Surgical treatment of rectovaginal and extrasphincter fistulas of the rectum in patients with diseases of the blood system

Introduction. Anal fistulas (AF) can be both an independent source of infection and the cause of perianal abscess recurrence. The use of sphincter-preserving plastic surgical methods for the elimination of AF in patients with hematologic malignancies is an insufficiently studied issue.

Aim: To demonstrate the possibility of using plastic surgical methods for the elimination of rectovaginal and anal fistulas in hematological patients.

Materials and methods. Between 2022 and 2024, 5 patients aged 36 to 56 years were operated on for complex anal and rectovaginal fistulas; of these, 3 patients had acute myeloblastic leukemia (AML), 1 had non-Hodgkin’s lymphoma, and one patient had immune thrombocytopenia. In one case, elimination of a rectovaginal fistula was performed using a split vaginal-rectal flap; in the rest — the anal fistulas were eliminated using a displaced lateral flap. The follow-up period ranged from 8 to 28 months.

Results. Elimination of the AF was achieved in 4 out of 5 patients. On the 2nd day after surgery, 1 patient developed thrombosis of hemorrhoids in the area of the displaced flap, and on the 10th day, a recurrence of the fistula was detected. Signs of 1st degree anal insufficiency were diagnosed in two patients who had previously undergone anal surgery. Treatment for hematologic malignancies was continued after surgery for two patients, one of whom underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT), while the other underwent induction of a second remission due to a AML relapse.

Conclusion. Given the minimal surgical trauma and low complication rate, fistula repair using displaced flaps can be used in hematological patients. If rehabilitation timelines are observed, it is possible to resume antitumor therapy, including performing allo-HSCT.

1. Chang H., Kuo M.C., Tang T.C., et al. Clinical Features and Recurrence Pattern of Perianal Abscess in Patients with Acute Myeloid Leukemia. Acta Haematol. 2017;138(1):10–3. DOI: 10.1159/000475589.

2. Solmaz S., Korur A., Gereklioğlu Ç., et al. Anorectal Complications During Neutropenic Period in Patients with Hematologic Diseases. Mediterr J Hematol Infect Dis. 2016;8(1):e2016019. DOI: 10.4084/MJHID.2016.019.

3. Shtyrkova S.V., Chabaeva Yu.A., Kulikov S.M. et al. Risk Factors for Relapses of Perianal Infectious Complications in Patients with Hematological Malignancies: Results of a Single-Center Prospective Trial. Kliinicheskaya Oncogematologiya. 2024;17(2):204– 12. (In Russian). DOI: 10.21320/2500-2139-2024-17-2-204-212.

4. Pini Prato A., Castagnola E., Micalizzi C., et al. Early diverting colostomy for perianal sepsis in children with acute leukemia. J Pediatr Surg. 2012;47(10):e23– 7. DOI: 10.1016/j.jpedsurg.2012.05.034.

5. Mudrov, A. A., Omarova М.М., Fomenko О.Yu., et al. Surgical Treatment of Rectovaginal Fistula with Vaginal Rectangular Flap. Khirurgiya. Zhurnal Im. N.I. Pirogova. 2021;7:5–11 (In Russian). DOI: 10.17116/hirurgia20210715.

6. Achkasov S. I., Shelygin Y.A., Titov A.Yu., et al. Method for eliminating a fi stulous opening in the rectum with a highly vascularized lateral fl ap in rectovaginal and rectal fi stulas: the patent no. 2022104283 from 18.12.2022 (In Russian).

7. Shelygin Y.A., Titov A.Yu., Mudrov A.A., et al. Method for eliminating rectovaginal fi stulas with y-shaped fl ap: the patent no. 2675348 from 18.12.2018 (In Russian).

8. Zutoia B., Uribe N., Balciscueta I., et al. Rectal Advancement Flap for the Treatment of Complex Cryptoglandular Anal Fistulas: A Systematic Review and Meta-Analysis. Int J Colorectal Dis. 2017;32(5):599–609. DOI: 10.1007/s00384-017-2779-7.

9. Francesco L., Bracchitta S., Naldini G. et al. FISSIT (Fistula Surgery in Italy) Study: A Retrospective Survey on the Surgical Management of Anal Fistulas in Italy over the Last 15 Years. Surgery. 2021;170(3):689–95. DOI: 10.1016/j.surg.2021.02.055.