Patient-related risk factors influence the risk of developing a stoma complication more than surgery-related risk factors. Preoperative and post-operative interventions, planning, vigilance and management should be focussed to at-risk groups, particularly obese patients.
Perianal manifestations of Crohn’s disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-date surgical and medical management of perianal fistulas, highlighting current consensus management guidelines and the evidence behind them, as well as future directions in management.
Background Rectovaginal fistula (RVF) is a devastating complication of Crohn’s disease (CD). Despite advances in medical and surgical treatment, management of CD RVF remains challenging. Surgery is the principal treatment with adjunctive medical therapy. This study tracks patients from initial fistula presentation through their treatment pathways. Methods We reviewed our retrospective RVF database (2009–2019). Patients were captured through imaging and surgical coding. Outcomes included patient satisfaction, fistula closure and stoma reversal. Results We identified 66 patients with CD RVF from our database of 327 RVF patients, with a median age of 40 years and mean follow up of 6.3 years. Cross-sectional analysis of patients’ initial symptoms, management and outcomes identified three groups: 1-quiescent luminal disease, with minimal fistula symptoms; 2-quiescent luminal disease, but moderate fistula symptoms (suitable for RVF repair); 3-poorly controlled luminal disease and active fistula, requiring medical control and/or defunctioning before RVF repair. Thirty-one patients were identified in group 1 (‘minimal symptoms’). The median age was 37 years and most were on Infliximab (32%) or combination therapy (45%). Patients reported a negative impact on the quality of life (QoL) (39%), such as sex avoidance and psychosocial impairment. Some patients later required defunctioning (22%) or proctectomy (13%). Fistula symptoms improved in 16% following medical treatment alone. One patient developed a mucinous adenocarcinoma. Nine patients were identified in group 2 (‘immediately suitable for repair’). The median age was 44 years. A low QoL was reported in 44%. Reparative procedures included rectal advancement flap and omentoplasty. Two patients were defunctioned. Fistula closure was seen in 44% after medical and surgical treatment. Twenty-six patients presented in group 3 (‘poorly controlled luminal disease and active fistula’) and 17 patients joined this group after symptom deterioration (15 from group 1 and 2 from group 2). The median age was 45 years. All patients were on biologics/combination therapy and defunctioned. Some 30% underwent proctectomy. Some patients declined stoma reversal (7%) and proctectomy (12%). Markedly poor QoL was reported in 35% of patients. Medical escalation resulted in fistula closure in 14% of patients. Conclusion Complex RVF with poorly controlled disease requires faecal diversion/proctectomy and optimal medical therapy. Well-timed reparative surgery in a selected group yields reasonable outcomes. Management is dependent on factors such as the extent of CD, fistula symptoms, response to medical treatment, suitability for local repair and patient choice.
Background Pouch vaginal fistulae (PVF) occur following restorative proctocolectomy with an incidence of 6%. The overall rate of pouch failure is 10% but may be as high as 29% with a PVF. PVF can be relatively asymptomatic, with low volume vaginal mucus discharge alone, or can cause considerable morbidity with persistent, passive leakage of faeces and gross perianal excoriation. Management is challenging with a range of reparative techniques reported and no gold standard. Despite a lack of evidence, anti-TNF agents are increasingly used. It is unclear whether there are factors which may predict fistula closure with anti-TNF therapy. The primary aim of fistula therapy should be fistula eradication or amelioration of fistula symptoms without worsening pouch function. Methods This is a retrospective analysis of the management of PVF in ulcerative colitis in a tertiary referral centre. Demographic, clinical history and presenting symptoms of fistula including pouch function were collected. Symptomatic burden related to the fistula and the presence or absence of gastrointestinal continuity were assessed. Results Fifty patients with PVF were identified between 1984 and 2019 and complete clinical notes were available and analysed for 30 of these. The median age at diagnosis was 36 (range 19–52) years. The median follow-up from pouch creation was 12.5 years. A PVF developed in 30% within 1 year of pouch creation and in 70% after 1 year. In this cohort, 17 (56%) maintained gastrointestinal continuity, of whom 13 were asymptomatic of fistula symptoms (11 after intervention), while 4 were symptomatic but declined intervention. Of the 11 patients who were asymptomatic following treatment, 3 had perianal pouch advancement, 1 had a redo transabdominal pouch, 2 had transvaginal repair, 2 had seton drainage and 3 patients were managed with anti-TNF therapy. Anti-TNF agents were used in 5 patients, 1 of whom was already defunctioned. Three achieved quiescence of symptoms, with 1 requiring pouch excision due to ongoing symptoms. Three patients with poor pouch function prior to anti-TNF therapy noted an improvement in pouch function. Pouch excision or permanent defunctioning was performed in 13 patients (predominantly due to the burden of fistula symptoms rather than poor pouch function). Conclusion Around 50% of patients with PVF required pouch excision or permanent defunctioning. The burden of fistula symptoms drove this decision, rather than overall poor pouch function. Anti- TNF therapy improved pouch function and fistula symptoms in a small group of patients but the evidence supporting its use and indications remain limited.
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