Individualisierte und differenzierte Therapie von rektovaginalen Fisteln

Zusammenfassung

Rektovaginale Fisteln (RVF) stellen für betroffene Patientinnen ein schwerwiegendes psychosoziales Problem dar und bedeuten für den Chirurgen eine komplexe therapeutische Herausforderung. Die Ursachen für RVF sind vielfältig, insbesondere sind postoperative Komplikationen, entzündliche Veränderungen, postaktinische Schäden, Geburtstraumen und Karzinominfiltrationen zu nennen. Die Therapie richtet sich nach der auslösenden Krankheit, nach Höhenlokalisation und Größenausdehnung der Fistel. Der vorliegende Artikel präsentiert die Behandlungsstrategien von RVF. Bei schweren Entzündungen sollte zunächst ein protektives Stoma angelegt und erst nach Abklingen der Entzündung das weitere Vorgehen geplant werden. Bei tief liegenden Fisteln empfehlen wir zunächst ein lokales Vorgehen wie beispielsweise preanal repair und Fistelexzision ggf. mit Anlage eines protektiven Stomas. Bei RVF-Rezidiven ist an die Interposition eines Muskelschwenklappens (z. B. Gracilis-Plastik) zu denken.

Abstract

Rectovaginal fistuale (RVF) are a serious and disabling problem for the patients and a surgical challenge for the treating physicians. The most common causes of RVF are postoperative complications, inflammatory bowel disease, complications of radiotherapy, obstetric complications, and neoplasia. Therapeutic options are diverse and results often unsatisfactory. This article presents the treatment of patients with rectovaginal fistulae in the general surgery department of University Hospital in Duesseldorf, Germany. The therapeutic strategy for treatment of RVF is divided according to aetiology, localisation, and comorbidity. A diverting ileostomy is particularly useful if acute inflammation exists. Secondary repair may then be a better option. An initial approach with a local repair by preanal repair is justified in low RVF. For failures muscle flaps are promising.

Schlüsselwörter

rektovaginale Fistel - preanal-repair - M. gracilis-Plastik - rezidivierende rektovaginale Fistel

Key words

rectovaginal fistula - preanal repair - gracilis muscle interposition - recurrent rectovaginal fistula

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