目的

探讨直肠肿瘤手术后出现直肠阴道瘘（RVF）的不同外科治疗方法的成功率和适应证。

方法

回顾性收集2014 年1 月至2022 年6 月期间北京协和医院收治的直肠肿瘤术后出现RVF 并住院治疗患者的临床资料，记录治疗方案，观察RVF 治愈情况。

结果

研究共入组37 例患者，平均年龄（58±13）岁。其中恶性肿瘤28 例，良性肿瘤9 例。出现RVF 接受1 次、2 次、3 次手术治疗患者分别为18 例（48.6%）、10 例（27.0%）、3 例（8.1%），手术方式包括转流术、经肛门RVF 修补术、经肛门联合经肛门内镜下RVF 修补术、经肛门括约肌RVF 修补术（Mason 术）、腹腔镜直肠前切除RVF 修补术（Dixon 术/Hartmann 术）、经阴道修补术、内镜RVF 修补术、盆腔引流术。最终7 例（18.9%）患者RVF 得到治愈，还纳造口，中位还纳时间距直肠手术37 个月，距发现RVF 29 个月。还纳成功患者中5 例为良性肿瘤，2 例为恶性肿瘤，良恶性肿瘤还纳成功率差异有统计学意义（P=0.005）。

结论

多数直肠肿瘤术后RVF 患者经历多次手术、仍无法还纳造口；部分患者在造口还纳后仍有再发RVF 风险。直肠恶性肿瘤术后发生的复杂型RVF 治疗成功率较良性肿瘤低。RVF修补方式应根据瘘口位置、大小、复杂程度选择：瘘口位置较高的患者，选择经腹入路修补；经腹手术困难、瘘口位置较低的患者，选择经肛门、经会阴途径修补，或多入路联合修补。对于有RVF 高危因素的患者，在初始手术时即应重视预防RVF。

Objective

To explore the difference and indication between various surgical treatment methods for rectovaginal fistula （RVF） that occurs after rectal tumor surgery.

Methods

Retrospectively collected clinical data of patients who developed RVF following rectal tumor surgery and were hospitalized for treatment in Peking Union Medical College Hospital from January 2014 to June 2022. The treatment plans，the outcomes of RVF healing were recorded.

Results

A total of 37 patients were included in the study，with an average age of （58 ± 13） years. Among them，twenty-eight had malignant tumors and 9 had benign tumors. Patients underwent 1，2，or 3 times of surgical treatments for RVF in 18 （48.6%），10 （27.0%），and 3 （8.1%） cases，respectively. Surgical methods included diversion surgery，transanal RVF repair，transanal combined with endoscopic RVF repair，transanal sphincteric RVF repair （Mason procedure），laparoscopic anterior rectal resection RVF repair （Dixon/Hartmann procedure），transvaginal repair，endoscopic RVF repair，and pelvic drainage surgery. Ultimately，seven patients’ （18.9%） RVF were cured and got stoma reversed，with a median reversal time of 37 months from the rectal surgery and 29 months from RVF discovery. Among the successfully reversed patients，five patients had benign tumors and 2 patients had malignant tumors，with a significant difference in reversal success rates between benign and malignant tumors （P=0.005）.

Conclusion

RVF following rectal tumor surgery causing lots of patients undergo multiple surgeries and are still unable to have their stomas reversed. Some patients face the risk of recurrent RVF even after stoma reversal. The success rate of treating complex RVF after malignant rectal tumor surgery is lower than that of benign tumors. The choice of RVF repair method should be based on the location，size，and complexity of the fistula. For fistulas located higher up，an abdominal approach is preferred. For cases where abdominal surgery is difficult or the fistula is located lower，transanal or perineal approach or a combined multi-approach repair is recommended. For patients with high-risk factors for RVF，prevention should be emphasized during the initial surgery.