Fistula complicating restorative proctocolectomy

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch-vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch-perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch-vesical fistula, successfully treated by excision of the fistula and pouch appendage.