Abstract
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.
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References
Fazio VW, Ziv Y, Church JM,et al. The ileal pouch anal anastomoses: complications and function in 1005 patients. Ann Surg 1995;222:120–7.
Marcello PW, Roberts PL, Schoetz DJ, Coller JA, Murray JJ, Veidenheimer MC. Long-term results of the ileoanal pouch procedure. Arch Surg 1993;128:500–4.
Keighley MR, Winslet MC, Flinn R, Kmiot W. Multivariate analysis of factors influencing the results of restorative proctocolectomy. Br J Surg 1989;76:740–4.
Mathey P, Ambrosetti P, Morel P,et al. Experience Suisse de l'anastomoe ileo-anale avec reservoir (ALA). Ann Chir 1993;47:1020–5.
Wexner SD, Rothenberger DA, Jensen L,et al. Ileal pouch vaginal fistulas: incidence, etiology and management. Dis Colon Rectum 1989;32:460–5.
Groom JS, Nicholls RJ, Hawley PR, Phillips RK. Pouch-vaginal fistula. Br J Surg 1993;80:936–40.
O'Kelly TJ, Merrett M, Mortensen NJ, Dehn TC, Kettlewell M. Pouch vaginal fistula following restorative proctocolectomy: aetiology and management. Br J Surg 1994;81:1374–5.
Kotanagi H, Kramer K, Fazio VW, Petras RE. Do microscopic abnormalities at resection margins correlate with increased anastomotic recurrence in Crohn's disease? Prospective analysis of 100 cases. Dis Colon Rectum 1991;34:909–16.
Fazio VW, Tjandra JJ. Pouch advancement and neoileoanal anastomosis for anastomotic stricture and anovaginal fistula complicating restorative proctocolectomy. Br J Surg 1993;79:694–6.
Dozois RR. Pelvic and perianastomotic complications after ileoanal anastomosis. Perspect Colon Rectal Surg 1988;1:113–21.
Gemlo BT, Wong D, Rothenberger DA, Goldberg SM. Ileal pouch-anal anastomosis patterns of failure. Arch Surg 1992;127:784–7.
Galandiuk S, Scott NA, Dozois RR,et al. Ileal pouchanal anastomosis, reoperation for pouch-related complications. Ann Surg 1990;212:446–54.
Emblen R, Erichsen AA, Morkrid L, Ganes T, Stien R, Bergan A. Failed ileoanal anastomosis: correlations between clinical function and anal canal neurophysiology and histologic examinations. Scand J Gastroenterol 1989;24:623–31.
Tuckson WB, McNamara MJ, Fazio VW, Lavery IC, Oakley JR. Impact of anal manipulation and pouch design on ileal pouch function. J Natl Med Assoc 1991;83:1089–92.
Sun WM, Read NW, Katsinelos P, Donelly TC, Short-house AJ. Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis. Br J Surg 1994;81:280–4.
Seow-Choen A, Tsunoda A, Nicholls RJ. Prospective randomized trial comparing anal function after handsewn ileoanal anastomosis with mucosectomyversus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy. Br j Surg 1991;78:430–4.
Luukkonen P, Jarvinen H. Stapledversus hand-sutured ileoanal anastomosis in restorative proctocolectomy a prospective randomized study. Arch Surg 1993;128:437–40.
McIntyre PB, Pemberton JH, Beart RW Jr, Devine RM, Nivatvongs S. Double-stapled vs handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. Dis Colon Rectum 1994;37:430–3.
Deutsch AA, McLeod RS, Cullen J, Cohen Z. Results of the pelvic-pouch procedure in patients with Crohn's disease. Dis Colon Rectum 1991;34:475–7.
Hyman NH, Fazio VW, Tuckson WB, Lavery IC. Consequences of ileal pouch-anal anastomosis for Crohn's colitis. Dis Colon Rectum 1991;34:653–7.
Bandy LC, Addison A, Parker RT. Surgical management of rectovaginal fistula in Crohn's disease. Am J Obstet Gynecol 1983;147:359–63.
Mazier WP, Senagore AJ, Schiesel EC. Operative repair of anovaginal and rectovaginal fistulas. Dis Colon Rectum 1995;38:4–6.
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Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.
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Lee, P.Y., Fazio, V.W., Church, J.M. et al. Vaginal fistula following restorative proctocolectomy. Dis Colon Rectum 40, 752–759 (1997). https://doi.org/10.1007/BF02055426
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DOI: https://doi.org/10.1007/BF02055426