The Treatment for Refractory Rectovaginal Fistula After Low Anterior Resection with Estriol, Polyglycolic Acid Sheets and Primary Closure: A Case Report

Introduction: Rectovaginal fistula (RVF) is a refractory complication that occurs after anastomotic leakage following low anterior resection for rectal disease. Due to its refractory nature, RVF is often managed with surgical treatment, such as stoma creation for fecal diversion, closure of the fistula and/or re-anastomosis, rather than conservative therapy.

Presentation Of Case: A 72-year-old woman who underwent laparoscopic low anterior resection developed RVF on post-operative day (POD) 15. Conservative therapy with the administration of estriol and total parenteral nutrition was started. In addition, a polyglycolic acid (PGA) sheet was inserted into the fistula using colonoscopy, and fibrin glue was applied. However, this treatment with the PGA sheet and fibrin glue seemed to be unsuccessful. Therefore, an operation for simple closure of the RVF was performed on POD47. The PGA sheet was then removed, and primary closure of the RVF from both sides of the rectum and vagina was performed. Following re-operation, solid food with low dietary fiber content was started on original POD55 (POD14 after re-operation), and the dietary fiber content was gradually increased. The patient was discharged from the hospital on original POD 83 (re-operation POD42).

Discussion: The administration of estrogen might result in increased vaginal compliance, decreased vaginal pH, increased vaginal blood flow and improved lubrication. Therefore, vaginal suture was made possible because the vaginal extensibility was restored.

Conclusion: Primary closure of the RVF following administration of estriol may be an effective treatment.