Current treatment of rectovaginal fistula in Crohn's disease

Rectovaginal fistula(RVF) continues to be the most difficult perianal manifestation of Crohn's disease to treat.This devastating and disabling complication has a significant impact on patients' quality of life and presents unique management challenges.Current therapeutic approaches include many medical therapeutics and surgical treatments with a wide range of success rates reported.However,current evidence is lacking to support any recommendation.The choice of repair depends on various patient and disease f...     

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.     

Current treatment of rectovaginal fistula in Crohn's disease

Rectovaginal fistula (RVF) continues to be the most difficult perianal manifestation of Crohn's disease to treat. This devastating and disabling complication has a significant impact on patients' quality of life and presents unique management challenges. Current therapeutic approaches include many medical therapeutics and surgical treatments with a wide range of success rates reported. However, current evidence is lacking to support any recommendation. The choice of repair depends on various patient and disease factors and basic surgical tenets. In this article, we review the current options to consider in the treatment of Crohn's-related RVF, and try to evaluate their effects on fistulae closure and quality of life.     

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.     

Benign rectovaginal fistulas: management and results of a personal series

Background Treatment of benign rectovaginal fistula has a high failure rate and entails difficult decisions. The purpose of this retrospective study was to clarify the concepts which may improve its management. Methods Between 1983 and 2004, 46 consecutive women of median age 41 years were treated by the same surgeon. Etiology of simple fistulas was iatrogenic (n=6), obstetric (n=4) and septic (n=3). Complex fistulas were due to inflammatory bowel diseases (IBD) (n=18, 11 pouchvaginal) or were iatrogenic (n=9), actinic (n=5) or septic (n=1). Surgical techniques included endorectal or vaginal advancement flaps, fistulectomy and sphincteroplasty, vaginal/rectal closure and epiploplasty, restorative proctectomy and restorative proctocolectomy. In 20 patients, a diverting stoma was performed as a single procedure or concomitant to the curative attempt. Results Overall, 33 of the 39 fistulas (85%) treated for cure healed, including all simple fistulas and 20 complex fistulas (8 iatrogenic, 3 actinic, 2 ulcerative colitis without restorative proctocolectomy; 5 pouch vaginal; 1 septic; 1 Crohn’s disease) (p=0.009). The first operation for the fistula was curative in 20 of 39 fistulas, including 10 of 13 simple and 10 of 26 complex fistulas (p=0.023). There was no significant age difference between cured and not-cured patients. Conclusions Simple versus complex fistulas is the most determinant factor for healing. In IBD fistulas, ulcerative colitis shows better prognosis than Crohn’s disease. For complex fistulas, a temporary diverting stoma seems necessary.     

Spontaneous rectovaginal fistula and repair using bulbocavernosus muscle flap

Spontaneous fistula between anorectum and vagina is extremely uncommon. Successful repair depends on etiology, location and the expertise of the surgeon. We report two cases of spontaneous stercoral perforation resulting in rectovaginal fistula (RVF). Both occurred in bedridden patients with fecal impaction. One patient was successfully repaired with a bulbocavernosus (BC) flap interposition. Flap interposition prevents vaginal stenosis in repair of multiple RVF. Received: 23 June 2000 / Accepted in revised form: 17 November 2000     

The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition

Transanal advancement flap repair (TAFR) has been advoated as the treatment of choice for patients with low rectovaginal fistulas. Recently, several studies have reported a significantly lower healing rate. We also encountered low healing rates after TAFR. In an attempt to improve our results, we added labial fat flap transposition (LFFT) to the TAFR of rectovaginal fistulas. The aim of the present study was to evaluate the outcome after TAFR and to investigate the impact of an additional LFFT. Between 1991 and 1997, 21 consecutive patients of median age 33 years underwent TAFR. The etiology of the fistulas was: obstetric injury (n=9), cryptoglandular abscess (n=8) and wound infection after anterior anal repair (n=4). The first 9 patients underwent TAFT with (n=3) or without (n=6) anterior anal repair. In the following 12 patients, LFFT was added to the advancement flap. In 4 of these a concomitant anterior anal repair was performed. The median follow-up was 15 months. The overall healing rate was 48%. In the first 9 patients, in whom no additional LFFT was performed, the rectovaginal fistula healed in 4 cases (44%). In the following 12 patients in whom an additional LFFT was performed, a similar healing rate was observed (50%). In conclusion, the outcome of transanal advancement flap repair of rectovaginal fistulas is poor. Addition of a labial fat flap transposition does not improve this outcome. Received: 25 January 2002 / Accepted in revised form: 6 February 2002     

Does local intestinal ascorbate deficiency predispose to fistula formation in Crohn's disease

Samples of maximally diseased and adjacent macroscopically normal intestine from 52 patients undergoing surgery for Crohn's disease were analyzed for ascorbate content; 26 of the patients had intestinal fistulas and 26 did not. Ascorbate analyses were also performed on samples of normal intestine from ten control patients. Diseased intestine from both groups of patients with Crohn;s disease contained significantly more ascorbate than the adjacent macroscopically normal intestine. Their diseased intestine also contained significantly more ascorbate than normal intestine from controls. Whereas diseased intestine from patients without fistulas contained 47 percent more ascorbate than their normal intestine (P<.001^*), the diseased intestine from patients with fistulas contained only 23 percent more ascorbate than their normal intestine (P<.02^*). Patients with fistulas appear unable to concentrate as much ascorbate in their diseased intestine as patients without fistulas. This difference may be a factor in the pathogenesis of fistula formation in Crohn's disease because of the importance of ascorbate in collagen production.     

The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum

Between 1981 and 1986, transanal rectal advancement flaps were employed in the surgical management of 39 anorectal fistulas at the Cleveland Clinic. Included were 23 low rectovaginal, 12 fistulas-in-ano and, four rectourethral fistulas. Nineteen fistulas occurred in patients with Crohn's disease while the other 20 included 11 due to obstetric or surgical injury. This technique has become the Clinic's standard management for low rectovaginal fistulas but is reserved for complex fistulas-in-ano. Active proctitis or malignancy are contraindications to the procedure. Surgery requires elevation of a broad-based rectal flap, curettage of the tract, and advancement and primary suture of the flap over the internal opening. Fistulas were eradicated in 27 cases (69.2 percent) including 11 of 19 due to Crohn's disease (57.9 percent) and 16 of the 20 (80.0 percent) from other causes (mean follow-up 25 months). Rectovaginal fistulas healed in 60.0 percent of those with Crohn's disease compared with 76.9 percent of those due to other causes. Complex fistulas-in-ano in Crohn's disease did less well. Only two of six of these fistulas healed. Temporary stomal diversion was used on nine occasions and a successful outcome was achieved in only four, indicative of the greater complexity of these cases. It is concluded that the transanal rectal advancement flap can be an effective method of repair for fistulas of the anorectal region including selected cases due to Crohn's disease Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.     

Rectalepidural fistula complicating Crohn's enterocolitis

A previously unreported complication of a patient with Crohn's enterocolitis and internal fistulation is presented. The patient presented with meningeal signs in the lumbosacral region, fever, and sepsis. Computerized axial tomography revealed air in the epidural space, and a presumptive diagnosis of rectalepidural fistula was made. Surgical management included a diverting end sigmoid colostomy and presacral drainage.     

Anal sphincter integrity and function influences outcome in rectovaginal fistula repair

PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defect on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preoperative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry studies. Follow-up was by mailed questionnaire in 36 patients (69 percent) and by telephone interview in 12 (23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18–70) years, and median follow-up was 15 (range, 0.5–123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before surgery. There were 27 endorectal advancement flaps and 35 sphincteroplasties (28 with and 8 without levatoroplasty). RESULTS: Success rates were 41 percent with endorectal advancement flaps and 80 percent with sphincteroplasties (96 percent success with and 33 percent without levatoroplasty;P=0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function(P=not significant). For sphincteroplasties, success rates were 73vs. 84 percent for normal and abnormal sphincter function, respectively (P=not significant). Results were better after sphincteroplastiesvs. endorectal advancement flaps in patients with sphincter defects identified by endoanal ultrasound (88vs. 33 percent;P=not significant) and by manometry (86vs. 33 percent;P = not significant). Poor results correlated with prior surgery in patients undergoing endorectal advancement flaps (45 percentvs. 25 percent;P = not significant) but not sphincteroplasties (80vs. 75 percent;P = not significant). CONCLUSIONS: All patients with rectovaginal fistula should undergo preoperative evaluation for occult sphincter defects by endoanal ultrasound or anal manometry or both procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of previous repairs. Patients with clinical or anatomic sphincter defects should be treated by sphincteroplasty with levatoroplasty.Read at the Minnesota Surgical Society, May 3, 1996, at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996, and at the Tripartite Meeting, July 8 to 10, 1996.     

Enteroduodenal fistulas in Crohn's disease

A case report of a patient suffering from an ileoduodenal fistula due to Crohn's disease is presented. Other reports are reviewed and different views on the treatment of such a fistula are discussed.     

Outcomes After Repair of Rectovaginal Fistulas Using Bioprosthetics

Purpose  The purpose of this study was to report the outcomes with the use of advancement flaps and bioprosthetic grafts for the management of rectovaginal fistulas. Methods  A retrospective analysis of prospectively collected data was performed for all patients treated with a rectovaginal fistula. Results  There were 44 patients in the advancement flap group. A mucosal flap repair was performed for 29 patients, and 15 patients had an anodermal flap repair. The mean follow-up was 10 (range, 6–22) months. There were 34 patients in the bioprosthetic repair group. A bioprosthetic interposition graft was used to repair the fistula in 27 patients with a mean follow-up of 12 (range, 6–22) months, and 7 patients had a bioprosthetic plug repair of their fistula with a mean follow-up of 6 (range, 3–12) months. The fistula recurred in 15 patients (34 percent) who were managed by a flap repair, 5 patients (19 percent) who were managed by a bioprosthetic sheet, and 1 patient (14 percent) who was treated with a bioprosthetic plug. Conclusions  Use of bioprosthetics for the management of rectovaginal fistulas is a new technique, which, based on early experience, seems to yield results equal to advancement flap repair. Dr. Ellis serves as a paid consultant for Cook Surgical. He has a Research Grant from Cook Surgical to study the long-term efficacy of Cook’s Anal Fistula Plug for treatment of anal fistulas.     

Pathophysiology of fistula formation in Crohn's disease

Fistulae represent an important complication in patient suffering from Crohn's disease(CD). Cumulative incidence of fistula formation in CD patients is 17%-50% and about one third of patients suffer from recurring fistulae formation. Medical treatment options often fail and also surgery frequently is not successful. Available data indicate that CD-associated fistulae originate from an epithelial defect that may be caused by ongoing inflammation. Having undergone epithelial to mesenchymal transition(EMT), intestinal epithelial cells(IEC) penetrate into deeper layers of the mucosa and the gut wall causing localized tissue damage formation of a tube like structure and finally a connection to other organs or the body surface. EMT of IEC may be initially aimed toimprove wound repair mechanisms since "conventional" wound healing mechanisms, such as migration of fibroblasts, are impaired in CD patients. EMT also enhances activation of matrix remodelling enzymes such as matrix metalloproteinase(MMP)-3 and MMP-9 causing further tissue damage and inflammation. Finally, soluble mediators like TNF and interleukin-13 further induce their own expression in an autocrine manner and enhance expression of molecules associated with cell invasiveness aggravating the process. Additionally, pathogen-associated molecular patterns also seem to play a role for induction of EMT and fistula development. Though current knowledge suggests a number of therapeutic options, new and more effective therapeutic approaches are urgently needed for patients suffering from CD-associated fistulae. A better understanding of the pathophysiology of fistula formation, however, is a prerequisite for the development of more efficacious medical anti-fistula treatments.     

Efficacy of oral adsorbent for treatment of peristomal fistula associated with Crohn's disease

Perianal fistulae are frequently seen complications in Crohn's disease. Although surgical procedures such as Seton's method have been devised, many patients still suffer from fistulae that are resistant to conventional therapy. We administreved oral adsorbent to a patient with disease Crohn's who had a complicated peristomal fistula that did not improve with conventional therapy. Six grams of oral adsorbent (AST-120) were added daily to a regimen of elemental diet therapy and prednisolone. The fistula gradually decreased in size after the administration of the oral adsorbent, and had healed completely after 40 days' treatment. There were no side effects from the oral adsorbent. This case report suggests that oral adsorbent is an effective treatment for peristomal fistula associated with Crohn's disease. Received: March 31, 1999 / Accepted: August 27, 1999     

Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial toimprove outcomes.     

Novel surgical repair with bilateral gluteus muscle patching for intractable rectovaginal fistula

Abstract. We created a novel surgical repair for intractable rectovaginal fistula and treated four patients who had previously undergone unsuccessful surgery. An X-shaped skin incision was made on the perineum, and then the rectum was carefully divided from the vagina. Defects of both the rectum and the vagina were closed with vertical mattress sutures. The external sphincter muscle also was approximated. The gluteus muscle was identified through another skin incision to the buttock, and cut at the attachment to the femur. Bilateral gluteus muscles were approximated at the midline of the perineum so that the vagina was sufficiently separated from the rectum. Established anorectal angle was 92.5° (SD=6.4°). Mean resting pressure was 101.3 cm H₂O (SD=13.1). All patients retained complete anal function without soiling. The unusual problem of erosion of the posterior vaginal wall with fistulation in a sexually active woman justifies greater efforts, and this surgical technique offers good prospects in this small group of patients.     

The relationship between fistulas in Crohn's disease and associated carcinoma

Patients with carcinoma involving chronic fistulizing Crohn's disease may have developed the malignancy due to chronic epithelial irritation at either end of the fistula tract. Alternatively, the carcinoma may be the cause of the fistula. Examples of each type of relationship are presented in the reports of four patients from our institution and supported by a review of the literature. The diagnoses of such carcinomas are often delayed due to lack of specificity of symptoms and signs. A high index of suspicion and regular surveillance of high-risk patients are recommended.