Evaluating surgical management and outcomes of colovaginal fistulas

Anastomotic Considerations in Diverticulitis

Diverticulitis is a common indication for colorectal surgery, both in the acute and the elective setting. The anastomosis between the colon and rectum is a critical component of colectomy for diverticular disease and should be approached thoughtfully. This article reviews important surgical considerations when creating a colorectal anastomosis in the setting of diverticular disease, whether following the reversal of an end colostomy, during an acute episode of diverticulitis, or electively for chronic or complicated disease. Timing of surgery and preoperative assessment, minimally invasive approaches, and intraoperative maneuvers and considerations are discussed.

Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips: A single-institution case series

AIM

Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over-the-scope (OTS) clips.

METHOD

A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported.

RESULTS

Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157 ± 98 days, the mean defect diameter was 4.5 mm (range 2-10 mm) and the mean fistula length was 15 mm (range 2-25 mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long-term success (mean follow-up 218 days, range 25-673 days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long-term success after four interventions; three patients have not undergone a repeat procedure after initial failure.

CONCLUSION

Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long-term success rates are similar to other gastrointestinal tract applications of OTS clips.

Diverticular Colovaginal Fistulas: What Factors Contribute to Successful Surgical Management?

BACKGROUND

Diverticular disease is the leading cause of colovaginal fistulas. Surgery is challenging given the inflammatory process that makes dissection difficult. To date, studies are small and include fistula secondary to multiple etiologies.

OBJECTIVE

The objectives of this study were to examine surgical outcomes of diverticular colovaginal fistulas and to identify variables associated with successful closure.

DESIGN

This was a retrospective study of a prospectively maintained clinical database.

SETTINGS

The study was conducted at a single tertiary referral center.

PATIENTS

Women with diverticular colovaginal fistulas, who underwent surgical repair with intent to close the fistula, were included.

INTERVENTIONS

Repair of colovaginal fistula through minimally invasive or open techniques was involved.

MAIN OUTCOME MEASURES

Successful closure of fistula, defined as resolution of symptoms and no stoma, was measured.

RESULTS

Fifty-two patients underwent surgical treatment of diverticular colovaginal fistula, 23 (44%) of whom underwent a minimally invasive approach (conversion rate of 22%). Ostomy construction and omental pedicle flaps were used in 28 (54%) and 38 patients (73%). Surgery was successful in 47 patients (90%). Accounting for secondary operations, ultimate success and failure rates were 49 (94.0%) and 3 (5.7%). There was no difference in postoperative morbidity between the 2 groups (5 patients with Clavien-Dindo III/IV complications in the success group versus 2 patients in the failure group; 10.6% vs 40.0%; p = 0.44). Failure to achieve fistula closure was not associated with perioperative variables, age, BMI, diabetes mellitus, ASA grade, steroid use, previous abdominal surgery or hysterectomy, use of omentoplasty, or ostomy. Patients who failed were more likely to be smokers (60.0% vs 12.8%; p = 0.03).

LIMITATIONS

Limitations include the retrospective design and lack of power.

CONCLUSIONS

Surgery is effective in achieving successful closure of diverticular colovaginal fistula. Smokers should be encouraged to stop before embarking on an elective repair. Although the use of fecal diversion and omental pedicle flaps did not correlate with success, they should be used when clinically appropriate. See Video Abstract at http://links.lww.com/DCR/A983. FÍSTULAS COLOVAGINALES DIVERTICULARES ¿QUÉ FACTORES CONTRIBUYEN AL ÉXITO DEL TRATAMIENTO QUIRÚRGICO?: La enfermedad diverticular es la causa principal de fístulas colovaginales. La cirugía es un reto dado el proceso inflamatorio que dificulta la disección. Hasta la fecha, los estudios son pequeños e incluyen fístulas secundarias a múltiples etiologías.

OBJETIVO

1) Examinar los resultados quirúrgicos de las fístulas colovaginales diverticulares; 2) Identificar variables asociadas a un cierre exitoso. DISEÑO:: Estudio retrospectivo de una base de datos clínicos prospectivamente mantenida. CONFIGURACIÓN:: Centro de referencia superior.

PACIENTES

Mujeres con fístulas colovaginales diverticulares, que se sometieron a una reparación quirúrgica con la intención de cerrar la fístula.

INTERVENCIONES

Reparación de la fístula colovaginal mediante técnicas mínimamente invasivas o abiertas.

MEDIDAS DE RESULTADOS PRINCIPALES

Cierre exitoso de la fístula definida como resolución de los síntomas y sin estoma.

RESULTADOS

Cincuenta y dos pacientes se sometieron a tratamiento quirúrgico de la fístula colovaginal diverticular, 23 (44%) de los cuales se sometieron a un acceso mínimamente invasivo (tasa de conversión del 22%). La construcción de la ostomía y los pedículos omentales se utilizaron en 28 (54%) y 38 pacientes (73%), respectivamente. La cirugía fue exitosa en 47 pacientes (90%). Tomando en cuenta las operaciones secundarias, las tasas finales de éxito y fracaso fueron 49 (94.0%) y 3 (5.7%). No hubo diferencias en la morbilidad postoperatoria entre los dos grupos (5 pacientes con complicaciones de Clavien-Dindo III / IV en el grupo de éxito versus a 2 pacientes en el grupo de fracaso, 10.6% versus a 40.0%; p = 0.44). El fracaso para lograr el cierre de la fístula no se asoció con variables perioperatorios, edad, IMC, diabetes, grado ASA, uso de esteroides, cirugía abdominal previa o histerectomía, uso de omentoplastia u ostomía. Los pacientes que fracasaron eran más propensos a ser fumadores (60.0% versus a 12.8%; p = 0.03).

LIMITACIONES

Las limitaciones incluyen el diseño retrospectivo y la falta de poder.

CONCLUSIONES

La cirugía es efectiva para lograr el cierre exitoso de la fístula colovaginal diverticular. Se debe aconsejar a los fumadores a parar de fumar antes de embarcarse en una reparación electiva. Mientras el uso de desviación fecal y pedículos omentales no se correlacionó con el éxito, deberían utilizarse cuando sea clínicamente apropiado. Consulte el Video del Resumen en http://links.lww.com/DCR/A983.

Do the Surgical Outcomes of Rectovaginal Fistula Repairs Differ for Obstetric and Nonobstetric Fistulas? A Retrospective Cohort Study

OBJECTIVES

Rectovaginal fistulas can occur from both obstetric and nonobstetric (eg, inflammatory bowel disease, iatrogenic, or traumatic) etiologies. Current data on factors contributing to rectovaginal repair success or failure are limited, making adequate patient counseling difficult. Our objective was to compare outcomes of transperineal rectovaginal fistula repair performed in a single referral center on women with obstetric and nonobstetric causes.

METHODS

We performed a retrospective cohort study of women who had a transperineal rectovaginal fistula repair performed by a urogynecologist at the University of Michigan from 2005 to 2015. Data were obtained by chart review and included demographics, medical comorbidities, fistula etiology, history of a prior fistula repair, failure of current repair, time to failure, and operative details. Repair failure was defined as fistula symptoms with presence of recurrent fistula on exam or imaging in the postoperative follow-up period. Comparisons between the obstetric and nonobstetric cohorts were performed using χ, Fisher exact, and Wilcoxon rank sum tests. Relative risks were calculated to identify predictors of failure.

RESULTS

Eighty-eight women were included-53 obstetric and 35 nonobstetric fistulas. The overall fistula repair failure rate was 22.7% (n = 20). Median follow-up was 157.0 days (range, 47.5-402.0). Of all the factors, only nonobstetric etiology was significantly associated with an increased risk of repair failure (relative risk, 3.53 [range, 1.50-8.32]; P = 0.004.

CONCLUSIONS

Nonobstetric rectovaginal fistulas have a nearly 4-fold increased risk of repair failure compared with obstetric fistulas. Our results will help surgeons adequately counsel patients on potential outcomes of surgical repair of obstetric versus nonobstetric rectovaginal fistulas.

Colovaginal and colo-ovarian fistula at a patient with asymptomatic diverticular disease

Colovaginal and colo-ovarian fistulas are rare entities that could be attributed to diverticular disease after an episode of acute diverticulitis. Τhey could initially be manifested with symptoms that lead patients to the gynecologist. Gynecologists should consider them in the differential diagnosis, especially after recurrent episodes of sinusitis. We report the case of a 51-year-old woman with a colovaginal and a colo-ovarian fistula due to subclinical diverticular disease, which should be involved in the differential diagnosis in those complicated fistulas, even if the patient had never before a clinical episode of acute diverticulitis or known diverticular disease, and a successful surgical approach.

Laparoscopic approaches to complicated diverticulitis

BACKGROUND

The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis.

PURPOSE

The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis.

CONCLUSIONS

New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.