Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 14, 2021; 27(14): 1451-1464
Published online Apr 14, 2021. doi: 10.3748/wjg.v27.i14.1451
Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair
Qian Zhou, Zhi-Min Liu, Hua-Xian Chen, Dong-Lin Ren, Hong-Cheng Lin
Qian Zhou, Zhi-Min Liu, Hua-Xian Chen, Dong-Lin Ren, Hong-Cheng Lin, Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
Qian Zhou, Zhi-Min Liu, Hua-Xian Chen, Dong-Lin Ren, Hong-Cheng Lin, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
Qian Zhou, Zhi-Min Liu, Hua-Xian Chen, Dong-Lin Ren, Hong-Cheng Lin, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
Author contributions: Zhou Q and Liu ZM drafted the manuscript and contributed equally to the study; Chen HX completed the statistical analysis; Lin HC and Ren DL served as the principal investigators, were responsible for the study plan, performed all of the surgical procedures, and finalized the manuscript; all authors have read and approved the final version of the manuscript.
Supported by The Sixth Affiliated Hospital, Sun Yat-sen University Clinical Research 1010 Program, No. 1010PY(2020)-18; Science and Technology Program of Guangzhou, China, No. 202002020081; National Natural Science Foundation of China, No. 81973847; and Natural Science Foundation of Guangdong Province of China, No. 2020A1515011254.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (No. E2018012).
Informed consent statement: Patients underwent sutured or stapled repair surgery after each agreed to treatment by written consent.
Conflict-of-interest statement: The authors declare having no conflicts of interest related to this study or its publication.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hong-Cheng Lin, FASCRS, MD, PhD, Doctor, Surgeon, Department of Coloproctology, The Sixth Affiliated Hospital of Sun Yat-sen University, No. 26 Yuancun Erheng Road, Guangzhou 510655, Guangdong Province, China. lhcheng@mail.sysu.edu.cn
Received: January 4, 2021
Peer-review started: January 4, 2021
First decision: January 23, 2021
Revised: January 29, 2021
Accepted: March 7, 2021
Article in press: March 7, 2021
Published online: April 14, 2021
ARTICLE HIGHLIGHTS
Research background

Currently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, on account of low primary healing rates and uncertainty regarding secondary repair.

Research motivation

Based on findings from a preliminary pilot study of the safety of stapled transperineal repair on low- and mid-level RVF, we designed a retrospective study to compare outcomes and recurrence rates between sutured and stapled transperineal repair.

Research objectives

Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were specifically assessed.

Research methods

This was a retrospective cohort study conducted on patients from the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University. In total, 82 adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among them, 37 patients were repaired with direct suture and 45 patients with stapler.

Research results

The two treatment groups shared similar clinical characteristics, such as aetiology, surgical history, fistula features, and Wexner score. The stapled repair group did not show superior results over the sutured repair group in regard to operative time, blood loss, and length of hospital stay. However, the patients in the stapled repair group showed a better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (2.22% vs 2.7%, P = 0.045) and, most important, lower recurrence rate (13.33% vs 45.95%, P = 0.001). No previous repair history, smaller diameter of fistula (Wexner < 0.5 cm), better control of defecation (Wexner < 10), and stapled repair showed protective effects on healing. Direct suture repair and preoperative high Wexner score (≥ 10) were further demonstrated to be risk factors for fistula recurrence.

Research conclusions

Stapled transperineal repair shows an advantage for management of non-inflammatory, low- and mid-level, or even with prior failure of repair of RVF, with high primary healing rate and low recurrence rates.

Research perspectives

Our retrospective analysis of only low- and mid-level fistulas introduces biases towards particular types of surgery in less complicated cases. In addition, our median follow-up was relatively short, with the expectation of later recurrent fistulas in both groups over time. The long-term efficacy of stapled repair needs further prospective, randomized controlled trials to fully understand and capitalise on its advantages in clinic.