2006-2011 era, P=0.70. Colonic disease was associated with an increased risk of developing perianal disease, whereas older age was associated with a decreased risk (both P<0.01). Over time, more patients were exposed to immunomodulators or biologicals before fistula diagnosis (18.5 vs. 32.1 vs. 52.1%, respectively, P=0.02) and started biological therapy thereafter (18.6 vs. 34.1 vs. 54.0%, respectively, P<0.01). The cumulative 5-year perianal fistula recurrence rate was not significantly different between eras (19.5 vs. 25.5 vs. 33.1%, P=0.28). In contrast, the cumulative 5-year rectovaginal rate attenuated from 5.7% (the 1991-2005 era) to 1.7% (the 2006-2011 era), P=0.01. CONCLUSION: Over the past two decades, the risk of developing a perianal fistula was stable, as well as its recurrence rate, underlining the lasting need for improving treatment strategies for this invalidating condition.

The role of a defunctioning stoma for colonic and perianal Crohn's disease in the biological era.

OBJECTIVE: A defunctioning stoma is a therapeutic option for colonic or perianal Crohn's disease. In the pre-biologic era the response rate to defunctioning in our unit was high (86%), but intestinal continuity was only restored in 11-20%. Few data exist on the outcome of defunctioning since the widespread introduction of biologicals. MATERIAL AND METHODS: All patients undergoing a defunctioning stoma for colonic/perianal Crohn's disease since 2003-2011 were identified from a prospective database. Indications for surgery, medical therapy, response to defunctioning and long-term clinical outcome were recorded. Successful restoration of continuity was defined as no stoma at last follow up. RESULTS: Seventy-six patients were defunctioned (57 with biologicals) and at last follow up, 20 (27%) had continuity restored. Early clinical response rate (<3 months) was 15/76 (20%) and overall response 31/76 (41%). Complex anal fistulae/stenosis were associated with a very low chance of restoring continuity (10% and 0%, respectively), while colitis was associated with a higher chance of restoring continuity (48%). Endoscopic or histological improvement in colitis after defunctioning was associated with a higher rate of restoring continuity (10/16, 63%) compared to no such improvement (4/15, 27%, p = 0.05). Those failing biologics had similar chance of restoration as those not receiving biologics, 15/57 (26%) and 5/19 (26%), respectively. CONCLUSION: Overall response to colonic defunctioning was 41%. Successful restoration of continuity occurred in 27%, but 48% in the absence of perianal disease. Response is appreciably less in the pre-biologic era, so patient and physician expectations need to be managed appropriately.

Obstetric Fistula "Disease" and Ensuing Care: Patients' Views in West-Africa.

We explored obstetric fistula patients' real-life experience of care in modern Health System. Our aim was to analyze how these women's views impacted their care uptake and coping. We conducted 67 in-depth interviews with 35 fistula patients or former patients in 5 fistula repair centers within referral hospitals in Mali and Niger. Perceptions of obstetric fistula influenced the care experience and vice versa. Obstetric fistula was viewed as a severe chronic disease due to length of care process, limitation of surgery and persisting physical and moral suffering. We highlight the opportunity to build on patients' views on obstetric fistula trauma and care in order to implement an effective holistic care process.

Puborectal sling interposition combined with seton drainage for pouch-vaginal fistula after rectal cancer surgery with colonic J pouch-anal reconstruction: report of a case.

The management of postoperative rectovaginal fistula (RVF) after rectal cancer surgery is difficult and requires reconstruction of the anastomotic site and fistula. Though various surgical procedures have been reported for the repair of RVFs, the results of surgical repair are often unsatisfactory, and failure of the initial repair leads to difficulty in the later operations. Furthermore, it has been reported that cases associated with local infection result in low success rates. We report a case of an 80-year-old woman with a recurrent colonic J pouch-vaginal fistula after anoabdominal rectal resection with partial internal sphincteric resection, who achieved a good outcome following a repair using a puborectal sling interposition combined with seton drainage. It may be a useful option for RVF management in repair of such pouch-vaginal fistula after coloanal anastomosis with intersphincteric resection.

Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu village, Iganga district, Uganda.

BACKGROUND: Obstetric fistula is a worldwide problem that is devastating for women in developing countries. The cardinal cause of obstetric fistula is prolonged obstructed labour and delay in seeking emergency obstetric care. Awareness about obstetric fistula is still low in developing countries. The objective was to assess the awareness about risk factors of obstetric fistulae in rural communities of Nabitovu village, Iganga district, Eastern Uganda. METHODS: A qualitative study using focus group discussion for males and females aged 18-49 years, to explore and gain deeper understanding of their awareness of existence, causes, clinical presentation and preventive measures for obstetric fistula. Data was analyzed by thematic analysis. RESULTS: The majority of the women and a few men were aware about obstetric fistula, though many had misconceptions regarding its causes, clinical presentation and prevention. Some wrongly attributed fistula to misuse of family planning, having sex during the menstruation period, curses by relatives, sexually transmitted infections, rape and gender-based violence. However, others attributed the fistula to delays to access medical care, induced abortions, conception at an early age, utilization of traditional birth attendants at delivery, and some complications that could occur during surgical operations for difficult deliveries. CONCLUSION: Most of the community members interviewed were aware of the risk factors of obstetric fistula. Some respondents, predominantly men, had misconceptions/myths about risk factors of obstetric fistula as being caused by having sex during menstrual periods, poor usage of family planning, being a curse.

Use of gracilis muscle as a "walking" flap for repair of a rectovaginal fistula.

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Genital fistulas in female Crohn's disease patients.: clinical characteristics and response to therapy.

BACKGROUND: Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life. AIMS: To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients. RESULTS: A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases. CONCLUSION: Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment.

Depression among women with obstetric fistula in Kenya.

OBJECTIVE: To establish the prevalence of depression and describe associated factors among fistula patients attending an obstetric fistula surgical camp in Kenya. METHODS: A cross-sectional study was conducted focusing on obstetric fistula patients attending a national fistula camp held in August 2008 at Kenyatta National Hospital, Nairobi, Kenya. A structured questionnaire was used to obtain sociodemographic data and medical histories for all consenting patients before surgery. Depression measures were obtained using the Patient Health Questionnaire-9. RESULTS: Of the 70 women interviewed, 2 (2.9%) and 12 (17.1%) reported a history of psychiatric illness and suicidal ideations, respectively. Depression was present in 51 (72.9%) patients, with 18 (25.7%) meeting criteria for severe depression. Depression was significantly associated with women older than 20 years of age (P=0.01), unemployment (P=0.03), lack of social support following fistula (P=0.04), and living with fistula for over 3 months (P=0.01). CONCLUSION: Women with obstetric fistula are predisposed to high levels of depression. A holistic management approach, including mental health care and family support, is recommended.

Caring for a patient with a fungating malignant lesion in a hospice setting: reflecting on practice.

This article attempts to demonstrate the process of using experiential learning to reflect on nursing practice. This will be discussed in relation to the Atkins and Murphy's model of reflection. A case study will be used to demonstrate the complex issues of symptom management and the implications for improving and maintaining a consistent quality of holistic care within a hospice. The case of 'Sylvia', a 68-year-old woman with a diagnosis of incurable cancer, will be discussed in relation to the management of a fungating malignant lesion, pain management, the control of malodour, and maintaining dignified and respectful care and optimizing self-esteem and quality of life.