Risk of Rectovaginal Fistula in Women with Excision of Deep Endometriosis Requiring Concomitant Vaginal and Rectal Sutures, with or without Preventive Stoma: A Before-and-after Comparative Study

Horace Roman, Bridoux V, Valérie Bridoux, Benjamin Merlot, Merlot B, Noailles M, Myriam Noailles, E. Magne, Eric Magne, Magne E, Resch B, Benoit Resch, B. Resch, Damien Forestier, Forestier D, Jean-Jacques Tuech, Tuech JJ, Jean–Jacques Tuech
Journal of Minimally Invasive Gynecology · 2021 · vol. 29(1) , pp. 56–64.e1 · doi:10.1016/j.jmig.2021.06.013 · PMID:34175463 · W3173870839
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This study investigated the risk of rectovaginal fistula in women undergoing deep endometriosis excision with vaginal and rectal suturing, comparing outcomes with and without a preventive stoma.

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Abstract

Study objectiveTo assess whether a liberal policy of preventive stoma (LPS) reduces the rate of rectovaginal fistulas in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures in comparison with a more restrictive policy of preventive stoma (RPS) and to assess the risk factors for rectovaginal fistula.DesignRetrospective before-and-after comparative study.SettingTwo referral centers, one with an LPS and the other with an RPS.PatientsA total of 363 patients with deep endometriosis infiltrating the rectum and the vagina.InterventionsRectal disc excision or colorectal resection concomitantly with vaginal excision.Measurements and main resultsTwo hundred forty-one and 122 women received surgery at the LPS and RPS centers, respectively. The rate of preventive stomas was 71.4% at the LPS center (n = 172) and 30.3% at the RPS center (N = 37). Rectovaginal fistula was recorded in 31 cases (8.5%): nineteen women were managed at the LPS center, and 12 women underwent surgery at the RPS center. It occurred in, respectively, 9.4%, 10.8%, 10.1%, and 7% of the women managed without and with a stoma at the RPS center and of those managed without and with a stoma at the LPS center (p = .72). The height of the rectal stapled line was significantly lower in the women undergoing a stoma, particularly in those managed at the RPS center (5.4 ± 1.8 cm). Performing rectal sutures within 8 cm from the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of stoma creation, surgical procedure carried out on the rectum, size of vaginal infiltration, or associated excision of deep endometriosis involving the pelvic nerves (odds ratio 3.4; 95% confidence interval, 1.3-9.1).ConclusionNo statistically significant differences were found in terms of the risk of rectovaginal fistula between women with rectovaginal endometriosis managed by either an LPS or an RPS; however, these findings need to be confirmed by a randomized trial.

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Condition tags

endometriosis

MeSH descriptors

Endometriosis Endometriosis Endometriosis Rectal Diseases Female Humans Postoperative Complications Postoperative Complications Postoperative Complications Rectovaginal Fistula Rectovaginal Fistula Rectovaginal Fistula Rectovaginal Fistula Rectum Retrospective Studies Sutures Treatment Outcome Vagina

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