Long-term efficacy of the button fistula plug in the treatment of Ileal pouch-vaginal and Crohn's-related rectovaginal fistulas

Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review

BACKGROUND

First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review.

METHODS

A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure.

RESULTS

Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%).

CONCLUSION

Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes

BACKGROUND

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

AIMS

To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

METHODS

A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

RESULTS

34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

CONCLUSION

PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

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.

Refining Approaches to Surgical Repair of Rectovaginal Fistulas

INTRODUCTION

Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics.

METHODS

A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques.

RESULTS

Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles.

CONCLUSIONS

Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.

Rectovaginal Fistulas Secondary to Obstetrical Injury

Rectovaginal fistula (RVF), defined as any abnormal connection between the rectum and the vagina, is a complex and debilitating condition. RVF can occur for a variety of reasons, but frequently develops following obstetric injury. Patients with suspected RVF require thorough evaluation, including history and physical examination, imaging, and objective evaluation of the anal sphincter complex. Prior to attempting repair, sepsis must be controlled and the tract allowed to mature over a period of 3 to 6 months. All repair techniques involve reestablishing a healthy, well-vascularized rectovaginal septum, either through reconstruction with local tissue or tissue transfer via a pedicled flap. The selection of a specific repair technique is determined by the level of the fistula tract and the status of the anal sphincter. Despite best efforts, recurrence is common and should be discussed with patients prior to repair. As the ultimate goal of RVF repair is to minimize symptoms and maximize quality of life, patients should help to direct their own care based on the risks and benefits of available treatment options.

Gracilis pull-through flap for the repair of a recalcitrant recto-vaginal fistula

Recto-vaginal fistulas are difficult to treat due to their high recurrence rate. Currently, no single surgical intervention is universally regarded as the best treatment option for rectovaginal fistulas. We present a case of recurrent recto-vaginal fistula surgically treated with a gracilis pull-through flap. The surgical goals in this patient were complete excision of the recto-vaginal fistula and introduction of fresh, vascularized muscle to seal the fistula. A defunctioning colostomy was performed 1 month prior to the present procedure. The gracilis muscle and tendon were mobilized, pulled through the freshened recto-vaginal fistula, passed through the anus, and anchored externally. Excess muscle and tendon were trimmed 1 week after the procedure. Follow-up at 4 weeks demonstrated complete mucosal coverage over an intact gracilis muscle, and no leakage. At 8 weeks post-procedure, the patient resumed sexual intercourse with no dyspareunia. At 6 months post-procedure, her stoma was closed. The patient reported transient fecal staining of her vagina after stoma reversal, which resolved with conservative treatment. The fistula had not recurred at 20 months post-procedure. The gracilis pull-through flap is a reliable technique for a scarred vagina with an attenuated rectovaginal septum. It can function as a well-vascularized tissue plug to promote healing.

Management of anoperineal lesions in Crohn's disease: a French National Society of Coloproctology national consensus

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.

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.

Management of rectovaginal fistulas and patient outcome

Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.

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.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.

Transvaginal repair of recurrent pouch-vaginal fistula

AIM

Pouch-vaginal fistula is an uncommon but unpleasant complication. The chance of successful repair with various surgical procedures is around 50% and the early promise of collagen button plugs was not followed by good long-term results. We report a series of patients who underwent transvaginal repair of pouch-vaginal fistula after failed collagen plugs accompanied by a video to show the operative technique.

METHOD

Patients were identified from a prospectively maintained database. Patient demographics, operation notes, complications and ultimate outcome were recorded.

RESULTS

Eleven patients, each of whom had previously undergone an attempt to close the fistula with a collagen button plug, underwent transvaginal repair. Nine (81%) were successful at a median follow-up of 14 (6-56) months. The remaining two patients reported symptomatic improvement.

CONCLUSION

Pouch-vaginal fistula can be successfully closed by the transvaginal technique after a failed button plug procedure.

The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study

BACKGROUND

Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear.

OBJECTIVE

A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas.

DATA SOURCES

Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles.

STUDY SELECTION

Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results.

INTERVENTION(S)

Any surgical intervention for the closure of rectovaginal fistulas was included.

MAIN OUTCOME MEASURES

The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning.

RESULTS

Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable.

LIMITATIONS

The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis.

CONCLUSIONS

No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.

Management and outcome of pouch-vaginal fistulas after IPAA surgery

BACKGROUND

After IPAA, the timing, management, and outcome of pouch-vaginal fistulas are poorly defined.

OBJECTIVE

The purpose of this study was to evaluate the frequency, management, and outcome of patients who develop a pouch-vaginal fistula.

DESIGN

This was a retrospective analysis of a prospectively maintained database.

SETTINGS

The study was conducted in a single-center, high-volume tertiary referral colorectal unit.

PATIENTS

Women with a pouch-vaginal fistula after IPAA from 1983 to 2010 were included in the study.

MAIN OUTCOME MEASURES

The healing rate of pouch-vaginal fistulas was measured.

RESULTS

Of 152 patients with a pouch-vaginal fistula after IPAA, 59 fistulas occurred at <12 months, constituting the early onset group, and 43 occurred at >12 months, constituting the late-onset group. Seventy-five patients (77.3%) underwent local repair (48 (49.5%) had ileal pouch advancement flap and 27 (27.8%) had transvaginal repair). The healing rate after ileal pouch advancement flap performed as a primary procedure was 42% and 66% when performed secondarily after a different procedure. The healing rate for transvaginal repair was 55% when done as a primary procedure and 40% when performed secondarily. Nineteen patients underwent redo ileal pouch construction, with an overall pouch retention rate of 40%. At median follow-up of 83 months (range, 5-480 months), 56 (57.7%) of the 102 patients had healed the pouch-vaginal fistula, whereas pouch failure occurred in 34 women (35%, 12 early onset and 22 late onset). Healing of the fistula was significantly lower (22% versus 73%; p < 0.001) and pouch failure higher (52.7% versus 22.7%, p < 0.001) when compared with Crohn's disease. On multivariate analysis, a postoperative delayed diagnosis of Crohn's disease was associated with failure (p = 0.01). No other factors were associated with pouch failure.

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Pouch-vaginal fistula after IPAA surgery is indolent and may persist after repairs. A delayed diagnosis of Crohn's disease is associated with a poor outcome and a higher chance of pouch failure.

Rectovaginal fistula: a new technique and preliminary results using collagen matrix biomesh

BACKGROUND

A rectovaginal fistula (RVF) is a debilitating condition that is difficult to treat. Many available techniques are invasive and involve extensive surgery. A local procedure with good closure rates would be preferable as a first step in the treatment of RVF. The aim of this study was the development of a local technique for the closure of RVF with good closure rates to prevent the use of more invasive procedures.

METHODS

This was a pilot study. Patients with RVF who had undergone multiple operations in the pelvic area, local radiotherapy, chemotherapy or had been diagnosed with Crohn's disease were included in the study. All had a history of surgery for RVF. A cross-linked collagen matrix biomesh was placed in the rectovaginal septum using a transperineal or a transvaginal approach. The main outcome measure in this study was the closure rate reported as absence of the fistula at 1 year.

RESULTS

Twelve patients were included in the study. Absence of fistula at 1 year was 0.64 (95 % confidence interval 0.30-0.85). Three patients (25.0 %) developed a recurrence, two were reoperated on with a gracilis flap transposition, and one was treated with laparoscopic ligation. In one patient (8.3 %), the fistula failed to close within 3 months after the mesh placement.

CONCLUSIONS

Our technique shows promising results. A local and simple technique with acceptable closure and morbidity rates, like our local repair with biomesh, would be ideal as a first step in treating RVFs. Long-term results are needed.

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano

BACKGROUND

The management of fistula-in-ano is a balance between fistula cure and preservation of continence.

OBJECTIVE

The aim of this study is to summarize the anal fistula plug literature for Crohn's and non-Crohn's fistula-in-ano in a homogenous patient population.

DATA SOURCES

PubMed, MEDLINE, Embase, and Cochrane medical databases were searched from 1995 to 2011. Abstracts from The American Society of Colon and Rectal Surgeons, The Society for Surgery of the Alimentary Tract, The European Society of Coloproctology, and the Association of Coloproctology of Great Britain and Ireland meetings between 2007 and 2010 were also evaluated.

STUDY SELECTION

Studies were included if results for patients with and without Crohn's disease could be differentiated. Patients with rectovaginal, anovaginal, rectourethral, or ileal-pouch vaginal fistulas were excluded as were studies where the mean or median follow-up was less than 3 months. Two researchers independently selected studies matching the inclusion criteria.

INTERVENTION

Anal fistula plug insertion was performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were the overall fistula closure rates and length of follow-up.

RESULTS

Seventy-six articles or abstracts were identified from the title as being of relevance. Twenty studies (2 abstracts, 18 articles) were finally included. Study sample size ranged from 4 to 60 patients; 530 patients were included in all studies (488 non-Crohn's and 42 Crohn's patients). The plug extrusion rate was 8.7% (46 patients). The proportion of patients achieving fistula closure varied widely between studies for non-Crohn's, ranging from 0.2 (95% CI 0.04-0.48) to 0.86 (95% CI 0.64-0.97). The pooled proportion of patients achieving fistula closure in patients with non-Crohn's fistula-in-ano was 0.54 (95% CI 0.50-0.59). The proportion achieving closure in patients with Crohn's disease was similar (0.55, 95% CI 0.39-0.70).

LIMITATIONS

This study was limited by the variability of operative technique and perioperative care between studies.

CONCLUSIONS

Fistula closure is achieved by using the anal fistula plug in approximately 54% of patients without Crohn's disease. The anal fistula plug has not been adequately evaluated in the Crohn's population.

Intraoperative, postoperative and reoperative problems with ileoanal pouches

BACKGROUND

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches.

METHODS

The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed.

RESULTS

Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation.

CONCLUSION

A structured management plan will minimize the adverse consequences of the problems associated with pouches.