title: Ileal pouch fistulas after restorative proctocolectomy: management and outcomes.
abstract: BACKGROUND
  Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm.
  
  
  METHODS
  Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011.
  
  
  RESULTS
  Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month-20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn's disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2-108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy.
  
  
  CONCLUSIONS
  Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.
authors.affiliation: Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA, gaert015@umn.edu.
authors.forename: W B
authors.initials: WB
authors.lastname: Gaertner
authors.forename: J
authors.initials: J
authors.lastname: Witt
authors.forename: R D
authors.initials: RD
authors.lastname: Madoff
authors.forename: A
authors.initials: A
authors.lastname: Mellgren
authors.forename: C O
authors.initials: CO
authors.lastname: Finne
authors.forename: M P
authors.initials: MP
authors.lastname: Spencer
mesh_terms: D000293:Adolescent; D000328:Adult; D039021:Colonic Pouches / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007077:Ileal Diseases / Q000209:etiology* / Q000601:surgery; D007412:Intestinal Fistula / Q000209:etiology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000601:surgery; D016737:Proctocolectomy, Restorative / Q000009:adverse effects*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult