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Obi M, Klingler M, Sapci I, Lavryk O, Lipman J, Steele SR, Hull T, Holubar SD. Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae. Tech Coloproctol 2024; 28:105. [PMID: 39141140 PMCID: PMC11324785 DOI: 10.1007/s10151-024-02983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/12/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Ileal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180-360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure. METHODS Patients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%). RESULTS Over a 12-year period, nine patients were identified; the median age at CPA was 41 (36-44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1-2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn's disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6-24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up. CONCLUSIONS Transanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.
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Affiliation(s)
- M Obi
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M Klingler
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, 9500, Cleveland, OH, 44122, USA
| | - I Sapci
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - O Lavryk
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, 9500, Cleveland, OH, 44122, USA
| | - J Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, 9500, Cleveland, OH, 44122, USA
| | - S R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, 9500, Cleveland, OH, 44122, USA
| | - T Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, 9500, Cleveland, OH, 44122, USA
| | - S D Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, 9500, Cleveland, OH, 44122, USA.
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Rogers P, Emile SH, Garoufalia Z, Strassmann V, Dourado J, Ray-Offor E, Horesh N, Wexner SD. Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review. Tech Coloproctol 2023; 28:7. [PMID: 38079014 DOI: 10.1007/s10151-023-02880-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023]
Abstract
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.
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Affiliation(s)
- P Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S H Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Z Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - V Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - J Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - E Ray-Offor
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- University of Port Harcourt, Dept of Surgery, Choba, Nigeria
| | - N Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - S D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Baker ME, Hull T, Holubar S, Lightner A, Qazi T. Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch. Abdom Radiol (NY) 2023; 48:2913-2917. [PMID: 36334124 DOI: 10.1007/s00261-022-03723-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.
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Affiliation(s)
- Mark E Baker
- Imaging Institute, 9500 Euclid Ave/L10, Cleveland, OH, 44195, USA.
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
- Crohn's Disease Focus Panel of the Society of Abdominal Radiology, East Dundee, USA.
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Lightner
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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4
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Phillips KE, Aljobeh A, Benammi S, Abdalla S, Calini G, Shawki SF, Larson DW, Mathis KL. Predictors of ileal pouch failure due to fistulas. Br J Surg 2023; 110:1046-1048. [PMID: 36680369 DOI: 10.1093/bjs/znac446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Kathryn E Phillips
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ahmad Aljobeh
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Rochester, Rochester, Minnesota, USA
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5
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Drefs M, Schömer Cuenca S, Wirth U, Kühn F, Burian M, Werner J, Zimmermann P. Predictors of outcome for treatment of enterovaginal fistula : Therapeutical strategies for treatment. Int J Colorectal Dis 2023; 38:187. [PMID: 37420132 PMCID: PMC10329052 DOI: 10.1007/s00384-023-04453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary. METHODS The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure. RESULTS Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031). CONCLUSION Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | | | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Maria Burian
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Petra Zimmermann
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany.
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Pellino G, Celentano V, Vinci D, Romano FM, Pedone A, Vigorita V, Signoriello G, Selvaggi F, Sciaudone G. Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes. Dig Liver Dis 2023; 55:342-349. [PMID: 35688686 DOI: 10.1016/j.dld.2022.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/25/2022] [Accepted: 05/15/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Valerio Celentano
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Surgery and Cancer. Imperial College, London, United Kingdom
| | - Danilo Vinci
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Maria Romano
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Agnese Pedone
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Vincenzo Vigorita
- Department of General and Digestive Surgery, University Hospital Complex of Vigo, Vigo, Spain; General Surgery Research Group, SERGAS-UVIGO, Galicia Sur Health Research Institute [IIS Galicia Sur], Vigo, Spain
| | - Giuseppe Signoriello
- Section of Statistic, Department of Mental Health and Public Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Guido Sciaudone
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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7
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Huang AL, Plietz M, Greenstein AJ, Khaitov S. Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis. Clin Colon Rectal Surg 2022; 35:469-474. [PMID: 36591405 PMCID: PMC9797281 DOI: 10.1055/s-0042-1758138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Alex Liu Huang
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Michael Plietz
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Alexander J. Greenstein
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Sergey Khaitov
- Colon and Rectal Surgery Division, Department of General Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
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8
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Machin M, Younan HC, Slesser AAP, Mohsen Y. Systematic review on the management of ileoanal pouch-vaginal fistulas after restorative proctocolectomy in the treatment of ulcerative colitis. Colorectal Dis 2021; 23:34-51. [PMID: 32810915 DOI: 10.1111/codi.15318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- M Machin
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - H-C Younan
- School of Public Health, Imperial College London, London, UK
| | - A A P Slesser
- Department of Surgery and Cancer, Imperial College London, London, UK.,Hillingdon Hospital NHS Foundation Trust, Uxbridge, UK
| | - Y Mohsen
- Department of Surgery and Cancer, Imperial College London, London, UK.,Hillingdon Hospital NHS Foundation Trust, Uxbridge, UK
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9
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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10
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Sahnan K, Adegbola S, Iqbal N, Twum-Barima C, Reza L, Lung P, Warusavitarne J, Hart A, Tozer P. Managing non-IBD fistulising disease. Frontline Gastroenterol 2020; 12:524-534. [PMID: 34712471 PMCID: PMC8515280 DOI: 10.1136/flgastro-2019-101234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kapil Sahnan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Samuel Adegbola
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Nusrat Iqbal
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Charlene Twum-Barima
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Lillian Reza
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Phillip Lung
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
- IBD Unit, St Mark's Hospital, Harrow, UK
| | - Phil Tozer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
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12
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Bhattacharya A, Shen B, Regueiro M. Endoscopy in Postoperative Patients with Crohn's Disease or Ulcerative Colitis. Does It Translate to Better Outcomes? Gastrointest Endosc Clin N Am 2019; 29:487-514. [PMID: 31078249 DOI: 10.1016/j.giec.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article discusses the use of endoscopy in patients with Crohn disease and ulcerative colitis in the postoperative setting. Endoscopy is the most sensitive and validated tool available in the diagnosis of recurrence of Crohn disease in the postoperative setting. It is also the most effective diagnostic modality available for evaluating complications of pouch anatomy in patients with ulcerative colitis. In addition to diagnosis, management postoperatively can be determined through endoscopy.
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Affiliation(s)
- Abhik Bhattacharya
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA.
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Abstract
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.
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15
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Quinn KP, Lightner AL, Faubion WA, Raffals LE. A Comprehensive Approach to Pouch Disorders. Inflamm Bowel Dis 2019; 25:460-471. [PMID: 30124882 DOI: 10.1093/ibd/izy267] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Indexed: 12/18/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or indeterminate colitis, UC with colonic dysplasia or neoplasia, and familial adenomatous polyposis. In general, patients experience good function outcomes and quality of life with an IPAA. Although pouchitis is the most well-recognized and frequent complication after IPAA, a number of additional inflammatory, postsurgical, structural, neoplastic, and functional complications may occur, resulting in pouch dysfunction. We herein provide a comprehensive review of pouch function and an approach to diagnosis and management of pouch complications.
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Affiliation(s)
- Kevin P Quinn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - William A Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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16
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Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease. Gastroenterol Res Pract 2018; 2018:3159543. [PMID: 30584421 PMCID: PMC6280273 DOI: 10.1155/2018/3159543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/17/2018] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.
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17
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Tekkis PP, Nicholls RJ. Reprint of: Redo Ileal Pouch Surgery—Indications and Outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Segal JP, Adegbola SO, Worley GHT, Sahnan K, Tozer P, Lung PFC, Faiz OD, Clark SK, Hart AL. A Systematic Review: The Management and Outcomes of Ileal Pouch Strictures. J Crohns Colitis 2018; 12:369-375. [PMID: 29155985 DOI: 10.1093/ecco-jcc/jjx151] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/13/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and stoma-free living. Pouch strictures are a complication with a reported incidence of 5-38%. The three areas where pouch strictures occur are in the pouch inlet, mid-pouch and pouch-anal anastomosis. AIM To undertake a systematic review of the literature and to identify management strategies available for pouch-anal, mid-pouch and pre-pouch ileal strictures and their outcomes. METHODS A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was performed. Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded. RESULTS Twenty-two articles were considered eligible. Pouch-anal strictures have been initially managed using predominately dilators which include bougie and Hegar dilators with various surgical procedures advocated when initial dilatation fails. Mid-pouch strictures are relatively unstudied with both medical, endoscopic and surgical management reported as successful. Pouch inlet strictures can be safely managed using a combined medical and endoscopic approach. CONCLUSION The limited evidence available suggests that pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical revision or resection. Management of mid-pouch strictures requires a combination of medical, endoscopic and surgical management. Pouch inlet strictures are best managed using a combined medical and endoscopic approach. Future studies should compare different treatment modalities on separate stricture locations to enable an evidenced-based treatment algorithm.
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Affiliation(s)
- Jonathan P Segal
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Samuel O Adegbola
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Guy H T Worley
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Kapil Sahnan
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Philip Tozer
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Phillip F C Lung
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Omar D Faiz
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Susan K Clark
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Ailsa L Hart
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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19
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Vallicelli C, Rottoli M, Boschi L, Cipriani R, Poggioli G. Redo Gracilis Muscle Transposition for Recurrent Complex Pouch–Vaginal Fistula: A Feasible and Effective Pouch Salvage Surgical Procedure. Am Surg 2017. [DOI: 10.1177/000313481708301209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Carlo Vallicelli
- Surgery of the Alimentary Tract Sant'Orsola–Malpighi Hospital Alma Mater Studiorum University of Bologna Bologna, Italy
| | - Matteo Rottoli
- Surgery of the Alimentary Tract Sant'Orsola–Malpighi Hospital Alma Mater Studiorum University of Bologna Bologna, Italy
| | - Luca Boschi
- Surgery of the Alimentary Tract Sant'Orsola–Malpighi Hospital Alma Mater Studiorum University of Bologna Bologna, Italy
| | - Riccardo Cipriani
- Unit of Plastic Surgery Sant'Orsola–Malpighi Hospital Alma Mater Studiorum University of Bologna Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract Sant'Orsola–Malpighi Hospital Alma Mater Studiorum University of Bologna Bologna, Italy
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20
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Mahmoud NN, Halwani Y, Montbrun SD, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP. Current management of perianal Crohn’s disease. Curr Probl Surg 2017; 54:262-298. [DOI: 10.1067/j.cpsurg.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/04/2017] [Indexed: 12/11/2022]
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21
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Araki T, Okita Y, Kawamura M, Kondo S, Toiyama Y, Hiro J, Yoshiyama S, Uchida K, Kusunoki M. Modified Martius flap procedure for refractory ileal pouch-vestibular fistula: a report of three cases. Int J Colorectal Dis 2017; 32:757-759. [PMID: 28035458 DOI: 10.1007/s00384-016-2746-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Pouch-vaginal or vestibular fistula is an uncommon, but devastating complication that occurs in women after ileal J pouch-anal anastomosis. The management of these fistulae is challenging, and it is associated with high recurrence and pouch loss rates. This report describes the use of the modified Martius flap procedure for three patients with ulcerative colitis who developed refractory pouch-vestibular fistulae. RESULTS Three patients with ulcerative colitis, who underwent total colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis, developed pouch-vestibular fistulae. The fistulae originated in the pouch-anal anastomosis site in all three cases. We performed fistulectomy and transvaginal closure with sphincteroplasty followed by the modified Martius flap procedure under diversion ileostomy. No complications occurred after ileostomy closure, and the postoperative anal function was good. CONCLUSION The modified Martius flap procedure is among the best options for patients with ulcerative colitis who develop refractory pouch-vestibular fistula as a complication of mucosal proctectomy.
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Affiliation(s)
- Toshimitsu Araki
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Satoru Kondo
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Junichiro Hiro
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shigeyuki Yoshiyama
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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22
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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23
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Ileal pouch-anal anastomosis 20 years later: is it still a good surgical option for patients with ulcerative colitis? Int J Colorectal Dis 2016; 31:1835-1843. [PMID: 27682647 DOI: 10.1007/s00384-016-2657-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-term results after ileo-pouch anal anastomosis (IPAA) are well established; data are conflicting in long-standing patients. We retrospectively evaluated long-term complications and functional results after follow-up longer than 20 years. METHODS Two hundred five patients with follow-up longer than 20 years have been identified out of 1112 IPAA performed in our institution; of these, 20 cases were lost at follow-up or decline to take part at the study. We evaluated long-term complications and failure rate also according to changes in histological diagnosis. Changes in functional results and quality of life (QoL) were analyzed at 5 and 20 years after IPAA. RESULTS Pouch failure rate was 10.8 % (35 % due to misdiagnosed Crohn). Incidences of fistulas, anastomotic stenosis, chronic pouchitis, and pre-pouch ileitis were 17.3, 12.9, 28.6, and 7.6 %, respectively. Most of the patients reported good functional outcomes. Day-time evacuations at 5 and after 20 years were 4.3 and 4.8 (p = n.s.) while during night-time were 0.8 and 1.2 (p < 0.05). Urgency was 6 and 9.4 % (p = n.s.), respectively; need of antimotility drugs was 16 and 35 % (p < 0.001). Dietary limitations and work restrictions were similar over time. Only sexuality got worse during follow-up. Satisfaction for surgery was always high and it did not change over time. CONCLUSION IPAA is still an excellent surgical option for UC with a low rate of pouch failure even after more than 20 years. Despite a slight worsening of functional results over time, the QoL remained high and most patients expressed satisfaction with the procedure and were willing to recommend it to others.
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24
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Abstract
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.
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Affiliation(s)
- Emmanouil P Pappou
- Division of Colorectal Surgery, New York-Presbyterian/Columbia University Medical Center, New York, New York
| | - Ravi P Kiran
- Division of Colorectal Surgery, New York-Presbyterian/Columbia University Medical Center, New York, New York
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25
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Maeda K, Koide Y, Hanai T, Sato H, Masumori K, Matsuoka H, Katsuno H. The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula. Colorectal Dis 2015; 17:1002-6. [PMID: 25891199 DOI: 10.1111/codi.12977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023]
Abstract
AIM Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula. METHOD Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome. RESULTS Birth injury (n = 7), low anterior resection for rectal cancer (n = 3), pouch surgery for ulcerative colitis (n = 2) and a procedure for prolapse and haemorrhoids (n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure. CONCLUSION Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed.
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Affiliation(s)
- K Maeda
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Y Koide
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - T Hanai
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Sato
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - K Masumori
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - H Katsuno
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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26
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Pellino G, Selvaggi F. Outcomes of salvage surgery for ileal pouch complications and dysfunctions. the experience of a referral centre and review of literature. J Crohns Colitis 2015; 9:548-57. [PMID: 25895878 DOI: 10.1093/ecco-jcc/jjv066] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/13/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction. METHODS We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre- and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3). RESULTS Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003). CONCLUSIONS Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction.
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Affiliation(s)
- Gianluca Pellino
- Unit of General Surgery, Second University of Naples, Naples, Italy
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27
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Bharadwaj S, Philpott JR, Barber MD, Graff LA, Shen B. Women's health issues after ileal pouch surgery. Inflamm Bowel Dis 2014; 20:2470-82. [PMID: 25185688 DOI: 10.1097/mib.0000000000000171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
: 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.
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Affiliation(s)
- Shishira Bharadwaj
- Departments of *Gastroenterology & Hepatology, and †Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio; and ‡Department of Clinical Heath Psychology, University of Manitoba, Winnipeg, MB, Canada
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28
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Sagar RC, Thornton M, Herd A, Brayshaw I, Sagar PM. Transvaginal repair of recurrent pouch-vaginal fistula. Colorectal Dis 2014; 16:O440-2. [PMID: 25204796 DOI: 10.1111/codi.12775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 07/11/2014] [Indexed: 02/08/2023]
Abstract
AIM Pouch-vaginal fistula is an uncommon but unpleasant complication. The chance of successful repair with various surgical procedures is around 50% and the early promise of collagen button plugs was not followed by good long-term results. We report a series of patients who underwent transvaginal repair of pouch-vaginal fistula after failed collagen plugs accompanied by a video to show the operative technique. METHOD Patients were identified from a prospectively maintained database. Patient demographics, operation notes, complications and ultimate outcome were recorded. RESULTS Eleven patients, each of whom had previously undergone an attempt to close the fistula with a collagen button plug, underwent transvaginal repair. Nine (81%) were successful at a median follow-up of 14 (6-56) months. The remaining two patients reported symptomatic improvement. CONCLUSION Pouch-vaginal fistula can be successfully closed by the transvaginal technique after a failed button plug procedure.
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Affiliation(s)
- R C Sagar
- John Goligher Department of Colorectal Surgery, Lincoln Wing, St James's University Hospital, Leeds, UK
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29
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Theodoropoulos GE, Choman EN, Wexner SD. Salvage procedures after restorative proctocolectomy: a systematic review and meta-analysis. J Am Coll Surg 2014; 220:225-42.e1. [PMID: 25535169 DOI: 10.1016/j.jamcollsurg.2014.10.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 10/12/2014] [Accepted: 10/13/2014] [Indexed: 02/06/2023]
Affiliation(s)
| | - Eran N Choman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL.
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30
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Ileal pouch fistulas after restorative proctocolectomy: management and outcomes. Tech Coloproctol 2014; 18:1061-6. [DOI: 10.1007/s10151-014-1197-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 06/25/2014] [Indexed: 12/11/2022]
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31
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Abstract
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.
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32
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Abstract
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.
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33
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Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M. German S3-Guideline: rectovaginal fistula. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2012; 10:Doc15. [PMID: 23255878 PMCID: PMC3525883 DOI: 10.3205/000166] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Indexed: 12/12/2022]
Abstract
Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. Methods: A systematic review of the literature was undertaken. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.
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Borowiec AM, McCall M, Lees GM. The trans-sphincteric posterior sagittal repair of recto-urinary and recto-vaginal fistulae using Surgisis™ mesh and fibrin sealant. Tech Coloproctol 2012; 18:201-3. [PMID: 23095950 DOI: 10.1007/s10151-012-0917-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 10/01/2012] [Indexed: 01/17/2023]
Abstract
Recto-urinary, recto-vaginal and ileo-anal pouch-associated fistulae are rare yet a significant clinical problem due to their profound impact on patients' quality of life and are a challenge to repair. In this report, we describe repair of these complex fistulae using a modified trans-sphincteric posterior sagittal approach with Surgisis™ mesh and fibrin sealant and review our repair outcomes.
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Affiliation(s)
- A M Borowiec
- Department of Surgery, 2C3.62 WMC, University of Alberta Hospital, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada,
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Maslekar S, Sagar PM, Harji D, Bruce C, Griffiths B. The challenge of pouch-vaginal fistulas: a systematic review. Tech Coloproctol 2012; 16:405-14. [DOI: 10.1007/s10151-012-0885-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 08/12/2012] [Indexed: 10/27/2022]
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Sagar PM, Pemberton JH. Intraoperative, postoperative and reoperative problems with ileoanal pouches. Br J Surg 2012; 99:454-68. [PMID: 22307828 DOI: 10.1002/bjs.8697] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches. METHODS The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed. RESULTS Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation. CONCLUSION A structured management plan will minimize the adverse consequences of the problems associated with pouches.
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Affiliation(s)
- P M Sagar
- John Goligher Department of Colorectal Surgery, General Infirmary at Leeds, Leeds, UK.
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Trans-vaginal repair of a recurrent pouch-vaginal fistula. Tech Coloproctol 2011; 15:483-5. [PMID: 21695439 DOI: 10.1007/s10151-011-0705-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 06/07/2011] [Indexed: 11/27/2022]
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Navaneethan U, Venkatesh PGK, Shen B. Risks and benefits of ileal pouch–anal anastomosis for ulcerative colitis. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/thy.10.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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40
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Recurrent Fistula between Ileal Pouch and Vagina-Successful Treatment with a Gracilis Muscle Flap. Case Rep Med 2009; 2009:676392. [PMID: 19718250 PMCID: PMC2729290 DOI: 10.1155/2009/676392] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 04/02/2009] [Indexed: 12/16/2022] Open
Abstract
Fistulae between an ileal pouch and the vagina are an uncommon complication of ileal pouch-anal anastomosis following proctocolectomy and mucosectomy in patients with familial adenomatous polyposis coli. Several reports describe the successful use of muscle flaps to close recurrent pouch-vaginal-fistulae (PVF). However, series only contain small numbers and an optimal management has not yet been determined. We report the case of a 26-year old woman with a third recurrence of a PVF after proctocolectomy for treatment of familial adenomatous polyposis in October 2005. Because local approaches failed, definitive closure of the fistula was achieved by interposition of a gracilis muscle flap between the pouch-anal anastomosis and the vagina. The postoperative course was uneventful; the patient was discharged 7 days after surgery and remained free of recurrence and symptomatic complaints for 22 months now. The gracilis muscle flap proved to be an effective method in the treatment of recurrent PVF.
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41
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Tekkis PP, Nicholls RJ. Redo Ileal Pouch Surgery—Indications and Outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg 2008; 248:39-43. [PMID: 18580205 DOI: 10.1097/sla.0b013e31817d077d] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas. MATERIAL AND METHODS A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral). RESULTS Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%. CONCLUSION The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.
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McLaughlin SD, Clark SK, Tekkis PP, Ciclitira PJ, Nicholls RJ. Review article: restorative proctocolectomy, indications, management of complications and follow-up--a guide for gastroenterologists. Aliment Pharmacol Ther 2008; 27:895-909. [PMID: 18266993 DOI: 10.1111/j.1365-2036.2008.03643.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for the majority of patients with ulcerative colitis who require surgery. Over 2500 patients in the UK have undergone restorative proctocolectomy. It is now increasingly being performed in district general hospitals as well as in specialist inflammatory bowel disease units. Gastroenterologists are increasingly involved in the management of patients following restorative proctocolectomy. AIM To provide gastroenterologists with a clear understanding of the investigation and evidence-based management of complications and the aftercare required in patients who have undergone restorative proctocolectomy. RESULTS Following restorative proctocolectomy, most patients have an excellent long-term functional outcome. Pouchitis, pelvic sepsis and poor function are the most common causes of failure. The development of cancer is rare; nevertheless, long-term follow-up is required. CONCLUSIONS The investigation and management of patients who develop complications require a multidisciplinary team approach to optimize the outcome. Protocols are suggested for investigation and management of patients with complications and for long-term cancer surveillance.
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Affiliation(s)
- S D McLaughlin
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK.
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Shen B, Remzi FH, Lavery IC, Lashner BA, Fazio VW. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 2008; 6:145-58; quiz 124. [PMID: 18237865 DOI: 10.1016/j.cgh.2007.11.006] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Bo Shen
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Berton F, Gola G, Wilson SR. Sonography of benign conditions of the anal canal: an update. AJR Am J Roentgenol 2007; 189:765-73. [PMID: 17885043 DOI: 10.2214/ajr.07.2485] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of this article is to describe our experience with sonography for the study of benign conditions of the anal canal and perianal soft tissues. CONCLUSION Assessment of the anal sphincters in patients with fecal incontinence and documentation of perianal inflammatory masses and tracts in those with perianal inflammatory disease are the major indications for imaging the anal canal. We augment traditional transanal sonography with transperineal scanning in both sexes and transvaginal scanning in women to better show the anal canal in its quiet state to allow an accurate assessment of the integrity of the anal sphincters and of evidence of acute or chronic inflammatory involvement.
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Affiliation(s)
- Francesca Berton
- Department of Medical Imaging, Section of Ultrasound, Toronto General Hospital, University of Toronto, Toronto, ON M5G 2N2, Canada
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Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:18-50. [PMID: 17880382 DOI: 10.1111/j.1463-1318.2007.01372.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- J G Williams
- McHale Centre, New Cross Hospital, Wolverhampton, UK.
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Smith M, Hooks VH, Jenkins B. Patch Repair of Ileoanal Pouch-Vaginal Fistula with Permacol™ Collagen Implant. Am Surg 2007. [DOI: 10.1177/000313480707300519] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Though uncommon, ileoanal pouch-vaginal fistulas after restorative proctocolectomy present quite a challenge. Multiple salvage procedures, including endoanal, transabdominal, and trans-vaginal, have been used. Because of high recurrence rates, multiple operations are not uncommon, and ultimate pouch failure rates have been reported as high as 45 per cent. The Permacol™ Collagen Implant is a surgical implant that has been used successfully in a variety of operations ranging from urological to maxillofacial. Its properties allow fibroblast infiltration and revascularization so that it gradually becomes permanently incorporated into the surrounding tissue, providing strength and inhibiting scarring and contraction. We report the first documented case of Permacol™ use in repair of ileoanal pouch-vaginal fistula and we feel that it warrants further investigation as an option in the treatment of these fistulas.
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Affiliation(s)
- Maurice Smith
- Department of Surgery, Medical College of Georgia, Augusta, Georgia and
| | | | - Barry Jenkins
- Department of Surgery, Medical College of Georgia, Augusta, Georgia and
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