Table 4 Interventions and success and failure rates in published studies (n = 11 studies)
Author, year | RVF/AVF sample size | Intervention(s) | Median follow-up duration, months (range) | Key outcome definitions | Success and failure rates | Post-operative infection rates | ||
|---|---|---|---|---|---|---|---|---|
Corte, 2015 [9] | 79 RVFs | Conservative procedures: seton drainage, vaginal advancement flap, rectal advancement flap, diverting stoma only, fistula plug, fibrin glue Major procedures: GMT, biomesh interposition, standard CAA or CRA, delayed CAA, abdominoperineal excision | 33.1 (4–190); success ascertained at 3 months | Success: absence of any vaginal discharge of feces, flatus, or mucous discharge during ≥ 3 months after the last procedure AND absence of stoma. Patients who underwent a stoma performed after RVF healing for a non-RVF-related condition were considered as success | Success rate: 14.4% (23/160) in RVFs with CD etiology (160 procedures among 34 patients with CD-related RVF) | Not reported | ||
El-Gazzaz, 2010 [14] | 65 RVFs | Advancement flap, coloanal anastomosis, episioproctomy, fibrin glue or plug | 44.6 (IQR: 13.1–79.1) | Healing (closed RVF): all pre-operative symptoms attributable to the fistula resolved at the time of follow-up and no fistula detected by physical examination at the last office visit | Healing rate, by type of current surgery: Mucosal advancement flap: 42.6% (20/47) CAA: 57.1% (4/7) Episioproctotomy: 71.4% (5/8)b Fibrin glue: 50.0% (1/2) Plug: 0% (0/1) | Not reported | ||
Gaertner, 2011 [15] | 51 RVFs | Operative treatment, operative treatment + infliximab | 38.6 (mean); (3–204) | Completely healed: no clinical evidence of fistula Minimally symptomatic: seton placement with minimal drainage and/or infliximab dependence Failure: persistent or recurrent symptomatic fistula, diverting procedure or proctectomy | Surgery only (n = 25) | Surgery + infliximab (n = 26) | Not reported | |
Completely healed | 24% (6/25) | 46% (12/26) | ||||||
Minimally symptomatic | 20% (5/25) | 15% (4/26) | ||||||
Healing rates: ‘completely healed’ + ‘minimally symptomatic’ | 44% (11/25) | 62% (16/26) | ||||||
Fistula closure | Not reported | 54%a (14/26) | ||||||
Healing rates by operative approach (numbers for calculation not reported) | ||||||||
Surgery only (n = 25) | Surgery + infliximab (n = 26) | |||||||
Transperianal repair (n = 6) | 100% | 50% | ||||||
Seton drainage (n = 35) | 33% | 65% | ||||||
Advancement flap (n = 8) | 50% | 0% | ||||||
Fibrin glue (n = 8) | 0% | 0% | ||||||
Martius flap (n = 4) | NA | 75% | ||||||
Collagen plug (n = 4) | NA | 50% | ||||||
Haennig, 2015 [10] | 12 RVFs | Seton drainage and associated treatment, infliximab, external drainage, fibrin glue, advancement flap, fistulotomy Other treatments (external drainage + infliximab, fistulotomy + infliximab, advancement flap + infliximab, infliximab [monotherapy], external drainage, bowel diversion) | 64 (2–263) | Interval to closure: closure not defined | RVF: time interval to closure = 30.6 months vs 12 months for anal fistulas, p = 0.02 RVF not significantly correlated with relapse (p = 0.24) | Not reported | ||
Jarrar, 2011 [16] | 21 AVFs | Transanal endorectal advancement flap repair | Follow-up calls at 7 ± 3 years | Healing: not defined | Healing rate, after 1st flap: 41.7% (5/12) Healing rate, after 2nd flap: 42.9% (3/7) Healing rate, after 3rd flap: 66.7% (2/3) Healing rate, overall: 83.3% (10/12) | Not reported by fistula type | ||
Korsun, 2019 [17] | 21 RVFs 2 AVFs | GMT | 47 (mean); (1–144) | Complete closure of fistula by 1st follow-up (~ 3 months post-operatively) without additional follow-up operations | Fistula closure rate: RVF: 71% (15a/21); including 1 patient with an abscess after GMT without fistula proof AVF: 50% (1a/2) Stoma closure rate: RVF: 55% (numerator unclear); 1 patient operated without stoma and 1 patient opting against stoma closure after fistula closure AVF: 50% (1a/2) | 4.8%a (1/21) patient with RVF had an abscess after the surgery without fistula proof | ||
Milito, 2019 [18] | 43 RVFs | Surgical approaches included drainage and seton, rectal advancement flap, vaginal advancement flap, transperineal approach using porcine dermal matrix, and Martius flap | 18 | Complete healing, healing rate and failure rate: not defined | Median time to ‘complete healing’: 6 months (range: 2–11 months) Healing rate: 81% (numbers for calculation not reported) Failure rate: 19% (numbers for calculation not reported) | Not reported | ||
Narang, 2016 [19] | 99 RVFs | Episioproctotomy, muscle interposition (including GMT and Martius flap), placement of biological plug and fibrin glue, rectal-advancement flap, sphincteroplasty, and transvaginal repair | 39.1 (mean) ± 52.2 (SD) | Healing: not defined Failure to heal: persistence of symptoms that were compatible with the initial symptoms before surgical repair or current fecal drainage through the vagina | Overall healing: 63.7% (63/99)b Healing in patients with prior seton: 55.8% (24/43) Healing in patients with prior stoma: 52.8% (19/36) Healing in patients with systemic steroid treatment within 30 days of surgery: 61.4% (35/57) Healing in patients with biologic therapy within 30 days of surgery: 63.2% (43/68)* *Note: numerator does not match the total healing count for infliximab and adalimumab, below Healing in patients with CD and obstetric injury: 74.0% (26/35)b Healing in patients with steroids within 30 days of surgery: 61.4% (35/57) Healing in patients with infliximab within 30 days of surgery: 47.9% (23/48) Healing in patients with adalimumab within 30 days of surgery: 55.0% (11/20) | 1 patient (1%a, 1/99) had urinary tract infection < 30 days after surgery | ||
Pinto, 2010 [22] | 45 of 125 RVFs were CD related | Endorectal advancement flap, GMT, transvaginal approach, transperineal approach | 16.3 (mean) | Success: not defined Recurrence: persistence of symptoms compatible with the initial complaints and confirmed by physical examination or supplemental studies | Initial success rate: 44.2% (34/77 procedures) Recurrence rate: 55.8% (43/77 procedures) Eventual success rate (those who healed either initially or after recurrence): 78% (numbers for calculation not reported) after an average of 1.8 procedures | Not reported by fistula type | ||
Sapci, 2019 [23] | 19 RVFs | Transanal advancement flap, transanal repair with tissue interposition (Martius or gracilis flap), episioproctotomy, fistulotomy, CAA, fistula plug | 29.6 (mean) | Success: no symptoms ≥ 6 months after definitive repair and/or stoma closure | Overall healing rate: 63% (12/19) Success rate in patients who received a biologic within 3 months of surgery: 50% (4/8) Successful closure by procedures: Transanal advancement flap: 50% (4/8) Transanal repair with tissue interposition (Martius or gracilis flap): 67% (2/3) Episioproctotomy: 100% (2/2) Fistulotomy: 100% (2/2) CAA: 100% (2/2) Fistula plug: 0% (0/2) Active smoker: 75% (6/8) Patients with peri-operative diversion had higher rates of success compared with no diversion group (66% vs 57%, p = 1)—numbers for calculation not reported | Not reported | ||
Schloericke, 2017 [24] | 58 RVFs | Non-resective procedures (transrectal/transvaginal omentoplasty or closure) Resective procedures (low anterior resection, subtotal colectomy, proctectomy, pelvic exenteration, double-barrel sigmoidostomy) | 13 (3–36) | Recurrence: not defined | Complicated recurrence due to development of multiple perianal fistulas with severe sepsis: 13.3% (2/15) | In 13.3%a (2/15) patients with CD, recurrence was complicated because of the development of multiple perianal fistulas with severe sepsis which led to emergency abdominoperineal excision of the rectum in one patient | ||