83 Dehydrated human amniotic membrane and amniotic fluid for the treatment of rectovaginal fistulas

Abstract

The presence of a rectovaginal fistula (RVF) can be devastating to patients thus greatly affecting their quality of life. The most common etiologies of RVF are those resulting from obstetric complications, pelvic radiation, malignancy, infection, and postoperative complications. The treatment of RVF is mainly surgical; however, current techniques still have a high rate of recurrence. Our objective is to present a novel surgical technique with the use of a dehydrated amniotic membrane (VendajeTM) and an amniotic suspension allograft (RheoTM) in repair of rectovaginal fistula. Two cases of chronic rectovaginal fistula were seen in the urogynecology office. Informed consent was obtained to proceed with surgical repair using the dehydrated amniotic membrane and amniotic suspension allograft. Under general anesthesia, the RVF fistula repair was done by first using a #5 silk suture that was threaded back and forth in the fistula tract to de-epithelialize the tract and uncover healthy tissue (Figure 1). The rectal side of the fistula tract was closed with 3-0 vicryl interrupted sutures. The amniotic membrane was soaked in 1 mL of the amniotic suspension before being placed into the fistula tract from the vaginal side. The vaginal side of the tract was reapproximated with 3-0 vicryl interrupted sutures (Figure 2). Finally, the remainder of the amniotic suspension was injected into the tract. The patients were also advised to use estrace vaginal cream to promote wound healing and increase blood supply to the surgical site. One case of complete resolution (5 mm to closure) of rectovaginal fistula and one case of 90% improvement (1cm to 1mm) of fistula is presented utilizing a novel therapeutic approach with the amniotic membrane pre-soaked in an amniotic suspension allograft followed by injection of remaining allograft into the fistula tract. This novel application of dehydrated human amniotic membrane allograft and amniotic suspension allograft is an effective therapy for chronic rectovaginal fistula. This procedure also highlights the importance of the complexity of the fistula and health of the supporting tissue prior to fistula repair seen in the case with 70% improvement.