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Management of pouch-vaginal fistulas - experience from our institution
P C Sivathondan1, A Bloemendaal1, S Travis2
1Oxford Colorectal Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.
Insights
Pouch-vaginal fistula (PVF) management remains challenging, with healing and gastrointestinal continuity rates around 50%. Anti-tumour necrosis factor (anti-TNF) therapy shows promise for late-presenting PVF and cases with Crohn's disease features.
Area of Science:
- Gastroenterology
- Colorectal Surgery
- Surgical Complications
Background:
- Pouch-vaginal fistula (PVF) is a rare but severe complication following ileo-anal pouch reconstruction.
- Effective management strategies for PVF are crucial for patient outcomes.
Purpose of the Study:
- To review recent management approaches for PVF.
- To evaluate the role of anti-tumour necrosis factor (anti-TNF) drugs in PVF treatment.
Main Methods:
- A retrospective review of 23 patients with PVF managed between 2007 and 2016.
- Data collected included original surgery details, PVF presentation, management, and outcomes, with a median follow-up of 6 years.
- Primary outcome was achieving gastrointestinal continuity, defined by the absence of a stoma.
Main Results:
- Overall healing and gastrointestinal continuity rates were 52% (12/23 patients).
- Pelvic sepsis at initial surgery was significantly associated with the need for a long-term ileostomy (P=0.009).
- Anti-TNF therapy was used in 12 patients, with 7 achieving GI continuity. Benefit was observed in late-presenting PVF and Crohn's-like disease.
Conclusions:
- PVF presents a significant surgical challenge with limited success rates for healing and GI continuity.
- Anti-TNF therapy may offer a beneficial treatment option for specific PVF patient subgroups, including those with late presentation or Crohn's disease features.
Aim:
Pouch-vaginal fistula (PVF) is an uncommon but serious complication of ileo-anal pouch reconstruction. This study aimed to review the recent management of PVF, in particular the role of anti-tumour necrosis factor (anti-TNF) drugs.
Method:
All patients presenting for management of PVF to our surgical service between 2007 and 2016 were studied. The median duration of follow-up from diagnosis of PVF was 6 years. Details of the original pouch surgery, timing of presentation of PVF, management and final outcome were recorded. Primary outcome was gastrointestinal (GI) continuity (as defined by the presence or absence of a stoma).
Results:
A total of 23 patients were identified (median age 45 years) of whom nine had pelvic sepsis at the time of original pouch surgery. Management included local surgical repair, defunctioning ileostomy, pouch excision and anti-TNF therapy. GI continuity was achieved in 12 patients (52%). Healing of the PVF was achieved in 12 patients (52%). Pelvic sepsis was significantly associated with the need for a long-term ileostomy (P = 0.009). Biological therapy was used in 12 patients, of whom seven maintained GI continuity. Patients with late presentation PVF (60 months or longer postsurgery) and those with clinical features of Crohn's disease appeared to benefit from anti-TNF treatment.
Conclusion:
PVF remains a challenging problem with overall healing rates and GI continuity rates of just over 50%. Anti-TNF therapy may have a role in patients with late presentation PVF and those with features suggestive of Crohn's disease.
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