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Surgical management of complicated rectovaginal fistulas and the role of omentoplasty

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Abstract

Background

Patients with rectovaginal fistulas have a significantly reduced quality of life. Therefore, surgical therapy is often needed even in palliative cases. The aim of the present study was to perform an analysis of the results of the different treatment options available today.

Methods

We performed a retrospective analysis of patients who underwent treatment for rectovaginal fistulas at the Department of Surgery, University of Schleswig–Holstein, Campus Luebeck and the Department of Surgery, WKK Heide, between January 2000 and September 2016. Complication and recurrence rate were retrospectively evaluated. The median follow-up period was 13 months (range 3–36 months).

Results

During the observation period, 58 patients underwent surgery (53 curative, 5 palliative) for rectovaginal fistulas. All patients who underwent curative surgery had an omentoplasty, and 39 of 53 (73.6%) patients underwent a resection. Thirty of 39 (77.0%) resections were low anterior resection, while non-continence-preserving resection included subtotal colectomy (n = 5), pelvic exenteration (n = 2), and proctectomy (n = 2). The fistulas were mainly secondary to inflammatory bowel disease (n = 18) or diverticulitis (n = 13), while 19 fistulas were a complication of different cancers or precancerous lesions. The median follow-up time was 13 months (range 6–36). Four patients (6.9%) had fistula recurrence (3 recurrences after low anterior resection, 1 after primary fistula closure). The mortality rate was 6.9% (n = 4).

Conclusions

Non-resecting methods should be used only in uncomplicated fistulas. Rectovaginal fistulas secondary to inflammatory or malignant disease mostly require extensive therapy. Omentoplasty is effective for the treatment of both high and low rectovaginal fistulas.

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References

  1. Tsang CB, Rothenberger DA (1997) Rectovaginal fistulas: therapeutic options. Surg Clin N Am 77:95–114

    Article  CAS  PubMed  Google Scholar 

  2. Champagne BJ, McGee MF (2010) Rectovaginal fistula. Surg Clin N Am 90:69–82

    Article  PubMed  Google Scholar 

  3. Denson L, Shobeiri SA (2014) Peroxide-enhanced 3-dimensional endovaginal ultrasound imaging for diagnosis of rectovaginal fistula. Female Pelvic Med Reconstr Surg 20:240–242

    Article  PubMed  Google Scholar 

  4. Saclarides TJ (2002) Rectovaginal fistula. Surg Clin N Am 82:1261–1272

    Article  PubMed  Google Scholar 

  5. Genadry RR, Creanga AA, Roenneburg ML, Wheeless CR (2007) Complex obstetric fistulas. Int J Gynaecol Obstet 99:51–56

    Article  Google Scholar 

  6. Homsi R, Daikoku NH, Littlejohn J, Wheeless CR Jr. (1994) Episiotomy: risks of dehiscence and rectovaginal fistula. Obstet Gynecol Surv 49:803–808

    Article  CAS  PubMed  Google Scholar 

  7. Bahadursingh AM, Longo WE (2003) Colovaginal fistulas: etiology and management. J Reprod Med 48:489–495

    PubMed  Google Scholar 

  8. Zhu Y, Tao G, Zhou N, Xiang C (2011) Current treatment of rectovaginal fistula in Crohn’s disease. World J Gastroenterol 17:963–967

    Article  PubMed  PubMed Central  Google Scholar 

  9. Wexner SD, Ruiz DE, Genua J, Nogueras JJ, Weiss EG, Zmora O (2008) Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg 248:39–43

    Article  PubMed  Google Scholar 

  10. Penninckx F, Moneghini D, D’Hoore A, Wyndaele J, Coremans G, Rutgeerts P (2001) Success and failure after repair of rectovaginal fistula in Crohn’s disease: analysis of prognostic factors. Colorectal Dis 3:406–411

    Article  CAS  PubMed  Google Scholar 

  11. Sordo-Mejia R, Gaertner WB (2014) Multidisciplinary and evidence-based management of fistulizing perianal Crohn’s disease. World J Gastrointest Pathophysiol 15:239–251

    Article  Google Scholar 

  12. Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M (2012) German S3-Guideline: rectovaginal fistula. Ger Med Sci 10:Doc15. https://doi.org/10.3205/000166

    PubMed  PubMed Central  Google Scholar 

  13. Berger MB, Khandwala N, Fenner DE, Burney RE (2016) Colovaginal fistulas: presentation, evaluation, and management. Female Pelvic Med Reconstr Surg 22:355–358

    Article  PubMed  PubMed Central  Google Scholar 

  14. Liu L, Herrinton LJ, Hornbrook MC, Wendel CS, Grant M, Krouse RS (2010) Early and late complications among long-term colorectal cancer survivors with ostomy or anastomosis. Dis Colon Rectum 53:200–212

    Article  PubMed  PubMed Central  Google Scholar 

  15. Zelga P, Tchórzewski M, Zelga M, Sobotkowski J, Dziki A (2016) Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies-new patients, old problem? Langenbecks Arch Surg 2016 Dec 16. (Epub ahead of print)

  16. Fausel RA, Kornbluth A, Dubinsky MC (2016) The first endoscopy in suspected inflammatory Bowel disease. Gastrointest Endosc Clin N Am 26:593–610

    Article  PubMed  Google Scholar 

  17. El-Gazzaz G, Hull TL, Mignanelli E, Hammel J, Gurland B, Zutshi M (2010) Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome, quality of life and sexual function. J Gastrointest Surg 14:1758–1763

    Article  PubMed  Google Scholar 

  18. Akiba RT, Rodrigues FG, da Silva G (2016) Management of complex perineal fistula disease. Clin Colon Rectal Surg 29:92–100

    Article  PubMed  PubMed Central  Google Scholar 

  19. Tucker J, Grzeskowiak L, Murphy EM, Wilson A, Clifton VL (2017) Do women of reproductive age presenting with pelvic floor dysfunction have undisclosed anal incontinence: a retrospective cohort study. Women Birth 30:18–22

    Article  PubMed  Google Scholar 

  20. Ramage L, Qiu S, Kontovounisios C, Tekkis P, Rasheed S, Tan E (2015) A systematic review of sacral nerve stimulation for low anterior resection syndrome. Colorectal Dis 17:762–771

    Article  CAS  PubMed  Google Scholar 

  21. Leroy A, Azaïs H, Giraudet G, Cosson M (2017) Quality of life and symptoms before and after surgical treatment of rectovaginal fistula. Prog Urol. https://doi.org/10.1016/j.purol.2016.12.001

    PubMed  Google Scholar 

  22. Imoto A, Matsuyama A, Ambauen-Berger B, Honda S (2015) Health-related quality of life among women in rural Bangladesh after surgical repair of obstetric fistula. Int J Gynaecol Obstet 130:79–83

    Article  PubMed  Google Scholar 

  23. Harb WJ (2015) Crohn’s disease of the colon, rectum, and anus. Surg Clin N Am 95:1195–1210

    Article  PubMed  Google Scholar 

  24. Schlussel AT, Steele SR, Alavi K (2016) Current challenges in the surgical management of Crohn’s disease: a systematic review. Am J Surg 212:345–351

    Article  PubMed  Google Scholar 

  25. Targownik LE, Coneys JG, Dhillon AS (2016) Emerging issues in the medical management of Crohn’s disease. Curr Opin Gastroenterol 32:103–109

    Article  CAS  PubMed  Google Scholar 

  26. Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, Burisch J, Gecse KB, Hart AL, Hindryckx P, Langner C, Limdi JK, Pellino G, Zagórowicz E, Raine T, Harbord M, Rieder F, European Crohn’s and Colitis Organisation (ECCO) (2017) Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J Crohns Colitis. https://doi.org/10.1093/ecco-jcc/jjx008

    Google Scholar 

  27. Hoffmann M, Phillips C, Oevermann E, Killaitis C, Roblick UJ, Hildebrand P, Buerk CG, Wolken H, Kujath P, Schloericke E, Bruch HP (2012) Multivisceral and standard resections in colorectal cancer. Langenbecks Arch Surg 397:75–84

    Article  PubMed  Google Scholar 

  28. Byrnes JN, Schmitt JJ, Faustich BM, Mara KC, Weaver AL, Chua HK, Occhino JA (2017) Outcomes of rectovaginal fistula repair. Female Pelvic Med Reconstr Surg 23:124–130

    Article  PubMed  Google Scholar 

  29. Park SO, Hong KY, Park KJ, Chang H, Shin JY, Jeong SY (2017) Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up. Int J Colorectal Dis. https://doi.org/10.1007/s00384-017-2784-x

    Google Scholar 

  30. Das B, Snyder M (2016) Rectovaginal Fistulae. Clin Colon Rectal Surg 29:50–56

    Article  PubMed  PubMed Central  Google Scholar 

  31. Hokenstad ED, Hammoudeh ZS, Tran NV, Chua HK, Occhino JA (2016) Rectovaginal fistula repair using a gracilis muscle flap. Int Urogynecol J 27:965–967

    Article  PubMed  Google Scholar 

  32. Lalwani S, Varma V, Kumaran V, Mehta N, Nundy S (2015) Complex rectovaginal fistula-an experience at a tertiary care centre. Indian J Surg 77:1142–1147

    Article  PubMed  PubMed Central  Google Scholar 

  33. van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG (2011) Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients. Int J Colorectal Dis 26:1463–1467

    Article  PubMed  PubMed Central  Google Scholar 

  34. Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, Weihs D, Eberl T, Tschmelitsch J (2016) Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: a prospective, randomized, multicenter trial. Surgery 159:1129–1139

    Article  PubMed  Google Scholar 

  35. Göttgens KW, Smeets RR, Stassen LP, Beets G, Breukink SO (2014) The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study. Dis Colon Rectum 57:888–898

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Lübeck, Germany

    M. Zimmermann, C. Benecke, T. Laubert, R. Meyer, H.-P. Bruch, R. Bouchard, T. Keck & M. Hoffmann

  2. Department of Surgery, WKK Heide, Heide, Germany

    E. Schloericke

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  1. E. Schloericke
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  2. M. Zimmermann
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  3. C. Benecke
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Correspondence to M. Hoffmann.

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Informed consent was obtained from all individual participants included in the study.

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Schloericke, E., Zimmermann, M., Benecke, C. et al. Surgical management of complicated rectovaginal fistulas and the role of omentoplasty. Tech Coloproctol 21, 945–952 (2017). https://doi.org/10.1007/s10151-017-1657-1

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  • DOI: https://doi.org/10.1007/s10151-017-1657-1

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