Repair of recurrent rectovaginal fistulas

doi:10.1067/msy.2001.116905

Surgery

Volume 130, Issue 4, October 2001, Pages 753-758

Presented at the 58th Annual Meeting of the Central Surgical Association, Tucson, Ariz, March 7-10, 2001.

https://doi.org/10.1067/msy.2001.116905 Get rights and content

Abstract

Background. Recurrent rectovaginal fistulas (RRVFs) pose a challenging problem, which can be treated by different surgical procedures. We performed this study to determine the ultimate success rate of various repair techniques. Methods. Using a standard data collection form, we retrospectively reviewed charts of patients treated for RRVF. Results. Between 1991 and 2000, 57 procedures were performed in 35 women who presented with RRVF. Median follow-up was 4 months (interquartile range, 1,25). The causes of RRVF included obstetrical injury (n = 15), Crohn's disease (n = 12), fistula occurring after proctocolectomy with ileal pouch-anal anastomosis (for ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial polyposis, n = 1), cryptoglandular disease (n = 2), and fistula occurring immediately after low anterior resection for rectal cancer (n = 1). The methods of repair used included mucosal advancement flap (n = 30), fistulotomy with overlapping sphincter repair (n = 14), rectal sleeve advancement (n = 3), fibrin glue (n = 1), proctectomy with colonic pull-through (n = 2), and ileal pouch revision (n = 6). Twenty-seven of 34 (79%) patients with adequate follow-up eventually healed after a median of 2 operations. Logistic regression was used to analyze outcome according to etiology of fistula, patient age, number of prior repairs, time interval between last repair and current repair, and presence of fecal diversion. Crohn's disease, the presence of a diverting stoma, and decreased time interval since prior repair were associated with a poorer outcome. Conclusions. Most RRVFs can be successfully repaired, although repeated operations may be necessary. Delaying repair may improve outcome. (Surgery 2001;130:753-8.)

Section snippets

Methods

The charts of all women treated for RRVF between 1991 and 2000 were reviewed. Information regarding the etiology of the fistulas and number and method of prior repairs was collected with a standard data collection form. The outcome of the repair was analyzed according to several factors, including etiology of fistulas, number of prior repairs, time interval between last repair and current repair, patient age, and whether a temporary diverting stoma was used.

Results

Between 1991 and 2000, 35 patients with an average age of 37 ± 9.6 years presented with RRVF. The most common complaints were stool per vagina (44%), vaginal drainage (39%), gas per vagina (33%), and pain (12%). Obstetrical injury was the most common etiology of recurrent fistulas (n = 15, 43%), followed by Crohn's disease (n = 12, 34%), fistula occurring after proctocolectomy with IPAA (ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial adenomatous polyposis, n = 1),

Discussion

Recurrent rectovaginal fistulas are a difficult problem for surgeons. MacRae et al⁵ reported an overall success rate of 61% per procedure for treatment of RRVF. Lowry et al¹ reported a success rate of 88% in patients undergoing a primary repair of a rectovaginal fistula. The success rate after one previous failed attempt was 85%, and if the patients had 2 prior repair attempts, the success rate dropped to 55%.¹ Decreased success with subsequent repairs may be attributed to unresolved

Conclusion

Most recurrent rectovaginal fistulas can be successfully repaired, although repeated operations may be necessary. Although patients with Crohn's disease have a poorer healing rate compared with those without Crohn's disease, they still have a 50% chance of ultimately healing their rectovaginal fistula. Delaying repair of a recurrent rectovaginal fistula may improve outcome.

Discussion

Dr Janice F. Rafferty (Cincinnati, Ohio). That was a very good presentation regarding a very frustrating problem. Thank you for sending me the manuscript in a timely fashion and for the opportunity to review it.

It is nice to see that you can give us data supporting what we have felt all along, which is the longer you wait, the greater the chance of repair. We all know that these women call our office the day that they begin passing gas after they are repaired, and counseling patients in time

References (22)

TL Hull et al.
Surgical approaches to low anovaginal fistula in Crohn's disease
Am J Surg
(1997)
LC Bandy et al.
Surgical management of rectovaginal fistulas in Crohn's disease
Am J Obstet Gynecol
(1983)
LT Hibbard
Surgical management of rectovaginal fistulas and complete perineal tears
Am J Obstet Gynecol
(1978)
AC Lowry et al.
Repair of simple rectovaginal fistulas: influence of previous repairs
Dis Colon Rectum
(1988)
IJ Kodner et al.
Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas
Surgery
(1993)
WP Mazier et al.
Operative repair of anovaginal and rectovaginal fistulas
Dis Colon Rectum
(1995)
G Ozuner et al.
Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas
Dis Colon Rectum
(1996)
HM MacRae et al.
Treatment of rectovaginal fistulas that has failed previous repair attempts
Dis Colon Rectum
(1995)
DA Rothenberger et al.
Endorectal advancement flap for treatment of simple rectovaginal fistulas
Dis Colon Rectum
(1982)
P Marchesa et al.
Advancement sleeve flaps for treatment of severe perianal Crohn's disease
Br J Surg
(1998)

DE Cutait et al.

Abdominoperineal endoanal pull-through resection

Dis Colon Rectum

(1985)

Cited by (87)

Management of rectovaginal fistula
2016, Seminars in Colon and Rectal Surgery
Rectovaginal fistulas remain a challenging problem for surgeons to correct despite advances in surgical techniques. These fistulas may be caused by a variety of disease processes and multiple options exist for the repair of a rectovaginal fistula. The etiology, location, and status of the surrounding tissue determine the most appropriate option for repair. Low, small fistulas caused by cryptoglandular disease or obstetrical trauma, are generally amenable to local repairs. In contrast, high or more complex fistulas and ones that result from inflammatory bowel disease, malignancy, or radiation often warrant more extensive repairs often with the protection of proximal diversion. Finally, the choice of repair depends on the status of the anal sphincter muscle both in terms of the option chosen for repair and the functional outcome. Patient preference and the surgeon׳s experience are also factors in the choice of technique.
Influence of diversion stoma on surgical outcome and recurrence rates in patients with rectovaginal fistula - A retrospective cohort study
2016, International Journal of Surgery
Rectovaginal fistula is an extremely distressing condition for the patients. There is still no generally accepted standard surgical treatment strategy. Especially the influence of diversion stoma creation on patients’ outcome remains controversial. Thus, the aim of this study was to analyze the influences of diversion stoma on the outcome of patients treated because of rectovaginal fistula with special regard to perioperative complications and recurrence rates.
Between 2003 and 2013, all patients treated due to rectovaginal fistula in our institutions were retrospectively analyzed. A total of 81 procedures were performed in 62 patients. Procedures were divided into two groups depending on the presence of a diversion stoma or not (diversion stoma, n = 42 vs. no stoma, n = 39).
The overall rate of fistula recurrence was 44% without statistical significance in-between the study groups (49 vs. 38%; p = 0.603). Diversion stoma had no influence on complication rates, wound infections or number of operative revisions. Patients treated with diversion stoma had significantly higher ASA-scores (2.6 ± 0.6 vs. 2.1 ± 0.8; p = 0.011), higher rates of malignoma (58 vs. 17%; p = 0.001) and larger sizes of fistula (1.67 ± 0.08 vs. 1.51 ± 0.46 mm; p = 0.012). The in-hospital stay was significantly longer in these patients (30 ± 66 vs. 15 ± 15 days; p = 0.023).
Our data suggest that diversion stoma creation does not influence the outcome of patients with rectovaginal fistula with special regard to rates of fistula recurrence. On the other hand it is mainly used in complex cases of sick patients and larger fistula sizes. Prospective clinical studies need to be conducted to reinforce these findings.
Re-operative surgery for genitourinary fistulae to the colorectum
2015, Seminars in Colon and Rectal Surgery
Citation Excerpt :
The success rate after one previous failed attempt was 85%, and if the patients had two prior repair attempts, the success rate dropped to 55%.42 Decreased success with subsequent repairs may be attributed to unresolved inflammation, tension, hematoma, or underlying Crohn׳s disease.41 While in the distant past treatment of Crohn׳s disease-associated rectovaginal fistula has been mostly surgical, complex new medical therapeutic options have taken over for most patients.
Re-operative surgery for genitourinary fistulas to the colorectum is very distressing condition for the patients. These fistulas are extremely complex and at times may require a staged, multidisciplinary approach in order to correct them. Post-operative and recurrent genitourinary fistula to the colorectum can occur as a consequence of pelvic disorders, including trauma, iatrogenic injury, inflammatory bowel disease, pelvic neoplasm, and infection. Basic surgical principles, such as gentle handling of the tissues, curetting of the fistula tract, adequate debridement of unhealthy tissue, and adequate mobilization of tissue to allow tension-free tissue approximation, are essential for a successful outcome. Surgical therapy for these fistulas remains largely based on the surgeons׳ preference and is influenced by many retrospective reports. Currently, there is no specific treatment algorithm available for these post-operative and recurrent genitourinary fistulas to the colorectum. Through this article, we will highlight the various treatment options available and have attempted to formulate a treatment algorithm for post-operative and recurrent rectourethral, rectovaginal, and ileal pouch vaginal fistulas.
Diagnosis and management of rectal fistulizing Crohn's disease
2023, Chinese Journal of Inflammatory Bowel Diseases
Recto-vaginal fistulas. Recommendations of the Polish Club of Coloproctology Scientific Society
2023, Polski Przeglad Chirurgiczny/ Polish Journal of Surgery
Surgical Intervention is Effective for the Treatment of Crohn’s-related Rectovaginal Fistulas: Experience from a Tertiary Inflammatory Bowel Disease Practice
2023, Journal of Crohn's and Colitis

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^*: Reprint requests: Amy L. Halverson, MD, 9500 Euclid Ave, Desk A111, Cleveland, OH 44195.

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Central Surgical AssociationRepair of recurrent rectovaginal fistulas*

Abstract

Section snippets

Methods

Results

Discussion

Conclusion

Discussion

Am J Surg

Am J Obstet Gynecol

Am J Obstet Gynecol

Repair of simple rectovaginal fistulas: influence of previous repairs

Dis Colon Rectum

Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas

Surgery

Operative repair of anovaginal and rectovaginal fistulas

Dis Colon Rectum

Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas

Dis Colon Rectum

Treatment of rectovaginal fistulas that has failed previous repair attempts

Dis Colon Rectum

Endorectal advancement flap for treatment of simple rectovaginal fistulas

Dis Colon Rectum

Advancement sleeve flaps for treatment of severe perianal Crohn's disease

Br J Surg

Abdominoperineal endoanal pull-through resection

Dis Colon Rectum

Central Surgical Association
Repair of recurrent rectovaginal fistulas*