five year review of rectovaginal fistulas at addis ababa fistula hospital professor gordon williams...

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