PULL-THROUGH SURGERY AS A THERAPEUTIC OPTION FOR INTESTINAL RECONSTRUCTION AFTER RECTOVAGINAL FISTULA

• DOI: https://doi.org/10.22533/at.ed.1595825280115

• Palavras-chave: Restorative Proctocolectomy, Intestinal Fistula, Rectovaginal Fistula, Colostomy

• Keywords: Restorative Proctocolectomy, Intestinal Fistula, Rectovaginal Fistula, Colostomy

• Abstract:

   Intestinal transit reconstruction (ITR) is a significant challenge in the practice of proctologic surgeons aiming to restore patients' quality of life. These include variable anatomy, previous pathological conditions such as a short remaining rectal stump, fibrosis, as well as complications inherent to the procedure such as fistulas, stenosis, dehiscence and intestinal dysfunction.  It is estimated that 30 to 60% of patients undergoing derivative ostomies, due to surgical complications, are candidates for RTI. The morbidity rates of RTI surgery after Hartmann's procedure vary between 10% and 50% and mortality rates are up to 28%. Pull-through surgery has emerged as a therapeutic option for hostile pelvises where the remaining intestine is pulled through the rectum and anastomosed with the anal canal. CASE REPORT: A 60-year-old female patient diagnosed with adenocarcinoma of the mid-rectum was followed up at the HCA's Coloproctology department, with the lesion staged and surgical resection indicated. She underwent rectosigmoidectomy in 2022 with primary anastomosis. On the 5th day after surgery, she developed a complication, dehiscence of the anastomosis and rectovaginal fistula. She was re-operated on at the same time and underwent a terminal colostomy, closure of the rectum (Hartmann) and vaginal raphe.  After 17 months, she underwent intestinal transit reconstruction (ITR) using the Pull-Through technique due to the impossibility of dissociating the rectum from the vagina. The patient remained hospitalized for 30 days, evolving with abdominal distension, nausea, difficulty evacuating and inappetence. Dilation of the anal stump was necessary on D15 post-operatively. She evolved without surgical complications and with sphincter preservation.  Pull-through surgery has emerged as an exceptional therapeutic option when primary colorectal anastomosis is not feasible. The Pull-Through technique is effective in selected cases of RTI in patients with a remaining rectal stump that is difficult to dissect due to a previous fistula with the vaginal canal.