In regard to the causes of simple rectovaginal fistulas (RVF) we examined the methods of diagnosis and the efficacy and outcome of surgical procedures. The study included all of our patients diagnosed with simple RVF between December 1988 and July 1998 (n = 19). Medical charts of these patients were reviewed regarding diagnostic investigations, operative procedure, outcome, and follow-up. The most common cause was obstetric trauma (n = 15, 79%) followed by infection (n = 4, 21%). Eight patients (42%) had undergone anal surgery prior to the development of RVF; two of these had undergone more than one procedure. Endoanal ultrasound was performed in 15 patients and identified the fistula in 11 (73%). A concomitant sphincter injury was visualized in 9 of 15 patients (60%). The most common initial operation performed was an endoanal advancement flap in 12 patients (63%). This operation was performed in combination with a sphincteroplasty in 4 patients, while 3 had sphincteroplasty alone. The mean hospital stay was 3 days (range 1-5). Postoperative morbidity was noted in 5 patients (26%) of and consisted of recurrent fistula and passage of gas per vagina. Surgery was successful in complete resolution of symptoms in 14 cases (74%). Two of the three recurrences were successfully repaired with a repeat endoanal advancement flap, and one is awaiting repair. The mean follow-up for the entire group was 35.8 months (range 6-84). Endoanal advancement flap should be the initial treatment of choice for simple, low rectovaginal fistulas. The procedure can also be employed with expectations of success even after a failed primary repair and should be combined with sphincteroplasty if a coexistent anteriorly based anal sphincter defect is noted either by clinical examination or endoanal ultrasonography.

The current standard of lymph node harvest should be applied to patients with poorly responding primary tumors after neoadjuvant therapy. However, a new standard may be necessary to define the adequate number of lymph nodes for tumors that respond well to neoadjuvant therapy.

We have demonstrated a specific temporal and spatial expression pattern for connective tissue growth factor in intra-abdominal adhesions during a three-week postoperative time course. According to what is known about the functional role of connective tissue growth factor in fibrogenesis, our findings warrant further investigations addressing a causal relationship between this growth factor and fibrous adhesion formation.