Rectovaginal fistula in Crohn's disease

Current update on the role of endoanal ultrasound: a primer for radiologists

Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.

Stem Cells and Stem Cell-Derived Factors for the Treatment of Inflammatory Bowel Disease with a Particular Focus on Perianal Fistulizing Disease: A Minireview on Future Perspectives

Inflammatory bowel disease remains a difficult disease to effectively treat, especially fistulizing Crohn's disease. Perianal fistulas in the setting of Crohn's disease remain an area of unmet need with significant morbidity in this patient population. Up to one third of Crohn's patients will have perianal fistulizing disease and current medical and surgical interventions are of limited efficacy. Thus, most patients experience significant morbidity, narcotic use, and loss of employment and end up with multiple surgical interventions. Mesenchymal stem cells (MSCs) have shown efficacy in phase 3 clinical trials, but considerable infrastructure challenges make MSCs limited with regard to scalability in clinical practice. Extracellular vesicles, being derived from MSCs and capturing the secretome functionality of MSCs, offer similar physiological utility regarding mechanism, while also providing an off the shelf regenerative medicine product that could be widely used in daily clinical practice.

Long-term outcomes of intestinal penetrating Crohn's disease following successful nonoperative management

There is a paucity of data on the surgical or medical treatment for abscess/fistula complicating Crohn's disease after successful nonsurgical management. We conducted a cohort study to investigate the long-term outcomes and the risk factors for the requirement of subsequent surgical intervention in Crohn's disease patients with complicating fistulas/abscess following successful nonsurgical management. Data were collected on penetrating Crohn's disease experiencing successful nonsurgical treatment between December 2012 and December 2021. Long-term outcomes and risk factors of surgery were assessed by univariate and multivariate analysis, and subgroup analysis was performed based on penetrating phenotype including abscess, fistula, and phlegmon. A total of 523 penetrating Crohn's disease patients; there were 390, 125, and 60 patients complicated with fistulas, abscess, and phlegmon, respectively. Long-term outcomes showed that BMI < 18.5 (kg/m 2 ), the recurrent abscess, and stricture were independent risk factors of surgery. Biologics and resolution of abscess were independent protective factors of surgery. Furthermore, in 399 patients undergoing early surgery, stricture and BMI < 18.5 (kg/m 2 ) were independent risk factors, and biologics and abscess resolution were protective of the early surgery. Subgroup analysis based on fistula, abscess, and phlegmon phenotype also demonstrated that concomitant stricture was an independent risk factor and the use of biologics was protective of surgical resection. Our data indicate that biologics can delay the requirement of surgery and may be given to patients with penetrating complicating Crohn's disease who have been successfully treated nonoperatively, but surgical resection should be considered in the setting of malnutrition and stenosis formation.

[Interdisciplinary surgical spectrum in cooperation of abdominal surgery and gynecology : What must the (general/abdominal) surgeon know?]

AIM

This short overview aims to concisely outline the most important gynecological issues from a predominantly operative point of view, which could also be relevant for general and abdominal surgeons as well as important gynecological aspects of primarily visceral surgical pathologies.

METHOD

Narrative review on the topic of interdisciplinary cooperation in gynecological/general and abdominal surgery through the use of PubMed® as well as the Cochrane Library with search terms, such as "operative profile of abdominal surgery and gynecology", "interdisciplinary surgery aspects of gynecology/abdominal surgery" as well as "interdisciplinary surgical approach-surgical complication".

RESULTS (MAIN POINTS)

As the close anatomical relationship suggests, numerous primarily gynecological pathologies can also occur in abdominal organs. Likewise, predominantly surgical pathologies can result in involvement of gynecological organs. This can make an intraoperative collaboration necessary. In addition, as a result of diagnostic uncertainty or within the context of complications, interdisciplinary collaboration can also be required preoperatively and postoperatively. Multidisciplinary knowledge as well as close cooperation of the involved specialties can improve the outcome of affected patients.

CONCLUSION

Many pathologies extend not only to the boundaries of an individual discipline but can also affect physiological systems exceeding those limits. Therefore, for an optimal treatment it is necessary to be aware of such aspects of the diseases and to establish structured procedures for interdisciplinary cooperation.

Treatment effect of ex vivo expanded allogeneic bone marrow-derived mesenchymal stem cells for the treatment of fistulizing Crohn's disease are durable at 12 months

BACKGROUND

Mesenchymal stem cells have been administered via direct injection to treat perianal Crohn's fistulizing disease. We herein sought to determine the safety and durability of treatment response to 12 months with 3 individual phase IB/IIA clinical trials of mesenchymal stem cells for refractory perianal, rectovaginal, and ileal pouch fistulas in the setting of Crohn disease.

METHODS

Three phase IB/IIA randomized placebo-controlled single-blinded clinical trials were performed for (1) perianal fistulas, (2) rectovaginal fistula, and (3) ileal pouch in situ with anovaginal and/or perianal fistulas. Bone marrow-derived mesenchymal stem cells (75 million in 7.5 mL) were injected at the time of exam under anesthesia on day 0 and month 3. Outcome measures were adverse events and combined clinical and pelvic magnetic resonance imaging healing at month 6 and month 12.

RESULTS

Across all 3 trials, 64 patients were enrolled; 49 were treatment and 15 were control. At 6 months, combined clinical and radiographic healing was achieved in 83.3%, 33.3%, and 30.8% of the perianal, rectovaginal, and pouch fistula treatment cohorts, respectively. At 12 months, the treatment response was durable, with 67.7% of perianal, 37.5% of rectovaginal, and 46.2% of peripouch fistulas maintaining complete clinical and radiographic healing. Two patients in the perianal fistula control cohort achieved combined clinical and radiographic healing at 12 months, whereas 0% of rectovaginal and pouch control patients healed.

CONCLUSION

Bone marrow-derived mesenchymal stem cells offer a safe and effective alternative treatment approach for severe perianal, rectovaginal, and peripouch fistulizing Crohn's disease. Treatment results are durable at 12 months.

A phase IB/IIA study of ex vivo expanded allogeneic bone marrow-derived mesenchymal stem cells for the treatment of rectovaginal fistulizing Crohn's disease

BACKGROUND

Crohn-related rectovaginal fistulas are notoriously difficult to treat. Studies of mesenchymal stem cells for the treatment of perianal Crohn fistulizing disease have largely excluded rectovaginal fistulas. The aim of this study was to determine the safety and efficacy of mesenchymal stem cells for refractory rectovaginal fistulizing Crohn disease.

METHODS

A phase IB/IIA randomized control trial was performed in a 3:1, single-blinded study. Patients included were adult women with an anovaginal/rectovaginal fistula in the setting of Crohn disease. Seventy-five million mesenchymal stem cells were administered with a 22G needle after curettage and primary closure of the fistula tract at day 0 and month 3. Adverse and serious adverse events were recorded at post-procedure day 1, week 2, week 6, month 3, month 6, and month 12, along with clinical healing, magnetic resonance imaging, and patient-reported outcomes.

RESULTS

A total of 19 patients were enrolled and treated-15 treatment and 4 control. There were no adverse or serious adverse events related to mesenchymal stem cell therapy. At 6 months, 50% of the treatment group and 0% of the control had complete clinical and radiographic healing; 91.7% of the treatment group had improvement at 6 months with only one patient having a lack of response, whereas only 50% of the control group had improvement at 6 months.

CONCLUSION

Bone marrow-derived mesenchymal stem cells offer a safe alternative treatment approach for rectovaginal fistulas in the setting of Crohn disease. Complete healing was achieved in half of the patients.

Surface-enhanced Raman spectroscopy analysis reveals biochemical difference in urine of patients with perianal fistula

BACKGROUND & AIMS

Perianal fistulising Crohn's disease (PFCD) is different from the characteristics and outcomes of traditional non-inflammatory bowel disease (IBD) anal fistulas. The presence of perianal disease was a poor prognostic indicator for Crohn's disease (CD) patients and PFCD patients were more likely to bear an increased risk of recurrence. However, the effective and accurate diagnosis methods to early distinguish PFCD from simple perianal fistula were still scarce. The purpose of this study is to develop a non-invasive detecting approach to predict CD in patients with perianal fistulas.

METHODS

Data on patients with anal fistulizing disease were collected from July 2020 to September 2020 in two IBD centers. Urine samples from PFCD and simple perianal fistula patients were investigated by surface-enhanced Raman spectroscopy (SERS). Principal component analysis (PCA)-support vector machine (SVM) was utilized to establish classification models to distinguish PFCD from simple perianal fistula.

RESULTS

After a case-matched 1:1 selection by age and gender, 110 patients were included in the study. By analyzing the average SERS spectra of PFCD and simple perianal fistula patients, it revealed that there were significant differences in intensities at 11 Raman peaks. The established PCA-SVM model distinguished PFCD from simple perianal fistula with a sensitivity of 71.43%, specificity 80.00% and accuracy 75.71% in the leave-one-patient-out cross-validation. The accuracy of the model in validation cohort was 77.5%.

CONCLUSIONS

Investigation of urine samples by SERS helps clinicians to predict Crohn's disease from perianal fistulas, which make patients achieve benefit from a more individualized treatment strategy.

Combined clinical and radiological remission of rectovaginal fistulas using fractional CO2 vaginal laser: a case series and medium-term follow-up

INTRODUCTION

Despite the advances in surgical and clinical approaches, there is no consensus regarding the best line of treatment from rectovaginal fistula (RVF). Faced with a challenging scenario in the approach of RVF, the fractional CO2 laser receives attention as a possible form of treatment.

OBJECTIVES

A single-center, prospective, open-label study evaluating the effectiveness and safety of laser therapy for RVF treatment.

SUBJECTS AND METHODS

The total of 15 patients was recruited at the Juiz de Fora University Hospital between August 2018 and July 2022. Inclusion criteria were presence of clinically suspects RVF of any etiology confirmed by pelvic magnetic resonance image (MRI) and gynecological examination. Five fractional CO2 laser sessions with monthly interval followed by complete evaluation through clinical examination and pelvic MRI were performed for all patients after the completion of treatment. Analysis of sexual function before and after the treatment was performed using Female Sexual Quotient (FSQ).

RESULTS

The evaluation through physical examination showed no persistent inflammatory signs in the vagina for all patients. Additionally, 10 of out 15 (67.7%) patients achieved clinical remission of RVF symptoms, while 33.3% patients reported significant improvement. Of note, five patients who did not have previous sexual activity returned to regular sexual activity while seven patients who have baseline sexual activity had improvement in their sexual function as assessed by the FSQ. Three out of four ostomized patients had their ostomy reversed and remained without complains. All six patients with RVF secondary to Crohn's disease reported a marked improvement in symptoms and sexual function. In seven (47%) patients radiological remission was confirmed by pelvic MRI.

CONCLUSION

CO2 fractional laser can be considered a promising and safe therapeutic alternative for the management of RVF.

Chronic Pelvic Pain: Role of Imaging in the Diagnosis and Management

Chronic pelvic pain (CPP) in women is not uncommon, and it may be difficult to identify the exact cause difficult to manage. It is major health problem for women that affects the quality of their daily lives. The etiology of chronic pelvic pain may be of gynecological or non-gynecological origin and associated with several predisposing and precipitating factors. Psychological and social factors also contribute to the syndrome of CPP and must be evaluated before managing these patients. Due to multifactorial etiology, CPP needs a multidisciplinary approach for diagnosis and management. A detailed history and physical examination supported by appropriate laboratory tests and imaging are the keys to diagnosis. In this paper, the role of imaging in diagnosis and management of CPP is reviewed. Imaging findings should be correlated with detailed clinical examination findings as there are imaging findings that may be unrelated and not the cause of CPP in a particular patient, imaging findings should be correlated with the clinical circumstances.

Perioperative Factors Affecting the Healing of Rectovaginal Fistula

Rectovaginal fistula is rare, but a severe complication in gynecology, which despite the effort of clinicians is still not treated successfully in many cases. According to statistics, the healing rates of surgery in patients with RVF range from 20 to 100%. The treatment effectiveness depends on the etiology of fistula, the age of the patients, the presence of comorbidities, the type of surgery and many other factors. Considering the low efficiency of treatment and the high risk of recurrence, the question of possible methods to improve the results occurs. In our review, we analyzed both modifiable and non-modifiable factors which may influence the treatment, healing rate and future fate of the patients. Taking into account all analyzed risk factors, including age, comorbidities, smoking status, microbiology, medications, stoma and stool features, we are aware that rectovaginal fistula's treatment must be individualized and holistic. In cases of poorly healing RVF, the drainage of feces, the use of antibiotic prophylaxis or the implementation of estrogen therapy may be useful. Moreover, microbiome research in women with RVF and towards estrogen therapy should be performed in order to create treatment algorithms in women with fistulae. Those interventions, in our opinion, may significantly improve the outcome of the patients.

Fibrin Glue Repair of a Traumatic Rectovaginal Fistula in a Pediatric Patient

BACKGROUND

Rectovaginal fistulas are often associated with obstetric trauma and present with leakage of stool or flatus from the vagina. They are often repaired via fistulaectomy, but sometimes more complex repairs are needed. There are limited data regarding success using fibrin glue to close the tract.

CASE

A developmentally delayed pediatric patient presented with right hip pain. Imaging studies identified a hairpin penetrating the rectovaginal space. The hairpin was removed during an exam under anesthesia, and the subsequent rectovaginal fistula was closed with fibrin glue. Closure of the tract has persisted for more than 1 year without need for further intervention.

SUMMARY AND CONCLUSION

Fibrin glue may be a minimally invasive and safe approach for rectovaginal fistulas in the pediatric patient.

Predictors of outcome for treatment of enterovaginal fistula : Therapeutical strategies for treatment

BACKGROUND

Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary.

METHODS

The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure.

RESULTS

Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031).

CONCLUSION

Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.

What is the best surgical option after failure of graciloplasty in patients with recurrent rectovaginal fistula? A study of 19 consecutive patients

BACKGROUND

Management of recurrent rectovaginal fistula (rRVF) remains challenging despite the good results of graciloplasty reported in the literature. However, little is known about how to avoid a permanent stoma if graciloplasty fails. The aim of our study was to report the management of rRVF after failure of graciloplasty.

METHODS

A retrospective study was performed on consecutive patients with rRVF after failure of graciloplasty treated at our institution in January 2005-December 2021.

RESULTS

There were 19 patients, with a median age at graciloplasty of 39 years (range 25-64 years). Etiologies of RVF were Crohn's disease (CD) (n = 10), postoperative (n = 5), post-obstetrical (n = 3), and unknown (n = 1). After failure of graciloplasty, 45 new procedures were performed, all of them with a covering stoma: trans-anal repairs (n = 31), delayed colo-anal anastomosis (DCAA) (n = 4), biological mesh interposition (n = 3), second graciloplasty (n = 3), stoma only (n = 2) and redo ileal pouch-anal anastomosis (IPAA) (n = 2). One patient was not re-operated on and instead treated medically for CD. After a mean follow-up of 63 ± 49 months, success (i.e., absence of stoma or RVF) was obtained in 11 patients (58%): 4/4 DCAA (100%), 5/31 after local repair (16%), 1 after stoma creation alone (50%) and 1 after redo IPAA (50%). Second graciloplasty and biologic mesh interposition all failed. All 8 patients with failed intervention had CD.

CONCLUSIONS

In cases of rRVF after failed graciloplasty, reoperation is possible, although the chance of success is relatively low. The best results were obtained with DCAA. CD is a predictor of poor outcome.

Rectovaginal Fistula in Crohn's Disease: When and How to Operate?

Rectovaginal fistula (RVF) occurring during the course of Crohn's disease (CD) constitutes a therapeutic challenge and is characterized by a high rate of recurrence. To optimize the outcome of CD-related RVF repair, the best conditions for correct healing should be obtained. Remission of CD should be achieved with no active proctitis, the perianal CD activity should be minimized, and local septic complications should be controlled. The objective of surgical repair is to close the fistula tract with minimal recurrence and functional disturbance. Several therapeutic strategies exist and the approach should be tailored to the anatomy of the RVF and the quality of the local supporting tissues. Herein, we review the medical and surgical management of CD-related RVF.

Surgical treatment of rectovaginal fistula-predictors of outcome and effects on quality of life

PURPOSE

To determine the results after rectovaginal fistula (RVF) repair and find predictors of outcome. Primary objective was fistula healing. Secondary outcomes were morbidity and patient health-related quality of life (HRQoL).

METHOD

An observational study of 55 women who underwent RVF repair including both local procedures and tissue transposition 2003-2018 was performed. Baseline patient and fistula characteristics were registered, combined with a prospective HRQoL follow-up and a general questionnaire describing fistula symptoms.

RESULTS

Healing rate after index surgery was 25.5% (n = 14) but the final healing rate was 67.3% (n = 37). Comparing the etiologies, traumatic fistulas (iatrogenic and obstetric) had the highest healing rates after index surgery (n = 11, 45.9%) and after repeated operations at final follow-up (n = 22, 91.7%) compared with fistulas of inflammatory fistulas (Crohn's disease, cryptoglandular infection, and anastomotic leakage) that had inferior healing rates after both index surgery (n = 7, 7.1%) and at final follow-up (n = 13, 46.4%). Fistulas of the category others (radiation damage and unknown etiology) included a small amount of patients with intermediate results at both index surgery (n = 1, 33.3%) and healing rate at last follow-up (n = 2, 66.7%). The differences were statistically significant for both index surgery (p = 0.004) and at final follow-up (p = 0.001). Unhealed patients scored lower than both healed patients and the normal population in 6/8 Rand-36 domains, but the differences were not statistically significant.

CONCLUSIONS

Most traumatic rectovaginal fistulas closed after repeated surgery whereas inflammatory fistulas had a poor prognosis. Low healing rates after local repairs suggest that tissue transfer might be indicated more early in the treatment process. Unhealed fistulas were associated with reduced quality of life. Trial registration Clinicaltrials.gov No. NCT05006586.

ACR Appropriateness Criteria® Anorectal Disease

This review summarizes the relevant literature for the selection of the initial imaging in 4 clinical scenarios in patients with suspected inflammatory disease or postoperative complication of the anorectum. These clinical scenarios include suspected perianal fistula or abscess; rectovesicular or rectovaginal fistula; proctitis or pouchitis; and suspected complication following proctectomy, coloproctectomy, or colectomy with a pouch or other anastomosis. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of anorectal disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Adipose-Derived Stem Cells in the Treatment of Perianal Fistulas in Crohn's Disease: Rationale, Clinical Results and Perspectives

Between 20 to 25% of Crohn’s disease (CD) patients suffer from perianal fistulas, a marker of disease severity. Seton drainage combined with anti-TNFα can result in closure of the fistula in 70 to 75% of patients. For the remaining 25% of patients there is room for in situ injection of autologous or allogenic mesenchymal stem cells such as adipose-derived stem/stromal cells (ADSCs). ADSCs exert their effects on tissues and effector cells through paracrine phenomena, including the secretome and extracellular vesicles. They display anti-inflammatory, anti-apoptotic, pro-angiogenic, proliferative, and immunomodulatory properties, and a homing within the damaged tissue. They also have immuno-evasive properties allowing a clinical allogeneic approach. Numerous clinical trials have been conducted that demonstrate a complete cure rate of anoperineal fistulas in CD ranging from 46 to 90% of cases after in situ injection of autologous or allogenic ADSCs. A pivotal phase III-controlled trial using allogenic ADSCs (Alofisel^®) demonstrated that prolonged clinical and radiological remission can be obtained in nearly 60% of cases with a good safety profile. Future studies should be conducted for a better knowledge of the local effect of ADSCs as well as for a standardization in terms of the number of injections and associated procedures.

Treatment of Rectovaginal Fistula Using Fractionate CO2 Vaginal Laser: A Case Series

Background: Rectovaginal fistulas (RVFs) are abnormal tracts that connect the lower gastrointestinal tract with the vagina. They can result from obstetric trauma, infection, local surgeries, cancer, radiation damage, and Crohn's disease. Despite the advances in surgical and clinical treatment, there is no consensus regarding the best line of treatment. Objective: To report five cases of patients with RVF submitted to intravaginal CO2 fractional laser treatment, as a complementary and additional therapeutic option in this scenery. Materials and methods: Five laser sessions with monthly intervals followed by complete evaluation through clinical examination and magnetic resonance imaging of the pelvis were performed for all patients. Results: Three patients had complete resolution of symptoms after the end of planned vaginal laser sessions, whereas two patients reported significant improvement in symptoms. Four patients who had stopped having sex due to their condition admitted to resuming regular sexual activity. In addition, all five patients had closure of the fistulous track confirmed by pelvic MRI. No adverse events from vaginal laser therapy were reported by any of the patients. Conclusions: We believe this method to be a complementary, promising, and safe therapeutic alternative for the management of RVF. It may potentially enable return to regular sexual activity. Future studies using this therapeutic strategy are needed to confirm the efficacy and safety of this method in this clinical setting. Clinical trial registration no.: CAAE 93673618.4.0000.5133.

Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach

BACKGROUND

Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD.

METHODS

A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure.

RESULTS

Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007).

CONCLUSIONS

The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

The use of magnetic resonance imaging technique and 3D printing in order to develop a three-dimensional fistula model for patients with Crohn's disease: personalised medicine

Introduction

Preoperative evaluation of magnetic resonance (MR) images may not be sufficient for the precise planning of anal fistula surgery or for stem cell therapy. Three-dimensional (3D) printing allows one to obtain spatial structures in a 1 : 1 scale with unprecedented precision.

Aim

To combine magnetic resonance imaging (MRI) with 3D printing for more precise visualisation of perianal Crohn’s disease.

Material and methods

MRI at 1.5T and a 3D printer were used. DICOM (Digital imaging and communications in medicine) images were imported into 3D Slicer v.4.8.0. Firstly, anal fistula was modelled on the basis of axial images. Fistula locations, the anus and anal canal, were marked with different coloured markers. The last step was to mark the skin that was connected to the anus and contact areas of the fistula with the skin. The prepared models were then exported to an STL format file. The anal fistula model was printed using a 3D printer. The development of the model, including printing, took approximately 6 h.

Results and conclusions

The accessibility of a rotatable 3D model before surgery allows for a more precise detection of the location and the degree of perianal disease. Moreover, this may also lower the inter-observer bias connected with interpretation of complex MR imaging before planned surgery. Development of MRI image transfer to 3D printing and the decreasing cost of 3D printers suggests a promising future of this technology in medical applications.

Assessing the previously repaired patient with an anorectal malformation who is not doing well

In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are 'not doing well' following their primary reconstruction.

Matrix-Delivered Autologous Mesenchymal Stem Cell Therapy for Refractory Rectovaginal Crohn's Fistulas

BACKGROUND

Crohn's rectovaginal fistulizing disease remains notoriously difficult to treat. A phase I clinical trial to evaluate the safety and feasibility of a novel protocol using a mesenchymal stem cell (MSC)-coated Gore Bio-A fistula plug for the treatment of medically and surgically refractory Crohn's rectovaginal fistulas was conducted.

METHODS

Five patients underwent an autologous subcutaneous adipose tissue harvest via a 2-cm abdominal wall incision at time of exam under anesthesia (EUA) with seton placement. MSCs were isolated, expanded, and impregnated on the plug. After 6 weeks, patients returned to the operating room for placement of the MSC-coated plug. The primary end points were safety and feasibility; the secondary end point was clinical and radiographic healing at 6 months.

RESULTS

Five female patients (median age [range], 49 [38-53] years) with a median disease duration (range) of 23 (7-34) years who were on biologic (n = 5) or combination therapy (n = 3) had successful harvest and expansion of MSCs and delivery of the Gore Bio-A plug. There were no serious adverse events or adverse events related to the MSCs or plug during the 6-month follow-up. At 6 months, 3 patients had complete cessation of drainage, and 2 had >50% reduction in drainage; all had a persistent fistula tract identified on magnetic resonance imaging and EUA at 6 months.

CONCLUSIONS

Surgical placement of an autologous adipose-derived MSC-coated fistula plug in diverted patients with Crohn's rectovaginal fistulas was safe and feasible. All patients had a reduction in the size of their fistula tract, and 3 of 5 had cessation of drainage, but none achieved complete healing.This was a phase I clinical trial of autologous mesenchymal stem cells on a plug for rectovaginal Crohn's fistulas.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.

Rectoperineal Fistula Repair Through Perineal Approach, Martius Flap, and House Advancement Flap

A rectoperineal fistula (RPF) is a relatively rare, non-life-threatening form of anorectal malformation that nevertheless causes significant physical discomfort, and remains technically challenging for surgeons to treat. We present a case of a 72-year-old female with a history of a recurrent perianal fistula with multiple approaches including endorectal advancement flap previously attempted. Our procedure involved laparoscopic loop ileostomy with transversus abdominis plane (TAP) block, and RPF repair through the perineal approach with primary repair involving Martius flap and house advancement flaps. The patient tolerated the procedure well with no known peri-operative complications and resolution of stool incontinence at subsequent post-operative visits, the first within a month of the procedure. This case was used to demonstrate and highlight the surgical technique of the RPF repair by Martius flap. Informed consent was obtained from the patient for video recording for educational purposes.

Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences

Purpose

Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures.

Methods

Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted.

Results

The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058).

Conclusion

Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.

Treatment Strategies in Crohn's-Associated Rectovaginal Fistula

Rectovaginal fistula (RVF) is a rare, but dreaded complication of Crohn's disease (CD) that is exceedingly difficult to manage. Treatment algorithms range from observation and medical therapy to local surgical repair and proctectomy. The multitude of surgical options and lack of consensus between experts speak to the complexity and shortcomings encountered to correct this disease process surgically. The key to successful management of these fistulae therefore rests on a multidisciplinary approach between the patient, gastroenterologists, and surgeons, with open communication about expectations and goals of care. In this article, we review the management of CD-associated RVF with an emphasis on surgical technique.

Stem cell therapy for perianal Crohn's

PURPOSE OF REVIEW

Perianal Crohn's disease is a morbid and disabling condition, notoriously difficult to successfully treat with conventional medical and surgical therapies. Mesenchymal stem cells (MSCs) are an emerging novel therapy for perianal Crohn's disease.

RECENT FINDINGS

Over 300 patients with perianal Crohn's disease have now been treated with MSCs in the context of clinical trials. All trials have demonstrated safety, and efficacy superior to conventional therapy with biologics and surgical intervention. This was consistent despite the heterogeneity in study protocols including variability in cell dosing, mode of delivery, repeat dosing, and allogeneic versus autologous donors. Sustained healing to 1 year has also been demonstrated in a recent extension of the largest phase III study confirming superior efficacy of MSCs to placebo at 1-year follow-up. However, several outstanding questions regarding the use of MSCs for perianal Crohn's disease remain, which, if answered, could enhance MSCs' treatment efficacy. These include defining the optimal MSC donor, optimal MSC source (e.g., bone marrow versus adipose tissue), investigating a potential alloimmune response following allogeneic cellular delivery, and determining the optimal mode for MSC delivery. In addition to these unanswered questions, significant challenges in the required infrastructure and cost required for cell-based therapies may drive future research toward identifying novel acellular therapies.

SUMMARY

Novel regenerative therapies offer promising new treatment options for perianal Crohn's disease, without the risk of opportunistic infection seen with biologics and incontinence with surgical techniques. Future research will help define the optimal MSC product and treatment protocol, and may even expand our horizon of regenerative medicine into acellular therapy as well as cell-based therapies.

Stem Cell Therapies for Inflammatory Bowel Disease

PURPOSE OF REVIEW

Stem cell therapies have demonstrated safety and efficacy in the treatment of perianal Crohn's disease as compared to conventional therapy. Thus, an understanding of their place in the treatment algorithm for inflammatory bowel disease has become imperative as we move into an era of regenerative medicine.

RECENT FINDINGS

There have now been over a dozen clinical trials highlighting stem cells as a useful therapeutic in Crohn's disease. Due to the success in the local treatment for perianal Crohn's disease, investigation is continuing in the space of targeted systemic delivery for the treatment of luminal disease. As we increase the number of patients treated in clinical trials, it is imperative to define the optimal cell donor, optimize treatment dosing and retreatment protocols, and understand methods for safely targeting and treating intraluminal disease.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease

Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.

Anti-TNF therapy for genital fistulas in female patients with Crohn's disease: a nationwide study from the Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID)

BACKGROUND

Genital fistulas represent a devastating complication of Crohn's disease. Only studies with small sample sizes have evaluated the efficacy of anti-TNF therapy for this complication.

AIMS

To assess the efficacy of anti-TNF therapy for genital fistulas complicating Crohn's disease and to identify predictive factors associated with clinical response at 1 year.

METHODS

Consecutive patients treated with anti-TNF therapy for genital fistulas complicating Crohn's disease from 1999 to 2016 in 19 French centres from the Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif were included in a retrospective cohort study. Outcome was clinical fistula closure at 1 year.

RESULTS

Among the 204 women with genital fistulas who received anti-TNF therapy, 131 were analysed. The first anti-TNF given was infliximab (79%), adalimumab (20%), or certolizumab (1%). At start of anti-TNF therapy, 56% of patients had seton drainage and 53% had concomitant immunosuppressive treatment. A complementary surgery was performed during the first year in 10 patients (8%). At 1 year, 37% of patients had complete clinical fistula closure, 22% had a partial response, and 41% had no response. Among patients without complementary surgery, 34% (41/121) had complete clinical fistula closure. Only complementary surgery was associated with better response on multivariate analysis (adjusted relative risk: 2.02, 95% CI: 1.25-3.26, P = 0.0043).

CONCLUSIONS

In the anti-TNF era, approximately one-third of patients with genital fistula in Crohn's disease had complete fistula closure at 1 year. Collaboration between surgeons and gastroenterologists appears to be very important to improve the rate of fistula closure.

MR Imaging of Perianal Fistulas

In this article, we begin with an introduction of the perianal region anatomy, then review the definition, etiology, epidemiology, and 2 major classification systems of perianal fistulas. The role of MR imaging for assessment of perianal fistulas is mainly discussed. Finally, the medical and surgical treatment principles are reviewed.

Martius' flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn's disease, endometriosis and a mullerian anomaly

Background

Rectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn’s disease that negatively affects patients’ social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options.

Case presentation

We describe a 31-year-old female patient with a Crohn’s disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient’s medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius’ flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy.

Conclusion

Martius’ flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn’s disease.

The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate.

MR Imaging of Perianal Crohn Disease

Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. ^© RSNA, 2017 Online supplemental material is available for this article.

Enterovaginal or Vesicovaginal Fistula Control Using a Silicone Cup

BACKGROUND

An enterovaginal or vesicovaginal fistula is a complication resulting in vaginal discharge of succus, urine, or stool that can lead to significant complications. For low-volume fistulae, tampons or pads may be used. With high-volume fistulae, frequent product change can be painful and unpredictable in terms of efficacy. The psychologic distress is profound. Surgery may not be an option, making symptom control the priority.

INSTRUMENT

We report the use of a reusable menstrual silicone vaginal cup placed to divert and contain drainage.

EXPERIENCE

The menstrual cup provided significant symptom relief. Drainage is immediately diverted from tissue, unlike with tampon or pad use, which involves longer contact periods with caustic fluids. A system was created by adapting the end of the cup by adding silastic tubing and an external leg bag to provide long-term drainage control.

CONCLUSION

Improvement in quality of life is of primary importance when dealing with fistula drainage. This simple and inexpensive device should be considered in those cases in which the drainage can be diverted as a viable option, especially in those who are symptomatic and awaiting surgical repair or in those for whom surgery cannot be performed.

Successful Laparoscopic Treatment for Refractory Rectovaginal Fistula of Behçet's Disease: A Case Report and Review of the Literature

Rectovaginal fistula caused by Behçet's disease is extremely rare, and the clinical course is very unfavorable. We describe rectovaginal fistula of Behçet's disease with successful laparoscopic treatment and review the literature. A 30-year-old woman with Behçet's disease was diagnosed with rectovaginal fistula and treated medically after fecal diversion colostomy. However, the fistula remained, and she underwent radical surgery. Laparoscopically, after mobilization of the rectum, the fistula was removed. The rectum was transected on the anal side of the fistula and removed after extraction through the vaginal incision. The vaginal incision was repaired by suturing, and rectal anastomosis was performed using a double-stapling technique. The omentum was fixed between the rectum and vagina, and the operation was completed. Six months after the laparoscopic surgery, no evidence of fistula recurrence has been seen on colonoscopy. We have reported a rare case of rectovaginal fistula of Behçet's disease treated with an altogether new surgical approach that might prove effective for refractory rectovaginal fistula.

A Systematic Review Assessing Medical Treatment for Rectovaginal and Enterovesical Fistulae in Crohn's Disease

BACKGROUND

Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management.

AIM OF THE STUDY

The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment.

METHOD

A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed.

RESULTS

Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response.

CONCLUSIONS

Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.

Should Immunomodulation Therapy Alter the Surgical Management in Patients With Rectovaginal Fistula and Crohn's Disease?

BACKGROUND

Rectovaginal fistula in Crohn's disease is challenging for both healthcare providers and patients. The impact of immunomodulation therapy on healing after surgery is unclear.

OBJECTIVE

The purpose of this study was to examine whether immunomodulation therapy impacts healing after surgery for rectovaginal fistula in Crohn's disease.

DESIGN

This was a retrospective analysis with a follow-up telephone survey.

SETTINGS

The study was conducted at two major tertiary referral centers.

PATIENTS

All of the patients who underwent rectovaginal fistula repair from 1997 to 2013 at our centers were included.

MAIN OUTCOME MEASURES

A χ test and logistical regression analysis were used to study treatment outcomes according to type of procedure, recent use of immunosuppressives, and number of previous attempted repairs. Age, BMI, smoking, comorbidities, previous vaginal delivery/obstetric injury, use of probiotics, diverting stoma, and use of seton were also analyzed.

RESULTS

A total of 120 (62%) patients were contacted, and 99 (51%) of them agreed to participate in the study. Mean follow-up after surgical repair was 39 months. Procedures included advancement flap (n = 59), transvaginal repair (n = 14), muscle interposition (n = 14), episioproctotomy (n = 6), sphincteroplasty (n = 3), and other (n = 3); overall, 63% of patients experienced healing. Sixty-eight patients underwent recent immunomodulation therapy but did not exhibit statistical significance in outcome after surgical repair. In the subset of patients with fistula related to obstetric injury, a 74% (n = 26) healing rate after surgical repair was observed. Age, BMI, diabetes mellitus, use of steroids, probiotics, seton before repair, fecal diversion, and number of repairs did not affect healing.

LIMITATIONS

This was a retrospective analysis; the high volume tertiary referral inflammatory bowel disease centers studied may not be reflective of rectovaginal fistula presentation, treatment, or results in all patients, and the 3-year follow-up may not be sufficiently long.

CONCLUSIONS

Despite a relatively low success rate (63%) in healing after surgical repair of a rectovaginal fistula, the recent use of immunomodulation therapy did not negatively impact healing. However, tissue interposition techniques had the highest success rates.

Predictors of Outcome of Rectovaginal Fistula Surgery in Women With Crohn's Disease

Background

Despite measures taken to control traditional risk factors like increased rectal disease activity, anorectal stenosis, and, to a lesser extent, obesity, rates of poor outcomes after rectovaginal fistula (RVF) surgery in women with Crohn’s disease (CD) are still high and require further elucidation. To bridge the gap, we sought to identify risk factors beyond the aforementioned determinants that may be associated with poor outcomes in these patients.

Methods

We designed a retrospective, unmatched, case-control study to test our hypothesis. The population comprised women with CD who underwent RVF surgery between the years of 2000 and 2013. Cases were defined as surgeries with an unsuccessful outcome at 4 weeks post-surgery, and controls represented those with a successful outcome at 4 weeks post-surgery. With multivariable logistic regression models, we sought to identify pertinent risk factors for poor outcomes after RVF surgery in these women.

Results

Of the 108 women with CD who were referred to our institution for evaluation of RVFs between 2000 and 2013, 39 underwent a total of 63 surgeries, of which 16 were cases and 47 were controls. There were no significant differences between them with regard to medications and clinical or mucosal disease severity, but a significantly higher proportion of poor outcomes arose from the group of women who underwent a mucosal flap procedure (88%) compared to those who had a seton placed (13%; P = 0.0004). The final adjusted logistic regression model demonstrated that women who underwent a mucosal flap procedure instead of a seton placement were 17.5 times more likely to have a poor surgical outcome (odds ratio (OR): 17.51; 95% confidence interval (CI): 3.12 - 98.43; P = 0.0012). Moreover, it was seen that women with active colonic mucosal disease, independent of rectal disease activity, were 4.4 times more likely to have a poor outcome (OR: 4.40; 95% CI: 1.06 - 18.26).

Conclusion

Mucosal flap procedures, representing the second, or definitive, stage in surgical treatment of RVF are associated with much worse outcomes and therefore should be preceded by aggressive medical optimization of the patient.

Early Diagnosis of a Small Adenocarcinoma in a Rectovaginal Fistula Related to Crohn's Disease

While adenocarcinomas have occasionally been reported in perianal fistulae, malignant changes occurring in rectovaginal fistulae are rare, with only a handful of reported cases. We report a 73-year-old woman with Crohn's disease who was diagnosed at an early stage with adenocarcinoma in a rectovaginal fistula. This rare disease poses many diagnostic challenges.

The results of seton drainage combined with anti-TNFα therapy for anal fistula in Crohn's disease

AIM

Combined infliximab and sphincter-sparing surgery can be effective in perianal fistula associated with Crohn's disease (CD). This study aimed to assess the efficacy of local surgery combined with infliximab on sustained fistula closure and to identify predictive factors for response after this combined treatment.

METHOD

Between 2000 and 2010, 81 patients with fistulising perianal CD were included in this observational study. Drainage with a loose seton was followed by infliximab therapy. The primary end-points were the rate of complete fistula closure and time required for this to occur.

RESULTS

The fistula was complex in 71 (88%) of the 81 patients. Local proctological surgery was carried out in 77 (95%), including seton drainage in 62 (80.5%) of these. This was continued for a median duration of 3.8 months and the patient then received infliximab therapy. The median follow-up after treatment was 64 months (2-263). Initial complete closure of the fistula occurred in 71 (88%) cases at a median interval of 12.4 months (1-147) from the start of treatment. Recurrence was observed in 29 (41%) patients at a median interval of 38.5 months (2-48) from the start of treatment. They were treated again with combined treatment with successful closure in 19 (65.5%) patients. The total rate of closure of the fistula was 75.3%. Female gender, anal stenosis, rectovaginal and complex fistula formation were factors independently associated with failure of combined treatment.

CONCLUSION

Seton drainage for several months combined with infliximab therapy is effective in closing the fistula in 75% of patients with complex perianal fistula formation associated with CD.

Contemporary surgical management of rectovaginal fistula in Crohn's disease

Rectovaginal fistula is a disastrous complication of Crohn’s disease (CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a women’s quality of life. Successful management is possible only after accurate and complete assessment of the entire gastrointestinal tract has been performed. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics. Before treatment is undertaken, establishing reasonable goals and expectations of therapy is essential for both the patient and surgeon. This article aims to highlight the various surgical techniques and their outcomes for repair of CD associated rectovaginal fistula.

Novel treatment for recalcitrant rectovaginal fistulas: fat injection

INTRODUCTION AND HYPOTHESIS

The treatment of recurrent rectovaginal fistula (RVF) is a challenge for the surgeon. Within plastic surgery fat harvesting and subsequent transplantation by injection is an established method for soft tissue augmentation. We hypothesized whether soft tissue augmentation by transperineal injection of autologous fat could stimulate fistula healing in women with recalcitrant RVF.

MATERIALS AND METHODS

Six patients with a recalcitrant RVF, 4 due to obstetric injury and 2 associated with Crohn's disease, were included in the pilot study. The fat graft from the lower abdomen was injected transperineally around the fistula tract. At the end of the injection procedure the fistula tract was transected transversely.

RESULTS

In 1 patient the fistula healed after a single treatment, while the other 5 required two treatments with a 6-week interval. In the patients with an RVF due to obstetric injury no recurrence occurred during follow-up, mean 41 months (range 4-53). In the 2 patients with Crohn's disease a new fistula developed after 23 and 25 months respectively.

CONCLUSION

We describe fat injection as a new and promising method for the treatment of a recalcitrant RVF where previous attempts had failed to heal the fistula. This method does not include wide dissection, thereby reducing the risk of injury to important neurovascular structures. The method is minimally invasive and causes minimal donor site morbidity. More advanced techniques can still be used in cases of recurrence.