Predictors of outcome for treatment of enterovaginal fistula : Therapeutical strategies for treatment

Abstract

Background: Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary.

Methods: The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure.

Results: Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031).

Conclusion: Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.

Keywords: Enterovaginal fistulas; Rectovaginal fistulas; Therapeutic outcome for enterovaginal fistulas.

Fig. 1

Flow diagram regarding the inclusion and exclusion criteria from database research to the final analysis of patient cohort with enterovaginal fistulas, treated at our institution. IBD, inflammatory bowel disease

Fig. 2

Outcome of fistula-specific therapy, stratified for etiology of fistulas and patient comorbidities. A Postoperatively derived enterovaginal fistulas showed a significantly more favorable therapy success rate than fistulas associated with tumor (p < 0.001) and radiation (p = 0.079). Non-IBD inflammatory fistulas were treated more successfully than fistulas associated with tumor (p = 0.0119) and radiation (p = 0.0310). No statistically significant differences in therapy outcome were monitored between fistulas after rectal, gynecological, or combined surgery, yet with a favorable tendency for gynecological pre-operation (B, C). D Patients with a CCI score were associated with a more unfavorable outcome after fistula treatment, yet not significantly (D; p = 0.0752). IBD, inflammatory bowel disease

Fig. 3

Outcome of fistula-specific therapy, stratified for applied treatment modalities. A transabdominal surgical approach for fistula treatment was associated with the highest primary success rate and therefore significantly better than any other applied therapy modality, when applied as first (A) or most invasive treatment (B) within the therapeutic sequence. Local surgical treatments still resulted in significantly better therapy outcome than the sole application of an ostomy as first (A) and most invasive treatment (B) and significantly better success rates than conservative treatment, when applied as most invasive treatment. C No statistically significant difference was monitored between the different applied first therapeutic options regarding fistula recurrence. D Significantly lower rates of fistula recurrence were observed after application of transabdominal surgery as the most invasive treatment within the therapeutic sequence. Conserv., conservative treatment; Endosc., endoscopic treatment; OP, surgery. p values as seen in figure

Fig. 4

Outcome of fistula-specific therapy, stratified for application of a diverting ostomy. A Patients treated with supportive ostomy showed no significant benefit for fistula recurrence (p = 0.1197). B Application of a supportive ostomy led to significantly lowered time to fistula closure (p = 0.0312). In patients with postoperatively derived fistula, application of supportive ostomy showed significantly higher rates of primary fistula closure (C; p = 0.0129) and lower probability of fistula recurrence (D; p = 0.0418)

Fig. 5

Flow chart on possible treatment approaches for enterovaginal fistula