Surgical Strategy for Rectovaginal Fistula After Colorectal Anastomosis at a High-volume Cancer Center According to Image Type and Colonoscopy Findings

Abstract

Background/Aim: The reported incidence of rectovaginal fistula is very low. Although some case reports have described surgical procedures, no systematic approach to the treatment of rectovaginal fistula according to diagnostic image and colonoscopy findings has been proposed. We present a comprehensive surgical strategy for rectovaginal fistula after colorectal anastomosis according to diagnostic image and colonoscopy findings. Patients and Methods: This retrospective study included 11 patients who developed rectovaginal fistula after colorectal anastomosis. Rectovaginal fistula was classified into 4 types according to contrast enema images and colonoscopy findings, i.e., "Alone type", "Dead space type", "Anastomotic stricture type", and "Dead space and Anastomotic stricture type". The surgical strategies were "Diversion (Stoma)", "Percutaneous drainage", "Anastomotic stricture type", "Endoscopic balloon dilation", "Curettage of foreign bodies", "Simple full-thickness closure", "Split-thickness closure", "Pedicled flaps packing", and "Reanastomosis". The surgical strategy appropriate for each rectovaginal fistula type was investigated. Results: Among "Alone type" cases, 5 (71.4%) healed with "only Diversion (Stoma)". "Alone type" cases (n=11) and all other cases (n=4) healed with "only Diversion (Stoma)" (n=5) or any other method (n=6) (p=0.022). Conclusion: For treatment of rectovaginal fistula after colorectal anastomosis, less invasive treatment approaches should be attempted first.

Treatment of Rectovaginal Fistula

“…Barugola et al reported that half of the RVFs healed within six months after the construction of a diverging stoma; the failed factors after fecal diversion alone were large fistula and the presence of pelvic sepsis [34]. Komori et al classified RVFs into four types: "Alone type," "Dead space type," "Anastomotic stricture type," and "Dead space and Anastomotic stricture type" according to the diagnostic imaging, and 71.4% (5/7) of patients with "Alone type" RVF healed with only diverting stoma [67].…”

Rectovaginal fistula after low anterior resection: Prevention and management

“…RVF after low anterior resection can be classified based on the location of the fistula as low (close to the posterior fourchette), middle or high (close to the cervix). However, some investigators have classified the fistula based on radiologic and/or endoscopic studies into four types, namely RVF alone, RVF with dead space, RVF with anastomotic stricture and RVF with dead space, and anastomotic stricture[ 13 ]. This newly proposed classification of RVF after rectal cancer surgery may indicate different approaches, e.g.…”

Minimally invasive endoscopic repair of rectovaginal fistula

“…Currently, the classification of “simple/complex” or “low/ middle/high” according to location, size, and etiology of RVF is most used[ 10 , 11 ]. With the development of diagnostic and therapeutic techniques, the imaging results, endoscopic exploration and gradually defined local anatomical structure will promote a classification consensus[ 12 , 13 ]. The anatomical features are always the principle of classification, which makes it necessary to achieve a more detailed and precise anatomical recognition[ 14 ].…”

“…Although the techniques for RVF repair have been developing, the etiology, classification, surrounding tissue condition, prior treatment procedures and the surgeon’s preference are always the basis for determining the approach. In addition, individualized, precise, and less-invasive surgical techniques for RVFs repair are gradually being recommended[ 13 , 33 ].…”