Results of operation for rectovaginal fistula in Crohn's disease

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 12 patients operated on for rectovaginal fistula. Disease involved the large intestine in 10 patients. Primary fistula repair was performed in four patients and four others had staged repair with preliminary fecal diversion. Four patients with severe colonic and anorectal disease had proctocolectomy performed as the first procedure. Of eight patients who underwent fistula repair, complete healing occurred in six. One patient has a persistent fistula, which is minimally symptomatic, and the other required proctocolectomy after three unsuccessful repairs. Success of operation correlated with quiescent intestinal disease and absence of rectal involvement. In selected patients with symptomatic fistulas, surgical repair is indicated and healing can be anticipated. Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12–17, 1988.     

Experience with perirectal fistulas in patients with Crohn's disease

The experience of the senior author has been reviewed in dealing with perianal fistulas in patients with Crohn's disease. Early surgical therapy was advocated, the theory being, that perianal fistulas start as intersphincteric fistulas. This fistula is easily controlled surgically by fistulotomy with partial internal anal sphincterotomy. Delay in surgical treatment, especially in Crohn's patients, results in more complicated fistulas that may require colostomy or proctectomy. The presence of Crohn's disease did not affect the healing of fistulotomy. In our series fistulotomy was the treatment of choice in patients with 26 fistulas; 18 of 19 went on to full healing. We conclude that early fistulotomy, before an intersphincteric fistula has time to blossom fistulotomy, before an intersphincteric fistula has time to blossom into a more difficult management problem, is the treatment of choice in patients with Crohn's disease who have perianal fistulas Read at the XIIth, Biennial Congress of the International Society of University Colon and Rectal Surgeons, Glasgow, Scotland, July 10 to 14, 1988. Work performed at the Orlando Regional Medical Center, Orlando, Florida.     

Perianal abscesses and fistulas

In a five and one-half year period, 1023 patients with anorectal abscesses and fistulas were treated. Under regional anesthesia the abscesses were unroofed and debrided and a primary fistulotomy was performed whenever a low fistula was identified. In 355 (34.7 per cent) an internal fistulous opening was demonstrated at the time of abscess drainage. Thirty-two patients had suprashincteric fistulas and underwent two-stage fistulotomy using a seton. Perianal abscesses were encountered in 42.7 per cent of the patients, followed by ischiorectal (22.7 per cent), intersphincteric (21.4 per cent), and supralevator (7.33 per cent). The patients with supralevator and intersphincteric abscesses had a high incidence of fistula identified during abscess drainage. The recurrence rates were 3.7 per cent in the group with abscess drainage only and 1.8 per cent in the group that had primary fistulotomy along with abscess drainage. The follow-up period averaged 36 months. To accomplish adequate drainage and identify the deeper components and associated fistulous opening (34.7 per cent of the entire group), careful examination under regional anesthesia is recommended. Early aggressive treatment of an anorectal abscess and fistula significantly reduces the possibility of recurrent abscesses and/or the need for further surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5 to 9, 1983. Recipient of the 1983 Rowell Laboratories Education Committee Award.     

Fistula-in-ano in Crohn's disease

The outcome of aggressive surgical treatment of 64 symptomatic anal fistulas in 55 patients with Crohn's disease has been studied. Forty-one fistulas, in 33 patients, were treated by conventional fistulotomy (17 subcutaneous, 19 intersphincteric, 5 low transsphincteric fistulas). Thirty wounds (73 percent) healed within 3 months and eight more wounds (93 percent) healed within 6 months. Three wounds did not heal within 12–18 months. Two of these patients subsequently required proctocolectomy. Wound healing was not influenced by the presence of rectal Crohn's disease or granulomatous inflammation in the tract. No change in continence was experienced by 26 of the 33 patients who underwent fistulotomy. Three patients required proctocolectomy and the remaining four patients experienced minor degrees of incontinence postoperatively. Sixteen high transsphincteric, five suprasphincteric, and one extrasphincteric fistula in 22 patients were treated by laying open external tracts and placing a noncutting seton through the sphincter, which was left in place for prolonged periods to maintain drainage. During follow-up (6 months to 10 years, median 2.5 years), three fistulas healed and seven remained quiescent. Nine patients required further treatment by a new seton and three patients required proctocolectomy. Eight of the 22 patients who had a seton inserted had no change in continence, and six patients in this group developed minor changes in continence, mostly related to diarrhea associated with intestinal disease. Anal fistulas in Crohn's disease, which involve minimal sphincter muscle, can be successfully treated by fistulotomy. High fistulas should be treated with seton drainage to limit recurrent suppuration and preserve sphincter function.Read at the 89^th meeting of the American Society of Colon and Rectal Surgeons, St Louis, Missouri April 29–May 4 1990.     

Recurrent anorectal abscesses

A prospective study of 100 recurrent anorectal abscesses in 97 patients was carried out to elucidate the cause of recurrence. Sixty-four patients had had one, 12 had had two, and the rest had had more than two prior abscesses. In 32 patients, the previous diagnosis was erroneous; the patients had hidradenitis suppurativa which was excised. In 68 patients, the cause of recurrence was insufficient prior treatment. Thirty-one patients (45 per cent) had fistulous abscesses requiring fistulotomy. Twenty-two patients (32 per cent) had large abscesses associated with fistula necessitating unroofing of the abscess along with fistulotomy. In 15 patients (22 per cent), no associated fistula was detected, but they were found to have missed components (i.e., ischiorectal, supralevator, postanal abscesses) and were successfully treated with drainage of the missed abscess component. All recurrent abscesses must be examined carefully under anesthesia to identify associated fistulas or missed components, or to exclude hidradenitis suppurativa. Read at the Meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

Repair of fistulas-in-ano using autologous fibrin tissue adhesive

PURPOSE: Our goal was to determine if autologous fibrin tissue adhesive derived from the precipitation of fibrinogen using a combination of ethanol and freezing, could be used to completely close both simple and complex fistulas-inano. METHODS: A 26-patient pilot study was performed in which 100 ml of a patient's blood was drawn 90 minutes before surgery. Autologous fibrin tissue adhesive was prepared. In the operating room the patient underwent an examination under anesthesia, and the primary and secondary fistula tract openings were attempted to be identified. The fistula tract was curetted, and autologous fibrin tissue adhesive was injected into the secondary fistula tract opening until fibrin glue was seen coming from the primary opening. A petroleum jelly gauze was then applied over the secondary opening, and the patient was sent home. Follow-up visits were scheduled for one week, one month, three months, and one year later. RESULTS: Twenty-six patients received autologous fibrin tissue adhesive fistula injections, with a mean follow-up of 3.5 months. Initial results were encouraging. Twenty-one of 26 patients (81 percent) had successful initial closure of their fistulas. Two of five failures were injected a second time, and one closed, giving an overall successful closure rate of 85 percent (22/26 patients). Of five patients who failed, mean time to failure was 3.8 weeks. In addition, there was no evidence of infection or complications related to the procedure. CONCLUSION: Our initial results are optimistic and require further support through longer follow-up data. Fibrin glue treatment of anorectal fistulas offers a unique mode of management that is safe, simple, and easy for the surgeon to perform. By using autologous fibrin tissue adhesive the patient avoids the risk of anal incontinence and the discomfort of prolonged wound healing which may be associated with fistulotomy.Supported by a grant from The Research Foundation of The American Society of Colon and Rectal Surgeons.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Anorectal Crohn's disease

A group of 86 patients with anorectal Crohn's disease were followed up from ten to 40 years to determine the course of the disease and the number of patients who later required proctectomy. The overall cumulative probability of avoiding proctectomy was 91.6 percent at ten years and 82.5 percent at 20 years. Resection of all proximal Crohn's disease did not ameliorate the anorectal disease, except in patients who had all proximal disease removed and had no recurrence. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, May 5 to 10, 1985.     

The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration

To determine whether primary fistulotomy should be performed at the time of incision and drainage of anorectal abscesses, a retrospective study of 117 patients who underwent incision and drainage of anorectal abscesses was conducted to ascertain what percentage of patients would subsequently develop a fistula-in-ano or recurrent abscess. None of the patients treated for intersphincteric abscesses developed recurrences. Of the 83 patients with perianal or ischiorectal abscesses, nine (11 per cent) developed recurrent abscesses and 31 (37 per cent) developed persistent fistula-in-ano for a combined persistence or recurrence rate of 48 per cent. These data support the policy of secondary fistulotomy to avoid division of sphincter muscle in the 52 per cent of patients who would not need it. In addition, the vast majority of perianal and ischiorectal abscesses can be drained under local anesthesia and hence a general anesthetic and hospital admission are obviated. Read at the meeting of the American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5 to 9, 1983.     

Perineal wound healing after proctectomy for inflammatory bowel disease

Summary One hundred fifty-one cases of patients who underwent proctectomy for inflammatory bowel disease at the Lahey Clinic were analyzed with respect to the factors that predispose to delay in perineal wound healing. Significantly poorer healing took place in patients with Crohn's colitis, in men with ulcerative colitis, and in patients with ulcerative colitis who underwent one-stage operations. Factors that were not statistically significant but that appeared to contribute to delay in healing were younger age of patients and presence of anal fistulas. A comparison is made with the results of other series, and recommendations for treatment and prevention are presented. Read at the annual meeting of the American Society of Colon and Rectal Surgeons, Orlando Florida, May 8 to 12, 1977.     

Rectovaginal fistula in Crohn's disease

Rectovaginal fistulas in the setting of Crohn's disease present a difficult management dilemma. Some patients with this problem require proctocolectomy, yet other patients with minimal symptoms never require an operation for treatment of the rectovaginal fistula. For a small percentage of patients, local surgical repair of the fistula may be warranted. Since 1980, this study has attempted local repair in seven patients with symptomatic rectovaginal fistulas from Crohn's disease. Five patients underwent staged repair of the fistula. Closure of the colostomy was eventually possible in three of these patients. Two of the three patients have had no evidence of recurrence at followup in excess of two years. The third patient required an ileostomy for intestinal disease and had no recurrence of the fistula. Two patients underwent primary repair of the rectovaginal fistula without fecal diversion; in one of these patients, the fistula recurred ten days after operation, necessitating a diverting ileostomy. The other patient remains cured 26 months after repair. The results of this review indicate that in the setting of quiescent rectal disease, an attempt to repair the fistula can be expected to have a reasonable chance of success. The presence of a rectovaginal fistula in a patient with Crohn's disease does not mandate removal of the rectum. Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim. California, June 12 to 17, 1988.     

Management of anorectal horseshoe abscess and fistula

Over a 10-year period 69 patients were treated consecutively for posterior and anterior horseshoe abscesses and fistulas. Fifty-nine patients had posterior and ten had anterior abscesses or fistulas. There were 52 patients with acute abscess. Treatment consisted of incision and drainage, incision and drainage with primary fistulotomy, incision and drainage with primary fistulotomy and counter-drainage, and incision and drainage with insertion of seton. Seventeen patients with chronic fistulas were treated by primary fistulotomy with curettage, or incision and drainage with insertion of seton. Patients were followed from three months to ten years with a mean follow-up of three years. No incidences of incontinence were reported in this series. The overall rate of recurrence was 18 percent, and included only patients with posterior abscesses and fistulas. Recurrence was related to the failure to maintain prolonged drainage in the midline after primary fistulotomy. The use of seton for delayed fistulotomy appears to promote wound drainage and precludes premature wound closure. More liberal use of the seton in the treatment of horseshoe abscesses and fistulas is advocated. Read at the meeting of the American Society of Colon and Rectal Surgeons, Houston, Texas, May 11 to 15, 1986. Supported in part by the Dorothy Rider Pool Health Care Trust Fund.     

Rectovaginal fistula in Crohn's disease

Summary and Conclusions Low rectovaginal fistulas occur in Crohn's disease but are not common. As with other manifestations of anorectal Crohn's disease, their incidence is directly proportional to the closeness of the diseased segment of bowel to the anus. Rectovaginal fistula in Crohn's disease signifies a bad prognosis. The fistula will not heal when treatment is limited to either medical treatment or proximal diversion of the fecal stream. Direct surgical treatment is reserved for those patients whose symptoms are unacceptable despite medical treatment. In nearly all of these cases, ileostomy and abdominoperineal excision are necessary. However, a few cases may be repaired when the rectal segment is normal and other conditions are favorable. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978. This paper received the Purdue Frederick Education Committee Award.     

Perirectal abscess in Crohn's disease

The role of surgical intervention in the treatment of patients with anorectal Crohn's disease is controversial. To clarify the success of aggressive drainage and the subsequent clinical course of patients with Crohn's disease and perirectal abscesses, the authors reviewed the records of 38 patients who presented with this condition during an eight-year period. Twenty-two male and 16 female patients (median age, 32 years; range, 17 to 61 years) with clinically or pathologically confirmed Crohn's disease of the bowel underwent operation for perirectal abscesses. Thirty-two percent of patients had no previous history of anorectal Crohn's disease. Thirty simple abscesses and 8 complex horseshoe abscesses were treated. At operation, 53 percent of patients underwent incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed. After resolution of the index abscess, recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage. More importantly, 44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sepsis. The healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision. We concluded that long-term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with Crohn's disease and perirectal abscess.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Ontario, Canada, June 11 to 16, 1989.     

Emergency colectomy for cytomegalovirus ileocolitis in patients with the acquired immune deficiency syndrome

The charts of all patients with the acquired immune deficiency syndrome (AIDS) who underwent emergency intra-abdominal surgery between January 1981 and July 1987 were reviewed. Eleven AIDS patients underwent 13 emergency laparotomies. Seven of these patients (64 percent) had cytomegalovirus (CMV) ileocolitis as the pathologic process requiring emergent surgical intervention. Four patients had hemorrhagic CMV proctocolitis and three had perforations of CMV ulcers of the ileum or rectosigmoid. The operations performed included three subtotal colectomies, two segmental resections, and two diverting stomas. The postoperative mortality rate in the CMV group was 28 percent at one day, 71 percent at one month, and 86 percent at six months. Furthermore, CMV ileocolonic pathology was directly responsible for 70 percent of the deaths in AIDS patients who underwent emergent exploratory laparotomy. Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988. This paper received the Chicago Society of Colon and Rectal Surgeons Award.     

A prospective survey of 474 patients with anorectal abscess

Summary A prospective survey of patients with anorectal abscesses treated at Cook County Hospital over a 35-month period produced data on 474 patients. The peak incidence was in the third decade of life. Males were affected 1.76 times more frequently than females. Perianal abscess was the most common anatomic type (42 per cent), with ischiorectal abscess (20 per cent) being second. The supralevator space was involved in 7 per cent of the abscesses. Primary fistulotomy was performed when an anal fistula could be demonstrated (34 per cent). Our standardized method of treatment, utilizing radial incisions for drainage, produced satisfactory results with a complication rate of 3 per cent, an in-hospital reoperation rate of 0.6 per cent, and an average hospital stay of 5.7 days Read at the meeting of the American Society of Colon and Rectal Surgeons, Atlanta, Georgia, June 10 to 14, 1979.     

The surgical management of anorectal diseases in AIDS and pre-AIDS patients

The charts of 340 patients with Acquired Immunodeficiency Syndrome (AIDS), AIDS-related complex (ARC), or AIDS-prodrome (AIDS-P), treated between January 1982 and April 1986 at the Roosevelt Division of the St. Luke's-Roosevelt Hospital Center, were reviewed. The incidence of anorectal disease was 34 percent. Fifty-two patients (15 percent) presentes with anorectal complaints prior to the diagnosis of AIDS, ARC, or AIDS-P. Over 50 percent of these patients were dead within 7.4 months. Fifty-one patients (15 percent) underwent 73 anorectal surgical procedures. Twenty-two of these patients (43 percent) were dead within six months, and only six patients had satisfactory wound healing 30 days after surgery. In addition to an 88 percent rate of poor healing, there was a 16 percent rate of major complications. Identification of these high-risk groups prior to any anorectal surgery is imperative to avoid unacceptable surgical complications. Aggressive surgical intervention should be reserved only for patients who did not fall into the high-risk groups presented. This paper received the New York Society of Colon and Rectal Surgeons A. W. Martin Marino, Sr., M.D., Award at the meeting of the American Society of Colon and Rectal Surgeons, Houston, Texas, May 11 to 15, 1986.     

Conservative treatment of anal fissure: An unselected,retrospective and continuous study

Summary Three hundred and ninety-three patients who had anal fissures were followed continuously for approximately five years. More than 44 per cent of them were cured nonsurgically within a four-to eight-week period. There was an 8 per cent complication rate, consisting of abscesses and fistulas, necessitating surgical treatment. The recurrence rate following healing was 27 per cent, but a third of these patients had recurrent fistulas that healed in response to further conservative treatment. The authors feel that conservative treatment of anal fissure is justified unless there is advanced anal stenosis. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978.     

Can the pouch be saved?

From 1980 to 1986, 165 patients underwent ileal reservoir procedures at the Lahey Clinic Medical Center; 142 (86 percent) had J-shaped pouches constructed, and 23 (14 percent) had S-shaped pouches constructed. In this series, 42 complications specifically related to the pouch occurred in 36 patients. Stricture was most common, followed by separation of the ileoanal anastomosis, pelvic sepsis, complex fistula, and a leaking pouch. Through judicious application of remedial operations and either delay in closure of the ileostomy or establishment of proximal loop ileostomy, only seven patients required reestablishment of fecal diversion. The authors urge aggressive diagnostic and therapeutic efforts to save the pouch and maintain satisfactory function in most patients. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987. This paper received the Piedmont Society of Colon and Rectal Surgeons Award.     

Surgical repair of rectovaginal fistulas in patients with Crohn's disease: Transvaginal approach

The surgical management of rectovaginal fistulas complicating Crohn's disease has been associated with unacceptably high failure rates. We sought to modify the available surgical techniques to provide a solution to this challenging problem. Between December 1983 and January 1990, 14 patients with Crohn's disease underwent repair of a rectovaginal fistula. A modified transvaginal approach was employed by the authors. A diverting loop ileostomy was performed on all patients, either as the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. The fistula was completely eradicated in 13 of the 14 women and did not recur during the mean follow-up period of 55.0 months (range, 3–77 months). Intestinal continuity was reestablished in these 13 patients within 6 months after the initial fistula repair. One patient with a very low-lying fistula constituted our only failure. We have found the transvaginal method preferable to the transanal approach because of the relative ease in raising the vaginal flap as compared with a flap of fibrotic and inflamed anorectal mucosa. On the basis of this study, we conclude that a modified transvaginal approach is an effective method for repair of rectovaginal fistulas secondary to Crohn's disease.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Anal sphincter reconstruction: Anterior overlapping muscle repair

Anal sphincter reconstruction for anal incontinence was performed in 55 women between 1973 and 1987 at The Jewish Hospital of St. Louis. The mean age was 34 years (range, 22–75 years). Incontinence was due to obstetric injury in 48 patients and to fistulotomy in 7 patients. Patients suffered from complete incontinence (41), incontinence of liquid stool and flatus (11), or incontinence of flatus only (3). All patients underwent an anterior overlapping sphincter muscle reconstruction, and one patient also had a posterior repair. Complete continence was restored in 28 patients, and partial continence was achieved in 24 patients. Only three patients remained totally incontinent. Clinical assessment did not accurately reflect functional outcome after 1 year of follow-up. No factor predicting outcome was found retrospectively. Clinical assessment of a patient's outcome may be inaccurate unless specific questions are asked. The use of a perineal drain reduced infection but did not affect outcome. Previous repair or associated rectovaginal fistula does not affect outcome. Sphincter injury owing to fistula disease may result in poor outcome after repair.Read at the meeting of The American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.