Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy.

PURPOSE: The purpose of the study was to evaluate the outcome of surgical management of pouch-vaginal fistulas in females who had undergone restorative proctocolectomy.

METHODS: This study was designed as a retrospective chart review of females treated for pouch-vaginal fistulas from 1983 to 2000. All patients were followed up using our prospective pouch registry, with additional data collected by interview or mailed questionnaire.

RESULTS: Sixty females were identified (mean age, 33.3 +/- 1.3 years), of whom 33 had their initial restorative proctocolectomy done at our institution. Preoperative diagnosis was ulcerative colitis (88 percent), indeterminate colitis (10 percent), and familial adenomatous polyposis (2 percent). Average time to pouch-vaginal fistula following restorative proctocolectomy was 21 months (range, 1-132 months). Postoperative pelvic sepsis had occurred in 17 (28 percent) patients. Primary treatment modalities included the following: local repairs (n = 46, 77 percent), the majority of which were ileal advancement flaps; redo restorative proctocolectomy (n = 6, 10 percent); and pouch excision (n = 5, 8 percent). Initial healing was achieved in 20 patients. An additional 11 patients with recurrences healed after repeat procedures. The overall healing rate was 52 percent at 49.4 +/- 3.8 months follow-up. Pouch failure was the eventual outcome in 13 (22 percent) patients and 16 (27 percent) patients had persistent pouch-vaginal fistula. A delayed diagnosis of Crohn's disease was made in 24 patients. Crohn's disease patients had lower success rates following ileal advancement flaps compared with the non-Crohn's group (25 vs. 48 percent, respectively), much lower overall healing rates of their pouch-vaginal fistulas (17 vs. 75 percent, respectively), and a higher incidence of pouch failure (33 vs. 14 percent, respectively).

CONCLUSION: Pouch-vaginal fistulas are a difficult problem in females following restorative proctocolectomy. However, local repair can be successful with good functional outcomes. Redo restorative proctocolectomy may also achieve healing if local repairs are not possible or have failed. A delayed diagnosis of Crohn's disease results in worse treatment outcome and higher pouch failure rates.