Ileal pouch vaginal fistulas: incidence, etiology, and management

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.

Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn's Disease: Experience of a Tertiary Center

BACKGROUND

The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis.

OBJECTIVE

Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn's disease phenotype of the pouch.

DESIGN

Retrospective cohort study of a prospectively maintained, IRB-approved database.

SETTINGS/PATIENTS

Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn's-related perianal disease.

INTERVENTIONS

Two hundred thirty-one operations for perianal or anovaginal fistula(s).

MAIN OUTCOME AND MEASURES

Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure.

RESULTS

Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03-0.43, p = 0.001). Overall pouch failure rate was 12.1%.

LIMITATIONS

Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset.

CONCLUSIONS

Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.

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.

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.

Management of pouch-vaginal fistulas - experience from our institution

AIM

Pouch-vaginal fistula (PVF) is an uncommon but serious complication of ileo-anal pouch reconstruction. This study aimed to review the recent management of PVF, in particular the role of anti-tumour necrosis factor (anti-TNF) drugs.

METHOD

All patients presenting for management of PVF to our surgical service between 2007 and 2016 were studied. The median duration of follow-up from diagnosis of PVF was 6 years. Details of the original pouch surgery, timing of presentation of PVF, management and final outcome were recorded. Primary outcome was gastrointestinal (GI) continuity (as defined by the presence or absence of a stoma).

RESULTS

A total of 23 patients were identified (median age 45 years) of whom nine had pelvic sepsis at the time of original pouch surgery. Management included local surgical repair, defunctioning ileostomy, pouch excision and anti-TNF therapy. GI continuity was achieved in 12 patients (52%). Healing of the PVF was achieved in 12 patients (52%). Pelvic sepsis was significantly associated with the need for a long-term ileostomy (P = 0.009). Biological therapy was used in 12 patients, of whom seven maintained GI continuity. Patients with late presentation PVF (60 months or longer postsurgery) and those with clinical features of Crohn's disease appeared to benefit from anti-TNF treatment.

CONCLUSION

PVF remains a challenging problem with overall healing rates and GI continuity rates of just over 50%. Anti-TNF therapy may have a role in patients with late presentation PVF and those with features suggestive of Crohn's disease.

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.

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.

Poor Outcomes of Complicated Pouch-Related Fistulas after Ileal Pouch-Anal Anastomosis Surgery

BACKGROUND AND AIMS

Development of a pouch-related fistula tract is an uncommon but highly morbid complication to restorative proctocolectomy with ileal pouch-anal anastomosis. Pouch failure with permanent ileostomy is reported in 21%-30% of patients, yet the factors contributing to pouch excision remain poorly defined. The aim of this study was to determine the incidence and treatment results of complicated pouch-related fistula, as well as to evaluate factors involved in excision after pouch failure.

MATERIAL AND METHODS

The study was conducted as a retrospective study. All patients with diagnosed pouch-related fistulas were registered with information related to fistula classification, treatments, and outcome.

RESULTS AND CONCLUSION

The final analysis included 48 (10.7%) of the 447 total ileal pouch-anal anastomosis patients with complicated pouch-related fistulas. Pouch-vaginal fistulas, pouch-perianal fistulas, and other pouch-related fistulas were observed in 19 (63%), 29 (60%), and 10 (21%) patients, respectively, corresponding to an accumulated risk of 8%, 6%, and 2%, respectively. Time from ileal pouch-anal anastomosis surgery to fistula presentation was 24 (0.2-212) months. Overall pouch failure, defined as pouch excision or a diverting stoma, was seen in 34 (71%) patients, while pouch excision was seen in 23 (48%) of the patients. Patients who developed Crohn's disease had a significantly higher risk of pouch excision, as did patients with an early onset of the fistula after ileal pouch-anal anastomosis (P = 0.006 and P = 0.007, respectively). In conclusion, the present study demonstrated a high risk of pouch failure in patients with complicated pouch-related fistulas. Furthermore, it showed that Crohn's disease and the development of early onset fistulas are associated with pouch excision.

Management of low colorectal anastomotic leak: Preserving the anastomosis

Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.

Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.

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.

Delayed transanal repair of persistent coloanal anastomotic leak in diverted patients after resection for rectal cancer

AIM

Anastomotic leakage is a feared complication of colorectal surgery and can be devastating in low pelvic anastomosis. With the advent of nonoperative treatments for leakage, the question of management of persistent low colorectal and coloanal anastomosis arises. A review of patients who have undergone transanal repair of anastomotic leakage is presented.

METHOD

A review of all anastomoses performed in the Division of Colorectal surgery at two institutions, from January 2000 to June 2008, was performed. Anastomotic leakage was defined as the finding at reoperation of a dehiscence, or radiographic findings of extravasation from the anastomosis, or the identification of intra-abdominal abscess formation at the site of the anastomosis, enterocutaneous fistula or rectovaginal fistula. Patients who underwent transanal repair of the leakage were identified.

RESULTS

There were 663 low anterior resections performed during the study period. Of these, 36 experienced leakage of a low colorectal or coloanal anastomosis. Of these 36 patients, five underwent transanal repair of the anastomotic leak. All had had a low anterior resection for rectal cancer (coloanal=4; low colorectal anastomosis=1). Four had had prior chemoradiation and ileostomy defunctioning at the initial operation. The fifth had an ileostomy created to treat a leak. Six transanal repairs were performed, including endorectal advancement flap (n=3), dermal flap (n=1), direct suture repair (n=1) and debridement of an infected cavity (n=1). At the time of the present assessment, four patients had undergone reversal of ileostomy after radiographic evidence of complete healing and the fifth patient has a persistent leak.

CONCLUSION

Transanal repair of a persistent low colorectal or coloanal anastomotic leakage is feasible in selected cases, even when chemoradiation has been performed.

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.

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.

What are the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery?

PURPOSE

Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery.

METHODS

The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence.

RESULTS

Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohn's disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohn's disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohn's disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent.

CONCLUSION

Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeon's preference and patient-related factors such as diagnosis.

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.

Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy

Introduction

Pouch-related fistula occurs in 5–10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas.

Methods

Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch–perineal, pouch–abdominal wall and pouch–vaginal fistula during follow-up.

Results

Median patient follow-up was 4·1 (range 0–19) years. By 15 years' follow-up, pouch–vaginal fistulas had occurred in 44 women (5·2 per cent). The prevalence of ileal pouch–perineal and pouch–abdominal wall fistula was 3·6 per cent (70 patients) and 1·5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1·28 (95 per cent confidence interval (c.i.) 1·00 to 1·65) and 1·73 (95 per cent c.i. 1·07 to 3·48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3·43 (95 per cent c.i. 2·43 to 4·84) and 4·02 (95 per cent c.i. 1·27 to 12·77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4·29 (95 per cent c.i. 2·33 to 7·91)), patient sex (HR 0·74 (95 per cent c.i. 0·58 to 0·95) for men versus women) and pelvic sepsis (HR 3·79 (95 per cent c.i. 2·48 to 5·79)).

Conclusion

This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula.

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.

Ileal pouch-vaginal fistula treated by abdominoanal advancement of the ileal pouch

Best approach for high fistulas

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.

Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results

PURPOSE

Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients.

METHODS

All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database.

RESULTS

Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent.

CONCLUSION

Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.

Review article: ulcerative colitis--surgical indications and treatment

The indication for surgery is a balance between the severity of the disease despite full medical treatment and the potential disadvantages of surgery. The decision requires cooperation between gastroenterologist and surgeon. Colectomy with ileostomy and preservation of the rectum in the emergency setting is the accepted procedure and can rapidly restore the patient to normal health allowing withdrawal of anti-inflammatory medication. After recovery all surgical possibilities are then open for the future. The elective indications for surgery include failure of medical treatment, retardation of growth in a child or adolescent and neoplastic transformation. The choice of operation includes conventional proctocolectomy, restorative proctocolectomy (RPC) and colectomy with ileo-rectal anastomosis. Each has relative advantages and disadvantages. RPC is the commonest procedure. It offers a satisfactory outcome in 70-90% of patients with a cumulative failure rate of 10-15% over a 10 year period. Causes of failure include sepsis (50%), dysfunction (30%) and pouchitis (10%). In selected cases salvage surgery to avoid failure can be successful with rates of around 70% for outlet obstruction and fistulation and 50% for pelvic sepsis.

A new ileal pouch salvage technique

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the surgical treatment of ulcerative colitis. Fistulas originating from the ileal pouch are uncommon but serious complications, sometimes leading to failure of the operation. We describe a technique to treat and salvage a pouch involved in a chronic fistulating ileal J-pouch-anal anastomosis by disconnecting the pouch, turning it inside out after repair, and reanastomosing it to the dentate line.

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.

Transposition of the rectus abdominis muscle for complicated pouch and rectal fistulas

PURPOSE

Operative repair for complicated pouch and rectal fistulas is often difficult. We present our experience with ten consecutive patients operated on for complicated pouch and rectal fistulas by transposition of the rectus abdominis muscle.

METHODS

Ten patients with high and complex pouch and rectal fistulas were treated with the interposition of a vascularized rectus abdominis muscle flap. All patients received standard bowel preparation and antibiotics. All were diverted by a temporary ileostomy.

RESULTS

Causes of fistulas included Crohn's disease (n = 3), previous rectal surgery (n = 5), anal atresia (n = 1), and sphincter repair (n = 1). Three patients had a third recurrence. The procedure was performed in combination with a plastic surgeon. All fistulas healed. No special postoperative care was required. There were no cosmetic or functional complaints caused by transposition of the rectus abdominis muscle.

CONCLUSIONS

Transposition of the rectus abdominis muscle is a suitable technique in treatment of fistulas between the rectum or ileal pouch and the vagina or urinary system, with no obvious side effects and excellent clinical outcome.

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment

OBJECTIVE

To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery.

SUMMARY BACKGROUND DATA

Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications.

METHODS

The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey.

RESULTS

Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit.

CONCLUSIONS

Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.

Vaginal fistula following restorative proctocolectomy

Vaginal fistula (VF) is a devastating complication following restorative proctocolectomy.

PURPOSE

This study was designed to examine the perioperative factors influencing the outcome and management of vaginal fistula.

METHOD

Between October 1983 and September 1994, 526 women underwent restorative proctocolectomy. Nineteen develop VF (3.6 percent), and six were referred from other institutions with this complication. These 25 women were followed for a minimum of nine months.

RESULTS

Preoperative diagnosis of ulcerative colitis was made in 23 of the patients with VF (92 percent), and indeterminate colitis and familial adenomatous polyposis was determined in the rest of the patients. Postoperatively, 12 of the 23 women (52 percent) with a preoperative diagnosis of ulcerative colitis had clinical/pathologic findings of Crohn's disease, and 1 woman was reclassified as having indeterminate colitis. Postoperative pelvic sepsis was significantly higher in women with VF than in those without VF (26.3 vs. 6.3 percent; P = 0.003). Median time until occurrence of VF following loop ileostomy closure was later for women with delayed findings of Crohn's disease at 16.5 (range, <1-72) months, compared with women without Crohn's disease at 0.5 (range, <1-67) months (P < 0.05). Of the 163 women with handsewn anastomosis performed at our institution, 12 developed VF (7.4 percent). In contrast, 7 of the 363 patients with stapled anastomosis had VF (1.9 percent; P = 0.003). Site of VF was found at the anastomosis in 12 patients, below in 12 patients, and above in 1 patient. Presence of Crohn's disease and anastomotic technique did not influence the site of VF. Initial management of VF consisted of transanal repair in 20 patients (advancement flap, 12; direct repair, 6; and neoileoanal anastomosis, 2), seton in 1 patient, transabdominal approach in 1 patient, transvaginal in 1 patient, observation in 1 patient, and pouch excision in 1 patient. Of the 13 women without Crohn's disease, 12 had transanal repair (10 healed, 1 had recurrence, and 1 had pouch excision), and 1 had successfully repair with transabdominal technique, for an overall success rate of 84.6 percent. Of the 12 women with VF and delayed findings of Crohn's disease, transanal repair was performed on 9, 1 had pouch excision without repair, 1 had seton placement and pouch excision, and 1 underwent observation. Transanal technique of repair in women with Crohn's disease successfully healed three women (33.3 percent). Overall, of the 12 women with delayed findings of Crohn's disease, 6 had pouch excision, 3 had recurrences, and 3 healed.

CONCLUSION

VF is an uncommon complication following restorative proctocolectomy and is associated with a high incidence of pelvic sepsis and handsewn anastomosis. Late presentation of VF is more common with Crohn's disease and is associated with a poor prognosis and pouch salvage rate. Transanal techniques are an effective means of VF repair.

Pouch salvage. Long-term outcome

PURPOSE

The aim of this study was to determine the outcome of pouch salvage operations and the factors that may influence successful reconstructions.

METHODS

This retrospective review includes data from 198 patients who had undergone restorative proctocolectomy at a single institution during an 11-year period. All patients who had undergone attempted pouch salvage and who still had a pouch in situ were reviewed by both postal questionnaire and at interview in the outpatients clinic.

RESULTS

Of 198 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis, 27 (13.6 percent) presented with pouch-specific complications requiring pouch salvage. A further five patients requiring pouch salvage were referred from other centers. Of 32 patients who underwent attempted pouch salvage, 16 (50 percent) had a successful outcome, 12 (37.5 percent) had pouch excision, and 3 (9 percent) are still defunctioned. There was one death (3 percent) in this series. Pelvic sepsis was a major cause of pouch failure, being present in 50 percent (8/16) of failed salvage procedures, and accounting for 58 percent (7/12) of pouch excisions.

CONCLUSIONS

Salvage surgery for major complications following ileoanal pouch construction is worthwhile in the absence of major pelvic sepsis. Overall success rate is 50 percent, and these results may be acceptable to highly motivated patients.

What happens to a pelvic pouch when a fistula develops?

PURPOSE

The aim of this article is to determine the outcome of the pelvic pouch after the occurrence of a fistula.

MATERIALS AND METHODS

From 1983 to 1995, 1,040 pelvic pouch surgeries were done at our institution. We reviewed the records of all patients with pouch-related fistulas. Data were collected from chart reviews and our pouch registry.

RESULTS

Among 59 patients (22 males) with fistulas, mean age was 33 (range, 19-57) years. Preoperative diagnosis was mucosal ulcerative colitis (n = 52), indeterminate colitis (n = 6), and familial polyposis (n = 1). Site of fistulas included pouch/vaginal (n = 24), pouch/ cutaneous (n = 11), pouch/perineal (n = 16), and pouch/ presacral (n = 8). Postoperative diagnosis was mucosal ulcerative colitis (n = 40), Crohn's disease (n = 14), indeterminate colitis (n = 4), and familial polyposis (n = 1). One hundred eleven (range, 1-7) surgeries for treatment were performed. At a mean follow-up of 26 (range, 1-121) months, 19 pouches (32 percent) had been excised, 34 patients had functioning pouches and no fistula, 5 patients had a closed fistula but refused ileostomy closure, and 1-patient had died of unrelated causes (but the fistula was closed). Pouch type and preoperative diagnosis did not statistically affect pouch failure rates (P = 0.43 and 0.10. respectively).

CONCLUSION

Successful treatment of fistula from a pelvic pouch can be achieved in more than 60 percent of patients. However, multiple procedures may be needed for a successful outcome. Ultimately, 32 percent had their pouches excised.

Pouch-related fistula following restorative proctocolectomy

Prognostic factors and outcome of pouch-related fistula were analysed from a series of 21 patients, 20 of whom had an ileal J pouch manually anastomosed to the dentate line following mucosectomy. Fistula occurred more often after pouch formation for ulcerative colitis than for familial adenomatous polyposis. In 6 patients the fistula occurred more than 5 months after closure of the diverting loop ileostomy. The origin of the leak was the anastomosis in 14 patients, the vertical staple line in two and the end of the efferent limb in five. Nine forms of treatment were utilized and these were successful in 11 patients and unsuccessful in ten including three pouch excisions. Adverse prognostic factors were late fistula, the presence of an enterocutaneous or a pouch-vaginal fistula track, and diagnosed or suspected Crohn's disease. Resolution of the fistula followed none of six diverting loop ileostomies performed alone, three of 33 attempted drainage procedures, four of ten direct closures, and four of five repeat ileal pouch-anal anastomoses. It is concluded that an aggressive therapeutic approach using repeat ileal pouch-anal anastomosis increases the success rate.

Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease

PURPOSE

Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohn's disease is, however, a contraindication. Because distinction between UC and Crohn's disease can be difficult, some patients with Crohn's disease inadvertently undergo IPAA. The aim of this study was to determine the long-term outcome of patients with Crohn's disease who have undergone IPAA.

METHODS

A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J-pouch, n = 35; S-pouch, n = 1; W-pouch, n = 1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitiis (n = 22), indeterminate colitis (n = 9), or Crohn's disease (n = 6). The stoma was closed in all patients.

RESULTS

A total of 11 of 37 patients developed complex fistulas (pouch-cutaneous (n = 6), pouch-vaginal (n = 4), or pouch-vesical (n = 1). Crohn's disease has recurred in the pouch (n = 20), anal canal (n = 4), pouch and anal canal (n = 10), and elsewhere (n = 3). After ten years (range, 3-14), the pouch remains in situ in 20 patients in whom frequency of bowel movement is seven times (3-10)/24 hours, in situ but defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent).

CONCLUSIONS

Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45 percent) but an acceptable long-term functional result if the pouch can be kept in situ.

Results from pouch salvage

Over an 11-year period, 17 salvage procedures were performed on a failed ileal pouch-anal anastomosis carried out for ulcerative colitis from a series of 157 patients. Ten pouches were saved, four excised and three defunctioned. Salvage procedures included five operations for fistulas (three of five successful), six reoperations on the ileoanal anastomosis (five of six successful), three new pouches after previous pouch excision (all failed), and three miscellaneous: excision of an efferent limb (successful), pouchpexy for a pouch prolapse (successful) and postanal repair for incontinence (failed). Pouch salvage may be successful in the motivated patient who wishes to avoid a permanent ileostomy.

Stenosis of the pouch anal anastomosis following restorative proctocolectomy

PURPOSE

To compare the incidence of stenosis after hand-sewn and stapled ileoanal anastomosis. Stenosis of the ileoanal anastomosis occurs in 5-16% of patients undergoing a restorative proctocolectomy but the incidence using a stapled technique is unknown.

METHODS

Between 1976 and 1990, 266 patients underwent restorative proctocolectomy or proctectomy at one hospital. In two hundred and eighteen the anastomosis was hand sewn and stapled in 48 (single 33; double 15).

RESULTS

Stenosis occurred in 31 (14.2%) of the hand-sewn and in 19 (39.6%) of the stapled anastomoses. This difference was highly significant (P < 0.001). Stenosis was not related to the size of the staple head used or to the stapling technique. There was no relationship between the development of stenosis and pelvic sepsis. Twenty six (hand-sewn 16, stapled 10) of the 48 patients with stenosis needed dilatation under general anaesthetic.

CONCLUSION

Stapled anastomoses may result in a high incidence of anastomotic stenosis.

Water-soluble contrast pouchography--technique and findings in 85 patients

A simple and safe technique for examining the ileal pouch in the post-operative period is described, and the findings in 85 patients reviewed. Extravasation from the ileo-anal anastomosis was seen in 10/85 (11%). In 14/85 (16%) the lateral view of the filled pouch showed a presacral space > 4 cm, which in 10 (71%) was due to a significant abnormality: six having an anastomotic leak with presacral abscess, two a large presacral haematoma, and two an abscess without anastomotic leak. Pouchography is recommended as a routine examination prior to closure of the covering ileostomy.

Pouch-vaginal fistula after restorative proctocolectomy: aetiology and management

Pouch-vaginal fistula is a rare complication following restorative proctocolectomy. Seven patients who developed such a fistula are presented. Six pouch-vaginal fistulas occurred at the level of the pouch-anal anastomosis and one 3 cm above the anastomosis, level with the posterior vaginal fornix. The anastomosis had been hand-sewn in four patients (following mucosectomy) and stapled in three. Five fistulas presented within the perioperative period (median 16 (range 10-30) days) and two at 186 and 273 days. Treatment was successful in the patients who presented early, and these remain continent with functioning pouches. If not already present (two patients), an ileostomy was raised. Repair was by endovaginal flap advancement, combined with fistulotomy and sphincter repair in two patients. Treatment was unsuccessful in the two patients who presented late; in both the diagnosis was revised to Crohn's disease, necessitating pouch excision.

Current surgical therapy for mucosal ulcerative colitis

PURPOSE

There are numerous surgical options for the treatment of mucosal ulcerative colitis.

METHODS

This article reviews the currently available options for the treatment of mucosal ulcerative colitis. Separate discussions will explore both the options in the emergency and elective settings.

RESULTS

Patients with mucosal ulcerative colitis may undergo surgery either as an emergency or in the elective setting. Emergency surgery is usually performed for one of the life-threatening complications of ulcerative colitis: fulminant colitis, toxic megacolon, or massive hemorrhage. The most commonly performed procedure under these conditions is a subtotal colectomy with end ileostomy. The rectal stump may be handled in a variety of ways. This procedure avoids proctectomy or anastomosis. Thus, patients will still have all necessary anatomic structures to allow for any of the definitive elective procedures. Elective surgery is performed for intractable disease, complications of medical therapy, dysplasia, or, occasionally, extraintestinal manifestations. In the elective setting, a definitive operation can be done to remove most or all of the disease-bearing colorectum and leave the patient with a means to control fecal elimination. Total abdominal colectomy with ileorectal anastomosis leaves the patient with diseased bowel but obviates the need for pelvic dissection. Although total proctocolectomy removes all potentially diseased mucosa, these patients have a permanent ileostomy. The stoma can either be a standard Brooke's ileostomy or a continent Kock pouch. The most common definitive procedure currently performed is the near-total proctocolectomy with ileal pouch-anal anastomosis. This option can be completed either with a rectal mucosectomy and hand-sewn anastomosis or with a double-stapled anastomosis, preserving the anal transition zone. This procedure is successful in eradicating almost all diseased mucosa while allowing the patient per anal defecation. Bowel movement frequency, degree of anal continence, and return to social and professional commitments have met with a great deal of satisfaction in most patients. A newer alternative to this procedure employs laparoscopy to facilitate a smaller incision. A one-stage procedure which omits the protective ileostomy and thus saves the patient one operation has also been used with some success in selected cases.

CONCLUSION

There are several surgical options for the treatment of mucosal ulcerative colitis. Each one has a role and should be discussed with the patient.

Fistula complicating restorative proctocolectomy

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch-vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch-perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch-vesical fistula, successfully treated by excision of the fistula and pouch appendage.