Determinants of fecal diversion prior to rectovaginal fistula surgery

Temporary fecal diversion (FD) is performed selectively in patients with rectovaginal fistulas (RVFs). This study aimed to identify the factors associated with FD in the treatment of RVF and determine whether FD is associated with increased recurrence-free survival.

A retrospective review of females who underwent repair of an RVF was performed. Patients were divided into 2 groups based on the use of FD. Recurrence was defined as evidence of RVF on clinical examination or imaging after at least 2 previous follow-ups, with healing noted.

A total of 158 patients underwent 424 surgical procedures, of whom 100 (63.3%) underwent FD and 58 (36.7%) did not. Patients were comparable in terms of age, body mass index, diabetes mellitus, smoking history, inflammatory bowel disease history, and fistula etiology. Patients in the FD group required a median of 3 repairs (IQR, 1-5) (P <.005). Interposition flaps were more common in the FD group than in the non-FD group: gracilis flap (13 [13%] vs 2 [3%]; P =.05) and Martius flap (17 [17%] vs 2 [3%]; P =.01). There were no significant differences in healing or recurrence rates. Multivariate analysis revealed an increased number of previous attempted repairs associated with the use of FD (P <.001). The cumulative 5-year Kaplan-Meier cure rates were 72.7% (95% CI, 61.0%-87.0%) in the FD group and 64.3% (95% CI, 48.0%-86.0%) in the non-FD group (P =.38).

Multiple previous RVF repairs and interposition flap repairs were associated with the use of FD. Selecting high-risk patients for FD before re-repair may allow the recurrence rate to be similar to that of lower-risk nondiverted patients.