title: Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin.
abstract: BACKGROUND
  Closure of rectoanovaginal fistula from a cryptoglandular or obstetrical origin can be difficult. Multiple techniques exist and none are perfect. Although episioproctotomy offers the advantage of a simultaneous repair of the sphincter complex, it is a more extensive procedure. A rectal-advancement flap appears less traumatic and divides no perineal tissue or sphincter. The aim of this study was to evaluate the results of episioproctotomy and rectal-advancement flap on healing, postoperative continence, and sexual function.
  
  
  METHODS
  Data were retrospectively collected regarding 87 women with cryptoglandular or obstetrical rectoanovaginal fistula treated from June 1997 to 2009, who underwent episioproctotomy or rectal-advancement flap at the discretion of the treating surgeon. Healing, use of seton or stoma, number of previous procedures, smoking, age, body mass index, dyspareunia, SF-12 health survey, the IBD Quality of Life, and the Fecal Incontinence Quality of Life, and the Female Sexual Function Index were obtained from our database and via telephone interviews. The Fisher exact probability and χ tests were used.
  
  
  RESULTS
  The mean age of these 87 women was 42.8 ± 10.5 years. Mean follow-up was 49.2 ± 39.2 months. Fifty (57.5%) patients underwent episioproctotomy and 37 (42.5%) underwent rectal-advancement flap. Thirty-nine (78%) patients healed after episioproctotomy vs 23 (62.2%) patients after rectal-advancement flap (P = .1). Episioproctotomy was associated with significantly better fecal (P < .001) and sexual (P = .04) function. There was no significant difference in other studied variables between the 2 techniques.
  
  
  CONCLUSIONS
  Despite episioproctotomy being a more extensive procedure, healing rates were comparable between episioproctotomy and rectal-advancement flaps. In this select population, episioproctotomy may provide better continence and may confer better sexual function compared with rectal-advancement flap. In appropriate patients surgeons should not hesitate to perform episioproctotomy on cryptoglandular or obstetrical-associated rectoanovaginal fistula.
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. hullt@ccf.org
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Hull
authors.forename: Galal
authors.initials: G
authors.lastname: El-Gazzaz
authors.forename: Brooke
authors.initials: B
authors.lastname: Gurland
authors.forename: James
authors.initials: J
authors.lastname: Church
authors.forename: Massarat
authors.initials: M
authors.lastname: Zutshi
mesh_terms: D000328:Adult; D016009:Chi-Square Distribution; D004841:Episiotomy / Q000379:methods*; D005242:Fecal Incontinence / Q000209:etiology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007407:Interviews as Topic; D011247:Pregnancy; D011788:Quality of Life; D012006:Rectovaginal Fistula / Q000209:etiology / Q000601:surgery*; D012007:Rectum / Q000293:injuries* / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps