Published online Apr 14, 2021. doi: 10.3748/wjg.v27.i14.1451
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
Currently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, on account of low primary healing rates and uncertainty regarding secondary repair.
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.
Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were specifically assessed.
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.
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.
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.
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.