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S3-Leitlinie: Rektovaginale Fisteln (ohne M. Crohn)

AWMF-Registriernummer: 088/004

S3 Guidelines: rectovaginal fistulas (without Crohn’s disease)

AWMF register number: 088/004

  • Leitlinien
  • Published:
coloproctology Aims and scope

Zusammenfassung

Rektovaginale Fisteln stellen eine seltene Erkrankung dar. Die Mehrzahl der rektovaginalen Fisteln ist traumatischer Genese. Die wichtigsten Ursachen sind Entbindungstraumata, lokale Infektionen und Eingriffe am Rektum. Rektovaginale Fisteln bei chronisch-entzündlichen Darmerkrankungen werden in dieser Leitlinie nicht behandelt.

Die Diagnose einer rektovaginalen Fistel ergibt sich aus Anamnese und klinischer Untersuchung. Andere pathologische Veränderungen sollten durch Zusatzuntersuchungen (Endoskopie, Endosonographie, Schichtuntersuchung) ausgeschlossen werden. Eine Beurteilung der Sphinkterfunktion ist für die Planung des operativen Vorgehens (Frage der simultanen Sphinkterrekonstruktion) sinnvoll.

Eine persistierende rektovaginale Fistel kann i. d. R. nur durch eine Operation zur Ausheilung gebracht werden. Es wurden verschiedene Operationsverfahren mit niedrigem Evidenzniveau beschrieben. Am häufigsten ist das transrektale Vorgehen mit endorektaler Naht. Der transperineale Zugang kommt in erster Linie bei simultaner Schließmuskelrekonstruktion zur Anwendung. Bei rezidivierenden Fisteln kann durch die Interposition von körpereigenem Gewebe (Martius-Lappen, M. gracilis) ein Verschluss erzielt werden. In neuen Studien wurde ein Verschluss durch Einbringen von Biomaterialien vorgestellt. Bei höher gelegenen Fisteln kommen auch abdominelle Verfahren zur Anwendung.

Häufiger als bei der Behandlung von Analfisteln ist bei der rektovaginalen Fistel eine Stomaanlage erforderlich. Je nach Ätiologie (v. a. Rektumresektion) wurde bei einem Teil der Patientinnen bereits ein Stoma im Rahmen der Primäroperation angelegt. Die Indikation zur Stomaanlage sollte sich in erster Linie nach dem Ausmaß des lokalen Defekts und der daraus resultierenden Belastung der betroffenen Frau richten.

Aufgrund des niedrigen Evidenzniveaus kann die vorliegende Leitlinie nur einen deskriptiven Charakter haben. Empfehlung für Diagnostik und Therapie beruhen überwiegend auf den klinischen Erfahrungen der Leitliniengruppe und können nicht durch die vorhandene Literatur komplett abgedeckt werden.

Abstract

Rectovaginal fistulas represent a rare condition and most have a traumatic origin. The most important causes are childbirth trauma, local infections and interventions concerning the rectum. Rectovaginal fistulas due to chronic inflammatory intestinal diseases will not be dealt with in these guidelines.

The diagnosis of rectovaginal fistula is made from the clinical history and examination. Other pathological alterations should be excluded by additional examinations (e.g. endoscopy, endosonography and multislice imaging). An assessment of sphincter function is recommended for planning the operative approach (question of simultaneous sphincter reconstruction).

A persistent rectovaginal fistula can as a rule only be successfully treated by surgery. A variety of surgical approaches with low evidence level have been described. The most common is the transrectal approach with endorectal suture. Transperineal access is the first choice for simultaneous sphincter reconstruction. Recurrent fistulas can be closed by the interpositioning of autologous tissue (Martius flaps, gracilis muscle transposition). In recent studies closure has also been presented with the inclusion of biomaterials. For fistulas in a more distal position abdominal procedures can also be applied.

Placement of a stoma is more often necessary for rectovaginal fistulas than for anal fistulas. Depending on the etiology (in particular rectum resection) a stoma will already have been placed during the primary operation in some patients. The indications for stoma placement should principally be based on the extent of the local defect and the resulting strain on the individual woman affected.

Due to the low evidence level these guidelines can only have a descriptive character. Recommendations for diagnostics and treatment are predominantly based on the clinical experiences of members of the guideline group and cannot be completely covered by the available literature.

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    A. Ommer, A. Herold, E. Berg, S. Farke, A. Fürst, F. Hetzer, A. Köhler, S. Post, R. Ruppert, M. Sailer, T. Schiedeck, B. Strittmatter, B.H. Lenhard, W. Bader, J.E. Geschwend, H. Krammer & E. Stange

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Ommer, A., Herold, A., Berg, E. et al. S3-Leitlinie: Rektovaginale Fisteln (ohne M. Crohn). coloproctology 34, 211–246 (2012). https://doi.org/10.1007/s00053-012-0287-3

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