Rectovaginal fistula after low anterior resection: Prevention and management

Abstract

Rectovaginal fistula after low anterior resection for rectal malignancy is one of the most challenging postoperative complications because it is difficult to treat and may complicate plans of adjuvant therapy. This problematic complication could lead to multiple operations, stoma formation, sexual dysfunction, fecal incontinence and psychosocial ramifications. This review comprehensively covers an overview of its incidence, risk factors, presentation and evaluation, management (ranging from conservative measures, endoscopic treatment and local tissue repair to radical resection and redo anastomosis) and treatment outcomes of rectovaginal fistula after low anterior resection. Notably, these therapeutic options and outcomes are influenced by several factors, including the size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis and surrounding tissue, presence of diverting stoma, previous attempted repair, and the surgeon’s experience. Also, strategies to prevent rectovaginal fistula after low anterior resection are presented with illustrations. Finally, a decision-making algorithm for managing this complication is proposed.

Successful omental flap coverage repair of a rectovaginal fistula after low anterior resection: a case report

“…RVF treatment is more difficult than the other complications, for example leakage. Conservative treatment is usually ineffective, especially considering that the diameter of the RVF with spontaneous healing was not larger than 1 cm [ 11 ]. Therefore, surgical treatment is often performed for RVF, such as colostomy or ileostomy for fecal diversion, fistula resection and direct closure, re-anastomosis, and muscle flap transposition, omental flap coverage.…”

The Colorectal Anastomosis: A Timeless Challenge

“…One of the more devastating complications is incorporating the vagina into the staple line, causing iatrogenic rectovaginal fistula which may go unrecognized for some time. 94 This complication can be avoided by completely dissecting the rectovaginal septum. A sizer may be placed inside the vagina to help delineate the anatomy.…”

Redo colorectal anastomosis for rectovaginal fistula following posterior pelvic exenteration – A video vignette

“…The patient developed an anastomotic leak with a rectovaginal communication. Rectovaginal fistulas are usually caused by accidental incorporation of the vaginal wall into the colorectal anastomosis while stapling [1][2][3]. Treatment options include diversion only, endoanal repair, pull-through, endoanal repair, endoscopy stent, and redo colorectal anastomosis [3].…”

“…Rectovaginal fistulas are usually caused by accidental incorporation of the vaginal wall into the colorectal anastomosis while stapling [1][2][3]. Treatment options include diversion only, endoanal repair, pull-through, endoanal repair, endoscopy stent, and redo colorectal anastomosis [3]. Since the patient already had a diversion ileostomy, an initial conservative treatment was proposed.…”

“…Redo anastomosis is associated with high fistula healing rate and satisfactory functional outcomes [4]. A tension-free anastomosis is essential for success, and the placement of omental tissue in the rectovaginal septum can be helpful [3].…”