In patients with CD and a complex rectovaginal fistula involving the posterior vaginal wall, is seton placement with delayed flap closure or immediate mucosal advancement flap preferred

What is known

- In a tertiary IBD cohort, seton placement at any operation reduced odds of postoperative RVF healing by 58% (OR 0.42, 95% CI 0.21–0.83). ¹ - That series argued short, wide anovaginal/rectovaginal tracts have low perianal sepsis risk, potentially obviating seton drainage in this phenotype, and noted setons may epithelialize/enlarge the tract. ¹ - Endorectal/mucosal advancement flap success ranges 43–100%, ~67% in Crohn's disease in the Hull/Fazio experience. ^1,2 - Series comparing techniques and reviews describe transrectal vs transvaginal flaps, multilayer/transperineal repair, and conservative approaches, but not a seton-sequencing trial. ^3–6

What is unknown / caveats

- One series associates seton use with lower healing; long-standing practice/other series still use seton drainage before repair - No head-to-head comparison of seton-then-delayed-flap vs immediate advancement flap - Evidence is retrospective cohorts and narrative reviews; flap success rates are highly heterogeneous - Seton-harm signal derives from a single tertiary series - Whether prior seton drainage helps or harms subsequent flap healing in the RV-fistula phenotype is unresolved by the retrieved data.

## References

1. Otero-Piñeiro AM, Jia X, Pedersen KE, Hull T, Lipman J, Holubar S, Steele SR, Lightner AL. Surgical Intervention is Effective for the Treatment of Crohn's-related Rectovaginal Fistulas: Experience From a Tertiary Inflammatory Bowel Disease Practice. J Crohns Colitis. 2023;17(3):396-403. PMID: 36219575.

2. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB, American Gastroenterological Association Clinical Practice C. AGA technical review on perianal Crohn's disease. Gastroenterology. 2003;125(5):1508-30. PMID: 14598268.

3. Athanasiadis S, Yazigi R, Köhler A, Helmes C. Recovery rates and functional results after repair for rectovaginal fistula in Crohn's disease: a comparison of different techniques. Int J Colorectal Dis. 2007;22(9):1051-60. PMID: 17404747.

4. Tracanelli L, Mathieu N, Trilling B, Vergniol J, Pigot F, Faucheron JL. Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach. Tech Coloproctol. 2021;25(10):1143-1149. PMID: 34436729.

5. [No authors listed]. Management of rectovaginal fistulas and patient outcome. Expert Rev Gastroenterol Hepatol. 2017;11(5):461-471. PMID: 28276809.

6. [No authors listed]. Contemporary surgical management of rectovaginal fistula in Crohn's disease. World J Gastrointest Pathophysiol. 2014;5(4):487-95. PMID: 25400993.

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_Draft — generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._