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World J Gastrointest Surg. Aug 27, 2021; 13(8): 764-771
Published online Aug 27, 2021. doi: 10.4240/wjgs.v13.i8.764
Rectovaginal fistula after low anterior resection: Prevention and management
Varut Lohsiriwat, Romyen Jitmungngan
Varut Lohsiriwat, Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Romyen Jitmungngan, Department of Surgery, The Golden Jubilee Medical Center, Mahidol University, Nakhon Pathom 73170, Thailand
Author contributions: Lohsiriwat V outlined the content and wrote and critically reviewed the manuscript; Jitmungngan R reviewed the literature and wrote the manuscript.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
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: Varut Lohsiriwat, MD, PhD, Professor, Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang-Lung Road, Bangkok 10700, Thailand. bolloon@hotmail.com
Received: January 28, 2021
Peer-review started: January 28, 2021
First decision: March 8, 2021
Revised: March 17, 2021
Accepted: April 29, 2021
Article in press: April 29, 2021
Published online: August 27, 2021
Processing time: 203 Days and 18.7 Hours
Abstract

Rectovaginal fistula after low anterior resection for rectal malignancy is one of the most challenging postoperative complications because it is difficult to treat and may complicate plans of adjuvant therapy. This problematic complication could lead to multiple operations, stoma formation, sexual dysfunction, fecal incontinence and psychosocial ramifications. This review comprehensively covers an overview of its incidence, risk factors, presentation and evaluation, management (ranging from conservative measures, endoscopic treatment and local tissue repair to radical resection and redo anastomosis) and treatment outcomes of rectovaginal fistula after low anterior resection. Notably, these therapeutic options and outcomes are influenced by several factors, including the size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis and surrounding tissue, presence of diverting stoma, previous attempted repair, and the surgeon’s experience. Also, strategies to prevent rectovaginal fistula after low anterior resection are presented with illustrations. Finally, a decision-making algorithm for managing this complication is proposed.

Keywords: Rectovaginal fistula; Rectal cancer surgery; Complication; Prevention; Management; Review

Core Tip: The current article provides a comprehensive overview of the incidence, risk factors, presentation, evaluation, management and outcomes of patients with rectovaginal fistula resulting from low anterior resection. Notably, the therapeutic options and results are influenced by several factors, including size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis, surrounding tissue, presence of diverting stoma, previously attempted repair, and the surgeon’s experience. Strategies to prevent rectovaginal fistula formation after rectal cancer surgery are also discussed. A decision-making algorithm for managing this complication is proposed at the end of article.