Contemporary surgical management of rectovaginal fistula in Crohn's disease

Abstract

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.© 2014 Baishideng Publishing Group Inc. All rights reserved.Key words: Rectovaginal fistula; Crohn's disease; Fistula; Advancement flap; Sleeve advancement; Episioproctotomy Core tip: Rectovaginal fistula secondary to Crohn's disease is a devastating and disabling condition with a significant negative impact on quality of life. Furthermore, these fistulae pose an extremely challenging dilemma for the clinician with unique and often frustrating management challenges. Medical management is often futile and surgery may offer the only chance for cure. In this article, we aim to review the various treatment options to close these difficult to treat fistulae, with an emphasis on surgical technique and complex decision making. INTRODUCTIONFistula-in-ano is the most common perianal manifestation of Crohn's disease (CD) and was first reported by Gabriel [1] in 1921, nine years before Crohn et al [2] identified regional enteritis as a clinical entity. These fistulae are classified by their relationship to the sphincter complex as either high (supra-or extra-sphincteric vs low (inter-or trans-sphincteric). Low fistulae that transverse the anal sphincter are more appropriately named anovaginal fistulae, but by convention, all such fistulae are termed rectovaginal fistula (RVF). After obstetrical trauma, CD is the most common etiological factor for RVF, and will occur in up to 10% of women with CD [3,4] . Rectovaginal fistulae secondary to CD are associated with significant morbidity and carry an increased risk for proctectomy [5,6] . It is a devastating and disabling condition and is a source of considerable social embarrassment Contemporary surgical management of rectovaginal fistula in Crohn's diseaseMichael A Valente, Tracy L Hull and has a significant negative impact on quality of life. Furthermore, CD associated RVF are an extremely challenging dilemma for the clinician and present unique and often frustrating management challenges. In this article, we aim to review the various treatment options to close these difficult to treat fistulae, with an emphasis on surgical technique and decision making. PRESENTATION AND DIAGNOSISThe presence of a fis...

Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula?

“…In recurrent RVF after local procedures, interposition of muscle was developed to introduce healthy, vascularized tissue into the rectovaginal space to allow better healing conditions. In a preliminary experience on eight consecutive cases with recurrent or complex RVF, we observed a success rate after gracilis muscle interposition of 60% . Since our paper, other authors reported also a success rate after gracilis interposition up to 79% .…”

“…Among the different surgical procedures used for RVF, tissue interposition methods were intended to interpose normal tissue between vaginal and rectal suture lines and bring well‐vascularized tissue into the rectovaginal space. Several papers have suggested that gracilis muscle interposition is associated with high success fates of around 60−80% and it represents for us the technique of choice after failure of local repair (i.e. rectal or vaginal flap) .…”

Treatment Strategies in Crohn's-Associated Rectovaginal Fistula

“…A waiting period of 3 to 6 months is recommended to permit maximal clearance of inflammation and infection. 3 In addition, some authors recommend evaluation of anal wall thickness with ultrasound to ensure it has normalized before definitive repair. 12 At our institution, we typically utilize ultrasound mostly to evaluate the intactness of the anal sphincter.…”

“…Local repair can be approached transanally, transvaginally, or transperineally. 3 Simple fistulotomy for low and superficial fistulas with no sphincter involvement may be considered. This will eradicate perianal sepsis; however, patients risk development of a keyhole deformity of the anus and impaired incontinence.…”

“…Current medications used to treat perianal CD include antibiotics, corticosteroids, immunomodulators, and biologics. 3 There are no randomized controlled trials to support the use of antibiotics in the treatment of fistulizing CD, with most evidence coming from small series. Regardless, metronidazole is frequently used, often in combination with other immunosuppressive agents.…”