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Surgeons Should Not Hesitate to Perform Episioproctotomy for Rectovaginal Fistula Secondary to Cryptoglandular or Obstetrical Origin

Hull, Tracy L. M.D.; El-Gazzaz, Galal M.D., Ph.D.; Gurland, Brooke M.D.; Church, James M.D.; Zutshi, Massarat M.D.

Diseases of the Colon & Rectum: January 2011 - Volume 54 - Issue 1 - p 54-59
doi: 10.1097/01.dcr.0000388926.29548.36
Original Contribution

BACKGROUND: Closure of rectoanovaginal fistula from a cryptoglandular or obstetrical origin can be difficult. Multiple techniques exist and none are perfect. Although episioproctotomy offers the advantage of a simultaneous repair of the sphincter complex, it is a more extensive procedure. A rectal-advancement flap appears less traumatic and divides no perineal tissue or sphincter. The aim of this study was to evaluate the results of episioproctotomy and rectal-advancement flap on healing, postoperative continence, and sexual function.

METHODS: Data were retrospectively collected regarding 87 women with cryptoglandular or obstetrical rectoanovaginal fistula treated from June 1997 to 2009, who underwent episioproctotomy or rectal-advancement flap at the discretion of the treating surgeon. Healing, use of seton or stoma, number of previous procedures, smoking, age, body mass index, dyspareunia, SF-12 health survey, the IBD Quality of Life, and the Fecal Incontinence Quality of Life, and the Female Sexual Function Index were obtained from our database and via telephone interviews. The Fisher exact probability and χ2 tests were used.

RESULTS: The mean age of these 87 women was 42.8 ± 10.5 years. Mean follow-up was 49.2 ± 39.2 months. Fifty (57.5%) patients underwent episioproctotomy and 37 (42.5%) underwent rectal-advancement flap. Thirty-nine (78%) patients healed after episioproctotomy vs 23 (62.2%) patients after rectal-advancement flap (P = .1). Episioproctotomy was associated with significantly better fecal (P < .001) and sexual (P = .04) function. There was no significant difference in other studied variables between the 2 techniques.

CONCLUSIONS: Despite episioproctotomy being a more extensive procedure, healing rates were comparable between episioproctotomy and rectal-advancement flaps. In this select population, episioproctotomy may provide better continence and may confer better sexual function compared with rectal-advancement flap. In appropriate patients surgeons should not hesitate to perform episioproctotomy on cryptoglandular or obstetrical-associated rectoanovaginal fistula.

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio

Funding/Support: This work was supported by the Department of Colorectal Surgery, Cleveland Clinic Foundation.

Financial Disclosure: None reported.

Presented at the meeting of The American Society of Colon and Rectal Surgeons, Minneapolis, MN, May 15 to 19, 2010.

Correspondence: Tracy L. Hull, M.D., Department of Colorectal Surgery A30, Cleveland Clinic Foundation, Cleveland, Ohio 44195. E-mail:

© The ASCRS 2011