Factors associated with fecal diversion prior to rectovaginal fistula repair.

BACKGROUND: Temporary fecal diversion (FD) is selectively performed in patients with rectovaginal fistulas (RVF). We aimed to identify the factors associated with FD in treatment of RVF and hypothesized that FD is associated with increased recurrence free survival METHODS: A retrospective review of females who underwent repair of a RVF was performed. Patients were divided into 2 groups based on the utilization of FD. Recurrence was defined as evidence of RVF on clinical exam or imaging after at least 2 prior follow ups noting healing. RESULTS: 158 patients underwent 424 surgical procedures of which 100 (63.3%) patients underwent FD, while 58 (36.7%) did not. Patients were comparable in terms of age, BMI, diabetes, smoking history, IBD history, and fistula etiology. Patients in FD group required a median of 3 (IQR 1-5) repairs (p<0.005). Interposition flaps were more common in FD group than non-FD: gracilis [13 (13%) vs 2 (3%); p=0.05] and Martius [17 (17%) vs 2 (3%); p=0.01]. There were no significant differences in healing or recurrence rates. Multivariate analysis revealed an increased number of prior attempted repairs was associated with the use of FD (p<0.001). The cumulative 5-yr Kaplan-Meier cure rate was 72.7% (61 - 87) in FD group and 64.3% (48 - 86) (p=0.38) in non-FD group. CONCLUSION: Multiple prior RVF repairs and interposition flap repairs are associated with the utilization of FD. Selecting high risk patients for FD before re-repair may allow the recurrence rate to be similar to lower risk non-diverted patients.