Repair of recurrent rectovaginal fistulas

Background. Recurrent rectovaginal fistulas (RRVFs) pose a challenging prob lem, which can be treated by different surgical procedures. We performed th is study to determine the ultimate success rate Of various repair technique s. Methods. Using a standard data collection form, we retrospectively reviewed charts of patients treated for RRVF Results. Between 1991 and 2000, 57 procedures were performed in 35 women wh o presented with RRVF Median follow-tip was 4 months (interquartile range, 1,25). The causes of RRVF included obstetrical injury (n = 15), Crohn's dis ease (n = 12), fistula occurring after proctocolectomy with ileal pouch-ana l anastomosis (for ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial polyposis, n = 1), cryptoglandular disease (n = 2), and fistula o ccurring immediately after low anterior resection for rectal cancer (n = 1) . The methods of repair used included mucosal advancement flap (n = 30), fi stulotomy with overlapping sphincter repair (n = 14), rectal sleeve advance ment (it = 3), fibrin glue (n = 1), proctectomy with colonic pull-through ( n = 2), and ileal pouch revision (n = 6). Twenty-seven of 34 (79%) patients with adequate follow-up eventually healed after, a median of 2 operations. Logistic,regression was used to analyze outcome according to etiology of f istula, patient age, number of prior repairs, time interval between last re pair and current repair, and Presence of fecal diversion. Crohn's disease, the presence of a diverting stoma, and decreased time interval since prior repair were associated with a poorer outcome. Conclusions. Most RRVFs can be successfully repaired, although repeated ope rations may be necessary. Delaying repair may improve outcome.