Successful management of rectovaginal fistula treated by endorectal advancement flap: report of two cases and literature review
© Kobayashi and Sugihara; licensee Springer. 2015
Received: 10 December 2014
Accepted: 6 January 2015
Published: 15 January 2015
Rectovaginal fistula (RVF) sometimes has a difficulty in treatment. This report describes two patients who suffered from RVF.
One patient was a 76-year-old woman who had a RVF over 30 years after the 3rd childbirth. She underwent endorectal advancement flap (ERAF). She had a nighttime soiling after ERAF once a month, which disappeared one year after surgery. Second patient was a 23-year-old woman who had a RVF one month after the first childbirth. She underwent ERAF, and did not have any complications.
Discussion and evaluation
Both patients did not develop recurrence for four years. Quality of life after ERAF was satisfactory in both patients. ERAF is a safe procedure in terms of both short and long outcomes. We also present a review of the literature concerning ERAF for RVF.
ERAF can be a potential option as a treatment for RVF.
There is a low incidence of rectovaginal fistula (RVF) in developed countries. RVF sometimes occur after childbirth (Lowry et al. 1988; Rothenberger et al. 1982; Wise et al. 1991) and is sometimes difficult for cure. Endorectal advancement flap (ERAF) is one of options as a treatment for RVF in the world. We herein describe two patients with RVF who were successfully treated by ERAF. To our knowledge, this is the first reported cases of RVF treated by ERAF in Japan. In addition, we report a review of the literature concerning ERAF for RVF.
The incidence of RVF in developed counties is low, but RVF is sometimes refractory.
The incidence of RVF after vaginal delivery is 0.1% to 0.5% (Goldaber et al. 1993; Venkatesh et al. 1989). RVF at the lower level is usually caused by obstetric events. RVF at the higher level is caused by radiotherapy or rectal surgery in many cases.
Literature review of endorectal advancement flap for rectovaginal fistula
No. of Pts
Median duration of fistula
Period of follow-up
Rate of cure
Rothebnerger et al.
Obstetric operative injury in 4 Infection in 1
Average 1 cm most were less than 2.5 cm
Lowry et al.
An unknown cause in 6 Obstetrical injury in 74% Perineal infection in 10% Operative Trauma in7% Unknown in 8%
Less than 2.5 cm
Stern et al.
Wise et al.
Obstetric in 25 Infectious in 8 Posttoperative in 2 Unknown in 5
With in 1 cm of the dentate line
Early Recurrence 2 Urinary tract infection 1 Urinary retention 1 Wound complication 3 Late Incontinence Gas/Liquid 5 Solid 2
Kodner et al.
Obstetric injury, 48 Cryptoglandular abscess-fistula,31 Cronhn’s disease, 24 Trauma or after operation 4
Ozuner et al.
Obstetric injury 13 Cryptoglandular abscess-fistula, 19 Crohn’s disease, 47 Trauma or after operation, 15 Mucosalulcerative colitis, 7
Less than 3 cm
Joo et al.
Flap retraction in 1 patient
Tsang et al.
52 (62 procedures)
Obstetrical Obstetric injury in 5 Cryptoglandular abscess-fistula in 48
Bleeding in 1 patient 23%
Sonoda et al.
Crohn’s disease in44 Trauma or after operation in 1 Other in 1
Devesa et al.
100% simple fistula
Loffler et al.
Cronhn’s disease Obstetric injury in 5
de Parades et al.
Cryptoglandular disease in11 Crohn’s disease in 7 Obstetric in 18 Crohn’s in 38
Pinto et al.
Traumatic in 7 Muscosalulcerative colitis in 3 Others in 9
<0.5 cm 47.8% 0.5-1.0 cm 35.9%>1.0 cm 16.3%
Low 78.6% Middle 15.7% High 5.7%
The most frequent cause of RVF was an obstetric event (Kodner et al. 1993; Lowry et al. 1988; Rothenberger et al. 1982; Wise et al. 1991). Recently, RVF associated with Crohn’s disease has been increasing (de Parades et al. 2011; Joo et al. 1998; Kodner et al. 1993; Loffler et al. 2009; Ozuner et al. 1996; Pinto et al. 2010; Sonoda et al. 2002). The median age of RVF varied from 30.5 to 45.5 years old. Duration of disease was 12 months to 31.2 months. The average number of procedure was 1.47 (Pinto et al. 2010). Therefore, the recurrence after the treatment for RVF is problematic. The cure rate of RVF was 41% to 91% (de Parades et al. 2011; Devesa et al. 2007; Joo et al. 1998; Kodner et al. 1993; Loffler et al. 2009; Lowry et al. 1988; Ozuner et al. 1996; Pinto et al. 2010; Rothenberger et al. 1982; Sonoda et al. 2002; Stern et al. 1988; Tsang et al. 1998; Wise et al. 1991). Devesa et al. reported that the success rate of ERAF for simple rectovaginal fistula was 100% (Devesa et al. 2007). In the present study, both patients had simple RVF and succeeded in the treatment. Lowry et al. reported that the cure rates in the first, the second, and the third procedures were 88%, 85%, and 55%, respectively (Lowry et al. 1988). Another paper demonstrated that the most important factor associated with cure in patients with RVF was form: whether it was simple or complex (Devesa et al. 2007). Ozuner et al. disclosed that Crohn’s disease was associated with the highest recurrence rate among the various causes of RVF (Ozuner et al. 1996). Especially, the success rate was lower in patients with Crohn’s disease accompanying small intestinal lesion (Joo et al. 1998). Therefore, ERAF is considered useful in patients with simple RVF after obstetric event.
Accurate diagnosis is mandatory before surgery. However, contrast radiography for rectovaginal fistula is sometimes difficult, because contrast radiography can only detect high rectovaginal fistulae unless the applicator does not extend the level of the internal anal opening.
There are some limitations in this study. There are a variety of treatments for rectovaginal fistula. Transverse transperineal approach as well as transabdominal approach exists. In some cases, Martius flap can be another option for RVF (Elkins et al. 1990). However, we could not compare these techniques in this study, because of lack of RVF cases.
We experienced two patients with RVF who were treated by ERAF successfully. Simple RVF after obstetric event is considered good indication for ERAF. ERAF can be a potential option for RVF in Japan.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
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