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Satora M, Żak K, Frankowska K, Misiek M, Tarkowski R, Bobiński M. Perioperative Factors Affecting the Healing of Rectovaginal Fistula. J Clin Med 2023; 12:6421. [PMID: 37835064 PMCID: PMC10573987 DOI: 10.3390/jcm12196421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
Rectovaginal fistula is rare, but a severe complication in gynecology, which despite the effort of clinicians is still not treated successfully in many cases. According to statistics, the healing rates of surgery in patients with RVF range from 20 to 100%. The treatment effectiveness depends on the etiology of fistula, the age of the patients, the presence of comorbidities, the type of surgery and many other factors. Considering the low efficiency of treatment and the high risk of recurrence, the question of possible methods to improve the results occurs. In our review, we analyzed both modifiable and non-modifiable factors which may influence the treatment, healing rate and future fate of the patients. Taking into account all analyzed risk factors, including age, comorbidities, smoking status, microbiology, medications, stoma and stool features, we are aware that rectovaginal fistula's treatment must be individualized and holistic. In cases of poorly healing RVF, the drainage of feces, the use of antibiotic prophylaxis or the implementation of estrogen therapy may be useful. Moreover, microbiome research in women with RVF and towards estrogen therapy should be performed in order to create treatment algorithms in women with fistulae. Those interventions, in our opinion, may significantly improve the outcome of the patients.
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Affiliation(s)
- Małgorzata Satora
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland; (M.S.); (K.Ż.); (K.F.)
| | - Marcin Misiek
- Department of Gynecology, Holy Cross Cancer Center, 25-734 Kielce, Poland;
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland;
| | - Marcin Bobiński
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland;
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Sapci I, Zutshi M, Akeel N, Hull T. What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery? Colorectal Dis 2023; 25:1653-1657. [PMID: 37461257 DOI: 10.1111/codi.16660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 09/05/2022] [Accepted: 05/29/2023] [Indexed: 08/17/2023]
Abstract
AIM Rectovaginal fistulas in patients with Crohn's disease are challenging to manage, and surgical treatment remains the best option for achieving permanent closure of the fistula. Biologicals are now used routinely for patients with Crohn's disease. The aim of this study was to investigate the surgical procedures used by us to treat rectovaginal fistula in patients with Crohn's disease in the era of biologicals. METHOD Patients with Crohn's disease who underwent surgery for a rectovaginal fistula between 2010 and 2020 were included in this retrospective study and were identified from a prospectively maintained institutional database. Collected variables included demographics, perioperative and operative variables and data regarding medications used. Success of the procedure was defined as no symptoms at least 6 months after definitive repair and/or stoma closure. RESULTS Twenty patients (out of 80 referred for evaluation) underwent surgery with intent to close the fistula and had at least 6 months of follow-up. Mean age was 44 ± 12 years with a median follow-up duration of 33 months (range 6-130 months). Forty per cent of the patients had a history of at least two surgeries to close the fistula. The overall healing rate was 70% (14/20). The most performed procedure was a transanal rectal advancement flap (7/20), with a success rate of 85%. CONCLUSION Rectovaginal fistula in Crohn's disease is difficult to cure; according to our results almost half of these patients have multiple surgeries due to recurrence. Multiple procedures may be offered for this challenging problem in motivated patients. Perioperative diversion should be strongly considered.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Massarat Zutshi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nouf Akeel
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Crippa J, Spinelli A. Evolving management strategies for perianal Crohn's fistulizing disease. Br J Surg 2021; 109:147-149. [PMID: 34849587 DOI: 10.1093/bjs/znab398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022]
Abstract
This is a review of perianal Crohn's disease providing insights into diagnostic, medical, and surgical pathways.
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Affiliation(s)
- Jacopo Crippa
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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4
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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; 25:1143-1149. [PMID: 34436729 DOI: 10.1007/s10151-021-02506-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 08/11/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. METHODS A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure. RESULTS Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). CONCLUSIONS The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.
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Frontali A, Rottoli M, Chierici A, Poggioli G, Panis Y. Rectovaginal fistula: Risk factors for failure after graciloplasty-A bicentric retrospective European study of 61 patients. Colorectal Dis 2021; 23:2113-2118. [PMID: 33851506 DOI: 10.1111/codi.15673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/27/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022]
Abstract
AIM Graciloplasty (GP) is indicated in the case of recurrent rectovaginal fistula (RVF) after failure of previous local treatments. The aim of this study was to assess risk factors for GP failure performed for RVF. METHODS This is a retrospective study based on a prospective database on GP, coming from two expert centres. RESULTS Sixty-one patients undergoing a first GP for RVF (n = 51) or ileal-vaginal fistula after ileal pouch anal anastomosis (n = 10), with a mean age of 42 years (range 24-72), were analysed. After a mean follow-up of 56 ± 48 months (range 1-183), failure of GP (considered as persistent stoma and/or clinical RVF) was noted in 24/61 patients (39%). The failure rate was 43% (13/30) in the case of Crohn's disease, 38% (3/8) in the case of ileal-vaginal fistula after ileal pouch anal anastomosis for ulcerative colitis, 30% (3/10) in the case of obstetrical RVF, 33% (1/3) in the case of post radiotherapy RVF and 40% (4/10) for other causes (not significant). Two risk factors for failure of GP were found on univariate analysis: (1) absence of postoperative antibiotic prophylaxis-only 3/24 (13%) patients with failure of GP received postoperative antibiotic prophylaxis versus 18/37 (49%) patients with success of GP (P = 0.0053); (2) postoperative perineal infection-11/23 (48%) with failure of GP developed postoperative perineal infection versus only 4/37 (10%) patients with success of GP (P = 0.0021). CONCLUSIONS Failure of GP for RVF is observed in approximately 40% of the patients whatever the aetiology of the fistula. A reduced failure rate was associated with systematic postoperative antibiotic prophylaxis.
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Affiliation(s)
- Alice Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Matteo Rottoli
- Department of Digestive Surgery, Medical and Surgical Sciences, Ospedale Policlinico di Sant'Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Andrea Chierici
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Gilberto Poggioli
- Department of Digestive Surgery, Medical and Surgical Sciences, Ospedale Policlinico di Sant'Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
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6
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Hauch A, McKee RM, Li WY, Crowley JS, Ramamoorthy S, Dobke M. Rectovaginal Fistula Repair 1 Year Later: Lessons Learned. Ann Plast Surg 2021; 87:187-193. [PMID: 33346534 DOI: 10.1097/sap.0000000000002626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Rectovaginal (RV) fistulas are notoriously difficult to treat. Various methods for repair exist, and refinements in techniques can lead to "successful" outcomes. Review of the literature demonstrates that outcomes studies are scarce and mostly limited to comments on closure rate. We have experienced "success" in our own series with 100% closure rate, regardless of fistula etiology and comorbidities (radiation, inflammation, etc). However, long-term outcomes, including various complications and quality of life changes, have previously been underreported. METHODS Critical analysis of various outcomes after fistula repair in 14 patients was performed. Patients were surveyed and interviewed with regard to problems before and after fistula repair to obtain objective data focusing on their experience and outcomes. Conclusions are based on physician assessment and patient surveys 1 year after fistula repair and at least 6 months after ostomy reversal and are discussed within the context of data from the literature. RESULTS Overall satisfaction rate after repairs was high. All patients would undergo attempt at repair again regardless of complications or functional changes (not present before repair). After repair, sexual dyspareunia affected 5 patients (36%); however, most abstained from sexual activity when their RV fistula became apparent. No patient admitted to dyspareunia before the development of their RV fistula. Anal sphincter and defecation function, as well as stool continence, were judged by surgeons and patients uniformly as adequate. However, 3 patients (21%) complained of intermittent problems with urination. A new/different type of pain affected 2 of 4 patients with Crohn disease. One of these patients subsequently developed a new postsphincteric RV fistula. Another patient noted new intermittent vaginal discharge after ostomy reversal, and magnetic resonance imaging suggested a residual fistula, which was not seen on follow-up sigmoidoscopy and "Blue Dye Test." CONCLUSIONS We previously reported on algorithms for repair and refinements in techniques for "successful" repair of RV fistulas with zero recurrence rate. Long-term follow-up indicates, however, that although the overall satisfaction rate after surgery is high, true "success," defined as permanent fistula closure, is not necessarily problem free. Long-term morbidity and the management of other unique sequelae and problems are underreported.
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Affiliation(s)
- Adam Hauch
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
| | - Ryan M McKee
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
| | - Wai-Yee Li
- Division of Plastic and Reconstructive Surgery, City of Hope Medical Center, Duarte
| | - Jiwon S Crowley
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
| | - Sonia Ramamoorthy
- Division of Colorectal Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Marek Dobke
- From the Division of Plastic and Reconstructive Surgery, UC San Diego School of Medicine, San Diego
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Studniarek A, Abcarian A, Pan J, Wang H, Gantt G, Abcarian H. What is the best method of rectovaginal fistula repair? A 25-year single-center experience. Tech Coloproctol 2021; 25:1037-1044. [PMID: 34101044 DOI: 10.1007/s10151-021-02475-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula. METHODS Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6 months. RESULTS One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6 months (range 0-203 months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes. CONCLUSIONS Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.
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Affiliation(s)
- A Studniarek
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA.
| | - A Abcarian
- Cook County Health and Hospitals Systems, Chicago, IL, USA
| | - J Pan
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA
| | - H Wang
- Division of Epidemiology and Biostatistics, and Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago, IL, USA
| | - G Gantt
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA
| | - H Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA.,Cook County Health and Hospitals Systems, Chicago, IL, USA
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8
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Nikolic M, Stift A, Reinisch W, Vogelsang H, Matic A, Müller C, von Strauss Und Torney M, Riss S. Allogeneic expanded adipose-derived stem cells in the treatment of rectovaginal fistulas in Crohn's disease. Colorectal Dis 2021; 23:153-158. [PMID: 32810356 PMCID: PMC7891611 DOI: 10.1111/codi.15324] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
Abstract
AIM Crohn's disease (CD)-related rectovaginal fistulas (RVFs) are rare, challenging to treat and associated with a high morbidity. Due to a significant lack of data, we aimed to analyse the safety and feasibility of allogeneic adipose-derived stem cells (ASCs) in the treatment of CD-related RVF. METHOD Four consecutive patients with CD-related RVF underwent treatment with expanded allogeneic ASCs extracted from a healthy donor in a tertiary referral centre in 2019. None of the patients had an intestinal diversion at the time of the treatment. Follow-up was performed 6 months postoperatively. RESULTS The median operation time was 45 min with a median hospital stay of 3 days. No intra-operative complications occurred. Three patients (75%) developed recurrent RVF after a median follow-up of 19 days. Two patients required surgical treatment including loose seton drainage due to discharge and pain. One patient developed recurrence of symptoms after 10 days, but refused further surgical therapy. Only one patient (25%) showed healing of the RVF, with re-epithelialization of both the vaginal and rectal opening and absence of clinical symptoms. CONCLUSION Expanded allogeneic ASC therapy represents a novel safe treatment option for CD-associated RVF. Although efficacy appears limited, further controlled studies are required to draw robust conclusions.
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Affiliation(s)
- M Nikolic
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - A Stift
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - W Reinisch
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - H Vogelsang
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - A Matic
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - C Müller
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - M von Strauss Und Torney
- Department of Visceral Surgery, St Clara Hospital and University Hospital Basel, Clarunis University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - S Riss
- Department of Surgery, Medical University of Vienna, Vienna, Austria
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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10
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Sahnan K, Adegbola S, Iqbal N, Twum-Barima C, Reza L, Lung P, Warusavitarne J, Hart A, Tozer P. Managing non-IBD fistulising disease. Frontline Gastroenterol 2020; 12:524-534. [PMID: 34712471 PMCID: PMC8515280 DOI: 10.1136/flgastro-2019-101234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kapil Sahnan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Samuel Adegbola
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Nusrat Iqbal
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Charlene Twum-Barima
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Lillian Reza
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Phillip Lung
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
- IBD Unit, St Mark's Hospital, Harrow, UK
| | - Phil Tozer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
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11
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Ryoo SB, Oh HK, Ha HK, Han EC, Kwon YH, Song I, Moon SH, Choe EK, Park KJ. Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences. Ann Surg Treat Res 2019; 97:149-156. [PMID: 31508396 PMCID: PMC6722290 DOI: 10.4174/astr.2019.97.3.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/04/2019] [Accepted: 07/19/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures. Methods Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted. Results The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058). Conclusion Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.
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Affiliation(s)
- Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heung-Kwon Oh
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heon-Kyun Ha
- Division of Colorectal Surgery, Department of Surgery, Myongji Hospital, Goyang, Korea
| | - Eon Chul Han
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Yoon-Hye Kwon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Song
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hui Moon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Choe
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Kyu Joo Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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12
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Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease. Gastroenterol Res Pract 2018; 2018:3159543. [PMID: 30584421 PMCID: PMC6280273 DOI: 10.1155/2018/3159543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/17/2018] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Le Baut G, Peyrin-Biroulet L, Bouguen G, Gornet JM, Stefanescu C, Amiot A, Laharie D, Altwegg R, Fumery M, Trang C, Vuitton L, Simon M, Gilletta de Saint Joseph C, Nahon S, Caillo L, Del Tedesco E, Plastaras L, Aubourg A, Pineton de Chambrun G, Seksik P, Viennot S. Anti-TNF therapy for genital fistulas in female patients with Crohn's disease: a nationwide study from the Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID). Aliment Pharmacol Ther 2018; 48:831-838. [PMID: 30194687 DOI: 10.1111/apt.14946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/16/2018] [Accepted: 07/26/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Genital fistulas represent a devastating complication of Crohn's disease. Only studies with small sample sizes have evaluated the efficacy of anti-TNF therapy for this complication. AIMS To assess the efficacy of anti-TNF therapy for genital fistulas complicating Crohn's disease and to identify predictive factors associated with clinical response at 1 year. METHODS Consecutive patients treated with anti-TNF therapy for genital fistulas complicating Crohn's disease from 1999 to 2016 in 19 French centres from the Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif were included in a retrospective cohort study. Outcome was clinical fistula closure at 1 year. RESULTS Among the 204 women with genital fistulas who received anti-TNF therapy, 131 were analysed. The first anti-TNF given was infliximab (79%), adalimumab (20%), or certolizumab (1%). At start of anti-TNF therapy, 56% of patients had seton drainage and 53% had concomitant immunosuppressive treatment. A complementary surgery was performed during the first year in 10 patients (8%). At 1 year, 37% of patients had complete clinical fistula closure, 22% had a partial response, and 41% had no response. Among patients without complementary surgery, 34% (41/121) had complete clinical fistula closure. Only complementary surgery was associated with better response on multivariate analysis (adjusted relative risk: 2.02, 95% CI: 1.25-3.26, P = 0.0043). CONCLUSIONS In the anti-TNF era, approximately one-third of patients with genital fistula in Crohn's disease had complete fistula closure at 1 year. Collaboration between surgeons and gastroenterologists appears to be very important to improve the rate of fistula closure.
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15
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Bhome R, Monga A, Nugent KP. A transvaginal approach to rectovaginal fistulae for the colorectal surgeon: technical notes and case series. Tech Coloproctol 2018; 22:305-311. [PMID: 29603042 PMCID: PMC5954075 DOI: 10.1007/s10151-018-1775-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/16/2017] [Indexed: 12/30/2022]
Abstract
Rectovaginal fistulae (RVF) are not uncommonly seen by the colorectal surgeon and gynaecologist, often debilitating for patients and typically managed with multiple operative procedures, achieving control rather than cure. Transvaginal repair is the least common surgical approach but has clear advantages and equivalent healing rates to other approaches. Here, we describe a simple, safe and effective flapless transvaginal technique for the repair of primary and recurrent low- and mid-level RVF of varying aetiology. We report 15 cases of RVF (nine recurrent) treated by this technique at a single UK centre. The healing rate was 67%. There were no major complications. Median follow-up was 48 months.
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Affiliation(s)
- R Bhome
- Department of Colorectal Surgery, University Hospitals Southampton NHS Trust, Southampton General Hospital, Southampton, SO16 6YD, UK
- Academic Surgery, University of Southampton, Southampton General Hospital, Level C South Academic Block, Southampton, SO16 6YD, UK
| | - A Monga
- Department of Gynaecology, University Hospitals Southampton NHS Trust, Princess Ann Hospital, Southampton, SO16 6YD, UK.
| | - K P Nugent
- Department of Colorectal Surgery, University Hospitals Southampton NHS Trust, Southampton General Hospital, Southampton, SO16 6YD, UK.
- Academic Surgery, University of Southampton, Southampton General Hospital, Level C South Academic Block, Southampton, SO16 6YD, UK.
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16
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Norderval S, Lundby L, Hougaard H, Buntzen S, Weum S, de Weerd L. Efficacy of autologous fat graft injection in the treatment of anovaginal fistulas. Tech Coloproctol 2017; 22:45-51. [PMID: 29285682 DOI: 10.1007/s10151-017-1739-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/23/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Injection of autologous fat is an established method within plastic surgery for soft tissue augmentation. The aim of the present study was to determine whether transperineal fat graft injection could promote healing of anovaginal fistulas. METHODS The procedures were performed at the University Hospital of North Norway, Tromsø, Norway, and at Aarhus University Hospital, Aarhus, Denmark, between May 2009 and September 2016. After abdominal liposuction, fat was injected around the fistula tract that was finally transected percutaneously with a sharp cannula and fat injected between the cut parts. The internal opening was closed with a suture. Patients had a minimum follow-up of 6 months after last fat graft injection. RESULTS Twenty-seven women underwent 48 procedures. The cause of fistula was obstetric (n = 9), abscess (n = 9), Crohn's disease (n = 7), radiation for anal cancer (n = 1) and endoscopic surgery after radiation for rectal cancer (n = 1). The mean amount of injected fat was 73 ml (SD ± 20 ml), and operating time was 63 min (SD ± 21 min). At median follow-up of 20 months (range 6-87 months) after the last injection, fistulas were healed in 21 women (77%), in 8 women after just one procedure. Healing was achieved in 6 of 7 women (86%) with Crohn's disease and in both women who had undergone radiation therapy. One woman developed an abscess and additional trans-sphincteric fistula 8 weeks after injection. CONCLUSIONS Fat graft injection for anovaginal fistulas is effective and safe.
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Affiliation(s)
- S Norderval
- Department of Gastrointestinal Surgery, University Hospital of North Norway, 9038, Tromsø, Norway. .,Gastrosurgical Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway. .,Norwegian National Advisory Unit on Incontinence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsø, Norway.
| | - L Lundby
- Department of Surgery, Pelvic Floor Unit, Aarhus University Hospital, Aarhus, Denmark
| | - H Hougaard
- Department of Surgery, Pelvic Floor Unit, Aarhus University Hospital, Aarhus, Denmark
| | - S Buntzen
- Department of Gastrointestinal Surgery, University Hospital of North Norway, 9038, Tromsø, Norway.,Gastrosurgical Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.,Norwegian National Advisory Unit on Incontinence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsø, Norway
| | - S Weum
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway.,Medical Imaging Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - L de Weerd
- Medical Imaging Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Plastic Surgery, University Hospital of North Norway, Tromsø, Norway
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A Systematic Review Assessing Medical Treatment for Rectovaginal and Enterovesical Fistulae in Crohn's Disease. J Clin Gastroenterol 2016; 50:714-21. [PMID: 27466166 DOI: 10.1097/mcg.0000000000000607] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management. AIM OF THE STUDY The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment. METHOD A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed. RESULTS Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response. CONCLUSIONS Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.
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18
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Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e841. [PMID: 27622109 PMCID: PMC5010332 DOI: 10.1097/gox.0000000000000850] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/17/2016] [Indexed: 01/10/2023]
Abstract
Supplemental Digital Content is available in the text. The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.
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19
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Should Immunomodulation Therapy Alter the Surgical Management in Patients With Rectovaginal Fistula and Crohn's Disease? Dis Colon Rectum 2016; 59:670-6. [PMID: 27270520 DOI: 10.1097/dcr.0000000000000614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rectovaginal fistula in Crohn's disease is challenging for both healthcare providers and patients. The impact of immunomodulation therapy on healing after surgery is unclear. OBJECTIVE The purpose of this study was to examine whether immunomodulation therapy impacts healing after surgery for rectovaginal fistula in Crohn's disease. DESIGN This was a retrospective analysis with a follow-up telephone survey. SETTINGS The study was conducted at two major tertiary referral centers. PATIENTS All of the patients who underwent rectovaginal fistula repair from 1997 to 2013 at our centers were included. MAIN OUTCOME MEASURES A χ test and logistical regression analysis were used to study treatment outcomes according to type of procedure, recent use of immunosuppressives, and number of previous attempted repairs. Age, BMI, smoking, comorbidities, previous vaginal delivery/obstetric injury, use of probiotics, diverting stoma, and use of seton were also analyzed. RESULTS A total of 120 (62%) patients were contacted, and 99 (51%) of them agreed to participate in the study. Mean follow-up after surgical repair was 39 months. Procedures included advancement flap (n = 59), transvaginal repair (n = 14), muscle interposition (n = 14), episioproctotomy (n = 6), sphincteroplasty (n = 3), and other (n = 3); overall, 63% of patients experienced healing. Sixty-eight patients underwent recent immunomodulation therapy but did not exhibit statistical significance in outcome after surgical repair. In the subset of patients with fistula related to obstetric injury, a 74% (n = 26) healing rate after surgical repair was observed. Age, BMI, diabetes mellitus, use of steroids, probiotics, seton before repair, fecal diversion, and number of repairs did not affect healing. LIMITATIONS This was a retrospective analysis; the high volume tertiary referral inflammatory bowel disease centers studied may not be reflective of rectovaginal fistula presentation, treatment, or results in all patients, and the 3-year follow-up may not be sufficiently long. CONCLUSIONS Despite a relatively low success rate (63%) in healing after surgical repair of a rectovaginal fistula, the recent use of immunomodulation therapy did not negatively impact healing. However, tissue interposition techniques had the highest success rates.
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Lo TS, Huang YH, Dass AK, Karim N, Uy-Patrimonio MC. Rectovaginal fistula: Twenty years of rectovaginal repair. J Obstet Gynaecol Res 2016; 42:1361-1368. [DOI: 10.1111/jog.13066] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/03/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Tsia-Shu Lo
- Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital, Keelung, Medical Center; Keelung Taiwan
- Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital, Taipei, Medical Center; Taipei Taiwan
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- School of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Yu-Hsin Huang
- Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital, Taipei, Medical Center; Taipei Taiwan
| | - Anil Krishna Dass
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- Urogynaecology Unit, Department of Obstetrics and Gynaecology, Penang Hospital; Penang Malaysia
| | - Nazura Karim
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- Department of Obstetrics and Gynecology; Hospital Tuanku Jaafar; Negeri Sembilan Malaysia
| | - Ma. Clarissa Uy-Patrimonio
- Division of Urogynecology, Department of Obstetrics and Gynecology; Chang Gung Memorial Hospital; Taoyuan Taiwan
- Department of Obstetrics and Gynecology; Dr Pablo O. Torre Memorial Hospital; Bacolod Philippines
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21
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Rectovaginal Fistula: What Is the Optimal Strategy?: An Analysis of 79 Patients Undergoing 286 Procedures. Ann Surg 2016; 262:855-60; discussion 860-1. [PMID: 26583676 DOI: 10.1097/sla.0000000000001461] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to assess results of surgery for rectovaginal fistula (RVF) and prognostic factors for success. BACKGROUND DATA Management of RVF remains challenging and numerous surgical options are available. Few large reports of RVF are available and success prognostic factors remain unknown. METHODS All patients operated for RVF from 1996 to 2014 were included. RESULTS Seventy-nine patients presented RVF due to Crohn disease in 34 (43%), postoperative in 25 (32%), obstetrical in 7 (9%), radiation proctitis in 4 (5%), and miscellaneous in 9 (11%). A total of 286 procedures (132 with associated stoma, 46%) were performed including 217 conservative (76%) [seton drainage (n = 59; 21%), vaginal (n = 49, 17%) or rectal advancement flap (n = 46; 16%), diverting stoma only (n = 27; 9%), plug (n = 15; 5%), glue (n = 13; 5%), or others (n = 8, 3%)]; and 69 major procedures (24%) [gracilis muscle interposition (n = 32; 11%), coloanal or colorectal anastomosis (n = 19; 7%) including 11 delayed anastomosis with colonic pull-through, biomesh interposition (n = 9, 3%), and abdominoperineal resection (n = 9; 3%)]. After a mean follow-up of 33 months, overall success rate was 57 of 79 (72%). Per-procedure-based multivariate analysis identified major procedure [odds ratio (OR): 6.4 (2.9-14.2); P < 0.001], diverting stoma [OR: 3.5 (1.4-8.7); P = 0.009], less than 9 months between diagnosis and first surgery [OR: 2.3 (1.1-5.3); P = 0.046], and first surgery in our institution [OR: 3.2 (1.5-6.9); P = 0.003], as independent factors for success. CONCLUSIONS Our study suggested that aggressive surgical treatment of RVF, including early use of temporary stoma and major procedure in case of failure of previous local treatment, leads to high success rates.
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Mege D, Frasson M, Maggiori L, Panis Y. Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula? Colorectal Dis 2016; 18:O61-5. [PMID: 26685113 DOI: 10.1111/codi.13242] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/18/2015] [Indexed: 12/28/2022]
Abstract
AIM Many surgical techniques are available for the treatment of rectovaginal fistula (RVF). There is hitherto little information on its treatment by biological mesh interposition. The aim of the present study was to analyse our results of RVF treatment using biological mesh interposition. METHOD Patients with RVF undergoing biological mesh interposition were identified. Success was defined by the absence of a diverting stoma and/or any vaginal discharge of faeces, flatus or mucous discharge. RESULTS Ten women [median age 39 (24.5-65) years] were included. Nine (90%) had recurrent RVF, and the median number of previous attempts at closure was 2.5 (0-8). The main cause of RVF was Crohn's disease (40%). All patients had faecal diversion. No intra-operative complications occurred from mesh interposition. Seven (70%) patients developed postoperative morbidity which was major (Dindo III) in two (20%). The primary success rate was 20% (2/10) but final success rate was achieved in 70% after reoperation with other procedures at 11.1 (2.7-13.1) months of follow-up. CONCLUSION The study has shown disappointing results with biological mesh interposition for RVF with a healing rate lower than achieved by gracilis muscle interposition.
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Affiliation(s)
- D Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - M Frasson
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
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Valente MA, Hull TL. Contemporary surgical management of rectovaginal fistula in Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:487-495. [PMID: 25400993 PMCID: PMC4231514 DOI: 10.4291/wjgp.v5.i4.487] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/27/2014] [Accepted: 07/17/2014] [Indexed: 02/07/2023] Open
Abstract
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.
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Tozer PJ, Balmforth D, Kayani B, Rahbour G, Hart AL, Phillips RKS. Surgical management of rectovaginal fistula in a tertiary referral centre: many techniques are needed. Colorectal Dis 2013; 15:871-7. [PMID: 23331635 DOI: 10.1111/codi.12114] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 08/17/2012] [Indexed: 12/15/2022]
Abstract
AIM Surgery is the mainstay of treatment for rectovaginal fistula (RVF). Published success rates vary with initial success being around 50% rising to 80% with repeated surgery. Fistulae in Crohn's disease are more likely to recur. METHOD A retrospective study was performed of RVF repair carried out between 2003 and 2008 in a tertiary referral centre. Patients undergoing surgery for an RVF under the senior author during the study period were identified and their clinical notes were reviewed. RESULTS Thirty-five patients underwent 50 operations. The median age was 42 years and 83% were tertiary referrals. Two patients were lost to follow-up. Healing occurred in 19 (58%) of 33 patients after a mean of 1.4 operations. The median time to success was 11 (2.5-48) months. The 'curative' group had an overall success of 73% (19 of 26). Seventy-five per cent of non-inflammatory bowel disease patients and 67% of those with Crohn's disease had successful treatment of the RVF. Twenty-four of 35 patients (67%) underwent creation of a stoma. Sixteen of 24 (67%) were deemed fit for restoration of continuity. No demographic or disease related factors were found to influence healing. CONCLUSION Cure of RVF can be achieved by a range of surgical approaches including abdominal and anal. A variety of different anal techniques are necessary, depending on the integrity of the anal sphincter and the presence or absence of perineal descent/internal intussusception.
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Affiliation(s)
- P J Tozer
- Imperial College London and St Mark's Hospital, London, UK
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25
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Schloericke E, Hoffmann M, Zimmermann M, Kraus M, Bouchard R, Roblick UJ, Hildebrand P, Nolde J, Bruch HP, Limmer S. Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas. Colorectal Dis 2012; 14:604-10. [PMID: 21752173 DOI: 10.1111/j.1463-1318.2011.02719.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery. METHOD A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig-Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome. RESULTS Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn's disease had no ileostomy raised. At a median follow-up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re-operation and bovine plug repair combined with a mucosa flap. CONCLUSIONS Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.
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Affiliation(s)
- E Schloericke
- Department of Surgery, University Hospital of Schleswig Holstein, Campus Luebeck, Luebeck, Germany.
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Pescatori M. Rectovaginal Fistulae. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:85-97. [DOI: 10.1007/978-88-470-2077-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Alvarez JA, Bermejo F, Algaba A, Hernandez MP, Grau M. Surgical repair and biological therapy for fecal incontinence in Crohn's disease involving both sphincter defects and complex fistulas. J Crohns Colitis 2011; 5:598-607. [PMID: 22115381 DOI: 10.1016/j.crohns.2011.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 05/16/2011] [Accepted: 06/07/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies. METHODS Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures. RESULTS Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation. CONCLUSION Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.
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Affiliation(s)
- J A Alvarez
- Department of General Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain.
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Piper HG, Trussler A, Schindel D. Gracilis transposition flap for repair of an acquired rectovaginal fistula in a pediatric patient. J Pediatr Surg 2011; 46:e37-41. [PMID: 21843707 DOI: 10.1016/j.jpedsurg.2011.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 04/12/2011] [Accepted: 05/05/2011] [Indexed: 12/25/2022]
Abstract
Acquired rectovaginal fistulas in the pediatric population are relatively rare but are often difficult to treat. We describe a young girl who acquired a neorectovaginal fistula after a repeat pull-through procedure for Hirschsprung's disease. Durable repair of the fistula was accomplished with a gracilis transposition flap, providing a well-vascularized muscle buttress between the neorectum and vagina. To our knowledge, this is the first report of a gracilis flap in a pediatric patient with an acquired fistula and should be considered for this complication after pull-through for Hirschsprung's as well as for other perineal fistulas such as those acquired after trauma, infection, or in the setting of inflammatory bowel disease.
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Affiliation(s)
- Hannah G Piper
- Department of Surgery, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA.
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Ruffolo C, Citton M, Scarpa M, Angriman I, Massani M, Caratozzolo E, Bassi N. Perianal Crohn’s disease: Is there something new? World J Gastroenterol 2011; 17:1939-46. [PMID: 21528071 PMCID: PMC3082746 DOI: 10.3748/wjg.v17.i15.1939] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/17/2011] [Accepted: 01/24/2011] [Indexed: 02/06/2023] Open
Abstract
Perianal lesions are common in patients with Crohn’s disease, and display aggressive behavior in some cases. An accurate diagnosis is necessary for the optimal management of perianal lesions. Treatment of perianal Crohn’s disease includes medical and/or surgical options. Recent discoveries in the pathogenesis of this disease have led to advances in medical and surgical therapy with good results. Perianal lesions in Crohn’s disease remain a challenging aspect for both gastroenterologists and surgeons and lead to a greatly impaired quality of life for all patients affected by this disease. A multidisciplinary approach is mandatory to obtain the best results.
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Zhu YF, Tao GQ, Zhou N, Xiang C. Current treatment of rectovaginal fistula in Crohn’s disease. World J Gastroenterol 2011; 17:963-7. [PMID: 21448347 PMCID: PMC3057157 DOI: 10.3748/wjg.v17.i8.963] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 12/01/2010] [Accepted: 12/08/2010] [Indexed: 02/06/2023] Open
Abstract
Rectovaginal fistula (RVF) continues to be the most difficult perianal manifestation of Crohn’s disease to treat. This devastating and disabling complication has a significant impact on patients’ quality of life and presents unique management challenges. Current therapeutic approaches include many medical therapeutics and surgical treatments with a wide range of success rates reported. However, current evidence is lacking to support any recommendation. The choice of repair depends on various patient and disease factors and basic surgical tenets. In this article, we review the current options to consider in the treatment of Crohn’s-related RVF, and try to evaluate their effects on fistulae closure and quality of life.
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Pescatori M. Fistole retto-vaginali. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:85-97. [DOI: 10.1007/978-88-470-2062-7_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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