Intravaginal endoscopic vacuum therapy of a rectovaginal fistula: expanding boundaries

A 36-year-old woman underwent anterior resection of the rectum owing to endometriosis. The procedure was complicated by a rectovaginal fistula, which needed several surgical reinterventions. Despite diversion colostomy and reconstruction of the posterior vaginal wall with a fasciocutaneous flap, the rectovaginal fistula persisted, with a 50-mm abscess interposed between the coloanal anastomosis and the neovagina. The patient was referred for endoscopic evaluation. Endoscopy confirmed a 4-mm fistulous tract at the coloanal anastomosis with communication between the abscess and vagina. Two sessions of endoscopic internal drainage were performed ( Fig. 1 a ); however, because of the lack of significant improvement in terms of the vaginal drainage and abscess dimensions, endoscopic intravaginal evaluation was performed, which revealed a 30-mm wide communication between the fornix and the abscess ( Fig. 1 b ). Endoscopic views showing: a endoscopic internal drainage of the abscess through the rectum; b the abscess cavity with a wide communication with the fornix on intravaginal view. A total of seven sessions of intracavitary endoscopic vacuum therapy (EVT) were performed through the vagina ( Fig. 2 a ), each 3–4 days apart, with progressive reduction of the cavity size ( Video 1 ). Foreign bodies (surgical sutures/staples) were retrieved between the sessions to enhance tissue healing. At the end of the intravaginal EVT treatment, successful shrinkage of the cavity had been achieved, with a residual pseudodiverticulum ( Fig. 2 b ). Because of the persistence of contrast extravasation from the rectum to the pseudodiverticulum on rectal evaluation, a 12/6t over-the-scope (OTS) clip was placed on the rectal side ( Fig. 2 c ). Endoscopic view showing: a the intravaginal endoscopic vacuum therapy; b the residual pseudodiverticulum after seven sessions of intravaginal endoscopic vacuum therapy had been completed; c an over-the-scope clip that was placed to close the fistulous tract between the rectum and the pseudodiverticulum. Intravaginal endoscopic vacuum therapy is performed to close a rectovaginal fistula. Video 1 After 1 month, a double endoscopic evaluation (rectal and vaginal) was performed simultaneously, which showed OTS clip displacement, with no extravasation of contrast or methylene blue on either side. A computed tomography scan with rectal contrast and magnetic resonance imaging confirmed resolution of the fistula, with there being no recurrence during 12 months of follow-up. Treatment of gastrointestinal fistulas frequently requires a multimodality approach, tailored to each phase of the healing process to enhance the possibility of clinical success 1 2 . To the best of our knowledge, this is the first report of intravaginal EVT, highlighting the expanding applications of EVT in the treatment of surgical complications. Endoscopy_UCTN_Code_TTT_1AQ_2AG