Index of Case Report: Volume 1: Issue 1
1 RIII of General Surgery of the High Specialty Regional Hospital of the Yucatan Peninsula. Merida Yucatan. Mexico.
2 Cirujano General del Servicio de Cirugía del Hospital General Playa del Carmen, Q. Roo. México
Surgery Service of the Playa del Carmen General Hospital.
Av. Constituyentes s / n with 135 street Colonia Ejido.
Playa del Carmen, Solidarity, Quintana Roo. Mexico. CP. 77712
Introduction. Colovaginal fistulas are rare and until March 1988 only 70 cases had been reported. The triad to suspect the presence of a colo-vaginal fistula is: 1 stools and / or flatus per vagina or vaginal discharge, fetid or recurrent vaginitis resistant to medical treatment; 2. Prior hysterectomy; and 3. History of diverticular disease with or without a history of diverticulitis. Clinical case. A 69-year-old patient with a surgical history of bilateral tubo-ovarian occlusion 34 years ago, a hysterectomy 25 years ago. Fifteen days prior to admission, it refers to the exit of intestinal material via the vagina; colonoscopy is requested, locating diverticula in the sigmoid, descending and transverse colon, without inflammation data. The colon by enema reported diverticula in left colon and sigmoid, lesion of 4 mm x 6 mm in. Findings: bladder, sigmoid, rectum and omentum on vaginal vault, sigmoid fistula per perforated diverticulum and sealed with retroperitoneal collection to left annex area and open and friable vaginal vault. Transverse-recto with end to end anastomosis was performed in two planes. Discussion. Carbonell, presents a similar case with the difference that in his case diverticular disease was complicated but in our case the process had time to be established. Barrera, reported a series of 3 cases of elderly women with a history of previous hysterectomy and development of colo-vaginal fistula although only one of them had a history of diverticulitis and Wen Y, collected 17 cases of colovaginal fistulas where diverticulitis was the main cause with 89% of cases. Conclusion. Colovaginal fistulas are rare, the antecedent of hysterectomy, the history of diverticular disease, and its clinical diagnosis is simple and its treatment is well established. But in our case the result was very bad with mortality of the patient.
Key words: Histerectomy; Vaginal fistula; Digestive system fistula; Diverticulitis; Primary closure.
Colovaginal fistulas are rare and until March 1988 only 70 cases had been reported. (1, 2) The colonic fistulas associated with diverticular disease are divided into 4 types: colo-vesical, colo-vaginal, colo-ileal and colo-cutaneous.
Wassef R, et al., (3) found in their study that colovaginal fistulas are observed more frequently in hysterectomized women and with the presence of a pelvic mass; Its treatment is surgical which consists of resection and end-to-end anastomosis, this can be in one or two surgical times and recommend that when a fistula develops, the management would be conservative and wait three months after the acute phase and operate in just one time Our patient was scheduled for surgery due to the chronicity of her condition.
Griffa B, et al., (4) treated five patients with fistulas secondary to diverticulosis and one case operated by diverticulitis which developed a stercoral fistula treated conservatively. They performed wide resection of sigmoid with end-to-end anastomosis and in three cases performed protective cecostomy. They succeeded in all their patients.
The triad to suspect the presence of a colo-vaginal fistula is: 1) stools and / or flatus from the vagina or vaginal discharge, fetid or recurrent vaginitis resistant to medical treatment; 2) previous hysterectomy; e 3) history of diverticular disease with or without diverticulitis. (5, 6)
It is known that a fistula is an abnormal communication between two epithelial surfaces and these can lead to undesirable emotional, interpersonal and financial consequences. (7) On the other hand, colovesical fistulas can be observed through a vaginal speculum examination (90% of the cases the fistula can be seen in the left vaginal vault), the second step is the performing a colon by enema, and a sigmoidoscopy and / or colonoscopy is also useful for the evaluation of the large intestine, finally the tomography is useful in cases of diverticulitis to evaluate abscesses and / or inflammatory processes. (6) Procedures that were used in our patient to make diagnosis.
Clinical case. A 69-year-old patient with the following important antecedents: systemic arterial hypertension of 10 years of evolution with medical treatment; Surgical: bilateral tubo-ovarian occlusion 34 years ago, hysterectomy 25 years ago for cervical cancer in situ. Current condition: started five years ago with abdominal pain type colic, mild intensity, recurrent that gave way with analgesics, a year ago became constant with increased intensity, why he went to a doctor performing abdominal tomography with diverticular disease report uncomplicated. Fifteen days prior to admission, he referred to the discharge of intestinal material through the vagina, so he went to the general surgery service for his evaluation, where there was evidence of fecal matter, only colonoscopy was performed where diverticula were reported in the sigmoid, descending and transverse colon, (Fig. 1) without inflammation data. Colon by enema was requested, which reported diverticula in left and sigmoid colon, linear lesion of 4 mm x 6 mm in sigmoid lateral to rectum on left side, which is related to sigmoid fistula. With the cabinet reports and normal laboratories as well as the presence of colovaginal fistula is scheduled for exploratory laparotomy. Intestinal preparation was performed with 4 liters of Nulytely as well as two soap enemas. During surgery, the following was found: large bladder, sigmoid, rectum, and omentum over the vaginal vault, sigmoid fistula per perforated diverticulum (fig. 2), sealed with a retroperitoneal collection to the left annex area, and 0.5 cm friable open vaginal dome; The vaginal cuff was washed and closed with polyglactin 910 (Vicryl) 00, left hemicolectomy up to the middle third of the transverse colon. Transverse-recto-end-terminal anastomosis was performed in two planes with Connell-Mayo suture of Poliglicaprone 25 (Monocryl) 000, and second plane with Lembert silk 000 points, passive drainage was placed in the pelvic cavity. He remained in full fasting for three days with parenteral nutrition support starting 75%, with adequate evolution, minimal drainage expenditure of serous features. Six days after surgery, complications began with fever and leukocytosis. She was reoperated and found a small abscess that did not justify the degree of systemic deterioration of the patient. He enters intensive therapy and dies at 7 days of hospitalization due to multiple organ failure.
Carbonell, et al., (8) present a case similar to ours with the difference that in their case the diverticular disease was complicated which was not our case since the process had time to be established. Diverticular disease is on the increase in Western countries and it is known that there are diverticula of colon in a third of the population over 45 years and up to two thirds of the over 85 years. Diverticulitis is simple in 75% of cases (uncomplicated) and complicated in 25% (abscesses, fistulas, obstruction, peritonitis and sepsis) similar to our case with fatal sepsis.
Fistulas occur in 2% of people with complicated diverticular disease, due to a local inflammatory process, associated with an abscess that decompresses spontaneously, perforates the adjacent viscera or manifests through the skin. Usually a single episode occurs, but there may be more in up to 8% of patients. It is proposed that 65% of the fistulas related to diverticular disease are colovesical and 25% colovaginal. (8)
Barrera EA, et al., (9) reported a series of three cases of elderly women with a history of previous hysterectomy and development of colo-vaginal fistula, although only one of them had a history of diverticulitis. Méndez-Sánchez N, et al., (10) present a case similar to ours with resection and primary closure management; the diagnostic method recommended by the authors is the vaginography with a sensitivity of 100% although it is a little used resource at present.
Syllaios A, et al., (11) report a case of colo-vesical fistula plus colo-ovarian fistula with a subclinical diverticular disease and without any previous abdominal surgical history, only diverticulosis in rectosigmoides at colonoscopy and with MRI was demonstrated multiple diverticular disease of colon sigmoid and a fistula towards the posterior wall of the vagina, very rare association in our environment. Marcucci T, et al. (12) in 16 patients with colovesical and colovaginal fistulas performed resection and anastomosis in one time, 3 cases in two times and 1 case with colostomy and Hartman’s pouch. They only had a recurrence in a case of colo-vesical fistula. Given that our patient was scheduled with previous intestinal preparation, the closure was in two planes.
Wen Y, et al., (13) collected 17 cases of colovaginal fistulas where diverticulitis was the main cause with 89% of the cases, they recommend the laparoscopic approach although in their study they had a high conversion rate of 8 cases ( 42%), just as our patient had a history of diverticular disease.
Smeenk RM, et al., (14) in their casuistry of 40 cases, found 35 cases of colo-vesical fistula and 5 cases of colo-vaginal fistula in 18 men and 22 women. 32 cases received primary closure. 14 patients with ileostomy, 8 cases with colostomy and Hartman procedure, morbidity at 30 days was 48 and 8% respectively. There was anastomotic leak in the primary closures and no leak in those who received a protective ileostomy. Therefore, they recommend the protection ileostomy in cases of primary closure, which was not done in our case.
Conclusions: colovaginal fistulas are rare, the antecedent of hysterectomy is very important, in addition the antecedent of diverticular disease is valuable, its clinical diagnosis is simple and its treatment is well established where generally good results are obtained. All these details were present in our case it was not the expected because our patient death; in addition to being the first case in our hospital because of its relatively recent creation.
2. Grissom R, Snyder TE. Colovaginal fistula secondary to diverticular disease. Dis Col Rect. November 1991; 34(11):1043–9.2. Grissom R, Snyder TE. Colovaginal fistula secondary to diverticular disease. Dis Col Rect. November 1991; 34(11):1043–9.
11. Syllaios A, Koutras A, Zotos PA, Koura S, Machairoudias P, Papakonstantinou A, et al. Colovaginal and colo-ovarian fistula at a patient with asymptomatic diverticular disease. J Surg Case Rep. 2018; 4:1-3.
12. Marcucci T, Giannessi S, Giudici F, Riccadonna S, Gori A, Tonelli F. Management of colovesical and colovaginal diverticular fistulas. Our experience and literature reviewed. Ann Ital Chir. 2017; 88:55-61.
14. Smeenk RM, Plaisier PW, van der Hoeven JA, Hesp WL. Outcome of surgery for colovesical and colovaginal fistulas of diverticular origin in 40 patients. J Gastrointest Surg. 2012 Aug; 16(8):1559-65.
Figure 1. Fistula in the sigmoid colon.
Figure 2. Purulent material in the orifice of the vaginal-vaginal fistulous tract.
|First Name:||Antonio Augusto|
|Affiliation:||Instituto Nacional de Câncer|
|Specialization:||Surgery and Urology|
|Affiliation:||Calixto Garcia Hospital|
Article Status: Required moderate review