Optimal strategies of rectovaginal fistula after rectal cancer surgery

Abstract

Purpose Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is a type of anastomotic leakage. The aim of this study was to find out the difference of leakage, according to RVF presence or absence and to identify the optimal strategy for RVF. Methods All female patients who underwent low anterior resection with colorectal anastomosis or coloanal anastomosis (n = 950) were retrospectively analyzed. Patients' demographics and perioperative outcomes were analyzed between the RVF group and leakage without the RVF (nRVF) group. We performed 4 types of procedures—primary repair, diverting stoma, redo coloanal anastomosis (RCA), and conservative procedure—to treat RVF, and calculated the success rates of each type of procedure. Results The leakage occurred in 47 patients (4.9%). Among them, 18 patients (1.9%) underwent an RVF and 29 (3.0%) underwent nRVF. The RVF group received more perioperative radiotherapy (27.8% vs . 3.4%, P < 0.015) and occurred late onset after surgery (181.3 ± 176.4 days vs . 23.2 ± 53.6 days, P < 0.001) more than did the nRVF group. In multivariate analysis for the risk factor of the RVF group, the RVF group was statistically associated with less than 5 cm of anastomosis more than was the no-leakage group. A total of 35 procedures were performed in 18 patients with RVF for treatment. RCA showed satisfactory success rates (85.7%, n = 6) and, primary repair (transanal or transvaginal) showed acceptable success rate (33.3%, n = 8). Conclusion After low anterior resection for rectal cancer, RVF was strongly correlated with a lower level of primary tumor location. Among the patients who underwent leakages, receipt of perioperative radiotherapy was significantly high in the RVF group than that of the nRVF group. Additionally, this study suggests that RCA might be considered another successful treatment strategy for RVF.

The treatment for refractory rectovaginal fistula after low anterior resection with estriol, polyglycolic acid sheets and primary closure: A case report

“…Regarding the treatment strategy, Woo et al analyzed 18 patients with RVF after low anterior resection [ 5 ]. In their study, different types of procedures were compared, including redo-coloanal anastomosis, diverting stoma, primary repair and conservative treatment.…”

“…Anastomotic leakage after low anterior resection for rectal cancer is a serious complication, with a recently reported incidence of 9.7%–12.4% [ 1 , 2 ]. Among the female patients, 1.6%–3.0% of the patients experiences rectovaginal fistula (RVF), which is more complicated than other complications and refractory to treatment [ [3] , [4] , [5] ].…”

“…Due to its refractory nature, RVF is often managed with surgical treatment, such as stoma creation for fecal diversion, closure of the fistula and/or re-anastomosis, rather than conservative therapy [ 5 , 6 ]. However, due to the low incidence and complicated clinical course following various options for treatment, the optimal strategy remains controversial.…”

Rectovaginal fistula after low anterior resection: Prevention and management

“…It was well evident that low colorectal anastomosis, especially within 5 cm from the anal verge, is an important risk factor for RVF after sphincter-preserving operations[ 5 , 7 - 9 ]. The increased likelihood of RVF following low anterior resection is explained by the fact that ‘safe’ low colorectal anastomosis requires complete dissection between the rectum and the vagina (sometimes until the pelvic floor muscle is reached) before creation of an anastomosis, but deep pelvic dissection can be difficult, even in a female pelvis.…”

Treatment of rectovaginal postanastomotic fistula with a transanal endoscopic operation – a video vignette

“…We report the case of a rectovaginal fistula after resection of the rectum with total mesorectal excision. The 55‐year‐old patient had undergone neoadjuvant chemoradiotherapy prior to surgery .…”