Management Of Rectovaginal Fistula Research Articles

Transvaginal approach for rectovaginal fistula: experience from a single institution

Transvaginal (TV) repair, featuring its feasibility, effectiveness, safety, and technically less demandingness, is one of the surgical approaches for management of rectovaginal fistula (RVF). However, there are limited numbers of publications available on the transvaginal approach for RVF repair. To this end, the purpose of this study is to evaluate the preliminary outcomes of the transvaginal approach performed by the team, and to further assess its feasibility, safety and effectiveness in the management of RVF. A retrospective analysis was conducted at a single institution. Patients with RVF who had undergone three transvaginal surgical techniques, i.e. transvaginal fistulectomy and stratified suture, transvaginal flip and ligation fistula tract and transvaginal fistula stapled closure were included. Besides, the demographics, operative data, postoperative complications and follow-up outcomes of the patients were collected prospectively. A total of 49 female patients (mean age, 35.76 ± 13.97years) underwent transvaginal approach, 42 of which were followed up with a median follow-up of 26months (range 3-82months), and 29 had closure of the fistula (successful closure rate of 59.1%). The successful closure rates were only significantly different between previous repair times (p = 0.031), and several minor complications including postoperative pain (n = 3), constipation (n = 1), and lower urinary tract infection (n = 1) were observed. Symptomatic improvement was reported in all patients with failed closure. Transvaginal approach for RVF repair is effective, safe, and feasible, and is therefore considered an alternative to transrectal advancement flap for low and mid-level traumatic RVF with normal sphincter function. With the advantage of better surgical access, transvaginal approach is recognized as the initial choice for the surgical repair of RVF.

Postoperative rectovaginal fistula: Can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases.

Management of rectovaginal fistula (RVF) remains a challenge, especially in cases of postoperative RVF as they are often large and surrounded by inflammatory and fibrotic tissue, making local repair difficult or even impossible. In this situation, colonic pull-through delayed coloanal anastomosis (DCAA) could be an interesting option. The aim of this study was to assess the results of DCAA for RVF observed after rectal surgery. All patients who underwent DCAA for RVF were reviewed. Success was defined as a patient without stoma and without any symptoms of recurrent RVF at the end of follow-up. From January 2010 to December 2020, 28 DCAA were performed for RVF after rectal surgery for rectal cancer (n=21) or endometriosis (n=7). Ten patients (36%) had at least one previous local procedure before DCAA. DCAA was associated with temporary ileostomy in 22/28 cases (79%). After a mean follow-up of 23 ± 23 (2-82) months, the success rate was 86% (24/28): three patients (11%) required a definitive stoma because of poor functional results (n=1), chronic pelvic sepsis with anastomotic leakage (n=1) or stoma reversal refused (n=1). Another patient (3%) presented with recurrence of RVF, 26months after DCAA. Although not significant, the success rate was higher in cases of DCAA with diverting stoma (20/22, 91%) than without (4/6, 67%) (p=0.191). In cases of postoperative RVF, DCAA is a safe option which can avoid definitive stoma in the great majority of the patients. Concomitant use of a temporary stoma appears to slightly increase the success rate.

Laparoscopic omental flap for rectovaginal fistula after low anterior resection

Abstract Introduction: Nearly 1.8% to 9.9% of patients suffer from a rectovaginal fistula after a low anterior resection. The treatment and management of rectovaginal fistulas is challenging for surgeons. Here, we report a case of rectovaginal fistula after low anterior resection that was successfully treated with laparoscopic omental flap surgery. Patient Concerns: An 89-year-old woman underwent laparoscopic low anterior resection for stage IIA rectal adenocarcinoma. The patient noticed fecal discharge from her vagina 6 days postoperatively. Diagnosis: Enema examination results using a contrast agent showed a 1 cm rectovaginal fistula located 1 cm proximal to the anastomotic stapler line. Interventions: We performed laparoscopic rectovaginal fistula repair using an omental flap and laparoscopic transverse colostomy 12 days postoperatively. The omentum was placed between the vaginal and rectal walls and secured with sutures. Outcomes: Oral food intake was resumed 2 days postoperatively, and there were no signs of recurrence of the rectovaginal fistula. The patient underwent a procedure to close the colostomy 36 days after the second surgery. Conclusion: Laparoscopic surgery is helpful in achieving good access during surgery, especially in narrow areas, such as the pelvis. It is essential to use a flap in good condition to treat a rectovaginal fistula. Omentum is an ideal flap with good blood flow that exerts no tension on the tissue. Hence, laparoscopic omental flap is a feasible treatment option for rectovaginal fistulas.

Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach.

Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6months since last procedure. Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

Evaluation and management of rectovaginal fistula in anorectal malformation: an observational study.

The rectovaginal fistula (RVF) is a type of female ARM in which the rectum terminates in the vagina. Due to its rarity, there are limited reports on its presentation, management, and follow-up. This paper deals with the clinical presentation, management, and outcome of RVF. It was a retrospective cohort study of 10years. The patients were evaluated for age, clinical presentation, associated anomalies, any prior surgical interventions performed elsewhere, and complications. After workup, the patients underwent three stages of surgery. Fifty-six patients of RVF were managed. The median age was 13.48months. The associated anomalies were present in 37 (66%) patients. Posterosagittal and anterosagittal anorectoplasty (PSARP and ASARP) were performed in 29 and 6 patients, respectively. Abdominoperineal pull-through (APPT) was performed in 16 patients of congenital pouch colon. The complications of the first stage included stomal stenosis (4) and stomal prolapse (3). Constipation was present in 39 patients 2years after the third surgery. RVF is a distinct entity, which needs careful clinical examination. With proper planning for diagnosis and treatment, it can be managed at specialized centers. Care may be needed for the associated anomalies. The follow-up is an integral part of its management.

Botulinum Toxin Injection for the Treatment of the Recurrent Rectovaginal Fistulas in Combination with Surgical Repair

Rectovaginal fistula is abnormal connections between the vagina and rectum. Via this connection, the passages of flatus or stool from rectum to vagina occur. Patient history and physical examination are usually enough to make diagnosis of fistula. Although there are so many defined surgical options including sphincteroplasty, advanced flap, muscle interposition, fibrin glue, plugs, and closure of fistulas remain a challenging condition with the high rate failure of surgical repair In this study, we aim to report the results of a new treatment approach with the injection of botulinum toxin into lateral internal sphincter on the management of rectovaginal fistula in conjunction with the surgical repair. Between 2013 and 2019, 8 patients with recurrent rectovaginal fistula underwent 10 surgical repairs in conjunction with 100 units botulinum toxin injection. Results of these patients were analyzed. We have treated 8 patients with recurrent rectovaginal fistula. The etiology of fistula in our patients included obstetrical trauna (3 patients), radiotherapy and rectal surgery (2 patients), vaginal reconstruction (2 patients) and Crohn’s disease (1 patient). The median number of their previous operations was 1.5 (range, 1–3). The sizes of fistulas range from 0.5 × 1 to 2 × 3 cm. In our surgical intervention, at the end, all of them were closed (100%) successfully. Botulinum toxin injection into lateral internal sphincter can be used successfully in combination with surgical intervention for the treatment of the rectovaginal fistulas.

Endorectal Local Advancement Flap in Treating Rectovaginal Fistula-Our Experience in Bangabandhu Sheikh Mujib Medical University

Background: Rectovaginal fistula is abnormal epithelial-lined connections between the rectum and vagina. Rectovaginal fistula represents an often devastating condition in patients and a challenge for surgeons. Successful management of this condition must take into account a variety of variables including the etiology, size, and location of the fistula. Repair options include advancement flaps, plugs, fistula ligation, and tissue interposition.
 Method: We treated five cases of low rectovagianl fistula by endorectal local advancement flap in Colorectal Surgery Unit of Bangabandhu Sheikh Mujib Medical University between January 2011 to January 2014. Aim of this study was to evaluate the outcome of Endorectal local advancement flap in terms of cure, recurrence or failure in the management of rectovaginal fistula.
 Result: Out of five, four patients had rectovaginal fistula due to obstetric cause, one was post-surgical. One patient developed partial flap necrosis. The patient was managed by conservative means. Post-operative hospital stay was 5 days (range 4 -7 days). All patients achieved complete healing after the procedure.
 Conclusion: Rectovaginal fistula repair by endorectal local advancement flap should be part of the armamentarium of colorectal surgeons for treating persistent rectovaginal fistula.
 Journal of Surgical Sciences (2014) Vol. 18 (2) : 62-66

Stapled Transperineal Fistula Repair of Rectovaginal Fistula: A Preliminary Experience.

This study is designed to assess the safety, efficacy, and postoperative outcomes of stapled transperineal repair in management of rectovaginal fistula (RVF). A prospective database of patients with RVF undergoing stapled transperineal repair between May 2015 and December 2017 was established and studied retrospectively. Seven consecutive RVF patients underwent stapled transperineal repair. The mean operative time was 119 ± 42 minutes. The estimated blood loss during operation was 24 ± 14 mL. Concomitant levatorplasty was performed with 4 patients and sphincteroplasty with 2 patients. Over a median follow-up of 6 months (range 3-33 months), no case was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (mean preoperative vs postoperative Wexner scores 3 [range 3-4] vs 1 [range 1-2], respectively; P = .01). Stapled transperineal repair of RVF appears safe and effective. The initial results are encouraging, suggesting the need for a more formal prospective assessment of this technique as part of a randomized trial for the management of low- and mid-vaginal fistulas.

Expert Commentary on the Evaluation and Management of Rectovaginal Fistulas.

Expert Commentary on the Evaluation and Management of Rectovaginal Fistulas.

Experience with Different Surgical Procedures in Recto-Vaginal Fistula Management

Experience with Different Surgical Procedures in Recto-Vaginal Fistula Management

Presentation and management of rectovaginal fistulas after delivery.

Obstetric trauma leading to rectovaginal fistula (RVF) formation results from perineal laceration and/or from prolonged ischemia and necrosis following obstructed labor. Due to modern obstetric care fistulas are rare in industrialized countries. Patients undergoing surgery for a RVF between January 2005 and December 2014 at the Department of Obstetrics and Gynecology, Tuebingen, Germany, were identified and their records were reviewed retrospectively. Of 48 patients, 13 developed RVF of obstetric etiology. Parity ranged from 2 to 4. RVF repair was performed in all patients using a transvaginal approach: fistula excision and multilayer closure (7 of 13) with Martius flap interposition (1 of 7) and sphincteroplasty (5 of 13). One RVF closed spontaneously. Due to significant destruction of the anal canal, large RVF and RVF recurrence, 4 of the 13 patients needed a temporary protective ileostomy. Fistula closure was achieved in 12 of 13 patients. The choice of RVF repair should be tailored to the underlying pathology and type of repair done previously and the patient's wishes.

Aetiology, evaluation and management of rectovaginal fistula: A rare entity and a major surgical challenge

Background Rectovaginal fistulas occur as a complication of surgery or radiation therapy, an obstetrical trauma, malignant process and inflammatory bowel disease. These fistulas comprise 5% of all anorectal fistulas. The presenting symptoms vary according to the characteristics of the fistula and the underlying cause.

Management of Rectovaginal Fistulas Following Vaginal Hysterectomy by Minimal Invasive Techniques

Management of Rectovaginal Fistulas Following Vaginal Hysterectomy by Minimal Invasive Techniques

Management of recto-vaginal fistulas after prosthetic reinforcement treatment for pelvic organ prolapse

To communicate our findings on successful treatment of recto-vaginal fistulas (RVFs) after prosthetic reinforcement surgery of pelvic organ prolapse (POP). A retrospective single center study between 1998 and 2008 was performed. A total of 80 patients with RVF were identified, of which five patients (6%), with a mean age of 65 years (range: 52-73), had undergone previous surgery for POP with prosthetic reinforcement. All patients complained about ongoing vaginal infections and febrile episodes. These symptoms were reported after a mean period of 18 mo after POP repair. As a first intervention, three patients underwent ablation of the prosthetic material (PM). As a second intervention, open proctectomy with a primary anastomosis, an omental patch, and a protective ileostomy were performed in two patients. One patient required a terminal colostomy due to complete destruction of the anal sphincters. In two other patients, ablation of the PM and proctectomy was performed as a one-step procedure. The postoperative course in all patients was uneventful, with a mean length of hospitalization of 20 d (range: 15-30). Closure of the ileostomy was achieved in all four patients within four months. After a mean period of 35 mo (range: 4-60) of follow-up, no recurrence was observed with normal continence in four patients. In our experience, the definitive treatment of high RVFs after PM repair for POP necessitates ablation of the PM, proctectomy with a primary colo-rectal anastomosis, an omental patch interposition, and a temporary ileostomy.

Current considerations in the management of rectovaginal fistula from Crohn’s disease

Rectovaginal fistulas are dreaded complications of Crohn's disease. Accurate assessment is essential for planning management. Treatment options range from observation to medical therapeutics to the need for surgical intervention. Ultimately, establishing reasonable expectations is mandatory when treatment algorithms are considered. In this article, we review the evaluation of these fistulas and the current options to consider in the treatment of Crohn's related rectovaginal fistula.

Surgical Treatment of Rectovaginal Fistulas

Rectovaginal fistulas account for less than 5% of all anorectal fistulas. They may occur as a result of obstetrical injuries, inflammatory bowel diseases, or pelvic cancer irradiation. The aim of the study was to describe the results of different methods of surgical treatment according to the etiology and localization of rectovaginal fistulas. Material and methods. The study included 23 female patients who underwent operations for rectovaginal fistulas within the period of 1995 to 2006. The age of patients ranged from 18 to 64 years, with an average age of 41 years. 14 patients received radical treatment according to the etiology and localization of the fistulas: four were treated with abdominal approach, six with a local excision of the rectovaginal fistula involving layer closure of rectal and vaginal openings and interposition of musculomucosal flaps, and four with a simple fistulectomy involving the removal of inflamed tissue and the reconstruction of the perineal body, anal sphincters, and all layers of the rectal and vaginal walls. In nine cases, patients received a palliative surgical treatment to address extensive tissue destruction resulting from radiotherapy for uterine cervix cancer or advanced rectal cancer. Results. Complete recovery occurred in patients who underwent laparotomy for rectovaginal fistulas following inflammatory bowel disease or complicating anterior resection of the rectum. Patients operated on using rectal and vaginal approaches displayed positive results, as did those who underwent. fistulectomy with perineal body and anal sphincter reconstruction. Conclusions. Various surgical techniques are available for the management of rectovaginal fistulas depending on their etiology, size, and location. The best results of low rectovaginal fistula treatment occurred using fistulectomy with layer closure and both-sided covering of the tissue defect with advancement vaginal and rectal flaps.

The Management of Rectovaginal Fistulas in Patients with Inflammatory Bowel Disease

Rectovaginal fistulas (RVF) pose a significant treatment challenge. Inflammatory bowel disease, particularly Crohn’s disease, is the second leading cause of these types of fistulas. Approximately one-third of all the patients with Crohn’s disease will have perianal manifestations, including RVFs at some point in their lives. The choice of treatment is dependent on the complexity of the fistula, the severity of the symptoms, the coexisting anorectal disease, and the degree of impairment of the patient’s quality of life. As a general principle, Crohn’s disease, including its perianal manifestations, preferably should be treated medically with surgical treatment being reserved for patients with refractory disease, debilitating symptoms, and significant impairment of quality of life. In this review we discuss the medical and surgical treatment of RVF in patients with inflammatory bowel disease.

Surgical management of rectovaginal fistula in a colorectal unit

This series of obstetric-related trauma represents only a small proportion (15%) of patients. The management of rectovaginal fistulae was largely dictated by the underlying aetiology with surgical intervention offering a potential cure in the majority. This often necessitated colonic defunctioning and subsequent repair in a staged procedure. Complete resolution with minimal morbidity may be achieved in 77% of these cases.

Rectovaginal fistulae in Crohn’s disease: a management paradox

Much has been written about the management of rectovaginal fistulae in Crohn's disease (CD), but there remains little or no consensus on the optimal therapeutic approach. This retrospective case review examined treatment and clinical outcome of women presenting with rectovaginal fistula between 1985 and 1995 in an attempt to clarify treatment guidelines. A total of 48 case notes was reviewed. Significant symptoms and signs were noted at presentation in 73% and 65% of women, respectively, and fistula classification revealed; three (6%) superficial, 36 (76%) transphincteric, six (12%) suprasphincteric and three (6%) unclassified. Fifteen patients were initially treated conservatively, of whom 73% were eventually rendered asymptomatic and none required proctectomy. Of the remaining 33 fistulae, 12 were treated by laying open or seton insertion, 13 by local repair using transperineal proctotomy or advancement flaps, two by defunctioning alone, and six by proctectomy. Eighty-three percent of patients undergoing laying open or seton insertion, 77% following local repair and 50% following stoma were eventually rendered asymptomatic. The proctectomy rates were 42%, 15%, and 50% in these three groups, respectively. The results of this study suggest that in the absence of significant symptoms, conservative management provides a good chance of fistula healing without need for proctectomy. However, if symptoms dictate the need for intervention, local repair provides a similar chance of success with a lower ultimate need for proctectomy than laying open or seton. Despite these broad generalities, this study highlights the difficulties we have in advising patients with proctovaginal fistulae in CD.