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.
Tsujinaka
Shingo
S
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.
Ruiz
Dan
D
Wexner
Steven D
SD
Baig
Mirza K
MK
Sands
Dana R
DR
Weiss
Eric G
EG
Nogueras
Juan J
JJ
Efron
Jonathan E
JE
Vernava
Anthony M
AM
D000293:Adolescent; D000328:Adult; D039021:Colonic Pouches / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D016737:Proctocolectomy, Restorative / Q000009:adverse effects* / Q000379:methods; D012006:Rectovaginal Fistula / Q000209:etiology / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome