# Delayed coloanal anastomosis for rectovaginal fistulas: Insights from a multicenter cohort (GRECCAR)

Maxime Collard, Jean-Jacques Tuech, Benjamin Fernandez, Stéphane Benoist, Jean-Luc Faucheron, Charles Sabbagh, Jérome Loriau, Léonor Benhaïm, Aurore Protat, Gilles Manceau, et al.

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## To cite this version:

Maxime Collard, Jean-Jacques Tuech, Benjamin Fernandez, Stéphane Benoist, Jean-Luc Faucheron, et al.. Delayed coloanal anastomosis for rectovaginal fistulas: Insights from a multicenter cohort (GRECCAR). Surgery, 2025, 188, pp.109767. 10.1016/j.surg.2025.109767. hal-05306425

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# Delayed coloanal anastomosis for rectovaginal fistulas: Insights from a multicenter cohort (GRECCAR)

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Maxime K. Collard, MD, PhDª, Jean-Jacques Tuech, MD, PhDᵇ, Benjamin Fernandez, MDᶜ, Stéphane Benoist, MD, PhDᵈ, Jean-Luc Faucheron, MD, PhDᵉ, Charles Sabbagh, MD, PhDᵉ, Jérôme Loriau, MDᵉ, Léonor Benhaïm, MD, PhDᵉ, Aurore Protat, MDᵉ, Gilles Manceau, MD, PhDᵉ, Frédéric Marchal, MDᵉ, Anaïs Laforest, MDᵉ, Simon Derieux, MDᵉ, Adeline Germain, MD, PhDᵉ, Simone Manfredelli, MDᵉ, Arielle Pierre, MDᵉ, Diane Mège, MD, PhDᵉ, Yann Parc, MD, PhDª, Jérémie H. Lefèvre, MD, PhDª,*

## ARTICLE INFO

Article history:

Accepted 30 August 2025

Available online 3 October 2025

## ABSTRACT

**Background:** Delayed coloanal anastomosis for treating rectovaginal fistulas focuses on optimizing healing by postponing the coloanal anastomosis until after the vaginal repair. This study aimed to evaluate the success rate, morbidity, and functional outcomes of this strategy.

**Methods:** This retrospective study included all patients who underwent delayed coloanal anastomosis for rectovaginal fistula between 2010 and 2023 across 16 GRECCAR-affiliated colorectal centers.

**Results:** A total of 78 patients (median age: 54.5 years) were included. The main cause of rectovaginal fistula was chronic leakage from colorectal or coloanal anastomosis (67%). The median time interval between the rectovaginal fistula diagnosis and delayed coloanal anastomosis was 9.0 months (interquartile range: 5.0–17.0 months). A total of 40% (31 of 78) of patients underwent delayed coloanal anastomosis after the failure of at least 1 previous treatment attempt. The overall morbidity, major morbidity, and anastomotic leakage occurrence after delayed coloanal anastomosis were 45%, 23%, and 17%, respectively. After a median follow-up of 31 months, the success rate of delayed coloanal anastomosis (healing of rectovaginal fistulas with preservation of bowel continuity) was 81% (63 of 78). No preoperative or intraoperative factors, including pelvic radiotherapy (P = .331) or failure of a previous treatments before delayed coloanal anastomosis (P = .982), were predictive of failure. In cases of anastomotic leakage after delayed coloanal anastomosis, the success rate decreased to 23% (3 of 13)

<footnote>ª Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France</footnote>

<footnote>ᵇ Department of General and Digestive Surgery, Hôpital Charles Nicole, Rouen, France</footnote>

<footnote>ᶜ Department of General and Digestive Surgery, Saint André Hospital, Bordeaux, France</footnote>

<footnote>ᵈ Department of General and Digestive Surgery, Hôpital du Kremlin-Bicêtre, France</footnote>

<footnote>ᵉ Department of Colorectal Surgery, Hôpital Universitaire de Grenoble, Grenoble, France</footnote>

<footnote>ᵉ Department of General and Digestive Surgery, Hôpital d'Amiens, Amiens, France</footnote>

<footnote>ᵉ Department of General and Digestive Surgery, Hôpital Saint-Joseph, Paris, France</footnote>

<footnote>ʰ Gustave Roussy, Département d'Anesthésie, Chirurgie et Interventionnel, Villejuif, France</footnote>

<footnote n="1">¹ Department of General and Digestive Surgery, Hôpital Huriez, Lille, France</footnote>

<footnote>ᵉ Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, Paris, France</footnote>

<footnote>ᵏ Department of General and Digestive Surgery, Institut de Cancérologie de Lorraine, Vandoeuvre-les-Nancy, France</footnote>

<footnote n="1">¹ Department of General and Digestive Surgery, Institut Monsouris, Paris, France</footnote>

<footnote>ᶜ Department of General and Digestive Surgery, Groupe Hospitalier Diaconesses—Croix Saint Simon, Paris, France</footnote>

<footnote>ⁿ Department of General and Digestive Surgery, Hôpital Universitaire de Nancy, Nancy, France</footnote>

<footnote>º Department of General and Digestive Surgery, Hôpital de Hautepierre—Hopitaux Universitaires, Strasbourg, France</footnote>

<footnote>P Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland</footnote>

<footnote>q Department of General and Digestive Surgery, Hôpital de la Timone, Marseille, France</footnote>

<footnote>* Corresponding author: Jérémie H. Lefèvre, MD, PhD, Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris VI, 184 rue du Faubourg Saint-Antoine, Paris, France 75012.</footnote>

<footnote>E-mail address: jeremie.lefevre@aphp.fr (J.H. Lefèvre);</footnote>

<footnote>Twitter: @jeremielefevre</footnote>
compared with the success rate of 92% (60 of 65) in the absence of anastomotic leakage (P < .001). A total of 42% (24 of 57) of patients reported severe low anterior resection syndrome or remained with a stoma because of poor functional outcomes.

**Conclusion:** Delayed coloanal anastomosis demonstrates a high success rate as high as 81% in treating complex rectovaginal fistulas. However, it is linked to significant postoperative morbidity and functional sequelae.

© 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license

(http://creativecommons.org/licenses/by/4.0/).

## Introduction

Rectovaginal fistula (RVF) is characterized by a persistent communication between the rectum and the vagina. The causes of RVF are diverse and are as follows: cryptogenic, postobstetric, Crohn disease, and iatrogenic, for example, from surgery or pelvic radiotherapy. RVF occurs in 1% of patients with Crohn disease.¹ Five percent of cases occur after low anterior resection²,³ and up to 6% of patients after pelvic radiotherapy.⁴

Although not life-threatening, RVF profoundly impacts quality of life, body image, intimacy, and social functioning of patients.⁵ Treatment options range from conservative management to permanent stoma creation. The failure rate remains high for most of the treatment options with a wide success rate ranging from 5% to 90%, depending on the treatment method and the underlying cause of RVF.⁶,⁷

The endorectal advancement flap is the first-line surgical management for most RVF involving healthy tissue (eg, cryptogenic or obstetric).⁸ For recurrent or complex RVF, such as radiation-induced RVF or anastomotic leakage (AL) after anterior resection, gracilis muscle flap or bulbocavernosus (Martius) flap may be considered.⁹ If there is a failure of all treatments following a step-up approach sequence, the transabdominal approach is indicated. It is sometimes a first approach and alternative to a definitive stoma most notably in cases of chronic AL of a colorectal/coloanal anastomosis (CRA/CAA).⁸ In such settings, the delayed CAA (DCAA) has been proposed as an alternative to immediate CCA. The aim is to increase the chances of healing of the RVF.⁶,¹⁰ This technique involves resecting the rectum or fistulized CRA/CAA, exteriorizing the mobilized colon through the anus for 1–4 weeks and suturing the fistula orifice in the vagina. The aim of the waiting period is to delay the confection of the CAA until after the vaginal suture. The exteriorized colonic stump is excised, and the CAA is handsewn. Our objective was to assess the outcomes of DCAA in treating RVF in a large multicenter cohort.

## Methods

### Patients

All patients who underwent a DCAA to treat an RVF between January 2010 and December 2023 in 16 tertiary referral colorectal centers from the French Research Group of Rectal Cancer surgery (GRECCAR) were included. Patients treated between January 2010 and June 2021 were identified from the pre-existing GRECCAR DCAA cohort.¹¹ Additional cases treated for RVF between July 2021 and December 2023 were subsequently included. Data were retrospectively collected by a designated surgeon in each center. The sample size of the cohort was determined retrospectively based on all eligible patients from participating centers over the set period. This study was conducted according to the ethical standards of the Committee on Human Experimentation of each institution and reported according to the Strengthening the

Reporting of Observational Studies in Epidemiology (STROBE) guidelines.¹²

### DCAA: surgical procedure

Some patients underwent 1 or more unsuccessful attempts for RVF treatment before proceeding to DCAA. Moreover, some patients had a diverting stoma (ileostomy or colostomy) before DCAA. From this perspective, practices differed among surgeons, with some considering a diverting stoma before DCAA to be always necessary, whereas others did not perform this procedure systematically.

The surgical technique for DCAA used by the participating centers was described in detail in the previous GRECCAR study on DCAA.¹¹ In summary, the principle of this procedure was to perform a CAA in 2 distinct stages. The first stage involved a dissection in the entire rectovaginal septum with a transection of the RVF tract and a low anterior resection of the rectum or, when necessary, a resection of a prior CRA or CAA. The colon was mobilized and exteriorized through the anus, forming a 5- to 10-cm colon stump. In cases where the colonic length was insufficient, the colon was brought down through the mesentery (Toupet procedure) or the inverted right colon was used (Deloyers' ma-neuver).¹³,¹⁴ The vaginal fistula opening was sutured trans-vaginally with interrupted stitches using braided absorbable sutures (Figure 1, A). A diverting stoma was created or left in place at the discretion of the surgeon. The time interval between the 2 stages was also determined by the surgeon, as there is no consensus on the optimal timing. During this waiting period, the patient always remained hospitalized. The colonic stump was wrapped in a petroleum gauze dressing, which was changed and examined at least once a day by both the surgeon and the nurse. The second stage involved excision of the exteriorized colonic stump and completion of a single-layer, hand-sewn CAA with interrupted absorbable sutures (Figure 1, B). For patients with a diverting stoma, stoma reversal was scheduled 6–8 weeks later. Stoma reversal occurred after confirmation of the anastomotic integrity without recurrence of the RVF. This was determined with a water soluble contrast computed tomography (CT) scan given through the stoma.

### Variables and outcomes definition

DCAA success was defined as no postoperative 30-day mortality, no RVF recurrence at the latest follow-up, and preserved bowel continuity. Postoperative morbidity was defined as any deviation from the normal postoperative course until 30 days after the second step of DCAA. This was graded according to the Clavien-Dindo classification.¹⁵ A complication classified as Clavien-Dindo III or higher was considered as a major morbidity. AL was defined as a communication between the intraluminal and extraluminal compartments due to a defect of the integrity of the CAA. AL was typically suspected based on clinical signs such as fever, chills, worsening abdominal pain, or signs of peritonitis, and/or an elevation of postoperative C-reactive protein. In such
<figure><img src="image_5.png" /><figcaption>**Figure 1.** Photograph showing the 2 stages of a delayed coloanal anastomosis: (A) At the end of the first stage with the vaginal suture completed and the colonic stump left in place. (B) At the end of the second stage with the handsewn coloanal anastomosis performed after the resection of the colonic stump.</figcaption></figure>

cases, a contrast-enhanced abdominal CT scan, occasionally combined with water-soluble contrast enema, was performed to confirm the diagnosis. More rarely, AL was discovered during surgical reintervention. In some patients, an AL was incidentally detected on a contrast-enhanced CT scan performed before stoma closure, even in the absence of clinical symptoms. Any pelvic abscess that occurred after the formation of the CAA has also been considered as AL. A pelvic abscess diagnosed after the first stage of DCAA but before the confection of the anastomosis was not considered as an AL.

## Bowel function assessment

After DCAA, bowel function was evaluated in all eligible patients. This was defined as patients who at the time of assessment had no definitive stoma because of an AL of the CAA. Patients who had a definitive stoma performed because of poor bowel function, despite the technical success of RVF treatment, were included in the bowel function assessment and classified as having poor bowel function. The treating surgeons contacted all eligible patients with a preserved bowel continuity via telephone, registered mail, or during follow-up clinic consultations. Once informed consent was obtained, patients were asked to complete the low anterior rectal syndrome (LARS) questionnaire, a validated tool specifically designed to evaluate bowel function after rectal resection.¹⁶ This questionnaire comprises 5 items, each offering 3 to 4 possible responses. The total score ranges from 0 to 42. The score categorizes outcomes into 3 levels: no LARS (score 0–20), minor LARS (score 21–29), and major LARS (score 30–42). Good bowel function was defined as having bowel continuity preserved after DCAA with no LARS or minor LARS (LARS score <30). Poor bowel function was defined as presenting with major LARS (LARS score ≥30) or requiring a definitive stoma because of poor bowel function.

## Statistical analysis

Qualitative data were reported as frequencies and percentages and compared with the $\chi^2$ test if the expected cell count was ≥5 and with the Fisher exact test if not. Quantitative data were expressed as medians and interquartile range (IQR) and compared using the Mann-Whitney *U* test. This test was also used for the comparison of ordinal data. Follow-up time was estimated using the reverse Kaplan-Meier method. All tests were 2-sided. All analyses were performed using the R software (version 4.2.3; R Core Team, Vienna, Austria).

## Results

### Population and RVF characteristics

Between January 2010 and December 2023, in 16 tertiary referral colorectal centers, 78 patients underwent DCAA to treat an RVF. Of these, 56 patients (72%) were from the pre-existing GRECCAR DCAA cohort,¹¹ and 22 (28%) were included retrospectively thereafter. The median age was 54.5 years (IQR: 42.5–64.8 years), and 97% (76 of 78) of patients were American Society of Anesthesiologists (ASA) class 1 or 2. In addition, 49% (38 of 78) had a history of pelvic radiotherapy. The causes of RVF were chronic AL of a CRA or CAA (67%), surgical injury to the rectum/vagina without CRA or CAA (18%), sequelae of pelvic radiotherapy (10%), and Crohn disease (5%). Among the 8 patients who developed an RVF after pelvic radiotherapy, 4 had been treated for anal canal cancer, 3 for cervical cancer, and 1 for rectal cancer, without any suspicion of local regrowth at the time of the DCAA. The median diameter of the RVF orifice on the vagina was 1.0 cm (IQR: 1.0–2.0 cm). A diverting stoma before DCAA was created in 81% (63 of 78) of patients. Forty percent (31 of 78) of patients had undergone at least 1 treatment attempt other than a diverting stoma for the RVF before DCAA. Details about patient and RVF characteristics, including previous treatment attempts, are provided in Table I.
<caption>**Table I**</caption>

Patient characteristics and previous treatments attempted to treat RVF before DCAA (N = 78)

<table><thead><tr><th>Variables</th><th>Values</th></tr></thead><tbody><tr><td><strong>Patient characteristics</strong></td><td></td></tr><tr><td>Age (yr)</td><td>54.5 (42.5–64.8)<sup>*</sup></td></tr><tr><td>BMI (kg/m<sup>2</sup>)</td><td>22.6 (20.3–25.6)</td></tr><tr><td>ASA score ≥3</td><td>2/78 (2.6)<sup>†</sup></td></tr><tr><td>Active smoker</td><td>8/68 (12)</td></tr><tr><td>Antiplatelet therapy</td><td>7/78 (9.0)</td></tr><tr><td>Anticoagulant therapy</td><td>5/69 (7.2)</td></tr><tr><td>Diabetes</td><td>6/78 (7.7)</td></tr><tr><td>Previous pelvic radiotherapy</td><td>38/78 (49)</td></tr><tr><td><strong>RVF characteristics</strong></td><td></td></tr><tr><td>Causes of RVF</td><td></td></tr><tr><td style="padding-left: 20px;">Chronic leakage of a CRA or CAA</td><td>52/78 (67)</td></tr><tr><td style="padding-left: 20px;">Surgical injury of the rectum/vagina (without CRA/CAA)</td><td>14/78 (18)</td></tr><tr><td style="padding-left: 20px;">Pelvic radiotherapy</td><td>8/78 (10)</td></tr><tr><td style="padding-left: 20px;">Crohn disease</td><td>4/78 (5.1)</td></tr><tr><td>Localization on the vagina of the RVF</td><td></td></tr><tr><td style="padding-left: 20px;">Lower third</td><td>30/78 (38)</td></tr><tr><td style="padding-left: 20px;">Middle third</td><td>25/78 (32)</td></tr><tr><td style="padding-left: 20px;">Upper third</td><td>23/78 (29)</td></tr><tr><td>Diameter of the vaginal fistulous opening (cm)</td><td>1.0 (1.0–2.0)</td></tr><tr><td><strong>Treatments attempted to treat RVF before DCAA</strong></td><td></td></tr><tr><td style="padding-left: 20px;">History of local treatment (fibrin glue, seton, plug, or advancement flap)</td><td>25/78 (32)</td></tr><tr><td style="padding-left: 20px;">History of Martius flap</td><td></td></tr><tr><td style="padding-left: 40px;">No</td><td>74/78 (95)</td></tr><tr><td style="padding-left: 40px;">Yes (1 side)</td><td>3/78 (3.8)</td></tr><tr><td style="padding-left: 40px;">Yes (both sides)</td><td>1/78 (1.3)</td></tr><tr><td style="padding-left: 20px;">History of graciloplasty</td><td>8/78 (10)</td></tr><tr><td style="padding-left: 20px;">Interposition of a biological mesh</td><td>1/78 (1.3)</td></tr><tr><td style="padding-left: 20px;">History of treatment via transabdominal approach with a CRA or CAA (without DCAA)</td><td>5/78 (6.4)</td></tr><tr><td>Diverting stoma before the DCAA<sup>‡</sup></td><td></td></tr><tr><td style="padding-left: 20px;">No stoma</td><td>15/78 (19)</td></tr><tr><td style="padding-left: 20px;">Colostomy</td><td>42/78 (54)</td></tr><tr><td style="padding-left: 20px;">Ileostomy</td><td>21/78 (27)</td></tr><tr><td>One of more treatments attempted before DCAA</td><td>31/78 (40)</td></tr></tbody></table>

ASA, American Society of Anesthesiologists; BMI, body mass index; CAA, coloanal anastomosis; CRA, colorectal anastomosis; DCAA, delayed coloanal anastomosis; RVF, rectovaginal fistula.

* Median (interquartile range) (25%–75%).

† n/N (%).

‡ Diverting stoma not included.

## DCAA: intra- and postoperative outcomes

The median time interval between RVF diagnosis and DCAA was 9.0 months (IQR: 5.0–17.0 months). For the first stage of DCAA, surgery was performed via midline laparotomy in 63% (49 of 78) of cases. A diverting stoma in addition to the DCAA was created in 65% (51 of 78) of patients. Among the 63 patients who had a diverting stoma before DCAA, 18 patients had a colostomy closed during the first step of DCAA without the creation of a new stoma. In 35 cases, a diverting ileostomy was present to protect the DCAA—21 were pre-existing and maintained, whereas 14 patients had a previous colostomy that was closed and replaced by a new ileostomy. The remaining 10 patients had a pre-existing colostomy that was left in place. After the first stage of DCAA, major morbidity occurred in 13% (10 of 78), including 1 patient who died of cardiac arrest of unknown etiology. Notably, this patient had undergone a thoraco-abdominopelvic CT scan, including thoracic angio-CT, 3 hours before the cardiac arrest due to shivering and confusion without fever, which did not identify any underlying pathology such as pulmonary embolism, intraabdominal abscess, or ischemic changes in the descending colon. Two patients developed necrosis of the intra-abdominal colon, both treated with urgent reoperation involving excision of the necrotized colon, remobilization of the colon, and redo-DCAA. The median time interval between the 2 stages of DCAA was 11.0 days (IQR: 7.0–16.0 days). Seventeen

percent of patients (13 of 77) experienced an AL of the CAA after the second stage of DCAA. The overall and major postoperative morbidity rates after the first and second stages of DCAA were 45% and 23%, respectively. Intra- and postoperative outcomes are detailed in Table II.

## RVF healing after DCAA

After a median follow-up of 31 months, the success rate of DCAA for treating RVF (no postoperative mortality, no recurrence of RVF, and preservation of bowel continuity) was 81% (63 of 78). Of the 15 patients classified as treatment failures, 1 patient died postoperatively, 6 experienced RVF recurrence, 5 developed AL without RVF recurrence but necessitating a definitive stoma, and 3 required a stoma because of poor bowel function despite technical success. Of the 6 patients with RVF recurrence, 3 maintained long-term bowel continuity and tolerated the RVF.

Univariate analysis revealed no significant association between DCAA success in treating RVF and any of the tested pre- or intra-operative variables, including history of pelvic radiotherapy (P = .331), failure of a previous treatment attempt before DCAA (P = .982), history of Martius flap (P > .999) or graciloplasty (P = .342), and the presence of a diverting stoma before (P = .250) or during DCAA (P = .472) (see Table III).

<caption>**Table II**</caption>

DCAA: surgery and postoperative morbidity (N = 78)

<table><thead><tr><th>Variables</th><th>Values</th></tr></thead><tbody><tr><td>Time interval between RVF diagnosis and DCAA (mo)</td><td>9.0 (5.0–17.0)<sup>*</sup></td></tr><tr><td><strong>First stage of DCAA characteristics</strong></td><td></td></tr><tr><td style="padding-left: 20px;">Surgical approach</td><td></td></tr><tr><td style="padding-left: 40px;">Laparotomy</td><td>49/78 (63)<sup>†</sup></td></tr><tr><td style="padding-left: 40px;">Laparoscopic</td><td>21/78 (27)</td></tr><tr><td style="padding-left: 40px;">Robotic</td><td>8/78 (10)</td></tr><tr><td style="padding-left: 20px;">Operative time (min)</td><td>240.0 (190.0–300.0)</td></tr><tr><td style="padding-left: 20px;">Toupet procedure</td><td>11/78 (14)</td></tr><tr><td style="padding-left: 20px;">Deloyers' maneuver</td><td>5/78 (6.4)</td></tr><tr><td style="padding-left: 20px;">Diverting stoma</td><td>51/78 (65)</td></tr><tr><td style="padding-left: 40px;">Colostomy</td><td>11/51 (22)</td></tr><tr><td style="padding-left: 40px;">Ileostomy</td><td>40/51 (78)</td></tr><tr><td><strong>Morbidity after the first stage of DCAA and before the second stage</strong></td><td></td></tr><tr><td style="padding-left: 20px;">Overall morbidity</td><td>27/78 (35)</td></tr><tr><td style="padding-left: 20px;">Major morbidity</td><td>10/78 (13)</td></tr><tr><td style="padding-left: 20px;">Clavien-Dindo classification</td><td></td></tr><tr><td style="padding-left: 40px;">I</td><td>1/78 (1.3)</td></tr><tr><td style="padding-left: 40px;">II</td><td>16/78 (21)</td></tr><tr><td style="padding-left: 40px;">III</td><td>9/78 (12)</td></tr><tr><td style="padding-left: 40px;">IV</td><td>0/78 (0)</td></tr><tr><td style="padding-left: 40px;">V (mortality)</td><td>1/78 (1.3)</td></tr><tr><td style="padding-left: 20px;">Pelvic abscess</td><td>2/78 (2.6)</td></tr><tr><td style="padding-left: 20px;">Intra-abdominal colon necrosis</td><td>2/78 (2.6)</td></tr><tr><td style="padding-left: 20px;">Necrosis of the exteriorized colon</td><td>1/78 (1.3)</td></tr><tr><td><strong>Morbidity after the second stage of DCAA</strong></td><td></td></tr><tr><td style="padding-left: 20px;">Overall morbidity</td><td>19/77 (25)</td></tr><tr><td style="padding-left: 20px;">Major morbidity</td><td>10/77 (13)</td></tr><tr><td style="padding-left: 20px;">Clavien-Dindo classification</td><td></td></tr><tr><td style="padding-left: 40px;">I</td><td>0/77 (0)</td></tr><tr><td style="padding-left: 40px;">II</td><td>9/77 (12)</td></tr><tr><td style="padding-left: 40px;">III</td><td>10/77 (13)</td></tr><tr><td style="padding-left: 40px;">IV</td><td>0/77 (0)</td></tr><tr><td style="padding-left: 40px;">V (mortality)</td><td>0/77 (0)</td></tr><tr><td style="padding-left: 20px;">Anastomotic leakage</td><td>13/77 (17)</td></tr><tr><td><strong>Global morbidity of DCAA (including morbidity after the first and the second step)</strong></td><td></td></tr><tr><td style="padding-left: 20px;">Overall morbidity</td><td>35/78 (45)</td></tr><tr><td style="padding-left: 20px;">Major morbidity</td><td>18/78 (23)</td></tr><tr><td style="padding-left: 20px;">Length of stay (d)</td><td>16.0 (13.0–21.0)</td></tr></tbody></table>

DCAA, delayed coloanal anastomosis; RVF, rectovaginal fistula.

* Median (interquartile range) (25%–75%).

† n/N (%).
**Table III**

Univariate analysis of pre-, intra-, or postoperative variables potentially associated with DCAA success in the treatment of RVF

<table><thead><tr><th>Variables</th><th>Failure</th><th>Success</th><th>P value</th></tr></thead><tbody><tr><td>Preoperative variables</td><td></td><td></td><td></td></tr><tr><td>Age (yr)</td><td>56.0 (50.0–66.0)*</td><td>54.0 (40.0–64.0)</td><td>.341</td></tr><tr><td>BMI (kg/m<sup>2</sup>)</td><td>22.9 (21.9–25.2)</td><td>22.2 (20.2–25.6)</td><td>.512</td></tr><tr><td>ASA score ≥3</td><td>1/15 (6.7)<sup>†</sup></td><td>1/63 (1.6)</td><td>.350</td></tr><tr><td>Active smoker</td><td>0/13 (0)</td><td>8/55 (15)</td><td>.337</td></tr><tr><td>Antiplatelet therapy</td><td>4/15 (27)</td><td>3/63 (4.8)</td><td>.023</td></tr><tr><td>Anticoagulant therapy</td><td>3/13 (23)</td><td>2/56 (3.6)</td><td>.043</td></tr><tr><td>Diabetes</td><td>1/15 (6.7)</td><td>5/63 (7.9)</td><td>.999</td></tr><tr><td>Previous pelvic radiotherapy</td><td>9/15 (60)</td><td>29/63 (46)</td><td>.331</td></tr><tr><td>Causes of RVF</td><td></td><td></td><td>.877</td></tr><tr><td>Chronic leakage of a CRA or CAA</td><td>10/15 (67)</td><td>42/63 (67)</td><td></td></tr><tr><td>Surgical injury of the rectum/vagina (without CRA/CAA)</td><td>2/15 (13)</td><td>12/63 (19)</td><td></td></tr><tr><td>Pelvic radiotherapy</td><td>2/15 (13)</td><td>6/63 (9.5)</td><td></td></tr><tr><td>Crohn disease</td><td>1/15 (6.7)</td><td>3/63 (4.8)</td><td></td></tr><tr><td>Localization on the vagina of the RVF</td><td></td><td></td><td>.551</td></tr><tr><td>Lower third</td><td>7/15 (47)</td><td>23/63 (37)</td><td></td></tr><tr><td>Middle third</td><td>3/15 (20)</td><td>22/63 (35)</td><td></td></tr><tr><td>Upper third</td><td>5/15 (33)</td><td>18/63 (29)</td><td></td></tr><tr><td>Diameter of the vaginal fistulous opening (cm)</td><td>1.0 (1.0–2.0)</td><td>1.1 (1.0–2.0)</td><td>.371</td></tr><tr><td>History of local treatment (fibrin glue, seton, plug, or advancement flap)</td><td>6/15 (40)</td><td>19/63 (30)</td><td>.542</td></tr><tr><td>History of Martius flap</td><td></td><td></td><td>.999</td></tr><tr><td>No</td><td>15/15 (100)</td><td>59/63 (94)</td><td></td></tr><tr><td>Yes (1 side)</td><td>0/15 (0)</td><td>3/63 (4.8)</td><td></td></tr><tr><td>Yes (both sides)</td><td>0/15 (0)</td><td>1/63 (1.6)</td><td></td></tr><tr><td>History of graciloplasty</td><td>0/15 (0)</td><td>8/63 (13)</td><td>.342</td></tr><tr><td>Interposition of a biological mesh</td><td>0/15 (0)</td><td>1/63 (1.6)</td><td>.999</td></tr><tr><td>History of treatment via transabdominal approach with a CRA or CAA (without DCAA)</td><td>0/15 (0)</td><td>5/63 (7.9)</td><td>.577</td></tr><tr><td>Diverting stoma before the DCAA</td><td></td><td></td><td>.250</td></tr><tr><td>No stoma</td><td>5/15 (33)</td><td>10/63 (16)</td><td></td></tr><tr><td>Colostomy</td><td>6/15 (40)</td><td>36/63 (57)</td><td></td></tr><tr><td>Ileostomy</td><td>4/15 (27)</td><td>17/63 (27)</td><td></td></tr><tr><td>Diverting stoma before the DCAA (ileostomy or colostomy)</td><td>10/15 (67)</td><td>53/63 (84)</td><td>.150</td></tr><tr><td>≥1 treatments attempted before DCAA<sup>†</sup></td><td>6/15 (40)</td><td>25/63 (40)</td><td>.982</td></tr><tr><td>Time interval between RVF diagnosis and DCAA (mo)</td><td>9.0 (4.0–13.0)</td><td>10.0 (5.0–17.0)</td><td>.300</td></tr><tr><td>Intraoperative variables</td><td></td><td></td><td>.510</td></tr><tr><td>Surgical approach</td><td></td><td></td><td></td></tr><tr><td>Laparotomy</td><td>11/15 (73)</td><td>38/63 (60)</td><td></td></tr><tr><td>Laparoscopic</td><td>4/15 (27)</td><td>17/63 (27)</td><td></td></tr><tr><td>Robotic</td><td>0/15 (0)</td><td>8/63 (13)</td><td></td></tr><tr><td>Minimally invasive approach (laparoscopic or robotic)</td><td>4/15 (27)</td><td>25/63 (40)</td><td>.349</td></tr><tr><td>Operative time (min)</td><td>255.0 (225.0–300.0)</td><td>237.5 (190.0–277.8)</td><td>.438</td></tr><tr><td>Toupet procedure</td><td>1/15 (6.7)</td><td>10/63 (16)</td><td>.681</td></tr><tr><td>Deloyers' maneuver</td><td>0/15 (0)</td><td>5/63 (7.9)</td><td>.577</td></tr><tr><td>Diverting stoma</td><td>11/15 (73)</td><td>40/63 (63)</td><td>.472</td></tr><tr><td>Time interval between 2 stages of DCAA (d)</td><td>10.0 (7.0–11.0)</td><td>11.0 (7.0–16.0)</td><td>.238</td></tr><tr><td>Postoperative variables</td><td></td><td></td><td></td></tr><tr><td>Pelvic abscess</td><td>0/15 (0)</td><td>2/63 (3.2)</td><td>.999</td></tr><tr><td>Intra-abdominal colon necrosis</td><td>2/15 (13)</td><td>0/63 (0)</td><td>.035<sup>§</sup></td></tr><tr><td>Overall morbidity</td><td>10/15 (67)</td><td>25/63 (40)</td><td>.059</td></tr><tr><td>Major morbidity</td><td>8/15 (53)</td><td>10/63 (16)</td><td>.004<sup>§</sup></td></tr><tr><td>Anastomotic leakage</td><td>10/15 (67)</td><td>3/63 (4.8)</td><td>&lt;.001<sup>†</sup></td></tr></tbody></table>

ASA, American Society of Anesthesiologists; BMI, body mass index; CAA, coloanal anastomosis; CRA, colorectal anastomosis; DCAA, delayed coloanal anastomosis; RVF, rectovaginal fistula.

Regarding postoperative outcomes (Table III), the DCAA success rate was significantly higher in the absence of AL (92%, 60 of 65) compared with 23% (3 of 13) when AL occurred after DCAA (P < .001). Both patients who developed intraabdominal colon necrosis after the first stage of DCAA experienced treatment failure and ultimately required a permanent stoma.

### Long-term bowel function after technical success of DCAA

Of the 78 patients, 11 were ineligible for bowel function assessment: 2 patients died before functional assessment with the

LARS score, and 9 had a permanent stoma because of AL of the CAA. Among the 67 eligible patients, functional assessment was obtained for 57 (85%), including 54 patients without stoma who responded to the LARS score after a median follow-up of 25.5 months and 3 patients with a definitive stoma because of poor bowel function despite technical success of the DCAA. The median LARS score among the 54 patients who completed the questionnaire was 25.0/42 (IQR: 15.2–35.0). Results are summarized in Figure 2. Good bowel function (no or minor LARS) was achieved in 58% (33 of 54) of patients after DCAA. None of the

<footnote>* Median (interquartile range) (25%–75%).</footnote>

<footnote>† n/N (%).</footnote>

<footnote>‡ Diverting stoma not included.</footnote>

<footnote>§ Statistically significant.</footnote>
<figure><img src="image_6.png" /><figcaption>**Figure 2.** Histogram showing the results of bowel function assessment in 57 patients evaluated among the 67 eligible patients after DCAA for RVF. DCAA, delayed coloanal anastomosis; LARS, low anterior resection syndrome; RVF, rectovaginal fistula.</figcaption></figure>

preoperative or intraoperative variables assessed in our cohort were associated with good or poor bowel function (see the Supplementary Table).

## Discussion

Of the 78 patients treated with DCAA for RVF, the procedure achieved an overall success rate of 81% with healing of the RVF and preservation of bowel continuity. However, postoperative morbidity remained significant with an AL rate of 17%, which was strongly associated with treatment failure (77% in cases of AL, *P* < .001). Despite technical success, 42% of patients experienced significant functional sequelae, including major LARS or permanent stoma because of poor bowel function.

The success rate of DCAA in treating RVF reported in recent cohorts with at least 10 patients was 85% (22 of 26) in the study by Lavryk et al,¹⁷ 86% (24 of 38) in the study by Blondeau et al,¹⁰ and 91% (10 of 11) in the study by Corte et al⁶ (see Table IV). These rates are comparable to those observed in our multicenter cohort, where the success rate was 81% (63 of 78). This surgical strategy has been reported to achieve the highest success rates in treating RVF.⁶ When comparing immediate CAA with DCAA without protective stoma after low anterior resection, DCAA appears to be associated with a similar AL rate, as reported in the literature.¹⁸,¹⁹ However, this equivalence has been challenged by 1 study that reported a 3% AL rate after DCAA.²⁰ It is important to note that the context of RVF differs significantly from that of DCAA after a low anterior resection for a rectal cancer. Although the goal of DCAA just after low anterior resection is to avoid a diverting ileostomy, the objective in RVF treatment is to maximize fistula healing and prevent recurrence. Notably, a diverting stoma was used in 65% of DCAA cases in our cohort, underlining that the eviction of the stoma was not the perspective. Interestingly, our study did not

<table><caption>**Table IV**
Comparison of published studies specifically addressing the management of DCAA*</caption><thead><tr><th>Study</th><th>No. of patients</th><th>Overall morbidity DCAA (%)</th><th>Major morbidity DCAA (%)</th><th>AL rate (%)</th><th>Healing of RVF without stoma (%)</th></tr></thead><tbody><tr><td>Current study</td><td>78</td><td>45</td><td>23</td><td>17</td><td>81</td></tr><tr><td>Lavryk et al<sup>17</sup> (2023)</td><td>26</td><td>65</td><td>NR</td><td>8</td><td>85</td></tr><tr><td>Blondeau et al<sup>10</sup> (2021)</td><td>38</td><td>65</td><td>16</td><td>NR</td><td>86</td></tr><tr><td>Corte et al<sup>6</sup> (2015)</td><td>11</td><td>NR</td><td>NR</td><td>NR</td><td>91</td></tr></tbody></table>

DCAA, delayed coloanal anastomosis; NR, not reported; RVF, rectovaginal fistula.

identify diverting stoma creation as a factor reducing the risk of DCAA failure in RVF treatment (*P* = .472), although systematic use of a protective stoma is preferred by many surgeons in this cohort and other teams.¹⁷

The overall and severe postoperative morbidity rates in our study were 43% and 23%, respectively. This is consistent with previously published data.¹⁰,¹⁷ For comparison, in the GRECCAR6 randomized trial conducted by our research group, the overall and severe morbidity rates after low anterior resection and immediate CAA for rectal cancer were 38% and 15%, respectively.²¹ This suggests that DCAA does not lead to higher major postoperative morbidity compared with immediate CAA. This finding has been corroborated by a randomized trial comparing immediate CAA and DCAA, which reported equivalent postoperative morbidity rates.¹⁸ In a previous GRECCAR study, intra-abdominal colon necrosis was identified in 10% of patients undergoing DCAA,¹¹ which is significantly higher than the rate reported after immediate CAA (<1%).²² This suggests an increased risk of this complication associated

<footnote>* Studies with fewer than 10 patients or published before 2000 or not specifically reporting DCAA outcomes in the context of RVF were not included.</footnote>
with DCAA. Identified risk factors for this complication after DCAA included male sex, body mass index (BMI) >25, and peripheral artery disease.¹¹ In our cohort of DCAA for RVF, the rate of intra-abdominal colon necrosis was only 2.6%, much lower than the previously reported 10%.¹¹ This may be explained by our exclusively female population, as a wider pelvis in females²³ could reduce ischemic compression of the mobilized colon. In addition, patients in our cohort were generally in good health (93% ASA 1 or 2) to be eligible for DCAA in RVF, resulting in a low prevalence of risk factors such as BMI >25 and peripheral artery disease. This likely reflects an implicit selection of patients considered fit for surgery rather than predefined exclusion criteria. Given the retrospective and multicentric nature of the study, no standardized criteria were applied, but patients with significant comorbidities were likely not considered for DCAA.

Postoperative morbidity after DCAA remains significant, with 23% experiencing severe complications and a nonzero postoperative mortality rate. This relatively high complication rate may be partly explained by the low number of procedures performed per center (an average of 5.6 DCAA for RVF per center over 14 years), which reflects the rarity and technical complexity of this surgical approach. Because of this significant morbidity, a step-up approach is often recommended for RVF treatment, starting with less invasive options and progressing to more invasive but more effective treatments.⁶,⁸ Our results showed that prior treatment failure for RVF was not predictive of DCAA failure (P = .982), supporting the rationale for a step-up approach. However, in some cases of complex RVF, particularly in the presence of AL from a CRA or CAA, the strategy may need adjustment because of the high failure rates of alternative treatments. In addition, high RVF locations may complicate or preclude perineal-only treatment and requiring a transabdominal approach. In such cases, opting directly for DCAA without prior treatment attempts is reasonable, and it is included in the proposed management algorithm.¹⁰,²⁴ A comparison with immediate CRA or CAA in high RVF would have been informative, but such a control group was not available in our cohort.

Regarding the functional outcomes observed, only 5% of evaluated patients (3 of 57) expressed a preference for a permanent stoma because of the functional results achieved, indicating that 95% preferred the obtained functional outcome over a definitive stoma. However, patient preference for choosing a stoma over suboptimal functional outcomes is inherently subjective. Therefore, the generalizability of this result should be approached cautiously, accounting for societal and cultural differences that may affect the shared decision-making process between patients and surgeons. The median LARS score in our study after DCAA for RVF was 25.0. This outcome is comparable to or better than functional outcomes reported in 2 prospective studies examining DCAA without a protective stoma after low anterior resection.¹⁸,¹⁹ In the trial by Biondo et al,¹⁸ the median LARS score was 36.0 in the DCAA group, whereas Evrard et al¹⁹ reported a median LARS score of 25, with 41% of patients experiencing major LARS, closely aligning with our findings. For context, the prevalence of LARS in the general population, independent of rectal surgery, is estimated to be approximately 15%.²⁵,²⁶ Regarding the risk of LARS after low anterior resection with immediate CAA, a population-based Swedish study involving 481 patients found that 53% experienced major LARS, and 5% required a permanent stoma because of poor functional outcomes.²⁷ Another recent study reported a 63% rate of major LARS in 132 patients after low anterior resection with immediate CAA.²⁸ In our study, 37% of patients experienced major LARS, and 5% required a stoma because of poor functional results. These findings suggest that the functional outcomes after DCAA for RVF are not worse compared with those observed after low

anterior resection with immediate CAA. It is noteworthy that in our cohort, 67% of patients developed RVF after low anterior resection with chronic AL of a CRA or CAA and 10% developed RVF as a sequela of pelvic irradiation. Thus, the expected functional outcomes after DCAA should be considered in light of preoperative functional status, which is often already compromised compared with the general population. However, as preoperative LARS scores were not available in this retrospective cohort, we were unable to assess changes in bowel function before and after the procedure.

Our study has several limitations. First, we lacked a control group of patients who underwent immediate CAA instead of DCAA for RVF treatment. This would have allowed us to assess the potential superiority of DCAA for this indication. Second, functional outcomes were exclusively evaluated using the LARS score. Although this score assessing bowel function correlates with quality of life,¹⁶ we did not directly assess quality of life outcomes. Third, we did not evaluate the impact of this surgery on urinary function, nor did we address its effect on sexual quality of life, which remains a significant concern after this type of procedure. In addition, the retrospective and multicenter design of the study did not allow for standardized management of key aspects of the surgical approach, including the treatment of AL. Decisions were left to the discretion of each team, introducing variability in patient care. Finally, the small number of patients in some subgroups (eg, Crohn disease) limited the statistical power of subgroup analyses, and, combined with the heterogeneity of the cohort and potential variability in surgical practices across centers, conclusions should therefore be interpreted with caution.

In conclusion, DCAA offers a high healing rate exceeding 80% for RVF. Despite significant morbidity, the functional outcomes are comparable to those achieved after low anterior resection with CAA.

## Funding/Support

The authors received no funding for this work.

## Conflict of Interest/Disclosure

The authors have no relevant financial disclosures.

## CRediT authorship contribution statement

**Maxime K. Collard:** Writing – review & editing, Writing – original draft, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. **Jean-Jacques Tuech:** Writing – review & editing, Data curation. **Benjamin Fernandez:** Writing – review & editing, Data curation. **Stéphane Benoist:** Writing – review & editing, Data curation. **Jean-Luc Faucheron:** Writing – review & editing, Data curation. **Charles Sabbagh:** Writing – review & editing, Data curation. **Jérôme Loriau:** Writing – review & editing, Data curation. **Léonor Benhaïm:** Writing – review & editing, Data curation. **Aurore Protat:** Writing – review & editing, Data curation. **Gilles Manceau:** Writing – review & editing, Data curation. **Frédéric Marchal:** Writing – review & editing, Data curation. **Anaïs Laforest:** Writing – review & editing, Data curation. **Simon Derieux:** Writing – review & editing, Data curation. **Adeline Germain:** Writing – review & editing, Data curation. **Simone Manfredelli:** Writing – review & editing, Data curation. **Arielle Pierre:** Writing – review & editing, Data curation. **Diane Mége:** Writing – review & editing, Data curation. **Yann Parc:** Writing – review & editing, Writing – original draft, Project administration, Data curation. **Jérémie H. Lefèvre:** Writing – review & editing, Writing – original draft, Visualization, Supervision,
Project administration, Methodology, Formal analysis, Conceptualization.

## Supplementary Materials

Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/j.surg.2025.109767.

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