Operative considerations for rectovaginal fistulas

Multidisciplinary approach to evaluation of rectovaginal fistulas

Thorough evaluation of a rectovaginal fistula is essential to optimize surgical repair. The underlying cause should be addressed and treated, which can affect the timing and the approach to repair. It is imperative to be well prepared because the highest chance of successful closure occurs during the initial repair attempt. Our objective was to demonstrate how multidisciplinary colorectal surgery and urogynecology teams use specific methods during the examination under anesthesia to evaluate a complex rectovaginal fistula and to optimize the surgical approach to repair. Anesthesia may be provided with monitored anesthesia care and a posterior perineal block. This pain control allows for a wide range of techniques to evaluate the fistula using anoscopy, fistula probe, hydrogen peroxide, and sigmoidoscopy. In addition, the teams show how curettage and subsequent seton placement can encourage closure by secondary intention and decrease the risk of abscess formation, respectively.

Successful Fistula Closure After Treatment with Colostomy and Infliximab in a Patient with Ulcerative Colitis Complicated by Rectovaginal Fistula

The patient was a 50-year-old Japanese woman who was diagnosed with total-colitis-type ulcerative colitis (UC) at the age of 26 years. She was treated with mesalazine and azathioprine, and her disease activity was well controlled. At the age of 50 years, the patient was experiencing fever, abdominal pain, diarrhea, bloody stool, and anal pain, which led to a diagnosis of a relapse of UC. Although steroid therapy was administered and tended to improve her symptoms, fecaloid vaginal discharge occurred, and rectovaginal fistula (RVF) was confirmed. Colostomy was performed, and infliximab was initiated as maintenance therapy for UC. All symptoms improved, and RVF closure was confirmed 6 months after the initiation of infliximab. To date, she has been free from relapse of UC. There have been only a few reports of UC complicated by RVF, and this condition is often difficult to treat. To the best of our knowledge, no other case of UC complicated by RVF in which the fistula was closed after treatment with colostomy and infliximab has been previously reported; thus, our report of the present case is valuable to the literature.

Stapled transperineal rectovaginal fistula repair for low- and mid-level rectovaginal fistulas: A comparison study with rectal mucosal advancement flap repair

BACKGROUND

As an innovative treatment, stapled transperineal rectovaginal fistula repair (STR) for rectovaginal fistula (RVF) has demonstrated effectiveness in preliminary reports. This study aims to compare STR with rectal mucosal advancement flap repair (RAF), a widely utilized surgical procedure, for the surgical outcome of the low- and mid-level RVF.

METHODS

In this retrospective cohort study, patients with low- and mid-level RVF who underwent STR or RAF were included from both the Sixth Affiliated Hospital of Sun Yat-sen University and Xi'an Daxing Hospital. Among the 99 total patients, 77 underwent STR and 22 underwent RAF. Patient demographics, operative data, and outcomes were collected and analyzed. Recurrence rate and associated risk factors were evaluated.

RESULTS

There were no statistically significant differences among patients in terms of clinical characteristics like age, BMI, aetiology, and fistula features. During the follow-up period of 20 months (interquartile range 3.0-41.8 months), a total of 28 patients relapsed, with a significantly lower recurrence rate in the STR group (20.8 %) than in the RAF group (54.6 %) (P = 0.005). In the multivariate Cox analysis, STR was an independent protective factor against recurrence (HR: 0.37, 95%CI: 0.17-0.79, P = 0.01). Logistic regression indicated that there was no statistically significant difference between these two procedures in terms of surgical complications (OR: 0.53, 95%CI: 0.19-1.48, P = 0.23).

CONCLUSION

For low- and mid-level RVF, STR may be an alternative option for treatment modality that offers a lower recurrence rate, without observed disadvantage in terms of surgical complication rates.

Disease Burden, Treatment Patterns, and Economic Impact of Rectovaginal Fistulas in Patients with Crohn's Disease: Findings from a Retrospective, Observational, Longitudinal Study Based on US Claims Databases

BACKGROUND

Crohn's-related rectovaginal fistulas (RVF) greatly impact quality of life and are notoriously difficult to treat. The aim of this study was to assess the burden of recurrent episodes of care for RVF and its economic impact.

METHODS

A retrospective observational cohort study of administrative US claims databases was conducted. Eligible patients were female adults, with a diagnosis code for Crohn's disease with or without a diagnosis/procedural code for RVF. For the RVF cohort, rates of recurrence of RVF episodes of care were estimated using Kaplan-Meier analyses. Healthcare resource utilization (HCRU) and direct healthcare costs were compared between the RVF cohort and RVF-free cohort.

RESULTS

Mean ages in the RVF cohort (n = 963) and RVF-free cohort (n = 56,564) were 47.2 and 50.8 years, with a mean follow-up period of 58.7 and 49.8 months, respectively. For the RVF cohort, the probability of having a second RVF episode of care within 2 years of the first one was estimated to be 35.9% and of having a third episode within 2 years of the second was 47.8%. During the first 2 years, the RVF cohort had 67% more inpatient admissions than the RVF-free cohort with each RVF episode of care being associated with 16% more admissions. The estimated incremental cost associated with having RVF was US$17,561, with an incremental cost of US$11,607 for each additional RVF episode of care.

CONCLUSIONS

This real-world study highlights the significant impact of RVF in patients with Crohn's disease with regard to repeat interventions and associated HCRU and direct healthcare costs, suggesting novel therapeutics are needed in this patient population.

Surgical management of rectovaginal fistula after stapled transanal rectal resection for prolapsed hemorrhoids

INTRODUCTION AND HYPOTHESIS

Rectovaginal fistula is an epithelium-lined direct communication route between the vagina and the rectum. The gold standard of fistula management is surgical treatment. Rectovaginal fistula after stapled transanal rectal resection (STARR) may be challenging to treat, due to the extensive scarring, the local ischemia, and the risk of rectal stenosis. We aimed to present a case of iatrogenic rectovaginal fistula after STARR that was successfully treated with a transvaginal primary layered repair and bowel diversion.

METHODS

A 38-year-old woman was referred to our division for continuous fecal discharge through her vagina that developed a few days after she had a STARR for prolapsed hemorrhoids. Clinical examination revealed a 2.5 cm-wide direct communication between the vagina and rectum. After proper counseling, the patient was admitted to transvaginal layered repair and temporary laparoscopic bowel diversion RESULTS: No surgical complications were observed. The patient was successfully discharged home on postoperative day 3. Bowel diversion was reversed after 2 months. At the current follow-up (6 months), the patient is asymptomatic and without recurrence.

CONCLUSIONS

The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this severe condition.

Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned

Background

Rectovaginal fistulas following an obstetric anal sphincter injury's repair are rare in developed country and their management could be challenging, particularly in cases of delayed repair. This study emphasizes the importance of accurately diagnosing and promptly repairing such fistulas for optimal patient well-being.

Case

A 30-year-old patient presented with gas incontinence and a greenish discharge from the vagina, 6 months after delivering her baby. Examination revealed a small pinhole lesion on the posterior vaginal wall, and an endoanal ultrasound confirmed the presence of a rectovaginal fistula. Surgical repair was delayed for 9 months due to the patient's breastfeeding. The fistula was eventually repaired through a transrectal approach, with excision of the fistulous tract and closure of both the rectum and vagina. A laparoscopic protective ileostomy was also performed due to the delayed repair. However, a recurrence of the fistula was detected 8 months later, requiring a second repair. The patient underwent physiotherapy for the anal sphincter and achieved optimal sphincter function. After 6 months, the ileostomy was successfully closed, and the patient remained continent.

Conclusions

This case highlights the importance of early recognition and prompt repair of rectovaginal fistulas following obstetric anal sphincter injury. Delayed repairs pose greater challenges and increase the risk of recurrence. Individualized surgical approaches, skilled pelvic floor repair, and a multidisciplinary approach are crucial for successful outcomes. This case underscores the need for careful planning and consideration of patient characteristics in the management of rectovaginal fistulas, aiming to achieve optimal outcomes and patient well-being.

Initial Clinical Outcomes Using Umbilical Cord-Derived Tissue Grafts to Repair Anovaginal Fistula

BACKGROUND

Perianal fistula is a debilitating disease and challenging condition to treat. Recently, the use of stem cells has been shown to improve healing of fistulas.

OBJECTIVE

The aim was to examine the use of an umbilical cord-derived stem cell graft in a pilot study as a novel scaffold/stem inlay implanted into fistula repairs for anovaginal fistula to examine healing rates.

DESIGN

This was a pilot study.

SETTINGS

This study took place in a colorectal surgery practice.

PATIENTS

Patients with anovaginal fistula consented to participate. Cryopreserved umbilical cord tissue graft with viable cells was incorporated as an inlay using a previously reported technique by the authors. Demographic data including history of previous repairs and IBD were included. All patients were followed for a minimum of 6 weeks.

MAIN OUTCOME MEASURES

The primary measures were safety and efficacy of novel stem cell graft in the treatment of anovaginal fistula.

RESULTS

From September 2017 to September 2019, 15 patients underwent anovaginal fistula repair. Three of these patients underwent a second repair, for a total of 18 repairs. No patient was intentionally diverted, but 3 patients presented for repair with a preexisting stoma. The majority of repairs were previous repair failures (12; 67%), and 7 repairs were performed on 5 patients with IBD. Median follow-up was 30 (6-104) weeks. The safety profile for cryopreserved umbilical cord tissue graft was excellent as no adverse events occurred. Overall complete healing rate was 39%, and 12 (67%) repairs resulted in improvement of symptoms.

LIMITATIONS

This was a small pilot study.

CONCLUSIONS

This is the largest series using cryopreserved umbilical cord graft for anovaginal fistula repair. The use of umbilical cord was safe and effective at closing defects. Randomized studies are necessary to determine added benefits over current standard of care. See Video Abstract at http://links.lww.com/DCR/B896 .

RESULTADOS CLNICOS INICIALES DEL USO DE INJERTOS DE TEJIDO DERIVADO DE PLACENTA PARA REPARACIN DE FSTULAS ANOVAGINALES

ANTECEDENTES:La fístula perianal es una enfermedad debilitante y una afección difícil de tratar. Recientemente, se ha demostrado que el uso de células madre mejora la curación de las fístulas.OBJETIVO:Deseamos examinar el uso de un injerto de células madre derivadas de cordón umbilical en un estudio piloto como una nueva matriz/injerto de células madre implantado en reparaciones de fístula para fístula anovaginal para examinar las tasas de curación.DISEÑO:Este fue un estudio piloto.ESCENARIO:Este estudio se llevó a cabo en una clínica de cirugía colorrectal.PACIENTES:Se obtuvo consentimiento informado de pacientes con fístula anovaginal. El injerto de tejido de cordón umbilical criopreservado con células viables se incorporó como incrustación utilizando una técnica previamente informada por los autores. Se incluyeron datos demográficos que incluían antecedentes de reparaciones previas y enfermedad inflamatoria intestinal. Todos los pacientes fueron seguidos durante un mínimo de 6 semanas.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas fueron la seguridad y la eficacia del nuevo injerto de células madre en el tratamiento de la fístula anovaginal.RESULTADOS:Desde 9/2017-9/2019, 15 pacientes fueron sometidas a reparación de fístula anovaginal. Tres de estos pacientes fueron sometidos a una segunda reparación, para un total de 18 reparaciones. Ningún paciente fue derivado intencionalmente mientras que 3 pacientes se presentaron para reparación con un estoma preexistente. La mayoría de las reparaciones fueron fallas de reparaciones previas (12, 67%) y se realizaron siete reparaciones en 5 pacientes con enfermedad inflamatoria intestinal (EII). La mediana de seguimiento fue de 30 semanas (6-104). El perfil de seguridad del injerto de tejido de cordón umbilical criopreservado fue excelente ya que no se produjeron efectos adversos. La tasa general de curación completa fue del 39% y 12 (67%) reparaciones dieron como resultado una mejoría de los síntomas.LIMITACIONES:Este fue un pequeño estudio piloto.CONCLUSIÓNES:Ésta es la serie más grande de utilización de injerto de cordón umbilical criopreservado para la reparación de una fístula anovaginal. La utilización del cordón umbilical resultó segura y eficaz para cerrar defectos. Se necesitan estudios aleatorizados para determinar los beneficios adicionales sobre el estándar de atención actual. Consulte Video Resumen en http://links.lww.com/DCR/B896 . (Traducción-Dr. Jorge Silva Velazco ).

Minimally invasive endoscopic repair of rectovaginal fistula

BACKGROUND

Surgical techniques for repair of rectovaginal fistula (RVF) have been continually developed, but the ideal procedure remains unclear. Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting.

AIM

To review the current applications and preliminary outcomes of this technique for RVF repair, aiming to give surgeons an alternative in clinical practice.

METHODS

Available articles were searched according to the search strategy. And the sample size, fistula etiology, fistula type, endoscopic repair approaches, operative time and hospital stay, follow-up period, complication and life quality assessment were selected for recording and further analysis.

RESULTS

A total of 11 articles were eventually identified, involving 71 patients with RVFs who had undergone endoscopic repair. The principal causes of RVFs were surgery (n = 51, 71.8%), followed by obstetrics (n = 7, 9.8%), inflammatory bowel disease (n = 5, 7.0%), congenital (n = 3, 4.2%), trauma (n = 2, 2.8%), radiation (n = 1, 1.4%), and in two patients, the cause was unclear. Most fistulas were in a mid or low position. Several endoscopic repair methods were included, namely transanal endoscopic microsurgery, endoscopic clipping, and endoscopic stenting. Most patients underwent > 1-year follow-up, and the success rate was 40%-93%, and all cases reported successful closure. Few complications were mentioned, while postoperative quality of life assessment was only mentioned in one study.

CONCLUSION

In conclusion, endoscopic repair of RVF is novel, minimally invasive and promising with acceptable preliminary effectiveness. Given its unique advantages, endoscopic repair can be an alternative technique for surgeons.

Local skin flap procedure for repair of rectovaginal fistula: A case report

Introduction

Rectovaginal fistula (RVF) is an increasingly common rectal surgery complication. Although various RVF closure operations have been reported, no one approach is considered ideal. Consequently, some patients must undergo more complex and technically challenging surgical procedures. We describe the successful use of simple local skin flap plasty for RVF repair.

Presentation of case

A 74-year-old Japanese female developed RVF after robot-assisted laparoscopic proctectomy with intersphincteric resection, hand-sewn coloanal anastomosis, and a temporary ileostomy. Three months later, reconstructive surgery was performed using a local flap. The fistula was successfully closed and healed well without complications.

Discussion

A local flap consists of the skin and subcutaneous tissue harvested from a nearby site that maintains its intrinsic blood supply.

Conclusion

This novel approach to RVF repair appears simple, effective, and safe.

•

A local flap consists of the skin and subcutaneous tissue harvested from a nearby site.

•

A local flap is simple, less invasive, and considered early in the process.

•

A local flap can be one of the RVF treatments.

Transvaginal repair of a rectovaginal fistula caused by transvaginal mesh prolapse surgery

Introduction

Transvaginal mesh surgery can cause mesh complications including rare rectovaginal fistula. We report a case of a rectovaginal fistula treated transvaginally without colostomy.

Case presentation

A 57-year-old female was referred to us due to post-hysterectomy prolapse and had transvaginal mesh surgery. She underwent transvaginal hysterectomy because of uterine prolapse at age 33 and had taken steroids to treat pemphigus. Two years later, she developed vaginal bleeding and discharge. Transvaginal mesh removal was planned to treat vaginal mesh exposure, but immediately before the operation digital rectal examination revealed rectovaginal fistula. Mesh removal and fistula closure were performed transvaginally without colostomy. Three years of follow-up showed no recurrence of mesh exposure, fistula, or prolapse.

Conclusion

Rectovaginal fistula following mesh surgery may be treated transvaginally without colostomy if infection is minimal. To evaluate mesh exposure on the posterior vaginal wall, rectal examination should be done along with vaginal examination.

Combined transabdominal-transanal surgical approach for iatrogenic rectovaginal fistula: two case reports

Rectovaginal fistula (RVF) is a type of anastomotic leakage that may occur after low anterior resection for rectal cancer. The repair of RVF can be challenging because of the scar tissue stenosis and incomplete obstruction. Two patients presented in our department with vaginal faecal discharge almost 7 months after the radical resection of rectal cancer. On vaginal examination, titanium nails related to the rectal surgery were found in the vaginal wall. The patients were diagnosed with RVF. Considering that RVF positions in the patients were high and might adhere to the pelvic tissue, a combined transabdominal-transanal resection and vaginal repair surgery was performed. About 3 months after surgery, both patients underwent colonic closure surgery, with consequent good recovery. A combined transabdominal-transanal approach may provide distinct advantages in surgical repair of difficult cases of RVF.

Application of platelet-rich plasma in rectovaginal fistulas in the patients with ulcerative colitis

BACKGROUND

There is a need for other than surgical methods of therapy for small and low rectovaginal fistulas (RVF) in the course of inflammatory bowel diseases (IBD), such as application of fibrin sealants, stem cells, biological therapy, or platelet-rich plasma. The aim of this study was to evaluate the results of the treatment after local application of PRP in aforementioned fistulas, exclusively in the patients with ulcerative colitis (UC).

PATIENTS AND METHODS

Medical records of 13 patients with small and low-lying, active RVF in the course of UC, and after restorative proctocolectomy for UC were evaluated. Curettage of fistulous tracts was performed with the following application of PRP in all patients.

RESULTS

Complete closure of RVF was achieved after the first injection in 4 patients, 3 women healed their fistulas following the second application, and two of them closed RVF after 3 injections. To sum up, the complete closure of RVF was achieved in 9 (69%) patients. Fistulas remained closed from 6 to 12 months.

CONCLUSIONS

The application of PRP in small, low, and recurrent IBD anal fistulas is effective, simple, and safe with an acceptable rate of healing. This therapy might also precede any further, surgical methods of treatment.

What is the best method of rectovaginal fistula repair? A 25-year single-center experience

BACKGROUND

The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula.

METHODS

Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6 months.

RESULTS

One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6 months (range 0-203 months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes.

CONCLUSIONS

Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.

Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair

BACKGROUND

Currently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, with a relatively low healing rate. Unclosed intermittent suture and poor suture materials may be the main reasons for this.

AIM

To evaluate the efficacy and safety of stapled transperineal repair in treating RVF.

METHODS

This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among the 82 total patients, 37 underwent repair with direct suturing and 45 underwent repair with stapling. Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were assessed.

RESULTS

The direct suture and stapled repair groups showed similar clinical characteristics for aetiology, surgical history, fistula features, and perioperative Wexner score. The stapled repair group did not show superior results over the suture repair group in regard to operative time, blood loss, and hospital stay. However, the stapled repair group showed better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (1/45 vs 17/37, P = 0.045), and lower recurrence rate (6/45 vs 17/37, P = 0.001). There was no protective effect from previous repair history, smaller diameter of fistula (< 0.5 cm), better control of defecation (Wexner < 10), or stapled repair. Direct suture repair and preoperative high Wexner score (> 10) were risk factors for fistula recurrence. Furthermore, stapled repair gave better efficacy in treating complex RVFs (i.e., multiple transperineal repair history, mid-level fistula position, and poor control of defecation).

CONCLUSION

Stapled transperineal repair is advantageous for management of RVF, providing a high primary healing rate and low recurrence rate.

Fistulas Healing. Stable Gastric Pentadecapeptide BPC 157 Therapy

This review is focused on the healing of fistulas and stable gastric pentadecapeptide BPC 157. Assuming that the healing of the various wounds is essential also for the gastrointestinal fistulas healing, the healing effect on fistulas in rats, consistently noted with the stable gastric pentadecapeptide BPC 157, may raise several interesting possibilities. BPC 157 is originally an anti-ulcer agent, native to and stable in human gastric juice (for more than 24 h). Likely, it is a novel mediator of Robert's cytoprotection maintaining gastrointestinal mucosal integrity. Namely, it is effective in the whole gastrointestinal tract, and heals various wounds (i.e., skin, muscle, tendon, ligament, bone; ulcers in the entire gastrointestinal tract; corneal ulcer); LD1 is not achieved. It is used in ulcerative colitis clinical trials, and now in multiple sclerosis, and addressed in several reviews. Therefore, it is not surprising that BPC 157 has documented consistent healing of the various gastrointestinal fistulas, external (esophagocutaneous, gastrocutaneous, duodenocutaneous, colocutaneous) and internal (colovesical, rectovaginal). Taking fistulas as a pathological connection, this rescue is verified with the beneficial effects in rats with the various gastrointestinal anastomoses, esophagogastric, jejunoileal, colo-colonic, ileoileal, esophagojejunal, esophagoduodenal, and gastrojejunal. This beneficial effect occurs equally when the gastrointestinal anastomoses are impaired with the application of NSAIDs, cysteamine, large bowel resection, as well as concomitant esophageal, gastric, and duodenal lesions and/or ulcerative colitis presentation, short bowel syndrome progression, liver and brain disturbances presentation. Particular aspects of the BPC 157 healing of the fistulas are especially emphasized.

Allogeneic expanded adipose-derived stem cells in the treatment of rectovaginal fistulas in Crohn's disease

AIM

Crohn's disease (CD)-related rectovaginal fistulas (RVFs) are rare, challenging to treat and associated with a high morbidity. Due to a significant lack of data, we aimed to analyse the safety and feasibility of allogeneic adipose-derived stem cells (ASCs) in the treatment of CD-related RVF.

METHOD

Four consecutive patients with CD-related RVF underwent treatment with expanded allogeneic ASCs extracted from a healthy donor in a tertiary referral centre in 2019. None of the patients had an intestinal diversion at the time of the treatment. Follow-up was performed 6 months postoperatively.

RESULTS

The median operation time was 45 min with a median hospital stay of 3 days. No intra-operative complications occurred. Three patients (75%) developed recurrent RVF after a median follow-up of 19 days. Two patients required surgical treatment including loose seton drainage due to discharge and pain. One patient developed recurrence of symptoms after 10 days, but refused further surgical therapy. Only one patient (25%) showed healing of the RVF, with re-epithelialization of both the vaginal and rectal opening and absence of clinical symptoms.

CONCLUSION

Expanded allogeneic ASC therapy represents a novel safe treatment option for CD-associated RVF. Although efficacy appears limited, further controlled studies are required to draw robust conclusions.

Incidence and Risk Factors for Postoperative Complications of Rectovaginal Fistula Repairs, Based on Different Surgical Routes

OBJECTIVE

To investigate incidence and risk factors for postoperative complications after rectovaginal fistula (RVF) repairs, based on different surgical routes.

METHODS

This retrospective cohort study utilized CPT codes to identify RVF repairs performed during 2005 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database. Demographic/clinical characteristics were compared among different surgical routes. Logistic regression was performed to identify associations.

RESULTS

Among 1398 RVF cases, 1391 were included for final analysis: 159 (11.4%) were performed transabdominally (group 1), 253 (18.2%) transperineally (group 2), and 979 (70.4%) transvaginally/transanally (group 3). Group 1 was older compared with groups 2 and 3 (58.72 ± 15.23 years vs 44.11 ± 13.51 years vs 46.23 ± 14.31 years, P < 0.0001). Race/ethnicity was comparable in all groups with non-Hispanic-White most common. Comparably, group 1 had higher preoperative comorbidities: hypertension requiring medication (P < 0.0001), chronic obstructive pulmonary disease (COPD) (P = 0.0347), preoperative infection (P = 0.002), functional dependence (P = 0.0001), and longer time between hospital admission to operation (P < 0.0001). Group 1 also had longer operating time (P < 0.0001); more American Society of Anesthesiologist ≥ 3 classification (P < 0.0001); and more likely inpatient status (P < 0.0001). The overall incidence of any postoperative complications was 13.2% (25.2%, group 1 vs 15.8%, group 2 vs 10.6%, group 3; P < 0.0001). The most common postoperative complications included unplanned readmission, postoperative superficial surgical site infection, and reoperation. The incidence of severe postoperative complications was 7.9% (17%, group 1 vs 7.1%, group 2 vs 6.6%, group 3, P < 0.0001): group 1 had highest rates of pulmonary embolism (P = 0.0004), deep venous thrombosis (P = 0.0453), bleeding requiring transfusion (P < 0.0001), stroke (P = 0.0207), unplanned reintubation (P = 0.0052), and death (P = 0.0004). Group 1 also had highest rates of minor postoperative complications like urinary tract infection (P = 0.0151), superficial surgical site infection (P = 0.0189), and pneumonia (P = 0.0103). In addition, group 1 had the greatest postoperative length of stay (P < 0.0001). In multivariate analysis, age (P = 0.0096), inpatient status at the time of surgery (P = 0.0004), and operating time >2 to 3 hours (P = 0.0023) were significant predictors of postoperative complications within 30 days after surgery.

CONCLUSIONS

The overall incidence of complications after RVF repairs+/-concomitant procedures was 13.2%. The overall incidence of severe complications was 7.9%. The abdominal approach had more postoperative complications but it was not an independent predictor of postoperative complications after RVF repair.

Martius flap reconstruction for rectovaginal fistula after stapled hemorrhoidopexy (Longo operation): a case report

PURPOSE

A rectovaginal fistula (RVF) is a rare disease. It's an epithelium-lined abnormal communication between rectum and vagina. It represents approximately 5% of all anorectal fistulas. RVF may have different causes.

METHODS

We present a case of a 58-year-old woman with a rectovaginal fistula after stapled hemorrhoidopexy (Longo operation).

RESULTS

A 58-year-old woman presented herself in our department with vaginal fecal discharge and vaginitis almost one month after a stapled hemorrhoidopexy was performed in another hospital. On vaginal examination, a large dorsal defect was palpated at four cm. On rectal examination, the stapler line was palpable at four cm and just distal to this stapler line, a large defect could be palpated. A lower gastrointestinal tract radiography was performed and identified a RVF. The patient was put on antibiotics and two operations were planned. First, a temporary ileostomy was created. After healing of the vaginitis, reconstructive surgery with anatomic fistula repair in combination with the interposition of healthy, vascularised tissue was performed. In this case, we chose the Martius flap. The operation as well as the postoperative course was uneventful.

CONCLUSIONS

Cases of postoperative RVF have been increasingly reported since the introduction of stapled hemorrhoidopexy. Patients with RVF can have a varying degree of symptoms. Diagnosis is primarily based on the patient's medical history together with a clinical examination. There are many surgical approaches for RVF. Anatomic fistula repair alone is associated with lower success rates compared with combined procedures with the adjunctive interposition of healthy, vascularised tissue.

Short-term outcomes of the over-the-scope clip proctology system for rectovaginal fistula repair: a prospective study

BACKGROUND

The over-the-scope clip proctology system is rather new and information regarding its use for the closure of anorectal fistulas is scarce. No study has been designed to focus exclusively on its application in the treatment of rectovaginal fistulas. The aim of the study was to evaluate the feasibility, safety, and effectiveness of the clip for rectovaginal fistula repair.

METHODS

From September 2014 to November 2017, consecutive patients underwent a rectovaginal fistula repair using the over-the-scope clip proctology system and were enrolled in a non-randomized prospective monocentric study. The primary outcome was fistula healing at 8 months. Secondary outcomes included assessment of morbidity and timing of rectovaginal fistula recurrence.

RESULTS

There were 16 patients with a median age of 40.1 years. The most common causes of rectovaginal fistula were adverse events following proctectomy or pelvic radiotherapy (6 patients), obstetric trauma (5 patients) and inflammatory bowel disease (3 patients). Most participants had undergone at least two previous surgical interventions before the clipping procedure. 11 patients had a temporary diverting stoma at time of the clipping procedure. Successful primary healing of the fistula was observed in 7 (43.7%) patients. Short-term complications were rare and included pain, which occurred in 4 patients, and spontaneous clip detachment, which occurred in 2 patients. Most recurrences appeared shortly after the procedure, with a median delay of 45 days (range 16-217).

CONCLUSIONS

We demonstrated the feasibility, safety, and reproducibility of the Over-The-Scope Clip Proctology system in rectovaginal fistula repair for the patients selected. Further trials should be designed, incorporating comparisons to well-established techniques, a longer follow-up period, and a larger cohort.

Stapled Transperineal Fistula Repair of Rectovaginal Fistula: A Preliminary Experience

PURPOSE

This study is designed to assess the safety, efficacy, and postoperative outcomes of stapled transperineal repair in management of rectovaginal fistula (RVF).

METHODS

A prospective database of patients with RVF undergoing stapled transperineal repair between May 2015 and December 2017 was established and studied retrospectively.

RESULTS

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).

CONCLUSIONS

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.

Successful repair of a rectovaginal fistula caused by a tension-free vaginal mesh (TVM): a case report

Rectovaginal fistula caused by a tension-free vaginal mesh (TVM) is a rare condition. Moreover, a rectovaginal fistula is a challenging issue to address for surgeons regardless of causes. Due to a low rate of occurrence, treatment modality for a rectovaginal fistula caused by a TVM has previously received little attention. A successful surgery using several key techniques to address a rectovaginal fistula caused by a TVM is herein reported. A 78-year-old woman who underwent a TVM for a rectocele three months ago was referred to our hospital with a two-month history of anal bleeding. Mesh protruding into both the vagina and the rectum was confirmed. The patient was operated on under diagnosis of a rectovaginal fistula caused by TVM. TVM was removed by transvaginal dissection of the rectovaginal septum with division of both anterior and posterior arms of the TVM. Layer-to-layer sutures of rectal and vaginal walls were crossly performed with a drain placed in the rectovaginal septum after saline irrigation followed by a covering sigmoid colostomy. The wound healed without infection after surgery, and a water-soluble contrast enema demonstrated the healing of the rectovaginal fistula two months after surgery. No recurrent fistula was confirmed 15 months after stoma closure.

Colorectal-Vaginal Fistulas: Imaging and Novel Interventional Treatment Modalities

Colovaginal and/or rectovaginal fistulas cause significant and distressing symptoms, including vaginitis, passage of flatus/feces through the vagina, and painful skin excoriation. These fistulas can be a challenging condition to treat. Although most fistulas can be treated with surgical repair, for those patients who are not operative candidates, limited options remain. As minimally-invasive interventional techniques have evolved, the possibility of fistula occlusion has enriched the therapeutic armamentarium for the treatment of these complex patients. In order to offer optimal treatment options to these patients, it is important to understand the imaging and anatomical features which may appropriately guide the surgeon and/or interventional radiologist during pre-procedural planning.

Combined Laparoscopic and Perineal Approach to Omental Interposition Repair of Complex Rectovaginal Fistula

INTRODUCTION

Surgical repair of rectovaginal fistula remains a challenge. Complex and recurrent rectovaginal fistula repairs often fail because of scarring and devascularization of the surrounding tissue. Omental interposition may promote healing by introducing bulky vascularized tissue into the rectovaginal septum.

TECHNIQUE

With the patient in the lithotomy position, the rectovaginal septum was dissected transperineally up to the fistula tract and the openings on both vaginal and rectal sides were closed using interrupted, absorbable sutures. The dissection was continued cranially to meet the laparoscopic dissection from above. The laparoscopic surgeon detached the omentum from the colon, then the anastomotic arterial branches between the Barlow's arcade and the gastroepiploic arcade were divided and the greater omentum was mobilized, retaining blood supply from the left gastroepiploic artery. The rectum was then mobilized commencing on the right lateral side of the mesorectum and then proceeding anteriorly. The peritoneum between the rectum and the vagina was incised and the anterior mobilization was continued to connect with the perineal dissection. The mobilized omentum was pulled down between the rectum and the vagina.The perineal operator secured the omentum around the rectal closure and at skin level with absorbable sutures. All of the patients had a defunctioning ileostomy or colostomy before omental repair.

RESULTS

Patients underwent repair for complex or recurrent rectovaginal fistulas with this novel approach. Fistula healing was evaluated during examination under anaesthesia. All of the patients had completely healed at the latest follow-up (median = 15 mo; range, 8-41 mo). Postoperative complications included 1 superficial wound infection that was treated conservatively and 1 rectovaginal hematoma, which required CT-guided aspiration.

CONCLUSIONS

Combined laparoscopic omental interposition with perineal rectovaginal fistula repair is a safe and effective treatment for complex rectovaginal fistulas.

Efficacy of autologous fat graft injection in the treatment of anovaginal fistulas

BACKGROUND

Injection of autologous fat is an established method within plastic surgery for soft tissue augmentation. The aim of the present study was to determine whether transperineal fat graft injection could promote healing of anovaginal fistulas.

METHODS

The procedures were performed at the University Hospital of North Norway, Tromsø, Norway, and at Aarhus University Hospital, Aarhus, Denmark, between May 2009 and September 2016. After abdominal liposuction, fat was injected around the fistula tract that was finally transected percutaneously with a sharp cannula and fat injected between the cut parts. The internal opening was closed with a suture. Patients had a minimum follow-up of 6 months after last fat graft injection.

RESULTS

Twenty-seven women underwent 48 procedures. The cause of fistula was obstetric (n = 9), abscess (n = 9), Crohn's disease (n = 7), radiation for anal cancer (n = 1) and endoscopic surgery after radiation for rectal cancer (n = 1). The mean amount of injected fat was 73 ml (SD ± 20 ml), and operating time was 63 min (SD ± 21 min). At median follow-up of 20 months (range 6-87 months) after the last injection, fistulas were healed in 21 women (77%), in 8 women after just one procedure. Healing was achieved in 6 of 7 women (86%) with Crohn's disease and in both women who had undergone radiation therapy. One woman developed an abscess and additional trans-sphincteric fistula 8 weeks after injection.

CONCLUSIONS

Fat graft injection for anovaginal fistulas is effective and safe.

Martius' flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn's disease, endometriosis and a mullerian anomaly

Background

Rectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn’s disease that negatively affects patients’ social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options.

Case presentation

We describe a 31-year-old female patient with a Crohn’s disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient’s medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius’ flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy.

Conclusion

Martius’ flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn’s disease.

The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate.

Genital tract fistula: a case series from a tertiary centre in South Africa

INTRODUCTION AND HYPOTHESIS

We describe the demographic profile, aetiology, management and surgical outcomes in women with genital tract fistula presenting to a tertiary urogynaecology unit.

METHODS

This retrospective audit included 87 patients managed in our unit between 2008 and 2015. Frequencies and means with standard deviations are presented for categorical and continuous data. Continuous dependent variables are categorized as above or below the median for bivariate analyses performed using the chi-squared test (α = 0.05).

RESULTS

The mean age of the women was 34.7 years, 64.4% were Black African, 70.2% were multiparous, 49.4% were married, 82.8% were employed, and 21.8% were HIV-infected, with 47.4% on antiretroviral treatment. Vesicovaginal (47.1%) and rectovaginal (41.4%) fistula were the most frequent injuries. The majority of the injuries (67.8%) were obstetric, with 26.4% occurring during caesarean delivery. Repair had been attempted previously in 43.7% of patients. In 63.2% of the repairs the approach was vaginal and in 35.6% abdominal. Interposition grafts were used in 23% of repairs. In 85.1% of patients the initial repair at our centre was successful. Patients with multiple repairs were more likely to have complications (p = 0.03). HIV infection was not significantly associated with complications.

CONCLUSIONS

A high rate of successful repair was found, with previous unsuccessful repairs associated with poorer outcomes, highlighting the need for centralized management.

Genital and reproductive organ complications of Crohn disease: technical considerations as it relates to perianal disease, imaging features, and implications on management

OBJECTIVE

A relatively large proportion of patients with Crohn disease (CD) develop complications including abscess formation, stricture, and penetrating disease. A subset of patients will have genital and reproductive organ involvement of CD, resulting in significant morbidity. These special circumstances create unique management challenges that must be tailored to the activity, location, and extent of disease. Familiarity with the epidemiology, pathogenesis, imaging features, and treatment strategies for patients with genital CD can aid imaging diagnoses and guide appropriate patient management. The purpose of this study is to illustrate the spectrum of CD in the genital tract and reproductive organs and discuss the complex management strategies in these patients as it relates to imaging.

CONCLUSION

Given the impact on patient outcome and treatment planning, familiarity with the epidemiology, pathogenesis, imaging features, and treatment of patients with genital Crohn disease can aid radiologic diagnoses and guide appropriate patient management.

Transvaginal Repair of Complex Rectovaginal Fistulas Using the Porcine Urinary Bladder Matrix as an Augmenting Graft

BACKGROUND

After the US Food and Drug Administration issued a safety warning concerning vaginal mesh implants in 2008, their use in correction of pelvic floor defects have decreased in the United States (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm). However, we are still treating patients who have had complications associated with their use, rectovaginal fistulas (RVFs) being one of them. Rectovaginal fistulas are considered complex if greater than 2.5 cm, recurrent, associated with inflammatory bowel disease, or if they are proximal in location. Various surgical techniques have been described for treating RVFs. Interposition grafts such as Martius, gracilis, omental J flaps, and rectus abdominis flaps have been used extensively in correcting RVFs (Am J Gastroenterol 2014;109(8):1141-1157). However, these techniques may increase morbidity or have poor cosmesis. Pelvic surgeons have chronicled the use of biologic grafts for fistula repair. Of the various biologic grafts in use, there have been no reports describing the use of porcine urinary bladder matrix (UBM) for fistula repair. We report on 2 cases of large, complex RVFs secondary to mesh erosion, which were effectively treated with transvaginal repair using the UBM.

CASES

An 80-year-old woman was referred by the colorectal service to our urogynecology service with complaints of rectal bleeding and vaginal spotting secondary to mesh erosion. Surgical history included hysterectomy with mesh augmented posterior repair with synthetic midurethral sling placement in 2002. Examination revealed a 3-cm mesh exposure located in the middle third of the posterior vaginal wall. On rectovaginal examination, a 3-cm full-thickness RVF with through-and-through mesh erosion was noted between the rectum and vagina.A 65-year-old woman presented to our service with complaints of passage of fecal material through the vagina. Surgical history was significant for hysterectomy in 1988 and prolapse repair with anterior and posterior vaginal mesh in 2009. Subsequently in 2011, she had part of the mesh removed because of exposure. Vaginal examination revealed mesh exposure at the right sulcus of the anterior wall consistent with evidence of prior sling and another mesh exposure on the posterior vaginal wall. Rectovaginal examination revealed palpable mesh in the rectovaginal septum with a 3-cm large and complex fistula. Both of our patients underwent transvaginal excision of mesh, RVF repair, and posterior repair with augmentation with UBM. At 6- and 10-month follow-up, they reported complete resolution of their symptoms with no fistula noted on physical examination.

CONCLUSIONS

Typically, traditional repair with use of muscular advancement flaps is performed for complex RVF closures. Recently, however, various biologic agents have been successfully used to augment RVF repair. In our cases, the use of UBM led to successful follow-up at 6 to 8 months. Despite existing literature, there remains a void in the depth of knowledge regarding the UBM grafts. Larger studies utilizing it for repair of RVFs are warranted to further understand the success and effectiveness of the UBM grafts for RVF repair.

Simultaneously Diagnosed and Successfully Treated Rectovaginal and Vesicovaginal Fistulae after Low Anterior Resection with Concomitant Resection of Female Genitalia

Rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) are infrequent but distressing complications after pelvic surgery. However, their adequate treatment is not well described. Here, we simultaneously encountered and successfully treated RVF and VVF after radical surgery for rectal cancer. A 70-year-old woman underwent low anterior resection (LAR) combined with resection of the uterus, the bilateral adnexa, and the upper side of the vagina, as well as diverted ileostomy for rectal cancer. A month after the surgery, she developed urinary incontinence and underwent medical treatment, but her symptoms did not improve. Evaluation with contrast enema before stoma closure revealed the presence of RVF and VVF. We repaired the VVF and RVF via transabdominal and transperineal approaches. After 6 months, ileostomy was closed and the patient had no recurrence of cancer and fistula. In LAR with hysterectomy and resection of the vaginal wall, there is a risk of RVF and VVF. The excision and closure of the fistula tract and omental flap can be effective to treat both fistulae.

Stable gastric pentadecapeptide BPC 157 heals rectovaginal fistula in rats

AIM

Rectovaginal fistula is a devastating condition providing more than 99% of patients for surgical treatment. We hypothesized that rectovaginal fistula may be healed by therapy with stable gastric pentadecapeptide BPC 157, in consistence with its initial clinical application and effect on external fistulas.

MAIN METHODS

BPC 157 (10μg/kg or 10ng/kg) was given perorally, in drinking water (0.16μg/ml or 0.16ng/ml, 12ml/rat/day) till sacrifice, or alternatively, intraperitoneally, first application at 30min after surgery, last at 24h before sacrifice. Controls simultaneously received an equivolume of saline (5.0ml/kg ip) or water only (12ml/rat/day). The assessment (i.e., rectal and vaginal defect, fistula leakage, defecation through the fistula, adhesions and intestinal obstruction as healing processes) was at day 1, 3, 5, 7, 10, 14 and 21.

KEY FINDINGS

Regularly, rectovaginal fistulas exhibited poor healing, with both of the defects persisting, continuous fistula leakage, defecation through the fistula, advanced adhesion formation and intestinal obstruction. By contrast, BPC 157 given perorally or intraperitoneally, in μg- and ng-regimens rapidly improved the whole presentation, with both rectal and vaginal defects simultaneously ameliorated and eventually healed. The maximal instilled volume was continuously raised till the values of healthy rats were achieved, there were no signs of defecation through the fistula. A counteraction of advanced adhesion formation and intestinal obstruction was achieved. Microscopic improvement was along with macroscopic findings.

SIGNIFICANCE

BPC 157 effects appear to be suited to induce a full healing of rectovaginal fistulas in rats.

Transvaginal primary repair of a suprasphincteric rectovaginal fistula

INTRODUCTION AND HYPOTHESIS

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

METHODS

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

RESULTS

Anatomy restoration was completed without complications.

CONCLUSION

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.