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Management and Outcome of Pouch-Vaginal Fistulas After IPAA Surgery

Mallick, Ismail H. Ph.D.; Hull, Tracy L. M.D.; Remzi, Feza H. M.D.; Kiran, Ravi P. M.D.

Diseases of the Colon & Rectum: April 2014 - Volume 57 - Issue 4 - p 490–496
doi: 10.1097/DCR.0000000000000094
Original Contributions: Inflammatory Bowel Disease

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.

Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio

Financial Disclosure: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013.

Correspondence: Tracy L. Hull, M.D., 9500 Euclid Ave, Desk A-30, Cleveland Clinic, Cleveland, OH 44195. E-mail: hullt@ccf.org

© 2014 The American Society of Colon and Rectal Surgeons