Outcomes After Repair of Rectovaginal Fistulas Using Bioprosthetics

Purpose  The purpose of this study was to report the outcomes with the use of advancement flaps and bioprosthetic grafts for the management of rectovaginal fistulas. Methods  A retrospective analysis of prospectively collected data was performed for all patients treated with a rectovaginal fistula. Results  There were 44 patients in the advancement flap group. A mucosal flap repair was performed for 29 patients, and 15 patients had an anodermal flap repair. The mean follow-up was 10 (range, 6–22) months. There were 34 patients in the bioprosthetic repair group. A bioprosthetic interposition graft was used to repair the fistula in 27 patients with a mean follow-up of 12 (range, 6–22) months, and 7 patients had a bioprosthetic plug repair of their fistula with a mean follow-up of 6 (range, 3–12) months. The fistula recurred in 15 patients (34 percent) who were managed by a flap repair, 5 patients (19 percent) who were managed by a bioprosthetic sheet, and 1 patient (14 percent) who was treated with a bioprosthetic plug. Conclusions  Use of bioprosthetics for the management of rectovaginal fistulas is a new technique, which, based on early experience, seems to yield results equal to advancement flap repair. Dr. Ellis serves as a paid consultant for Cook Surgical. He has a Research Grant from Cook Surgical to study the long-term efficacy of Cook’s Anal Fistula Plug for treatment of anal fistulas.     

Spontaneous rectovaginal fistula and repair using bulbocavernosus muscle flap

Spontaneous fistula between anorectum and vagina is extremely uncommon. Successful repair depends on etiology, location and the expertise of the surgeon. We report two cases of spontaneous stercoral perforation resulting in rectovaginal fistula (RVF). Both occurred in bedridden patients with fecal impaction. One patient was successfully repaired with a bulbocavernosus (BC) flap interposition. Flap interposition prevents vaginal stenosis in repair of multiple RVF. Received: 23 June 2000 / Accepted in revised form: 17 November 2000     

Rectovaginal fistula after STARR procedure complicated by haematoma of the posterior vaginal wall: report of a case

We report the case of a patient treated with the stapled transanal rectal resection (STARR) procedure for obstructed defecation, who developed an early postoperative haematoma of the posterior vaginal wall and, after 30 days, a rectovaginal fistula (RVF), even though the intervention had been performed according to the standardized technique. After clinical examination and three-dimensional anal endosonography, we carried out a successful surgical correction with double vaginal and rectal flaps with repair of the rectovaginal septum and without faecal diversion. The STARR procedure, even if performed according to a rigorous application of the methodological standards, may be followed by a RVF possibly due to a blood collection leading to ischaemia of the vaginal wall.     

Endorectal Advancement Flaps in the Treatment of High Anal Fistula of Cryptoglandular Origin: Full-Thickness <Emphasis Type="Italic">vs</Emphasis>. Mucosal-Rectum Flaps

Purpose  The treatment of high anal fistula using endorectal advancement flaps represents an important technique to attain cure of fistulation and preserve anal continence. The creation of the advancement flap may comprise the rectal mucosa only or involve the full transection of the rectal wall. A comparison between full-thickness flaps and mucosal (partial-thickness) flaps was made to analyze the defining elements of successful fistula treatment: recurrence rates and anal continence. Methods  A retrospective review of 54 consecutive patients with high anal fistula of cryptoglandular origin was undertaken. Patient risk was categorized according to previous anal surgery. Continence was assessed according to the Vaizey score. Recurrence rates were recorded in a long-term, complete follow-up. Results  Thirty-four patients underwent surgery using a partial-thickness flap; in 20 patients the full-thickness flap was used. There were no major intraoperative or postoperative complications. Continence scores revealed significant incontinence in 11.1 percent of all patients. Full transection of the rectal wall for flap creation did not pose a threat to continence. Twenty-four percent of all patients suffered from a recurrence. Patients with four or more previous anal surgeries were at highest risk for failure. A single patient in the full-thickness flap group (5 percent) as opposed to 12 patients (35.3 percent) in the partial-thickness group suffered from recurrence. Conclusion  The comparison of partial-thickness to full-thickness endorectal advancement flaps suggests an improvement of recurrence rates without higher incontinence rates when a full mobilization of the rectal wall is performed.     

Success of Episioproctotomy for Cloaca and Rectovaginal Fistula

Purpose Surgical repair of rectovaginal fistula with an advancement flap has had suboptimal results. The existing literature documenting episioproctotomy as a surgical option in females with rectovaginal fistula or cloaca is limited. This study was designed to examine our experience with episioproctotomy in this group. Additionally we were interested in risk factors, which might predict failure. Methods All females who had repair of a rectovaginal fistula or cloaca with episioproctotomy from 1998 to 2004 were studied. Data were collected from chart review and telephone contact. This included demographics, body mass index, tobacco use, Crohn’s disease, previous surgery, and diverting stoma. Results Data were obtained from 42 females (mean age, 39.2 (range, 25–70) years). The mean follow-up was 37 (range, 2–84) months. Nine females had a cloaca and the rest had a rectovaginal fistula with an anterior sphincter defect. Eleven (all with anterior tissue) had recurrence of fistula. None with cloaca had recurrence. Eight of 11 recurrences occurred in females who had failed at least one previous repair. No variables that were studied significantly affected recurrence. Median (25th, 75th percentiles) postoperative Wexner incontinence scores for those with and without recurrence were 8 (7, 12) and 5 (2, 6) respectively. Conclusions Episioproctotomy is a successful technique for repair of rectovaginal fistula and cloaca. Incontinence score postoperatively were acceptable. It should be considered a first line of surgical treatment in those with a fistula that includes compromise of the anterior sphincter complex. This multimedia article (video) has been published online and is available for viewing at . As a subscriber to Diseases of the Colon & Rectum, you have access to our SpringerLink electronic service, including Online First. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum

Between 1981 and 1986, transanal rectal advancement flaps were employed in the surgical management of 39 anorectal fistulas at the Cleveland Clinic. Included were 23 low rectovaginal, 12 fistulas-in-ano and, four rectourethral fistulas. Nineteen fistulas occurred in patients with Crohn's disease while the other 20 included 11 due to obstetric or surgical injury. This technique has become the Clinic's standard management for low rectovaginal fistulas but is reserved for complex fistulas-in-ano. Active proctitis or malignancy are contraindications to the procedure. Surgery requires elevation of a broad-based rectal flap, curettage of the tract, and advancement and primary suture of the flap over the internal opening. Fistulas were eradicated in 27 cases (69.2 percent) including 11 of 19 due to Crohn's disease (57.9 percent) and 16 of the 20 (80.0 percent) from other causes (mean follow-up 25 months). Rectovaginal fistulas healed in 60.0 percent of those with Crohn's disease compared with 76.9 percent of those due to other causes. Complex fistulas-in-ano in Crohn's disease did less well. Only two of six of these fistulas healed. Temporary stomal diversion was used on nine occasions and a successful outcome was achieved in only four, indicative of the greater complexity of these cases. It is concluded that the transanal rectal advancement flap can be an effective method of repair for fistulas of the anorectal region including selected cases due to Crohn's disease Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.     

The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition

Transanal advancement flap repair (TAFR) has been advoated as the treatment of choice for patients with low rectovaginal fistulas. Recently, several studies have reported a significantly lower healing rate. We also encountered low healing rates after TAFR. In an attempt to improve our results, we added labial fat flap transposition (LFFT) to the TAFR of rectovaginal fistulas. The aim of the present study was to evaluate the outcome after TAFR and to investigate the impact of an additional LFFT. Between 1991 and 1997, 21 consecutive patients of median age 33 years underwent TAFR. The etiology of the fistulas was: obstetric injury (n=9), cryptoglandular abscess (n=8) and wound infection after anterior anal repair (n=4). The first 9 patients underwent TAFT with (n=3) or without (n=6) anterior anal repair. In the following 12 patients, LFFT was added to the advancement flap. In 4 of these a concomitant anterior anal repair was performed. The median follow-up was 15 months. The overall healing rate was 48%. In the first 9 patients, in whom no additional LFFT was performed, the rectovaginal fistula healed in 4 cases (44%). In the following 12 patients in whom an additional LFFT was performed, a similar healing rate was observed (50%). In conclusion, the outcome of transanal advancement flap repair of rectovaginal fistulas is poor. Addition of a labial fat flap transposition does not improve this outcome. Received: 25 January 2002 / Accepted in revised form: 6 February 2002     

Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair

BACKGROUNDCurrently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, with a relatively low healing rate. Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIMTo evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODSThis was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among the 82 total patients, 37 underwent repair with direct suturing and 45 underwent repair with stapling. Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were assessed.RESULTSThe direct suture and stapled repair groups showed similar clinical characteristics for aetiology, surgical history, fistula features, and perioperative Wexner score. The stapled repair group did not show superior results over the suture repair group in regard to operative time, blood loss, and hospital stay. However, the stapled repair group showed better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (1/45 vs 17/37, P = 0.045), and lower recurrence rate (6/45 vs 17/37, P = 0.001). There was no protective effect from previous repair history, smaller diameter of fistula (< 0.5 cm), better control of defecation (Wexner < 10), or stapled repair. Direct suture repair and preoperative high Wexner score (> 10) were risk factors for fistula recurrence. Furthermore, stapled repair gave better efficacy in treating complex RVFs (i.e., multiple transperineal repair history, mid-level fistula position, and poor control of defecation).CONCLUSIONStapled transperineal repair is advantageous for management of RVF, providing a high primary healing rate and low recurrence rate.     

Transanal advancement flap repair of transsphincteric fistulas

OBJECTIVE: The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after transanal advancement flap repair and to examine the impact of this procedure on fecal continence. METHODS: Between January 1992 and January 1997, 44 consecutive patients with a transsphincteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent transanal advancement flap repair. There were 34 male patients, and the median age was 44 (range, 19–72) years. Twenty-four patients (55 percent) had previously undergone one or more prior attempts at repair. With the patient in prone jackknife position, the internal opening of the fistula was exposed using a Parks retractor. The crypt-bearing tissue around the internal opening and the overlying anoderm was excised. A layer of mucosa, submucosa, and internal sphincter fibers was mobilized 4 to 6 cm proximally. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the anoderm below the level of the internal opening. The median follow-up was 12 months. Fecal continence was evaluated in 43 patients by means of a questionnaire. RESULTS: Transanal advancement flap repair was successful in 33 patients (75 percent). Success was inversely correlated with the number of prior attempts. In patients with no or only one previous attempt at repair the healing rate was 87 percent. In patients with two or more previous repairs the healing rate dropped to 50 percent. In 15 patients (35 percent) continence deteriorated after transanal advancement flap repair. Twenty-six patients (59 percent) had a completely normal continence preoperatively. Ten of these patients (38 percent) encountered soiling and incontinence for gas after the procedure, whereas three subjects (12 percent) complained of accidental bowel movements. Eighteen patients (41 percent) had continence disturbances at the time of admission to our hospital. In two of these patients (11 percent), incontinence deteriorated. CONCLUSIONS: The results of transanal advancement flap repair in patients with no or only one previous attempt at repair are good. In patients who have undergone two or more previous attempts at repair the outcome is less favorable. Remarkably, the number of previous attempts did not adversely affect continence status.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Repeat Transanal Advancement Flap Repair: Impact on the Overall Healing Rate of High Transsphincteric Fistulas and on Fecal Continence

Purpose Transanal advancement flap repair (TAFR) has been advocated as the treatment of choice for transsphincteric fistulas passing through the upper or middle third of the external anal sphincter. It is not clear whether previous attempts at repair adversely affect the outcome of TAFR. The purpose of the present study was to evaluate the success rate of a repeat TAFR and to assess the impact of such a second procedure on the overall healing rate of high transsphincteric fistulas and on fecal continence. Methods Between January 2001 and January 2005, a consecutive series of 87 patients (62 males; median age, 49 (range, 27–73) years) underwent TAFR. Median follow-up was 15 (range, 2–50) months. Patients in whom the initial operation failed were offered two further treatment options: a second flap repair or a long-term indwelling seton drainage. Twenty-six patients (male:female ratio, 5:2; median age, 51 (range, 31–72) years) preferred a repeat repair. Continence status was evaluated before and after the procedures by using the Rockwood Faecal Incontinence Severity Index (RFISI). Results The healing rate after the first TAFR was 67 percent. Of the 29 patients in whom the initial procedure failed, 26 underwent a repeat TAFR. The healing rate after this second procedure was 69 percent, resulting in an overall success rate of 90 percent. Both before and after the first attempt of TAFR, the median RFISI was 7 (range, 0–34). In patients who underwent a second TAFR, the median RFISI before and after this procedure was 9 (range, 0–34) and 8 (range, 0–34), respectively. None of these changes were statistically significant. Conclusions Repeat TAFR increases the overall healing rate of high transsphincteric fistulas from 67 percent after one attempt to 90 percent after two attempts without a deteriorating effect on fecal continence. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

Contemporary surgical management of rectovaginal fistula in Crohn's disease

Rectovaginal fistula is a disastrous complication of Crohn's disease(CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a women's quality of life. Successful management is possible only after accurate and complete assessment of the entire gastrointestinal tract has been performed. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics. Before treatment is undertaken, establishing reasonable goals and expectations of therapy is essential for both the patient and surgeon. This article aims to highlight the various surgical techniques and their outcomes for repair of CD associated rectovaginal fistula.     

Benign rectovaginal fistulas: management and results of a personal series

Background Treatment of benign rectovaginal fistula has a high failure rate and entails difficult decisions. The purpose of this retrospective study was to clarify the concepts which may improve its management. Methods Between 1983 and 2004, 46 consecutive women of median age 41 years were treated by the same surgeon. Etiology of simple fistulas was iatrogenic (n=6), obstetric (n=4) and septic (n=3). Complex fistulas were due to inflammatory bowel diseases (IBD) (n=18, 11 pouchvaginal) or were iatrogenic (n=9), actinic (n=5) or septic (n=1). Surgical techniques included endorectal or vaginal advancement flaps, fistulectomy and sphincteroplasty, vaginal/rectal closure and epiploplasty, restorative proctectomy and restorative proctocolectomy. In 20 patients, a diverting stoma was performed as a single procedure or concomitant to the curative attempt. Results Overall, 33 of the 39 fistulas (85%) treated for cure healed, including all simple fistulas and 20 complex fistulas (8 iatrogenic, 3 actinic, 2 ulcerative colitis without restorative proctocolectomy; 5 pouch vaginal; 1 septic; 1 Crohn’s disease) (p=0.009). The first operation for the fistula was curative in 20 of 39 fistulas, including 10 of 13 simple and 10 of 26 complex fistulas (p=0.023). There was no significant age difference between cured and not-cured patients. Conclusions Simple versus complex fistulas is the most determinant factor for healing. In IBD fistulas, ulcerative colitis shows better prognosis than Crohn’s disease. For complex fistulas, a temporary diverting stoma seems necessary.     

Anal sphincter integrity and function influences outcome in rectovaginal fistula repair

PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defect on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preoperative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry studies. Follow-up was by mailed questionnaire in 36 patients (69 percent) and by telephone interview in 12 (23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18–70) years, and median follow-up was 15 (range, 0.5–123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before surgery. There were 27 endorectal advancement flaps and 35 sphincteroplasties (28 with and 8 without levatoroplasty). RESULTS: Success rates were 41 percent with endorectal advancement flaps and 80 percent with sphincteroplasties (96 percent success with and 33 percent without levatoroplasty;P=0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function(P=not significant). For sphincteroplasties, success rates were 73vs. 84 percent for normal and abnormal sphincter function, respectively (P=not significant). Results were better after sphincteroplastiesvs. endorectal advancement flaps in patients with sphincter defects identified by endoanal ultrasound (88vs. 33 percent;P=not significant) and by manometry (86vs. 33 percent;P = not significant). Poor results correlated with prior surgery in patients undergoing endorectal advancement flaps (45 percentvs. 25 percent;P = not significant) but not sphincteroplasties (80vs. 75 percent;P = not significant). CONCLUSIONS: All patients with rectovaginal fistula should undergo preoperative evaluation for occult sphincter defects by endoanal ultrasound or anal manometry or both procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of previous repairs. Patients with clinical or anatomic sphincter defects should be treated by sphincteroplasty with levatoroplasty.Read at the Minnesota Surgical Society, May 3, 1996, at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996, and at the Tripartite Meeting, July 8 to 10, 1996.     

Endorectal sliding flap repair of complicated anterior anoperineal fistulas

This report presents experience with a safe and effective form of treatment for anal fistulas that involve a significant portion of the sphincter mechanism. The technique includes removal of the involved crypt, closure of the internal opening with a sliding endorectal flap, and counter drainage of the fistula tract. This series includes eight patients treated over a five-year period with a follow-up of up to five years. This limited series had no complications and one case of early recurrence. Most of these patients had had previous failed attempts at correction of the fistula. The main advantage of this mode of treatment is preservation of the integrity of the sphincter muscle, thus avoiding the high risk of incontinence that is inherent especially with anteriorly located fistulas in females. It is proposed that, because it does not transect the sphincter anteriorly, this technique is safer than the placement of setons, as has been previously advised for management of anterior fistulas. The different treatment techniques for anal fistulas, including complications, recurrence rates, surgical techniques, and indications for types of management are reviewed. Read at the meeting of the American Society of Colon and Rectal Surgeons, Houston, Texas, May 11 to 15, 1986.     

Fecal fistula: A late complication of Marlex® mesh repair

Marlex^® mesh is an excellent prosthetic material for closure of major abdominal defects. Most of its complications are seroma and infections. We have used Marlex mesh intraperitoneally for closure of burst abdomen in a patient who had a gastrectomy for recurrent duodenal ulcer. A year and a half later, this patient developed a fecal fistula to the skin due to incorporation of the Marlex mesh into the splenic flexure of the colon. The patient underwent a second operation during which the fistula was resected and the Marlex removed. We concluded that intraperitoneal placement of Marlex mesh is not recommended.     

A case of a gastrobronchial fistula after esophageal reconstruction successfully closed with an intercostal muscle flap

A 63-year-old man with esophageal cancer underwent a subtotal esophagectomy via the thoracolaparotomy approach. Two years after the operation, a gastrobronchial fistula unexpectedly occurred in the right bronchus. After admission, medication including omeprazole and nutritional support administered through an enteral tube improved his general condition, and the gastrobronchial fistula was successfully closed with the seventh intercostal muscle flap. After the operation, sputa were aspirated with a bronchofiberscope through a tracheal incision rather than blindly with a catheter. He was in good condition 10 months after the operation.     

Impact of two different types of anal retractor on fecal continence after fistula repair

Purpose This study was designed to compare two different types of anal retractors (Parks vs. Scott) with regard to their impact on fecal continence after fistula repair. METHODS: Between November 2000 and November 2001, 30 patients were randomized into two groups. In Group A (n = 15), a Parks retractor was used during fistula repair, whereas in Group B (n = 15), the repair was performed with a Scott retractor. Before and three months after surgery, maximum anal resting pressure and maximum anal squeeze pressure were recorded. In addition, continence status was evaluated using both the Rockwood Fecal Incontinence Severity Index and the scoring system according to Parks. RESULTS: In Group A, the median anal resting pressure dropped from 76 mmHg to 42 mmHg. In Group B, no significant difference was observed between the preoperative and postoperative anal resting pressure. The difference in the changes from baseline between the two groups was statistically significant (P = 0.035). No significant changes in anal squeeze pressure were observed. In Group A, the median Rockwood fecal incontinence score increased from 0 to 12. In Group B, the median Rockwood fecal incontinence score did not change after the operation. The difference between the two groups was statistically significant (P = 0.038). CONCLUSIONS: The use of a Parks retractor during perianal fistula repair has a deteriorating effect on fecal continence, probably because of damage to the internal anal sphincter. Because this side effect was not observed after the use of a Scott retractor, we advocate the use of this retractor during all fistula repairs. Read at the meeting of the Netherlands Association of Surgery (NWH), Scheveningen, the Netherlands, May 30 to 31, 2002.     

Salvage irrigation-suction in gracilis muscle repair of complex rectovaginal and rectourethral fistulas

AIM:To evaluate the efficacy of gracilis muscle transposition and postoperative salvage irrigation-suction in the treatment of complex rectovaginal fistulas(RVFs)and rectourethral fistulas(RUFs).METHODS:Between May 2009 and March 2012,11female patients with complex RVFs and 8 male patients with RUFs were prospectively enrolled.Gracilis muscle transposition was undertaken in all patients and postoperative wound irrigation-suction was performed in patients with early leakage.Efficacy was assessed in terms of the success rate and surgical complications.SF-36 quality of life(QOL)scores and Wexner fecal incontinence scores were compared before and after surgery.RESULTS:The fistulas healed in 14 patients after gracilis muscle transposition;the initial healing rate was73.7%.Postoperative leakage occurred and continuous irrigation-suction of wounds was undertaken in 5patients:4 healed and 1 failed,and postoperative fecal diversions were performed for the patient whose treatment failed.At a median follow-up of 17 mo,the overall healing rate was 94.7%.Postoperative complications occurred in 4 cases.Significant improvement was observed in the quality outcomes framework scores(P<0.001)and Wexner fecal incontinence scores(P=0.002)after the successful healing of complex RVFs or RUFs.There was no significant difference in SF-36 QOL scores between the initial healing group and irrigationsuction-assisted healing group.CONCLUSION:Gracilis muscle transposition and postoperative salvage wound irrigation-suction gained a high success rate in the treatment of complex RVFs and RUFs.QOL and fecal incontinence were significantly improved after the successful healing of RVFs and RUFs.     

A late colon pouch vaginal fistula after low anterior resection – case report and discussion of aetiology

Spontaneous stercoral perforation resulting in rectovaginal fistula is uncommon. A patient is reported who developed a colon pouch vaginal fistula during an episode of severe constipation more than 3 years after successful surgery for rectal cancer. Patients with colon pouch to anus anastomosis may have an incresed lifelong risk of this complication and faecal impaction should be treated urgently. Colon pouch to anus anastomosis has become the standard reconstruction technique following low anterior resection and total mesorectal exision. Early vaginal fistula remains a well recognised complication whether a straight coloanal or a colon pouch to anal anastomosis is performed. No previous report has been found of a late colon pouch vaginal fistula in the absence of radiotherapy or recurrent disease. Received: 12 January 1999 / Accepted in revised form: 15 February 1999