Could stoma reduce the risk of rectovaginal fistula in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures? A 363-patient comparative study

Background: Even though preventive stoma is unlikely to ensure primary healing in women with juxtaposed rectal and vaginal sutures, it may be considered, in selected patients at risk of rectovaginal fistula, to reduce fistula related complications. Objective: To assess whether a generalized use of preventive stoma reduces the rate of rectovaginal fistula in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures. Study Design: Retrospective comparative study including 363 patients with deep endometriosis infiltrating the rectum and the vagina. They were managed by either rectal disk excision or colorectal resection, concomitantly with vaginal excision, in two centers (Rouen and Bordeaux) each following differing policies concerning the use of stoma. The prevalence of rectovaginal fistula was assessed, and risk factors analysed. Results: 241 and 122 women received surgery in respectively Rouen and Bordeaux. The rate of preventive stoma was 71.4% in Rouen (N=172) and 30.3% in Bordeaux (N=37). Rectovaginal fistula were recorded in 31 cases (8.5%): 19 women in Rouen and 12 women in Bordeaux. Performing rectal sutures less than 8 cm above the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of other risk factors (OR 3.4, 95%CI 1.3-9.1). Conclusions: No statistically significant differences were found in terms of risk of rectovaginal fistula between women with rectovaginal endometriosis managed respectively by a generalized or restrictive use of preventive stoma. A higher risk of rectovaginal fistula independently related to a low rectal stapled line, less than 8 cm above the anal verge.