Management of a rectovaginal fistula (RVF) following low circular-stapled colorectal anastomosis is difficult and often unsatisfactory. We report herein the case of a 66- year-old woman who developed a RVF following low anterior resection using the double-stapling technique for rectal cancer. The RVF spontaneously closed with nonoperative treatment that included simple observation without dietary restrictions. The spontaneous closure occurred within approximately 25 days. Minimally symptomatic patients may be candidates for nonoperative treatment

Hidaka Shigekazu

Nakagoe Tohru

Nanashima Atsushi

Sawai Terumitsu

Shibasaki Shin-Ichi

Tanaka Kenji

Tsuji Takashi

Yamaguchi Hiroyuki

Yasutake Tohru

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Acta Med. Nagasaki 48 :81-84Case Report Spontaneous Closure of a Rectovaginal Fistula that Developed after Double-stapled Anastomosis in Low Anterior ResectionTohru NAKAGOE, Terumitsu SAWAI, Takashi Tsuji, Kenji TANAKA, Shigekazu HIDAKA, Atsushi NANASHIMA, Shin-ichi SHIBASAKi, Hiroyuki YAMAGUCHi, Tohru YASUTAKEFirst Department of Surgery, Nagasaki University School of Medicine Management of a rectovaginal fistula (RVF) following low circular-stapled colorectal anastomosis is difficult and often unsatisfactory. We report herein the case of a 66-year-old woman who developed a RVF following low ante-rior resection using the double-stapling technique for rectal cancer. The RVF spontaneously closed with nonoperative treatment that included simple observation without dietary restrictions. The spontaneous closure occurred within ap-proximately 25 days. Minimally symptomatic patients may be candidates for nonoperative treatment.      ACTA MEDICA NAGASAKIENSIA 48: 81-84, 2003Key Words: rectovaginal fistul, spontaneous closure, rectal             cancer, low anterior resection, double-stapling           techniqueIntroduction Rectovaginal fistula (RVF) following low circular-stapled colorectal anastomosis has been reported,' al-beit with incidence rates as low as 2.9%,2 2.2%,3 or 1.0%.4 The RVF, which leads to vaginal flatus, fecal leakage, and/or vaginal discharge, is an extremely uncomfort-able complication. The management of RVF is diffi-cult and often unsatisfactory.'' Many surgeons believe that active operative treatment seems to be the most effective treatment.',` There have been few reports on the successful closure of such RVFs with nonoperative treatments.',',' We report herein a case of patient who developed a RVF following low anterior resection using the double-stapling technique for rectal cancer that was successfully treated with the nonoperative treatmentAddress Correspondence: Tohru Nakagoe, M.D. First Department of Surgery, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan TEL: +81-95-849-7304 FAX: +81-95-849-7306 E-mail: nakagoe@net.nagasaki-u.ac.jpof simple observation without dietary restrictions.Case report A 66-year-old woman was admitted to our hospital on July 11, 2000 with a chief complaint of hematochezia and constipation that had lasted for approximately 6 months. Her past medical history included an ectopic pregnancy (with emergency laparotomy) and viral hepatitis C at 28 years of age. She had also undergone an emergency laparotomy at age 43 for adhesive in-testinal obstruction caused by prior laparotomy.  On admission, physical examination of the abdomen revealed no abnormal findings except for a laparotomy scar. Abnormal findings of laboratory tests included elevated serum levels of CA 19-9 (133.8 U/mL; normal range<37 U/mL), whereas serum level of carcinoembryonic antigen (CEA) was within the normal range (4.4 ng/mL; normal range<5.0 ng/mL). Anti-HCV was positive. Laboratory tests also revealed liver dysfunction that included elevated serum levels of AST (317 IU/L; nor-mal range, 13-33 IU/L), ALT (163 IU/L; normal range, 8-42 IU/L), thymol turbidity test (TTT; 10.5 U; normal range, 0-4.0 U), zinc sulfate turbidity test (ZTT; 14.2 U; normal range, 4.0-12.0 U), and low albuminemia (3.8 g/dL, normal range, 4.0-5.0 g/dL). The abnormal find-ings were compatible with chronic hepatitis C.  Colonoscopy showed an ulcerating tumor of the rec-tum. The lower edge of the tumor was located 6 cm from the dentate line. The tumor approximately en-compassed the entire circumference of the bowel. The colonoscopic biopsy showed an adenocarcinoma. Barium enema revealed the tumor of the rectum, but there was no evidence of multiple tumors in other sites of the colon. Abdominal computed tomography (CT) demon-strated no metastasis to the liver or para-aortic lymph nodes, but there were a couple of small nodules in the mesorectum that were considered lymph node metas-Tohru Nakagoe et al : Spontaneous Closure of Rectovaginal Fistulatases.   Under the diagnosis of rectal cancer, low anterior resection using the double-stapling technique' was per-formed on August 1, 2000. Lymph nodes at the root of the inferior mesenteric artery were removed and the superior hemorrhoidal artery was divided, preserv-ing the left colic artery. The entire mesorectum was mo-bilized to the pelvic floor in the avascular plane via sharp dissection. Lateral lymph node dissection with autonomic nerve preservation" was performed. The rectum was dissected free of the posterior wall of the vagina. The TA55® stapler (US Surgical Corp., Norwalk, CT) was used to divide the distal rectum, which was 4 cm below the cancer. The anastomosis was constructed approximately 2 cm above the dentate line using the premium CEEA®31 stapler (US Surgical Corp.). The premium CEEA® stapler was closed and fired so that the posterior wall of the vagina was not included in the premium CEEA® stapler anastomosis. When the premium CEEA® stapler was disengaged form the anastomosis and extracted per anum, the perineal op-erator felt that the premium CEEA® stapler got caught in the anterior wall of the anastomotic portion of the rectum. However, we confirmed completeness of the rectal tissue ring (so-called 'doughnut') by means of in spection. We also checked the integrity of the anastomosis by insufflation of saline solution into the rectum and subsequently confirmed there was no leakage of saline solution within the stapled anastomosis. No diverting colostomy was performed.  The resected specimen revealed an ulcerating tumor of the rectum (maximal diameter, 7.0 cm) with 4.0 cm of distal resection margin. The histological report showed a well-differentiated adenocarcinoma with Dukes C stage (tumor invaded to non-peritonealized, perirectal tissues, presence of lymph node metastasis, presence of lymphatic and venous invasion, no liver metastasis, and no peritoneal dissemination). The patient had an uneventful course until the 11th postoperative day (August 12, 2000) when the patient presented with vaginal flatus and fecal leakage. By vaginoscopy with rectal digital examination, there was a well-circumscribed 7 mm hole through the rectal-vaginal septum 3.5 cm from the level of the introitus vagina. No tumor was present. Staples were palpable just beneath the vagi-nal mucosa within the fistula. A fistulogram was not conducted because the patient denied consent. Pelvic CT showed a collection of air in the vagina and also showed a deformed, thin posterior wall of the vagina at exactly the same level of the stapled anastomosis portion, which was considered a RVF (Fig. 1). The pa-tient had no fever and laboratory tests also showed no inflammatory changes. The patient felt that theamount of vaginal flatus and fecal leakage were toler-able. Therefore, under the patient's informed consent, the patient was conservatively treated with nonoperative therapy such as simple observation without dietary restrictions. Fortunately, the amount of the vaginal flatus and fecal leakage gradually decreased after August 17, 2000 (16th postoperative day), and com-pletely disappeared on September 6, 2000 (36th post-operative day). Closure of the rectovaginal fistula was confirmed by vaginoscopy with rectal digital examina-tion and colonoscopy (Fig. 2). During the postopera-tive period, the patient received no local therapy such as fibrin glue or blood coagulation factor XIII, which accelerates wound healing. Of note, the patient did not receive pre- and/or post-operative radiotherapy. The patient was discharged from the hospital on September 22, 2000 (52nd postoperative day). Upon this writing (April 20, 2002), the patient is and disease-free. In ad-dition, the patient has not had any signs or symptoms of the RVF during the 20.3 months of follow-up.Figure 1 Pelvic CT showed a deformed, thin posterior wall of the vagina at exactly the same level of the stapled anastomosis portion, which was considered a rectovaginal fis-tula (arrow). Collection of air in the vagina was observed. Anastomosis included staples.Tohru Nakagoe et al : Spontaneous Closure of Rectovaginal FistulaFigure 2 On the 42nd postoperative day, closure of the rectovaginal fistula was confirmed by colonoscopy. Arrow in-dicates the scar of the rectovaginal fistula within the stapled anastomosis.Discussion Many surgeons believe that the posterior wall of the vagina may be included in the circular stapled anastomosis when describing the etiology of RVF after circular-stapled low anterior resection.""" In the current case, we confirmed by visualization during the operation that the posterior wall of the vagina was not included in the circular-stapled anastomosis. However, when the circular stapler was extracted per anum, the perineal operator felt that the circular stapler got caught in the anterior wall of the anastomotic portion of the rectum. Therefore, RVF may have resulted from sev-eral factors including minor leakage of the anterior portion of the colorectal anastomosis, consequent ab-scess formation and spontaneous drainage of the ab-scess through the devascularized vagina. We believe that that the surgical technique involved in the circu-lar stapled anastomosis may have been an important factor in the etiology of this complication.' 11  We previously reported the cases of 4 patients who developed RVF after double-stapled anastomosis in low anterior resection. These were successfully repaired surgically via a transvaginal approach! Although 2 of the 4 patients in that series had been conservatively treated using total parenteral hyperalimentation with bowel rest for over 30 days, spontaneous closure had failed and operative treatment had become necessary.2At that time, we had believed that operative treatment seemed to be the most reliable, effective treatment to cure such RVF. We describe, in the current report, our first experience of a patient with RVF that was suc-cessively treated nonoperatively.  Few studies on successful closure with nonoperative treatment for such RVFs have been reported. 1,7,8,12,13 In order to clarify the incidence and management of RVF following low anterior resection, questionnaires obtained from active members of the American Society of Colon and Rectal Surgeons revealed the followingl: a total of 57 patients were reported to have postoperative RVF; of these, 53 had circular-stapled anastomosis; 14 were managed nonoperatively (simple observation, parenteral hyperalimentation with bowel rest, or low-residue diets and antibiotics); and 39 were managed operatively; suc-cessful closure was obtained in 10 of 14 patients who were treated nonoperatively. In addition, surprisingly, some patients were treated successfully with low-residue diets and antibiotics. Ochiai et al.' reported that suc-cessful closure of a RVF was obtained with bowel rest and administration of blood coagulation factor XIII, which accelerates wound healing.  In general, bowel rest and nutritional support (total parenteral nutrition) undoubtedly provided a favorable environment for tissue granulation and healing of the intestinal fistula. 14 Also, it has been agreed that healing of the fistula was primarily related to local anatomical conditions. 14 An increase of pressure and amount of stool within the rectum may be an obstacle to spontaneous healing of RVF. The current patient had smooth evacua-tion because there was not an anastomotic stricture. These conditions might have favored spontaneous clo-sure of the RVF, although its definite mechanism re-mains unclear.  Once a RVF occurs, management must be individual ized.' Now, we feel that patient selection for nonoperative treatment may be difficult. Rex and Khubchandani l reported that observation with low-residue diets, anti-biotics, or bowel rest may be attempted with a high success rate in the minimally symptomatic patient. For the patient in this current report, early decrease in the amount of vaginal flatus and vaginal fecal leakage oc-curred (on 5th day from onset of RVF). Therefore, such patients may be candidates for nonoperative treatment, although this is inconclusive because of the relative paucity of patients reported.References1. Rex Jr. JC, Khubchandani IT: Rectovaginal fistula: complication of    low anterior resection. Dis Colon Rectum 35: 354-356, 1992 2. Nakagoe T, Sawai T, Tuji T, et al: Successful transvaginal repairTohru Nakagoe et al : Spontaneous Closure of Rectovaginal Fistula   of a rectovaginal fistula developing after double-stapled anastomosis    in low anterior resection: report of four cases. Surg Today 29: 443-   445, 1999 3. Antonsen HK, Kronborg 0: Early complications after low anterior    resection for rectal cancer using the EEA stapling device. A pro-   spective trial. Dis Colon Rectum 30: 579-583, 1987 4. Baran JJ, Goldstein SD, Resnik AM: The double-staple technique    in colorectal anastomoses: a critical review. Am Surg 58: 270-272,   1992 5. Sugarbaker PH: Rectovaginal fistula following low circular sta-   pled anastomosis in women with rectal cancer. J Surg Oncol 61:    155-158, 1996 6. Bauer JJ, Sher ME, Jaffin H, Present D, Gelerent I: Transvaginal    approach for repair of rectovaginal fistulae complicating Crohn's    disease. Ann Surg 213: 151-158, 1991 7. Fleshner PR, Schoetz DJ, Roberts PL, et al: Anastomotic-vaginal    fistula after colorectal surgery. Dis Colon Rectum 35: 938-943,   1992 8. Ochiai T, Moriwaki M, Shigematu Y, et al: A case of rectovaginal    fistula after low anterior resection by double stapling technique    who was cured by conservative treatment. J Jpn Soc Coloproctol    46: 368-373, 19939. Cohen Z, Myers E, Langer B, et al: Double stapling technique for    low anterior resection. Dis Colon Rectum 26: 231-235, 1983 10. Moriya Y, Sugihara K, Akasu T, Fujita S: Nerve-sparing surgery    with lateral node dissection for advanced lower rectal cancer. Eur   J Cancer 31: 1229-1232, 1995 11. Nakagoe T, Sawai T, Tsuji T, et al: Avoidance of rectovaginal fis-   tula as a complication after low anterior resection for rectal can-   cer using a double-stapling technique. J Surg Oncol 71; 196-197,   1999 12. Eden TW: A case of superior recto-vaginal fistula dealt with by    the abdominal route after preliminary colostomy. J Obstet Gynecol    Br Commonw 26: 175-185, 1914 13. Antonsen HK, Kronborg 0: Early complications after low anterior    resection for rectal cancer using the EEA stapling device. A pro-   spective trial. Dis Colon rectum 30: 579-583, 1987 14. Levy E, Frileux P, Cugnenc PH, et al: High-output external fistu-   lae of the small bowel: management with continuous enteral nu-   trition. Br J Surg 76: 676-679, 1989

Spontaneous Closure of a Rectovaginal Fistula that Developed after Double-stapled Anastomosis in Low Anterior Resection

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Spontaneous Closure of a Rectovaginal Fistula that Developed after Double-stapled Anastomosis in Low Anterior Resection

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