Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2018  |  Volume : 23  |  Issue : 4  |  Page : 182--185

Vestibulo-rectal pull through in H-fistula in girls


Kuntal Bhaumik, Sachchidananda Das, Subir K Chatterjee 
 Department of Pediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India

Correspondence Address:
prof. Kuntal Bhaumik
Indira Kunj, 3rd Floor, 38/39, Bangur Avenue, Block-D, Kolkata - 700 055, West Bengal
India

Abstract

Aims and Objectives: Vestibulo-rectal pull-through (VRPT) in H-fistula in girls was first described by Chatterjee et al. We are presenting our experience with this approach in 47 cases. Materials and Methods: We have total 47 cases of which one is a recurrent fistula operated outside. A circumferential incision is made around the fistula in the vestibule; fistula tract is dissected liberally and delivered by invagination into the bowel. Then, the fistula tract is excised adequately and closed from within the bowel lumen so that no anterior outpouching of the rectum remains. The perineal body is repaired through the vestibular incision. In no cases, protective colostomy was performed. Only the recurrent fistula case had colostomy done in another institution. Results: Complete cure was obtained in 45 out of 47 cases. Two of our earlier cases had recurrences perhaps due to inadequate mobilization, but in later cases, we had no recurrence. Conclusion: VRPT yields good result without the need for colostomy. Incisions on the perineal skin or the anal verge are avoided, thus improving the cosmetic outcome.



How to cite this article:
Bhaumik K, Das S, Chatterjee SK. Vestibulo-rectal pull through in H-fistula in girls.J Indian Assoc Pediatr Surg 2018;23:182-185


How to cite this URL:
Bhaumik K, Das S, Chatterjee SK. Vestibulo-rectal pull through in H-fistula in girls. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2018 Dec 14 ];23:182-185
Available from: http://www.jiaps.com/text.asp?2018/23/4/182/242718


Full Text



 Introduction



H-fistula in girls included in the Krickenback classification of anorectal malformations under “rare and regional variants” is a relatively common anomaly in the Asian countries.[1],[2],[3],[4],[5] This anomaly was first reported by Bryndorf and Madsen in 1959. These babies have four openings in the perineum. They pass stool through the normal anus and also through an opening in the vestibule. Although various approaches to the problem have been described, we are happy with the vestibulo-rectal pull-through (VRPT) approach which was first described by Chatterjee with good results.[1],[2],[3] We report a series of 47 cases operated by this approach.

 Materials and Methods



We have treated 47 girls with H-fistula in the past 14 years. Out of 47 cases, one was a recurrent fistula treated through anterior sagittal anorectoplasty (ASARP) approach with guarded colostomy performed outside. The cases were operated from 5 to 11 months of age. The recurrent case was operated at 18 months of age. The diagnosis was confirmed by clinical findings. Only in a few cases, fistulogram and magnetic resonance imaging (MRI) were performed to document the fistula. X-ray was performed by Tsuchida's technique[4] where contrast fluid is introduced into the bowel through a balloon catheter with a perforation below and not above the ballon, and lateral radiograph is taken The fistula site is well demonstrated by this technique [Figure 1]. MRI is also excellent to demonstrate the location of the fistula [Figure 2].{Figure 1}{Figure 2}

We performed VRPT in all of our 47 cases after bowel preparation with oral laxatives for 2 days before the operation, and normal saline bowel wash in the previous evening and in the morning of the operation. No prior or preoperative colostomy was performed except in the recurrent case who had colostomy done in another institution. After the patient is anesthetized, she is placed in the frog's position by strapping the legs and feet with the operating table. At the onset, the anus is gradually dilated with fingers. In most of the cases, the rectal opening of the fistula is visible in the midline of the anterior rectal wall above the anal valves. A catheter is passed through this opening and the catheter comes out through the vestibular opening [Figure 3]. Rarely, the rectal opening is small and not visible. In these cases the catheter is passed through the vestibular opening and the catheter comes out through the anus. Then a circular incision is made around the vestibular opening, the dissection is proceeded strictly on the wall of the fistula. Shortly, the rectal wall is reached and the dissection on its outside wall is continued liberally all around the fistula [Figure 4]. At this stage on pulling the fistula its rectal end looks funnel-shaped. Now the catheter is withdrawn gradually from the rectal side till its end is at the vestibular end of the fistula. The fistula is transfixed with the catheter. On further pulling down the catheter from the rectal side, the fistula will be invaginated into the rectum [Figure 5]. Now the catheter is taken out, the fistula tract is excised and closed with interrupted absorbable sutures. Then, another seromuscular suture is placed in the outer wall of the rectum through the vestibular incision. Perineal body is reconstructed over the rectal sutures. Then the posterior vaginal wall is mobilized proximally, and the mobilized posterior vaginal wall is pulled down and fixed to the distal margin of the vestibular incision (fourchette). On the postoperative period, we keep the babies nil orally for 48 h, and then we allow feed. The urethral catheter is kept for 72 h to avoid soiling in the early postoperative period. Intravenous antibiotics administered for 72 h. The babies are discharged on the 5th postoperative day with the instruction to apply antibiotic ointment at the surgical site.{Figure 3}{Figure 4}{Figure 5}

 Results



The H fistula is adequately removed by the VRPT approach. Two of our earlier cases recurred, perhaps due to minimum rectal mobilization where rectal outpouching remained, facilitating the development of recurrence. Recurrence in two girls healed after secondary perineal surgery. In this approach, cosmesis is not compromised as the only externally visible incision is around the vestibular fistula. The anus remained normally functioning without laxatives or dilatation. They were continent with normal bowel habits as they had a normal sphincter control.

 Discussion



The anomaly has been reported chiefly from the Asian countries but also occurs elsewhere.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] The external opening of the fistula is usually behind the vagina and the internal opening is in the anterior anal wall just above the dentate line.[13] In 1993, Narasimarao et al. described a new technique.[14] They laid open the fistula, the fistula was then dissected from its bed, and the most distal part of the fistular mucosa was utilized in rectal reconstruction. However, he suggested a preoperative colostomy that would need three separate operations.

Wakhlu et al. reported a large series of 56 patients. They performed ASARP in all cases with good results. The whole length of the fistula was laid open from vestibular to the rectal opening, and the laid-open fistula tract was excised. One patient had a recurrence and seven patients required anal dilatation.[15] Kulshrestha reported 13 cases of congenital and acquired H-type anorectal fistula treated by anterior sagittal anorectovaginoplasty with satisfactory results.[16]

Rintala et al. removed the fistula from the perineal approach. They had four recurrences out of 10 cases.[5]

Akhparov et al.[17] operated 28 cases by invaginated extirpation of them four had recurred; two by transperineal resection of the fistula with its ligation, all recurred; 18 by anorectoplasty with fistula extirpation and pull-through of the anterior rectal wall outside the anal canal. There were no recurrences in the last procedure.

Lawal et al.,[18] treated eight cases. In five cases, the posterior sagittal approach was used. After ligating the fistula in the anterior rectal wall, the anterior rectal wall was pulled down over the fistula and sutured to the anal verge. In the last 3 cases, transanal mobilization of the anterior rectal wall was made without interfering with the perineal body.

Li et al.,[19] operated on 182 cases. Fistula occurred in 21 cases (11.54%). Eight of them healed spontaneously, whereas the other 13 patients required reoperation.

Faced by the high incidence of recurrences authors differ in choosing the right technique of surgical approach for this anomaly. A scar is inevitable in the perineum in cases where the transperineal operation has been done. Postoperative constipation, soiling, and bleeding were also reported by authors who operated through ASARP approach.

Chatterjee, senior most author of the article, after facing three recurrences changed over to ASARP for better exposure, but Das (second author) continued VRPT with the very good outcome.[3]

We performed VRPT in all of our cases. The colostomy was not performed. There was no perineal skin incision and no cutting into the anal verge. Cosmetic result is very good as there is no scar in the perineum. There should be the adequate mobilization of the rectal wall along the fistula from the vestibular site so that the fistula tract can be easily invaginated into the rectum. Abolition of the anterior outpouching of the rectum must be ensured. There is normal sphincter control in all of our cases.

Routine preoperative or concurrent colostomy is traumatic to the patient as well as the parents and there is a need for multiple surgeries and anesthesia. However, we believe that protective colostomy as adopted by some authors as a routine procedure may rarely be needed in exceptional cases where perineal fistula opening is highly infected, or there are multiple fistula. We did not encounter such cases in our series, and we did not adopt protective colostomy in any cases.

 Conclusion



VRPT is a simple procedure and carries very little post operative complication. Proper bowel preparation is mandatory. It yields good result without the need for colostomy. Incisions on the perineal skin or the anal verge are avoided, thus improving the cosmetic outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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