Five year review of rectovaginal fistulas at Addis Ababa Fistula Hospital

Professor Gordon Williams Dr Habtemariam Tekle

Mary Venn

Introduction

• Incidence: 3.3% - 15%• Primarily caused by prolonged obstructed

labour• No standard classification

Objectives

To identify –Aetiology –Patient characteristics – Extent of rectovaginal injury–Patients requiring a colostomy–Outcomes

Methods

• 5 years retrospective data from 2004 –2009• Operation register & patient cards reviewed• Information recorded on a prepared

questionnaire

Causes of Rectovaginal FistulaCauses Number (%)

Child birthMean duration of labour 3.8 days

282 (89.5)

Post coital 22 (7)

Accidents 8 (2.5)

Other 3 (1)

Total 315

Characteristics of All Rectovaginal Fistula

• N = 315• Type– High 111 (35.2%)– Mid 90 (28.6%)– Low 86 (23.3%)– Circumferential 36 (11.4%)– Combined 28 (8.9%)

Characteristics of Obstetric Rectovaginal Fistula (N = 282)

Primiparous 200 (70.9%) Multiparous 82 (29.1%)Concurrent VVF 240 (85.1%)Position of fistula– High 108 (38.3%)– Mid 88 (31.2%)– Low 58 (20.6%) – Combined 28 (9.9%)

Characteristics of Post-coital Fistula

• N = 22• Parity– nulliparous 15

• Age– Mean 24

• Type– Low 20 (90.9%)

Associated Injuries

• N = 315• Stricture 6 (2%)• Concurrent VVF 244 (77.5%)• Concurrent tear 19 (6%)• None 46 (14.5%)

Colostomy

• Colostomy 67 (21%)– AAFH: 51 – Elsewhere: 16– Needed revision: 2– Time from opening to closure of colostomy: 5 months

• Colostomy not closed: 6– Lost to follow up: 3– RVF not closed: 2– Patient died: 1

Cure & Surgical Technique: First time surgery

Single layer closure 9/14Two layer closure 245/261Abdominal approach 1/1End to end anastomosis 16/21Unspecified 5

Outcomes

Overall closure success 294 (93%)– 1st operation 276 (88%)– 2nd operation 13 – 3rd operation 3– 4th operation 1– 7th operation 1

Outcomes of Concurrent VVF in Patients with RVF (N = 240)

Closed at 1st attempt 169 (70%)Broken 63Abandoned 6Died 1

Outcomes for Colostomy Patients• N = 67• Cured– 1st operation 51 (77%)– 2nd operation 8– 3rd operation 1– 7th operation 1

• No Follow up 3• Pin hole remained 1• Could not be repaired 1• Died 1

Conclusions

• RVF is mainly caused by childbirth and long duration of labour in primiparous

• Patients who had colostomy had an obstetric cause & were high & circumferential RVF’s

• Patients with concurrent VVF & RVF had less success• Standard classification needed for prediction of

outcome • Criteria for colostomy have to be settled