title: Management and outcome of pouch-vaginal fistulas after IPAA surgery.
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.
  
  
  METHODS
  This was a retrospective analysis of a prospectively maintained database.
  
  
  METHODS
  The study was conducted in a single-center, high-volume tertiary referral colorectal unit.
  
  
  METHODS
  Women with a pouch-vaginal fistula after IPAA from 1983 to 2010 were included in the study.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Ismail H
authors.initials: IH
authors.lastname: Mallick
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Hull
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: Ravi P
authors.initials: RP
authors.lastname: Kiran
mesh_terms: D000328:Adult; D039021:Colonic Pouches / Q000473:pathology; D003424:Crohn Disease / Q000175:diagnosis / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D016737:Proctocolectomy, Restorative; D016016:Proportional Hazards Models; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D013997:Time Factors; D016896:Treatment Outcome; D014624:Vaginal Fistula / Q000209:etiology / Q000601:surgery*