Vaginal fistula following restorative proctocolectomy

Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review

BACKGROUND

First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review.

METHODS

A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure.

RESULTS

Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%).

CONCLUSION

Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes

BACKGROUND

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

AIMS

To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

METHODS

A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

RESULTS

34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

CONCLUSION

PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Anastomotic Considerations in Crohn's Disease

A number of factors should be considered when performing an intestinal anastomosis in the setting of surgery for Crohn's disease. Preoperative risk factors, such as malnutrition, abdominal sepsis, and immunosuppressive medications, may increase the risk of postoperative anastomotic complications and alter surgical decision-making. The anatomical configuration and technique of constructing the anastomosis may have an impact on postoperative function and risk of recurrence, particularly in the setting of ileocolic resection, where the Kono-S anastomosis has gained popularity in recent years. There may be circumstances in which it may be more appropriate to perform an ostomy either without an anastomosis or to temporarily divert an anastomosis when the risk of anastomotic complications is felt to be high. In the setting of total abdominal colectomy or proctocolectomy for Crohn's colitis, restorative procedures may appropriate in lieu of a permanent stoma in certain scenarios.

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis

Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.

Systematic review on the management of ileoanal pouch-vaginal fistulas after restorative proctocolectomy in the treatment of ulcerative colitis

AIM

Ileoanal pouch-vaginal fistula (PVF) is a relatively common complication of restorative proctocolectomy with ileal pouch-anal anastomosis. There are several operative approaches in the management of PVF. There is currently no consensus as to which approach is the most effective or which should be attempted first.

METHOD

A systematic review was undertaken following a publicly available protocol registered with PROSPERO (CRD42019133750) in accordance with PRISMA guidelines. Online searches of databases MEDLINE and Embase, Cochrane Library, ClinicalTrials.gov, EU Clinical Trials and ISRCTN registry were performed.

RESULTS

Twenty-seven articles met the criteria for inclusion in the study: 13 retrospective cohort studies, two prospective cohort studies, eight case series, three case reports and a case-control study. A narrative synthesis was performed due to heterogeneity between included articles. Our study included 577 PVFs, and the incidence rate was 2.1%-17.1%. Both local and abdominal approaches were used in the management of PVF. The overall success of local and abdominal procedures was 44.9% and 60.2% respectively. ROBINS-I assessment revealed a critical risk of bias. GRADE assessment indicated a very low certainty in effect size and evidence quality.

CONCLUSION

Local interventions and abdominal approaches have a high failure rate. The results of this review will aid the counselling of patients with this condition. Furthermore, we provide an algorithm for discussion on the management of PVF based on experience at our local centre. The studies available on the management of PVF are low quality; a large prospective registry and Delphi consensus are required to further this area of research.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

What Is the Best Surgical Treatment of Pouch-Vaginal Fistulas?

BACKGROUND

Pouch-vaginal fistula is a debilitating condition with no single best surgical treatment described. Closure of these fistulas can be incredibly difficult, and transanal, transabdominal, and transvaginal approaches have been reported with varying success rates. Recurrence is a major problem and could eventually result in repeat redo pouch or permanent diversion.

OBJECTIVE

The aim of our study was to investigate healing rates for procedures done for pouch-vaginal fistula closure.

DESIGN

This is a retrospective analysis of a prospectively maintained database complemented by chart review.

SETTINGS

This study reports data of a tertiary referral center.

PATIENTS

Patients who underwent surgery for pouch-vaginal fistula from 2010 to 2017 were identified. Patients who underwent surgery with intent to close the fistula were included, and patients who had inadequate follow-up to verify fistula status were excluded.

INTERVENTIONS

Patients included underwent surgery to close pouch-vaginal fistula.

MAIN OUTCOME MEASURES

Success of the surgery was the main outcome measure. Success was defined as procedures with no reported recurrence of fistula on last follow-up.

RESULTS

A total of 70 patients underwent surgery with an intent to close the pouch-vaginal fistula, 65 of whom had undergone index IPAA for ulcerative colitis, but 13 of these patients later had the diagnosis changed to Crohn's disease. Thirty-nine patients (56%) had a fistula originating from anal transition zone to dentate line to the vagina (not at the pouch anastomosis). In the total group of 70 patients, our successful closure rate was 39 (56%) of 70. Procedures with the highest success rates were perineal ileal pouch advancement flap and redo IPAA (61% and 69%).

LIMITATIONS

The retrospective nature and small number of cases are the limitations of the study.

CONCLUSIONS

Although numerous procedures may be used in an attempt to close pouch-vaginal fistula, pouch advancement and redo pouch were the most successful in closing the fistula. See Video Abstract at http://links.lww.com/DCR/A841.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

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.

Correlation between Radiotherapy and Suture Fistulas following Colo-anal Anastomosis for Carcinoma of the Rectum Evaluation of 152 Consecutive Patients

Introduction

The aim of this study was to evaluate the prevalence of suture fistulas and their possible correlation with adjuvant therapy in patients who underwent colo-anal anastomosis and J pouch reconstruction with a protective colostomy. The reliability of the radiological screening and monitoring program was also verified.

Methods

One hundred and fifty-two consecutive patients were evaluated radiologically with water-soluble radio-opaque contrast enema before surgery for closure of the protective colostomy. Fifty-seven patients were treated with surgery alone (group A) and 95 patients received adjuvant treatment (group B).

Results

A total of 54 fistulas were seen: 17 in group A (28.9% of patients in group A) and 37 in group B (38.9% of patients in group B). Six fistulas involved the rectovaginal septum. All fistulas were managed medically. The time to resolution was 30 days in 76.4% of patients in group A and about 50 days in 82% of patients in group B. Rectovaginal fistulas always took much longer to heal in both groups and failed to heal in two of the four cases in group B.

Conclusions

Two factors appear to contribute to the high prevalence of fistulas in this series: extension of radiological screening to all operated patients and adjuvant radiotherapy. However, the postoperative course was not compromised by radiotherapy in that these fistulas resolved with medical treatment alone, although healing took longer. The incidence of rectovaginal fistulas was substantially the same in the two groups, but two of the four occurring in group B did not heal. Postoperative monitoring with water-soluble contrast enema appears to be the diagnostic procedure of choice because it is well tolerated, non-invasive and a reliable aid in planning surgical bowel recanalization since no false negative cases were detected clinically after closure of the colostomy.

Crohn's Disease of the Ileoanal Pouch

Crohn's disease (CD) of the pouch is an increasingly recognized diagnosis after ileal pouch-anal anastomosis. This post-ileal pouch-anal anastomosis diagnosis in conjunction with pouchitis remains the leading reason for pouch excision. Unfortunately, CD of the pouch remains a difficult diagnosis with lack of a uniform definition largely because of its similarity to common postoperative pouch complications, including pouchitis, abscess formation, or stricture at the anastomosis. Once diagnosed, treatment algorithms largely include multimodal therapy including biologics. This review focuses on the definition, etiology, diagnosis, and treatment for CD of the pouch, a postoperative de novo diagnosis of CD.

The Failed J Pouch

The development and refinement of proctectomy with ileal pouch-anal anastomosis (IPAA) since its introduction in the 1970s has made it the optimal procedure of choice in patients with chronic ulcerative colitis and patients with familial adenomatous polyposis. However, it is a procedure that can be associated with significant morbidity. Pouch failure due to infection, mechanical, or functional disability represents a challenge to both surgeon and patient. Practicing surgeons who deal with revisional pouch surgery face a variety of intraoperative, postoperative, and reoperative challenges. Success requires a strategy that includes critical planning, preparation, specialized surgical techniques, and experience to achieve long-term success, minimize the adverse consequences of IPAA-related complications, and ensure solutions and hope to patients.

Complex Rectovaginal Fistula-an Experience at a Tertiary Care Centre

Complex rectovaginal fistulae are difficult to manage. With an initial failed attempt, a simple fistula becomes complex and the success rate of a subsequent repair decreases. A review of our prospectively maintained records over a period of 16 years revealed 25 patients with rectovaginal fistulae. A variety of procedures was performed in these patients according to their aetiology, site and if there had been a previous attempt at repair. The mean age of the patients was 45 years. The most common cause was operative trauma in 14 cases. Ten patients had previous attempts at repair which had not been successful. The surgical procedures we performed included re-enforcement flaps, resection with diversion, repair with re-enforcement with omentum and simple diversion. Two patients developed recurrence, and one of them healed after a second repair. No recurrence developed in 10 patients who had failed attempts at repair elsewhere. Our experience has shown that most complex rectovaginal fistulae can be successfully repaired but they might require repeated operations. Faecal diversion is usually necessary, and in recurrent fistulae, we found that rather than a local repair, a muscle flap or omental interposition improves the chances of healing.

Women's health issues after ileal pouch surgery

: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis and familial polyposis who require colectomy. This surgical intervention allows for resection of colon, while offering intestinal continuity with fecal continence, discontinuation of most medications related to ulcerative colitis and reduction in the risk of colitis-associated neoplasia. As a proportion of these patients are women of childbearing age, it is important to understand the impact on reproductive health and function. Although limited data exist, restorative proctocolectomy/IPAA does not seem to adversely affect menstrual function. In general, sexual function is reported to improve postsurgery with the ability to achieve orgasm unaltered. However, dyspareunia is commonly reported post restoratively. Of concern, there are data to suggest that fertility is decreased post-IPAA. The reasons stated are pelvic adhesions and obstruction of fallopian tubes. Laparoscopic approach may improve fertility outcomes by reducing postoperative adhesions as compared with the open approach. Once achieved, pregnancy in patients with IPAA is characterized by a transient increase in stool frequency that resolves postdelivery. Whether vaginal delivery or cesarean section is preferred route of delivery in these patients is still controversial. But commonly cesarean section is advocated for patients' post-IPAA to prevent anal sphincter injury and long-term effects on pouch function. All of these issues should be included in the discussion with women who are contemplating IPAA, so they are well aware of them before deciding on the best management plan.

Management and outcome of pouch-vaginal fistulas after IPAA surgery

BACKGROUND

After IPAA, the timing, management, and outcome of pouch-vaginal fistulas are poorly defined.

OBJECTIVE

The purpose of this study was to evaluate the frequency, management, and outcome of patients who develop a pouch-vaginal fistula.

DESIGN

This was a retrospective analysis of a prospectively maintained database.

SETTINGS

The study was conducted in a single-center, high-volume tertiary referral colorectal unit.

PATIENTS

Women with a pouch-vaginal fistula after IPAA from 1983 to 2010 were included in the study.

MAIN OUTCOME MEASURES

The healing rate of pouch-vaginal fistulas was measured.

RESULTS

Of 152 patients with a pouch-vaginal fistula after IPAA, 59 fistulas occurred at <12 months, constituting the early onset group, and 43 occurred at >12 months, constituting the late-onset group. Seventy-five patients (77.3%) underwent local repair (48 (49.5%) had ileal pouch advancement flap and 27 (27.8%) had transvaginal repair). The healing rate after ileal pouch advancement flap performed as a primary procedure was 42% and 66% when performed secondarily after a different procedure. The healing rate for transvaginal repair was 55% when done as a primary procedure and 40% when performed secondarily. Nineteen patients underwent redo ileal pouch construction, with an overall pouch retention rate of 40%. At median follow-up of 83 months (range, 5-480 months), 56 (57.7%) of the 102 patients had healed the pouch-vaginal fistula, whereas pouch failure occurred in 34 women (35%, 12 early onset and 22 late onset). Healing of the fistula was significantly lower (22% versus 73%; p < 0.001) and pouch failure higher (52.7% versus 22.7%, p < 0.001) when compared with Crohn's disease. On multivariate analysis, a postoperative delayed diagnosis of Crohn's disease was associated with failure (p = 0.01). No other factors were associated with pouch failure.

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Pouch-vaginal fistula after IPAA surgery is indolent and may persist after repairs. A delayed diagnosis of Crohn's disease is associated with a poor outcome and a higher chance of pouch failure.

Endoscopic features associated with ileal pouch failure

BACKGROUND

Endoscopic features as predictors in pouch failure have not been studied. A well-constructed J-pouch typically has an "owl's eye" appearance in the proximal pouch body. We hypothesized that loss of the owl's eyes is associated with a high risk for pouch failure. The aim of this study was to evaluate the association between the distorted endoscopic appearance of owl's eyes and pouch failure.

METHODS

A total of 711 available pouch endoscopic images from 426 J-pouch patients were reviewed and scored blindly. A scoring system was generated for distorted owl's eyes. Multivariable analyses were performed to assess the link between the endoscopic feature or other variables and pouch failure.

RESULTS

A total of 37 patients (8.7%) developed pouch failure, with a median of 5.0 (interquartile range, 2.0-11.0) years of follow-up. Multivariable analyses showed that 2 or more "beak" abnormalities were associated with failure rates of 33.3%, 44.4%, and 72.2% by 5, 10, and 15 years of ileal pouch-anal anastomosis, respectively (hazard ratio = 3.7; 95% confidence interval, 1.5-9.0). In addition, diagnosis of Crohn's disease or surgical complications, the postoperative use of anti-tumor necrosis factor biologics, and a high cuff endoscopy inflammation score had statistically significant hazard ratios of 3.2, 5.8, and 1.5 for pouch failure, respectively.

CONCLUSIONS

Distorted appearance of "beak" portion of owl's eyes along with Crohn's disease of the pouch or surgery-related complications, postoperative use of biologics, and persistent cuffitis were the risk factors associated with pouch failure. The assessment of endoscopic owl's eye structure may provide an additional clue to predict pouch outcome.

Diagnosis and differential diagnosis of Crohn's disease of the ileal pouch

Approximately 20%-30% of patients with ulcerative colitis will eventually require colectomy despite recent advances in medical therapy. Ileal pouch-anal anastomosis has become the surgical treatment of choice. A subset of patients with ileal pouches can develop Crohn's disease or a Crohn's-disease-like condition of the ileal pouch after surgery. Diagnosis, differential diagnosis, and management of Crohn's disease of the ileal pouch have been challenging. A combined assessment of clinical history, endoscopy, histology, abdominal/pelvic imaging, and examination under anesthesia is often necessary for accurate diagnosis, disease classification, management, and prognosis. A multidisciplinary approach with gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and radiologists is advocated.

A comprehensive review of inflammatory bowel disease focusing on surgical management

The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.

Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function

PURPOSE

Rectovaginal fistula (RVF) repair can be challenging. Additionally, women may experience sexual dysfunction and psychosocial ramifications even after a successful repair. The aim of this study was to investigate variables looking for predictors of healing/failure and examine long-term quality-of-life (QOL) and sexual function in women with low RVF from obstetrical or cryptoglandular etiology

METHODS

From June 1997-2009, 268 women underwent RVF repair. Of those, 100 with obstetric or cryptoglandular etiology agreed to participate in this study. Healing, type of procedure, use of seton or stoma, number of previous procedures, smoking, age, body mass index (BMI), dyspareunia, QOL using SF-12, FIQL, IBS-QOL, and female sexual function index was obtained from our prospective database and telephone contact. Fisher's exact test, chi-square test, and multivariable-logistic-regression model were used to identify the variables associated with healing/failure.

RESULTS

Mean follow-up was 45.8 ± 39.2 months; mean age 42.8 ± 10.5 years; and BMI was 28.8 ± 7.6. Sixty (60%) fistulas were obstetric and 40 (40%) cryptoglandular and 68/100 patients (68%) healed. On multivariate analysis, treatment failure was related to a heavier BMI (p = 0.001) and number of repairs (p = 0.02). Looking at each type of repair, episioproctotomy had significant healing compared to the other choices (but was not significant on multivariate analysis). Forty-seven women were sexually active at follow-up and 12/47 (25.5%) reported dyspareunia. Fecal incontinence was reported preoperatively in 42 women, more often in those with obstetric-related RVF (76% vs. 24% p < 0.05). Healing was not affected by age, smoking, co-morbidities, preoperative seton, or stoma use. Fecal and sexual function and QOL were comparable between women with healed and unhealed RVF.

CONCLUSION

Patients with higher BMI and more repairs had a decreased healing rate following RVF repair. Despite surgical outcome, QOL and sexual function were surprisingly similar regardless of fistula healing.

Are there predictors of outcome following rectovaginal fistula repair?

BACKGROUND

Rectovaginal fistula is a distressing condition for patients and for physicians who are continuously challenged in providing durable treatment options. The aim of this study is to assess the results of rectovaginal fistula repair and identify predictive factors for poor outcome.

METHODS

Retrospective analysis of patients who underwent rectovaginal fistula repair from 1988 to 2008 was performed. chi tests and logistical regression analysis were used to study treatment outcomes according to the following fistula characteristics: etiology, size, location, and number of prior attempts at fistula repair. In addition, patient factors such as age, body mass index, smoking history, comorbid condition of diabetes, use of steroid and immunosuppressive medications, number of prior vaginal deliveries, and presence of a diverting stoma were analyzed.

RESULTS

A total of 184 procedures were performed in 125 patients. Inflammatory bowel disease was the most common indication for surgery (45.6%), followed by obstetric injury (24%) and surgical trauma (16%). The mean duration of fistula presence was 31.2 months. The procedures performed included endorectal advancement flap (35.3%), gracilis muscle interposition (13.6%), seton placement (13.6%), and transperineal (8.7%) and transvaginal repair (8.1%). The overall success rate per procedure was 60%, with no difference in recurrence rates based on the type of repair. Patients with Crohn's disease had more recurrent fistulas (44.2% success per procedure; P < .01), although 78% eventually healed after an average of 1.8 procedures. Patients with obstetric injuries had an 89% success rate after an average of 1.3 procedures per patient, which is similar to the success rate for traumatic fistulas. Pouch vaginal fistulas had a 91% success rate after an average of 1.6 procedures per patient. The overall success rate per patient was 88% after multiple procedures with a mean follow-up of 16.3 months. Age, body mass index, diabetes, use of steroids and immunosuppressive agents, size and location of the fistula, number of vaginal deliveries, time interval between a recurrent episode and subsequent repair, and the presence of fecal diversion did not affect outcomes. The presence of Crohn's disease and a smoking history are strongly associated with rectovaginal fistula recurrence (P = .02).

CONCLUSIONS

Despite a relatively low initial success rate (60%), most rectovaginal fistulas can be successfully repaired with subsequent operations. Crohn's disease and smoking are associated with adverse outcomes.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

Crohn's disease of the pouch: diagnosis and management

Approximately 30% of patients with ulcerative colitis will eventually require surgery. Ileal pouch-anal anastomosis has become the surgical treatment of choice in ulcerative colitis patients with refractory disease or dysplasia who require proctocolectomy. A subset of patients with ileal pouches may develop Crohn's disease or a Crohn's disease-like condition of the pouch after the surgery. Diagnosis and management can be challenging. A combined assessment of endoscopy, histology, radiographic imaging and examination under anesthesia is often necessary for an accurate diagnosis, disease classification, management and prognosis. A multidisciplinary approach by a medical and surgical team, together with experienced pathologists and radiologists, is advocated.

Crohn's disease of the ileal pouch: reality, diagnosis, and management

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with ulcerative colitis or indeterminate colitis who require surgery. A subset of patients with ileal pouches may develop Crohn's disease or a Crohn's disease-like condition of the pouch after the surgery. Diagnosis, differential diagnosis, and management can be challenging. A combined assessment of endoscopy, histology, radiography, and examination under anesthesia is often necessary for an accurate diagnosis. A multidisciplinary approach by a medical and surgical team is advocated. It is advisable to inform ulcerative colitis patients before the surgery of the potential risk for Crohn's disease along with other inflammatory and noninflammatory complications.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Urogenital complications of Crohn's disease

Urogenital complications in Crohn's disease is a very narrow, specific area for consideration. The most frequent conditions that fall under this rubric include fistulous disease involving the genitourinary tract, nephrolithiasis, intrinsic renal diseases associated with Crohn's disease, and considerations in those who have had surgical procedures that alter normal pelvic anatomy. Fistulas involving the ureters, urinary bladder, and vagina are discussed. Nephrolithiasis is commonly in the form of calcium oxalate and uric acid, and is a well-known complication of Crohn's disease secondary to multiple mechanisms. Intrinsic renal disease is relatively rare and includes interstitial nephritis, amyloidosis, IgA nephropathy, and obstructive uropathy. Women who have undergone ileopouch anal anastomosis procedures are at risk for sexual dysfunction, dyspareunia, and decreased fecundity.

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients

OBJECTIVE

Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.

BACKGROUND

The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes.

METHODS

Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone.

RESULTS

Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080).

CONCLUSIONS

Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

Surgical management of pouch-vaginal fistula after restorative proctocolectomy

BACKGROUND

Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF.

METHODS

After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula.

RESULTS

The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision.

CONCLUSIONS

Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Ileal pouch-anal anastomosis-vaginal fistula: a review

BACKGROUND

Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch-anal anastomosis. Its optimal management has not been determined because of its low incidence.

METHODS

The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch-anal anastomosis. References from these articles were searched manually for further references.

RESULTS AND CONCLUSION

Pouch-vaginal fistula occurs in 6.3 (range, 3.3-15.8) percent of female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND

Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis.

METHODS

Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients.

RESULTS

A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent.

CONCLUSION

Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Pouch-vaginal fistula after ileal pouch-anal anastomosis: treatment and outcomes

PURPOSE

Pouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution.

METHODS

Patients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy.

RESULTS

Since November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision.

CONCLUSIONS

The management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.

Management and outcome of pouch-vaginal fistulas following restorative proctocolectomy

PURPOSE

The aim of this study was to assess the short-term and long-term outcomes of surgical repair of patients with pouch-vaginal fistulas after restorative proctocolectomy.

METHODS

A descriptive study was undertaken of all patients developing pouch-vaginal fistulas following restorative proctocolectomy between 1978 and 2003 in a single tertiary referral institution. Kaplan-Meier survival analysis was used to evaluate the time to first pouch-vaginal fistula recurrence and pouch-vaginal fistula-free survival at last follow-up.

RESULTS

Sixty-eight patients (mean age, 32.2 years; standard deviation, 10.7) were identified with a median follow-up of 5.5 (range, 0.2-25.5) years. The origin of the pouch-vaginal fistulas was the pouch-anal anastomosis in 52 (76.5 percent) patients, pouch body/top in 9 (13.2 percent), or cryptoglandular or other source in 7 (10.3 percent). Associated early complications in patients with pouch-vaginal fistulas included pelvic sepsis in 20 (29 percent) patients, anastomotic separation in 6 (24 percent), anastomotic stricture in 16 (24 percent), small bowel obstruction in 17 (25 percent), hemorrhage in 2 (3 percent), or pouchitis in 12 (18 percent). Surgery was undertaken in 59 (87 percent) patients with 14 (20.6 percent) of them undergoing pouch excision/diversion or seton drainage. Forty-five (66 percent) patients underwent primary repair. First recurrence of pouch-vaginal fistula occurred in 27 of 45 (60 percent) patients with a median pouch-vaginal fistula-free interval of 1.6 years (95 percent confidence interval, 0.6-2.7). Fourteen (51.9 percent) patients with recurrent pouch-vaginal fistulas healed following one or more repeat procedures. The diagnosis of Crohn's disease was made in eight (12 percent) patients, with pouch-vaginal fistulas persisting or recurring in all patients with Crohn's disease within five years of the primary treatment. Median pouch-vaginal fistula-free survival was 1.4 years for patients with Crohn's disease and 8.1 years for patients with ulcerative colitis or familial adenomatous polyposis. The pouch-vaginal fistula-free survival improved with repeated local or abdominal repairs for patients with ulcerative colitis. The overall pouch failure rate for patients with pouch-vaginal fistulas was 35 percent (median pouch survival, 4.2 years).

CONCLUSIONS

Pouch-vaginal fistulas can persist and recur indefinitely, even after repeated repairs. Repair in those patients with Crohn's disease uniformly failed within five years from primary repair. Patients with recurrent pouch-vaginal fistulas and ulcerative colitis should be offered salvage surgery because successful closure following initial failure occurs in approximately 50 percent.

Restorative proctocolectomy in patients with ulcerative colitis having a recto-vaginal fistula

OBJECTIVE

Recto-vaginal fistula is a rare complication of ulcerative colitis. There are few reports of restorative proctocolectomy carried out in patients with ulcerative colitis having a rectovaginal fistula. We report our experience with this condition.

PATIENTS AND METHODS

Between 1 January 1976 and 31 December 2001, 838 patients underwent restorative proctocolectomy for ulcerative colitis at one hospital. These included 400 women of whom 4 (1%) had an already present rectovaginal fistula. We reviewed all patients who presented with a rectovaginal fistula. These patients were contacted by telephone to establish function and satisfaction.

RESULTS

The mean age was 30.0 years (range 19-39 years). The mean age at onset of ulcerative colitis was 21.5 years (range 13-34 years). One patient was asymptomatic, the fistula being discovered at operation. In the other three patients the recto-vaginal fistula had occurred at a mean of 108 months (range 72-192 months) after the onset of ulcerative colitis. Three of four patients had had previous episodes of acute severe disease. Three patients had a narrow rectum with deep ulceration. The mean distance between the anorectal junction and the site of fistulation was 2.7 cm (range 0-7 cm). Three patients had a three-stage and one patient a two-stage procedure. Mean follow-up after closure of the loop ileostomy was 107 months (range 17-276 months). All patients were treated successfully but 2 (50%) had a recurrence at 156 and 40 months after the closure of the loop ileostomy. One patient was diverted and the fistula was closed by a subsequent transanal repair and the other patient was treated with success by temporary loose seton technique. Two patients had excellent functional results whereas two other had some difficulties in continence. Nevertheless all patients were satisfied with the outcome.

CONCLUSIONS

Patients with ulcerative colitis and a recto-vaginal fistula can be successfully treated by restorative proctocolectomy, nevertheless they are at risk of late recurrence of the fistula.

Treatment of fistulizing Crohn's disease

The primary goals of the clinician in the treatment of fistulizing Crohn's disease (CD) include (1) defining the anatomy of the fistula, (2) draining any associated infectious material, (3) eradicating the fistulous tract through medical or surgical therapies, and (4) preventing recurrence of fistulas. Evaluation and therapeutic decisions require close collaboration between the gastroenterologist and surgeon. Appropriate evaluation should include identification of septic complications, delineation of the fistulous tract including the origin and terminus of the fistula, and determination of the extent of bowel involvement with active CD. Drainage of abscesses and control of septic complications through the placement of drains or setons is essential. Conservative therapy with avoidance of sphincter muscle-cutting procedures is the standard approach. The appropriate approach to asymptomatic patients is uncertain because there are little data to indicate if treatment alters the natural course of disease.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

Gracilis muscle transposition for iatrogenic rectourethral fistula

OBJECTIVE

To assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.

SUMMARY BACKGROUND DATA

Iatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors' experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.

METHODS

A retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions.

RESULTS

Eleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients.

CONCLUSIONS

Gracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.

Gracilis muscle transposition for iatrogenic rectourethral fistula

OBJECTIVE

To assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.

SUMMARY BACKGROUND DATA

Iatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors' experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.

METHODS

A retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions.

RESULTS

Eleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients.

CONCLUSIONS

Gracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.

Outcome after septic complications in J pouch procedures

BACKGROUND

Despite the wide range of surgical approaches for pouch salvage, septic complications are among the main causes of pouch failure.

METHODS

This study analysed the mode and outcome of various therapeutic approaches for pouch salvage and the impact of time of diagnosis, localization and form of septic complications on the risk of pouch failure in 131 patients with septic complications of a total of 706 patients undergoing a J pouch procedure.

RESULTS

Septic complications consisted of 76.3 per cent fistulas, 15.3 per cent anastomotic breakdowns and 8.4 per cent pelvic abscesses. A total of 107 patients (81.7 per cent) with septic complications required a mean of 2.2 surgical procedures. The frequency of permanent defunctioning and excision of the pouch in the 131 patients with septic complications was 23.7 and 6.1 per cent respectively. The estimated cumulative 3-, 5- and 10-year rate of pouch failure in patients with septic complications was 19.6, 31.1 and 39.2 per cent respectively. The risk of pouch failure was significantly affected by the site of origin of septic complications (P = 0.02). The 5-year pouch failure rate increased in a subgroup of patients with septic complications at the pouch-anal anastomosis when the anal sphincter was involved (50.1 versus 29.2 per cent; P = 0.18).

CONCLUSION

Pouch failure as a result of septic complications may occur several years after ileal pouch-anal anastomosis. For prevention of pouch failure, surgery for septic complications is required in a high percentage of patients and repeated attempts are justified. Follow-up studies are required for further analysis of pouch failure.

Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis

OBJECTIVE

To analyze the association between pre- and perioperative factors and pouch-related septic complications (PRSC) in ulcerative colitis (UC) and in familial adenomatous polyposis (FAP) after ileal pouch-anal anastomosis (IPAA).

SUMMARY BACKGROUND DATA

For patients with UC and FAP, IPAA is the surgical therapy of choice, but in some patients the outcome is compromised by PRSC.

METHODS

A total of 706 consecutive patients (494 UC, 212 FAP) were assessed in a study aimed at identifying subgroups of patients who were at high risk for PRSC. The rate of PRSC was analyzed as a time-dependent function (Kaplan-Meier estimation). Patients with UC and FAP were stratified separately according to associated factors (age, sex, surgeon's experience, temporary ileostomy, colectomy before IPAA, anastomotic tension, and several factors specific for UC).

RESULTS

In all, 131 (19.2%) patients had PRSC (23.4% UC, 9.4% FAP). In patients with UC, the estimated 1-year PRSC rate was 15.6% and the estimated 3-year PRSC rate was 24.2%. In patients with FAP, the estimated 1-year and 3-year PRSC rates were 9.2%. The difference between the estimated rates of PRSC was significant (P <.001). In the univariate analysis, patients with UC younger than 50 years, with severe proctitis, with preoperative hemoglobin levels less than 10 g/L, or receiving corticoid medication had a significantly higher risk for PRSC (P =.039, P =.037, P =.047, P =.003, respectively). Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P <.001). Patients with FAP proved to have a significantly higher risk for PRSC in the univariate and multivariate analyses if anastomotic tension had occurred (RR 3.60, P =.0086).

CONCLUSIONS

Pouch-related septic complications occur as late complications and should therefore be considered in regular, specific long-term follow-up examinations. The authors identified significant risk factors for PRSC specific to patients with UC and FAP; these must be considered for each individual surgical strategy.

Repair of recurrent rectovaginal fistulas

BACKGROUND

Recurrent rectovaginal fistulas (RRVFs) pose a challenging problem, which can be treated by different surgical procedures. We performed this study to determine the ultimate success rate of various repair techniques.

METHODS

Using a standard data collection form, we retrospectively reviewed charts of patients treated for RRVF.

RESULTS

Between 1991 and 2000, 57 procedures were performed in 35 women who presented with RRVF. Median follow-up was 4 months (interquartile range, 1,25). The causes of RRVF included obstetrical injury (n = 15), Crohn's disease (n = 12), fistula occurring after proctocolectomy with ileal pouch-anal anastomosis (for ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial polyposis, n = 1), cryptoglandular disease (n = 2), and fistula occurring immediately after low anterior resection for rectal cancer (n = 1). The methods of repair used included mucosal advancement flap (n = 30), fistulotomy with overlapping sphincter repair (n = 14), rectal sleeve advancement (n = 3), fibrin glue (n = 1), proctectomy with colonic pull-through (n = 2), and ileal pouch revision (n = 6). Twenty-seven of 34 (79%) patients with adequate follow-up eventually healed after a median of 2 operations. Logistic regression was used to analyze outcome according to etiology of fistula, patient age, number of prior repairs, time interval between last repair and current repair, and presence of fecal diversion. Crohn's disease, the presence of a diverting stoma, and decreased time interval since prior repair were associated with a poorer outcome.

CONCLUSIONS

Most RRVFs can be successfully repaired, although repeated operations may be necessary. Delaying repair may improve outcome.

Transvaginal repair of pouch-vaginal fistula

BACKGROUND

The results of surgery for ileoanal pouch-vaginal fistula have been disappointing. Intra-anal procedures result in fistula healing in, at best, approximately 50 per cent of patients. A transvaginal approach was developed to achieve direct access to the internal opening, enabling closure without damage to the anal sphincter.

METHODS

Fourteen patients were treated between January 1992 and December 1998. All had had restorative proctocolectomy for ulcerative colitis and all were defunctioned. Histological review confirmed the diagnosis in all patients.

RESULTS

Median age was 40 (range 25-52) years. Median follow-up was 18 (range 6-60) months. The operation was successful in 11 of the 14 patients, after one attempt in six patients, after two attempts in four, and after three attempts in one patient. The operation failed in three patients, who had a permanent ileostomy. The number of bowel actions in the patients who had successful closure ranged from 2 to 10 (median 6) in 24 h, with no faecal incontinence reported.

CONCLUSION

This simple technique achieved healing in 11 of 14 patients. This compares favourably with the poor results in 28 patients treated by other procedures in the same hospital, with certain healing in five and definite failure in 20.

Anorectal Crohn's disease

Anorectal disease affects many patients with Crohn's disease. Clinical manifestations vary from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management needs to be conservative and must focus on draining septic sites, preserving sphincter function, and palliating symptoms. Medical management has had some success in improving symptoms, but as yet, it has not been able to ameliorate most perianal complaints quickly and enduringly. Many new and exciting treatment modalities are being investigated with the hope that more effective approaches to these complex and difficult problems can be realized.