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Background: Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary., Methods: The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure., Results: Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031)., Conclusion: Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas., (© 2023. The Author(s).)

Purpose: To determine the results after rectovaginal fistula (RVF) repair and find predictors of outcome. Primary objective was fistula healing. Secondary outcomes were morbidity and patient health-related quality of life (HRQoL)., Method: An observational study of 55 women who underwent RVF repair including both local procedures and tissue transposition 2003-2018 was performed. Baseline patient and fistula characteristics were registered, combined with a prospective HRQoL follow-up and a general questionnaire describing fistula symptoms., Results: Healing rate after index surgery was 25.5% (n = 14) but the final healing rate was 67.3% (n = 37). Comparing the etiologies, traumatic fistulas (iatrogenic and obstetric) had the highest healing rates after index surgery (n = 11, 45.9%) and after repeated operations at final follow-up (n = 22, 91.7%) compared with fistulas of inflammatory fistulas (Crohn's disease, cryptoglandular infection, and anastomotic leakage) that had inferior healing rates after both index surgery (n = 7, 7.1%) and at final follow-up (n = 13, 46.4%). Fistulas of the category others (radiation damage and unknown etiology) included a small amount of patients with intermediate results at both index surgery (n = 1, 33.3%) and healing rate at last follow-up (n = 2, 66.7%). The differences were statistically significant for both index surgery (p = 0.004) and at final follow-up (p = 0.001). Unhealed patients scored lower than both healed patients and the normal population in 6/8 Rand-36 domains, but the differences were not statistically significant., Conclusions: Most traumatic rectovaginal fistulas closed after repeated surgery whereas inflammatory fistulas had a poor prognosis. Low healing rates after local repairs suggest that tissue transfer might be indicated more early in the treatment process. Unhealed fistulas were associated with reduced quality of life. Trial registration Clinicaltrials.gov No. NCT05006586., (© 2022. The Author(s).)

Background: The rectovaginal fistula (RVF) is a rare complication after low anterior resection (LAR) for rectal cancer. The aim of this study was to evaluate the risk factors for RVF after LAR for rectal cancer., Methods: This was a retrospective multi-institution study of 371 female rectal cancer patients who underwent LAR with anastomosis between January 2007 and December 2011. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses., Results: The overall RVF rate was 3.0 % (11/371). The RVF was diagnosed on median postoperative day 83 (15-766). In 81.8 % (9/11) of the patients, the diagnosis of RVF was made after hospital discharge. Multivariate analysis identified prognostic nutritional index (PNI; odds ratio (OR) 6.97; 95 % confidence interval (CI) 1.47-33.08; P = 0.015), preoperative chemotherapy (OR 27.31; CI 3.49-213.62; P = 0.002), tumor size (OR 5.90; CI 1.04-33.47; P = 0.045), intraoperative bleeding (OR 13.91; CI 1.34-144.42; P = 0.027), and lateral lymph node dissection (OR 4.92; CI 1.02-23.63; P = 0.045) as independent risk factors for RVF after LAR., Conclusions: Risk factors of RVF were PNI (<45), preoperative chemotherapy, tumor size (≧ 50 mm), intraoperative bleeding (≧ 200 ml), and lateral lymph node dissection. Before an operation, obtaining the information about these risk factors is of great importance in LAR for rectal cancer.

Introduction: The burden of perineal Crohn's disease (PCD) remains poorly characterized, and many patients ultimately require fecal diversion or proctectomy. Our goal was to characterize the clinical course of patients presenting with perineal Crohn's disease, focusing on the cohort of patients ultimately requiring fecal diversion, and identify modifiable predictors for this unfortunate outcome., Methods: We performed a retrospective review of 81 consecutive patients who underwent 172 operations to address complications of PCD. Diverted patients were compared to those who did not require diversion in regard to demographics, surgical procedure, postoperative infliximab, and presence of proctitis (chi square, t tests). Logistic regression was utilized to predict the need for fecal diversion. The number of visits needed to undergo care for this condition was quantified., Results: Eight-one patients underwent a total of 172 surgical procedures and had a total of 2713 outpatient visits (range 1-118) to address symptoms of perineal Crohn's disease. Following first intervention, only 57.1 % healed at 3 months. These rates were highest in patients treated with fistulotomies and were not impacted by whether patients received postoperative infliximab (p = 0.703). Patients (23.5 %) underwent three or more surgical procedures to control their PCD and ultimately only 60 % healed without diversion, which was performed in 19 (23.5 %) patients. Patients undergoing more than three operations (OR = 10.9, p = 0.006) and women with rectovaginal fistula (OR = 3.88, p < 0.01) were at a high risk for diversion. Modifiable factors such as infliximab, smoking, proctitis, and surgery aimed at closing the internal anal opening did not alter outcome., Conclusions: In the patients with perineal Crohn's, complex fistulas healing rates appear to be independent of postoperative infliximab or procedures aimed at closing the internal anal opening. Those who do not heal require numerous specialist visits.

Objective: Local surgical procedures in the presence of Crohn's disease have a markedly reduced success rate, especially in the treatment of recurrent anovaginal and distant rectovaginal fistulas. In these patients, local surgery (e.g., flap closure) has unsatisfactory results if the anal canal is destroyed by ulceration and indurations or in patients with extensive defects of the perineum., Materials and Methods: Over a period of 6 years (2000 to 2006), 12 patients with recurrent rectovaginal fistulas were treated with graciloplasty. The age of the female patients ranged from 24 to 47 years, the mean age being 38 years. The presence of Crohn's disease in all patients had a mean duration of 12 years. Corticosteroids, mesalazin, or azathioprin were administered preoperatively. All patients were diverted by a temporary ileostomy before graciloplasty. RESULTS Rectovaginal fistula was closed in 11 of 12 patients after graciloplasty with a mean follow-up of 3.4 years. One rerecurrence of a rectovaginal fistula was documented. One of 12 ileostomies was not closed due to persistence of the fistula tract. One patient had a pouch-anal and, additionally, a pouch-vaginal fistula. In this patient, the first transposition of the gracilis muscle was unsuccessful. After a few months, she underwent renewed graciloplasty. There was no recurrence of a fistula within the follow-up period. Reconstruction of the perineum constituted an additional positive effect of the graciloplasty. In one patient, the preexisting fecal incontinence persisted, even after secondary implantation of a pacemaker. Due to diarrhea and persistent fecal incontinence, the patient opted for a renewed ileostomy., Conclusions: In our series, gracilis transposition in the treatment of recurrent anovaginal and rectovaginal fistulas in patients with Crohn's disease has excellent short-term results. In addition, graciloplasty can reconstruct the perineal defect.

Background and Aims: Rectovaginal fistulas in patients with Crohn's disease are difficult to resolve, and surgical failure is very frequent. Recent studies have shown that adult stem cells extracted from certain tissues, such as adipose tissue, can develop into different tissues, such as muscle., Patient and Methods: We report here the case of a young patient with Crohn's disease who had a recurrent rectovaginal fistula that was treated by autologous stem-cell transplantation with a lipoaspirate as the source of stem cells., Results: Although Crohn's disease is the worst condition for a surgical approach in cases of rectovaginal fistula, we observed good closure. Since the surgical procedure 3 month ago the patient has not experienced vaginal flatus or fecal incontinence through her vagina. Thus our treatment seems to be effective., Conclusion: Cell transplantation to overcome healing problems is a new surgical tool, and careful evaluation of this new modality may provide an opportunity to define a new era in the treatment of surgical challenges associated with healing disorders. Ethical and safety items do not seem to be critical problems using autologous stem cells.

We report on a new and simple operative technique for closure of anovaginal fistulas with an anocutaneous flap in patients with Crohn's disease. From January 1989 till December 1990 this operation was performed in 10 women with Crohn's disease. Seven of the ten patients suffered from Crohn's proctitis. In these patients a protective enterostomy was applied before the operative closure of the fistula. All fistulas healed primarily. Within a median follow up of 18 months (7-24 months) a relapse occurred in 3 patients; two of these were treated successfully with fibrin injection in one case and a further operative closure of the fistula using the same procedure in the second case. In the third patient a seton was placed into the recurrent fistula track, which is still present after 4 weeks.

Between December 1981 and March, 1987, 188 ileal reservoir and ileoanal anastomosis procedures were performed at the University of Toronto. Anal anastomotic complications occurred in 24 (12.8%) patients. There were 19 patients who developed a leak as a result of non-healing of the ileoanal anastomosis (group 1). Late fistulae occurred in 5 patients (group 2). Various treatments were employed. In group 1, 2 of 15 (13%) patients treated with drainage and antibiotics, 3 of 7 (43%) in whom the anastomosis was resutured, and 5 of 7 (71%) in whom repair was performed by advancing the ileal outlet and resuturing the anastomosis, healed their anastomosis. One patient was treated successfully by performing a fistulotomy. Treatment was unsuccessful in one patient in whom the ileal reservoir and ileoanal anastomosis were revised and re-anastomosed. One patient (50%) in group 2 was treated successfully by advancing the ileal outlet and resuturing the anastomosis. Complete healing of the anastomosis was achieved in 12 patients (50%), although 3 patients subsequently required excision of the reservoir because of inability to evacuate spontaneously (1), incontinence (1), or psychological reasons (1). All nine (38%) patients who were functioning with their ileal reservoir were continent. One patient intubated the reservoir. The rate of urgency and soiling, and the number of bowel movements per 24 hours did not differ significantly from those of patients without these anastomotic complications. Our results suggest that early diagnosis and repair of ileoanal anastomotic dehiscence by advancement of the ileal outlet and resuturing of the ileoanal anastomosis results in improved reservoir salvage and satisfactory functional results.