QS111 - Factors associated with fecal diversion prior to rectovaginal fistula repair

Image or Table (Do Not add text here):

Purpose/Background: Rectovaginal fistulas (RVFs) are complex diseases that are difficult to treat. Various surgical treatments are available for the management of RVFs. In an effort to restore quality of life and optimize conditions for fistula closure, temporary fecal diversion (FD) is selectively performed; however, the role of FD remains controversial. We aimed to identify the factors associated with FD in treatment of RVF. We hypothesized that FD is associated with multiple unsuccessful repairs of RVF, obesity, history of radiation, and complex repairs.

Methods/Interventions: After institutional review board approval, a retrospective review of females who underwent repair of a RVF (1992–2023) at our tertiary referral center was performed. Patients were divided into 2 groups based on the utilization of FD. Data collected included etiology of the RVF, age, BMI, the type of repair performed, utilization of FD, rate of RVF healing. Multivariate analysis was performed to identify factors associated with FD.

Results/Outcomes: A total of 159 patients underwent 265 surgical procedures for the management of RVF. A total of 96 (60%) patients underwent FD, while 63 (40%) did not. Patients were comparable in terms of age, BMI, diabetes, smoking history, IBD history (26, 27% FD vs. 21, 33% in no FD), idiopathic [28 (29%) vs 15 (24%)] and cryptoglandular fistulas [8 (8%) vs 7 (11%)]. In FD there were more patients with history of pelvic irradiation (11, 11.5%) compared to non-FD (2, 2.3%; p=0.06). There were 9 (9%) patients with a history of ileal pouch anal anastomosis in the FD group and 12 (19%) who did not have FD. Primary repair was commonly sufficient in non-FD group (33, 52%) while patients in FD group required a median of 3 (IQR 1-5) repairs (p < 0.005), which signifies fistula complexity in FD group. Patients with a history of prior repair attempts performed at outside hospitals were more likely to undergo FD (p < 0.005).

Between FD and non-FD groups the use of primary repair [27 (28%) vs 13 (21%), p= 0.29]; rectal advancement flap [45 (47%) vs 27 (58%) (p=0.15)], and episioproctotomy [21 (22%) vs 10 (16%), p=0.35] were comparable. Interposition flaps were more common in FD group than non-FD: gracilis (13, 14% vs 2,3%; p=0.03) and Martius (16, 17% vs 3, 5%; p=0.02). Additionally, while not significant, patients with FD requirement more frequent returns to operating room for debridement of pelvic sepsis associated with RVF (p=0.06).

Of those who had FD, 68 (71%) underwent stoma reversal , and the median time to closure was 362.5 days (IQR 159-564). Of those who did not get their stomas reverse, 17 (61 %) didn’t do so due to persistent symptoms, 7 (25%) were lost to follow-up, and 3 (11%) transitioned to palliative care. Multivariate analysis revealed that an increased number of prior attempted repairs was significantly associated with the need for FD, while fistula etiology, BMI, and time since diagnosis were not significantly associated with FD.

Conclusion/Discussion: Multiple prior unsuccessful repairs of RVFs and interposition flap repairs are associated with the utilization of FD as part of the management strategy for fistula closure. Selecting high risk patients, i.e. those who have failed prior attempted repairs, for FD before re-repair may allow the recurrence rate to be similar to lower risk non-diverted patients.