Long-term ileoanal pouch survival after pouch urinary tract fistulae.

BACKGROUND: Ileoanal pouch is a demanding procedure with many potential technical complications including bladder or ureteral injury, while inflammation or stricture of the anastomosis or anal transition zone may lead to the formation of strictures and fistulae, including to the adjacent urethra. Pouch urinary tract fistulae are rare. We aimed to describe the presentation, diagnostic workup, and management of patients with pouch urinary at our center. METHODS: Our prospectively maintained pouch registry was queried using diagnostic codes and natural language processing free-text searches to identify ileoanal pouch patients diagnosed with any pouch-urinary tract fistula from 1997 to 2022. Descriptive statistics and pouch survival using Kaplan-Meier curves are presented. Numbers represent frequency (proportion) or median (range). RESULTS: Over 25 years, urinary fistulae were observed 27 pouch patients; of these, 16 of the index pouches were performed at our institution [rate 0.3% (16/5236)]. Overall median age was 42 (27-62) years, and 92.3% of the patients were male. Fistula locations included pouch-urethra in 13 patients (48.1%), pouch-bladder in 12 patients (44.4%), and anal-urethra in 2 (7.4%). The median time from pouch to fistula was 7.0 (0.3-38) years. Pouch excision and end ileostomy were performed in 12 patients (bladder fistula, n = 3; urethral fistula, n = 9), while redo ileal pouch-anal anastomosis (IPAA) was performed in 5 patients (bladder fistula, n = 3; urethral fistula, n = 2). The 5-year overall pouch survival after fistula to the bladder was 58.3% vs. 33.3% with urethral fistulae (p = 0.25). CONCLUSION: Pouch-urinary tract fistulae are a rare, morbid, and difficult to treat complication of ileoanal pouch that requires a multidisciplinary, often staged, surgical approach. In the long term, pouches with bladder fistulae were more likely to be salvaged than pouches with urethral fistulae.

Difference in the frequency of pouchitis between ulcerative colitis and familial adenomatous polyposis: is the explanation in peripouch fat?

AIM: Patients with ulcerative colitis (UC) have an unexplained higher incidence of pouchitis and a greater amount of peripouch fat compared with patients with familial adenomatous polyposis (FAP). The aims of this study were to compare the peripouch fat areas between patients with UC and patients with FAP, and to explore relationship between peripouch fat and pouchitis or chronic antibiotic-refractory pouchitis (CARP). METHOD: Patients with an abdominal CT image from our prospectively maintained Pouch Database were included. Abdominal fat and peripouch fat were measured on CT images at different levels or planes. Comparisons of peripouch fat and CARP were performed before and after propensity score matching. RESULTS: A total of 277 patients with UC and 40 patients with FAP were included. Compared with patients with FAP, patients with UC were found to have a higher incidence of pouchitis (58.5% vs 15.0%, P < 0.001) and CARP (24.5% vs 2.5%, P = 0.002) and a higher total peripouch fat area (P = 0.030) and mesenteric peripouch fat area (P = 0.022) at Level-3. Univariate and multivariate analyses showed that diagnosis (UC vs FAP) and peripouch fat areas at Level-3 and Level-5 were independent risk factors for CARP. With propensity score matching, 38 pairs of patients with UC and FAP were matched successfully. After matching, patients with UC were found to have higher total peripouch fat area and higher mesenteric peripouch fat area at Level-3, and a higher incidence of pouchitis (57.9% vs 13.2%, P < 0.001) and CARP (23.7% vs 2.6%, P = 0.007). CONCLUSION: Our study demonstrates that patients with UC have more peripouch fat than those with FAP, which may explain the difference in the frequency of pouchitis and CARP between these groups of patients.

Outcomes of ileal pouch-anal anastomosis without primary diverting loop ileostomy if postoperative sepsis develops.

BACKGROUND: The aim of the present study was to assess the short-term and long-term consequences of diverting loop ileostomy (DLI) omission in ileal pouch-anal anastomosis (IPAA) surgery complicated by postoperative pelvic sepsis. METHODS: This was a retrospective review of a prospectively maintained database. Of 4031 patients who underwent IPAA in 1983-2014, 357 developed IPAA-related pelvic sepsis with or without anastomotic dehiscence. Patients with Crohn's disease or cancer were excluded. The patient cohort was divided into two groups, depending on the presence or absence of DLI. Patient characteristics, short-term and long-term outcomes were compared. Long-term pouch survival was estimated with the Kaplan-Meier method. Quality of life (QOL) in the groups was compared at the latest follow-up. RESULTS: Three hundred and twenty-six patients developing pelvic sepsis had diversion at the time of IPAA (D group) and in 31 who developed pelvic sepsis DLI had been omitted (O group). The length of hospital stay was significantly longer in the O group 11.5 (3-33) days versus 8 (2-59) days in the D group (p = 0.006). Forty-eight percent of patients from the O group with anastomotic leak underwent reoperation and had a DLI formed at this second procedure versus 12% in the D group requiring reoperation (p < 0.0001). In long-term follow-up, there was no difference in pouch survival between the groups: 99 versus 97% after 5 years and 88 versus 87% after 10 years, in the O group and D group, respectively (p = 0.40). There was no difference in QOL observed between the groups. CONCLUSIONS: Omission of DLI in selected patients who had IPAA surgery did not increase pouch failure or adversely affect QOL in the long term, if pelvic sepsis occurred.

Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care.

AIM: Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes. METHOD: Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed. RESULTS: In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06). CONCLUSION: IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

Long-term outcomes after circular stapled hemorrhoidopexy versus Ferguson hemorrhoidectomy.

BACKGROUND: We aimed to compare long-term outcomes and quality of life in patients undergoing circular stapled hemorrhoidopexy to those who had Ferguson hemorrhoidectomy. METHODS: Patients who underwent Ferguson hemorrhoidectomy and circular stapled hemorrhoidopexy between 2000 and 2010 were reviewed. Long-term follow-up was assessed with questionnaires. RESULTS: Two hundred seventeen patients completed the questionnaires. Mean follow-up was longer in the Ferguson hemorrhoidectomy subgroups (7.7 ± 3.4 vs. 6.3 ± 2.9 years, p = 0.003). Long-term need for additional surgical or medical treatment was similar in the Ferguson hemorrhoidectomy and circular stapled hemorrhoidopexy groups (3 vs. 5%, p = 0.47 and 3% in both groups, p > 0.99, respectively). Eighty-one percentage of Ferguson hemorrhoidectomy and 83% of circular stapled hemorrhoidopexy patients stated that they would undergo hemorrhoid surgery again if needed (p = 0.86). The symptoms were greatly improved in the majority of patients (p = 0.06), and there was no difference between the groups as regards long-term anorectal pain (p = 0.16). The Cleveland global quality of life, fecal incontinence severity index, and fecal incontinence quality of life scores were similar (p > 0.05). CONCLUSIONS: This is one of the longest follow-up studies comparing the outcomes after circular stapled hemorrhoidopexy and Ferguson hemorrhoidectomy. Patient satisfaction, resolution of symptoms, quality of life, and functional outcome appear similar after circular stapled hemorrhoidopexy and Ferguson hemorrhoidectomy in long term.

Risk of adhesive obstruction after colorectal surgery: the benefits of the minimally invasive approach may extend well beyond the perioperative period.

BACKGROUND: Risk of adhesive small-bowel obstruction (SBO) is high following open colorectal surgery. Laparoscopic surgery may induce fewer adhesions; however, the translation of this advantage to a reduced rate of bowel obstruction has not been well demonstrated. This study evaluates whether SBO is lower after laparoscopic compared with open colorectal surgery. METHODS: Patients who underwent laparoscopic abdominal colorectal surgery, without any previous history of open surgery, from 1998 to 2010 were identified from a prospective laparoscopic database. Details regarding occurrence of symptoms of SBO (colicky abdominal pain; nausea and/or vomiting; constipation; abdominal distension not due to infection or gastroenteritis), admissions to hospital with radiological findings confirming SBO, and surgery for obstruction after the laparoscopic colectomy were obtained by contacting patients and mailed questionnaires. Patients undergoing open colorectal surgery for similar operations during the same period and without a history of previous open surgery also were contacted and compared with the laparoscopic group for risk of obstruction. RESULTS: Information pertaining to SBO was available for 205 patients who underwent an elective laparoscopic procedure and 205 similar open operations. The two groups had similar age, gender, and sufficiently long duration of follow-up. Despite a significantly longer duration of follow-up for the laparoscopic group, admission to hospital for SBO was similar between groups. Patients who underwent laparoscopic surgery also had significantly lower operative intervention for SBO (8% vs. 2%, p = 0.006). CONCLUSIONS: Although the rate of SBO was similar after laparoscopic and open colorectal surgery, the need for operative intervention for SBO was significantly lower after laparoscopic operations. These findings especially in the context of the longer follow-up for laparoscopic patients suggests that the lower incidence of adhesions expected after laparoscopic surgery likely translates into long-term benefits in terms of reduced SBO.

Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis.

BACKGROUND: Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. METHODS: A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. RESULTS: A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). CONCLUSION: Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA.

Combined surgery in pelvic organ prolapse is safe and effective.

OBJECTIVE: In women, rectal prolapse is often accompanied by other signs of generalized pelvic floor weakness including uterine and bladder prolapse. The purpose of this study was to compare whether there are differences in outcomes of rectal prolapse surgery between women having combined pelvic organ prolapse (POP) surgery with a urologist or urogynecologist (CS) vs those having abdominal rectal prolapse surgery alone (RP). METHOD: Charts were reviewed to collect perioperative data on those having surgery from 1995 to 2001. Phone surveys were conducted to obtain Cleveland Clinic Foundation (CCF) Incontinence score, Knowles-Eccersley-Scott-Symptom (KESS) Constipation Score, Short Form 36 (SF-36) quality of life score and recurrence rate. Appropriate statistical analysis was performed. RESULTS: Ninety-four operations were performed (23 CS and 71 RP). Forty-six (49%) could be contacted by phone. Mean follow-up was similar in both groups (CS 4.1 vs RP 3.6 years; P = 0.796). There were no significant differences between both groups regarding age, American Society of Anesthesiology classification Score, complications, length of hospital stay, CCF Incontinence score, KESS Constipation Score, SF-36 Score and recurrence rate of rectal prolapse. The operative time (CS 226 vs RP 122 min; P < 0.001) and blood loss (CS 377 vs RP 183 ml; P < 0.001) were significantly increased in the CS group. CONCLUSION: Combined surgery for POP is safe and effective when considering outcomes of rectal prolapse surgery. Therefore surgeons should not hesitate to address all pelvic floor issues during the same operation by working in partnership with the anterior pelvic floor colleagues.

Surgery of recurrent parastomal hernia: direct repair or relocation?

PURPOSE: Parastomal hernia is a common late complication after stoma creation. The management options are many; unfortunately, most literature suggests unsatisfactory results. There are few studies comparing the outcomes after repair of parastomal hernias especially in recurrent cases, and the results are controversial. The aim of this study was to compare outcomes after repair of recurrent parastomal hernias between direct repair (DR) and relocation (RL). METHOD: We performed a retrospective chart review of patients who underwent direct repair or RL for recurrent parastomal hernia during the period between 1990 and 2005. Perioperative data and re-recurrence rates were obtained and analysed with appropriate statistical methods. RESULTS: With mean follow-up time of 2 years, 50 operations were available for evaluation; 27 (54%) DR and 23 (46%) RL [five same-side RL (SSRL) and 18 opposite-side RL (OSRL)]. There were no deaths and there were similar complication rates between groups. Four of five (80%) SSRL had a re-recurrent parastomal hernia. Considering only DR with OSRL, although OSRL had longer operative time and hospital stay than DR, the re-recurrence rate was lower (38%vs 74%; P = 0.02). However, with Kaplan-Meier calculated and longer predicted follow-up time, re-recurrence rates were similar (Log rank P = 0.09). CONCLUSION: Recurrent parastomal hernia repair is associated with high re-recurrence rates.OSRL seems to have promising short-term outcomes; however, whether these results hold up long-term remains unclear. Therefore, larger cohorts of patients with longer follow-up or prospective randomized trials are needed.

Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy.

BACKGROUND: The aim of this study was to compare safety, early and late outcomes, quality of life and functional results of laparoscopically assisted versus open ileal pouch-anal anastomosis (IPAA). METHODS: Patients who had laparoscopically assisted IPAA between 1992 and 2007 were identified from a database and retrospectively matched for age, sex, body mass index (BMI) and operation date to patients who had open IPAA at a ratio of 1:2. Intraoperative, postoperative and long-term functional outcomes were compared. Quality of life was determined by the Cleveland Global Quality of Life scale at 1 and 5 years. RESULTS: A total of 119 patients (59 men, 60 women; mean(s.d) age 35.5(14.2) years, BMI 24.7(5.0) kg/m(2)) had laparoscopically assisted IPAA, with conversion in nine patients (7.6 per cent); these were compared with 238 patients who had open IPAA. The 30-day and long-term results were similar, as well as quality of life at 1 and 5 years, except that patients in the laparoscopic group had shorter median time to stoma action (2 versus 3 days; P = 0.001) and marginally shorter hospital stay. Median operating times were longer in the laparoscopic group (272 versus 163 min; P = 0.040). CONCLUSION: Laparoscopically assisted IPAA had similar outcomes to open IPAA, but with some short-term advantages.

Complications and functional results after ileoanal pouch formation in obese patients.

OBJECTIVE: Ileoanal pouch formation (IPAA) can be technically challenging in obese patients, and there is little data evaluating results after the procedure in these patients. We compare outcomes for patients with a body mass index (BMI) > or =30 undergoing IPAA when compared with those for patients with BMI <30. METHODS: Retrospective analysis of prospectively accrued data for patients with BMI > or =30 undergoing IPAA. Patient and disease-related characteristics, complications, long-term function, and quality of life (QOL) using the Cleveland Global Quality of Life scale (CGQL) were determined for this group of patients (group B) and compared with those for patients with BMI <30 (group A). Kruskal-Wallis and Wilcoxon rank sum tests were used to compare quantitative or ordinal data and chi-square or Fisher's exact tests for categorical variables. Long-term mortality and complication rates were estimated using the Kaplan-Meier method with group comparisons performed using log rank tests. RESULTS: There were 345 patients (median BMI 32.7) in group B and 1,671 patients in group A. When the cumulative risk of complications over 15 years was compared, group B patients had a significantly higher chance of getting a complication (94.9% vs 88%, p = 0.006). The rates of pelvic sepsis (6.7% vs 5.3%, p = 0.3), pouchitis (58.1 vs 54.4%, p = 0.9), pouch failure (6% vs 4.5%, p = 0.9), and hemorrhage (5.6% vs 4.8%, p = 0.7) were similar for group B and group A. Group B patients, however, had a significantly higher risk of the development of wound infection (18.8% vs 8.1%, p < 0.001) and anastomotic separation (10.4% vs 5.4%, p < 0.001), whereas group A patients had a higher rate of development of obstruction over time (26.7% vs 22.3%, p = 0.02). Long-term outcome including QOL and function after 15 years was comparable between groups. CONCLUSIONS: Although technically demanding, IPAA can be undertaken in obese patients with acceptable morbidity. Good long-term functional results and QOL that is comparable to nonobese patients may be anticipated.

Current considerations in the management of rectovaginal fistula from Crohn's disease.

Rectovaginal fistulas are dreaded complications of Crohn's disease. Accurate assessment is essential for planning management. Treatment options range from observation to medical therapeutics to the need for surgical intervention. Ultimately, establishing reasonable expectations is mandatory when treatment algorithms are considered. In this article, we review the evaluation of these fistulas and the current options to consider in the treatment of Crohn's related rectovaginal fistula.

Repair of recurrent rectovaginal fistulas.

BACKGROUND: Recurrent rectovaginal fistulas (RRVFs) pose a challenging problem, which can be treated by different surgical procedures. We performed this study to determine the ultimate success rate of various repair techniques. METHODS: Using a standard data collection form, we retrospectively reviewed charts of patients treated for RRVF. RESULTS: Between 1991 and 2000, 57 procedures were performed in 35 women who presented with RRVF. Median follow-up was 4 months (interquartile range, 1,25). The causes of RRVF included obstetrical injury (n = 15), Crohn's disease (n = 12), fistula occurring after proctocolectomy with ileal pouch-anal anastomosis (for ulcerative colitis, n = 3; indeterminate colitis, n = 1; familial polyposis, n = 1), cryptoglandular disease (n = 2), and fistula occurring immediately after low anterior resection for rectal cancer (n = 1). The methods of repair used included mucosal advancement flap (n = 30), fistulotomy with overlapping sphincter repair (n = 14), rectal sleeve advancement (n = 3), fibrin glue (n = 1), proctectomy with colonic pull-through (n = 2), and ileal pouch revision (n = 6). Twenty-seven of 34 (79%) patients with adequate follow-up eventually healed after a median of 2 operations. Logistic regression was used to analyze outcome according to etiology of fistula, patient age, number of prior repairs, time interval between last repair and current repair, and presence of fecal diversion. Crohn's disease, the presence of a diverting stoma, and decreased time interval since prior repair were associated with a poorer outcome. CONCLUSIONS: Most RRVFs can be successfully repaired, although repeated operations may be necessary. Delaying repair may improve outcome.

Fecal incontinence in women with urinary incontinence and pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of and factors associated with fecal incontinence in women with urinary incontinence or pelvic organ prolapse. METHODS: Study subjects were recruited prospectively, and all participants received questionnaires regarding bowel function and underwent a standardized history and physical examination. Fecal incontinence was defined as the involuntary loss of feces sufficient to be considered a problem by the patient. RESULTS: Forty-two subjects had fecal incontinence, an overall prevalence of 17%. One hundred seventy women had urinary incontinence, pelvic organ prolapse, or both, and 36 of these (21%) had fecal incontinence. One hundred (40%) women had urinary incontinence, of whom 31 also had fecal incontinence. Seventy women had isolated pelvic organ prolapse and five (7%) were incontinent of feces. Univariate analysis revealed that any degree of pelvic organ prolapse, increasing degrees of prolapse within each vaginal segment, urinary incontinence, advanced age, postmenopausal status, increased vaginal parity, prior hysterectomy, history of irritable bowel syndrome, and abnormal sphincter tone were associated significantly with fecal incontinence. Multiple logistic regression analysis indicated that only urinary incontinence (odds ratio [OR] 4.6, P < .001, 95% confidence interval [CI] 1.9, 11.2), abnormal anal sphincter tone (OR 2.3, P = .04, 95% CI 1.1, 5.1), and irritable bowel syndrome (OR 8.3, P = .002, 95% CI 2.1, 32.8) were associated with fecal incontinence. CONCLUSIONS: There is a high rate of fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Clinicians providing health care to a similar group of women should inquire routinely and specifically about fecal incontinence.

Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients.

BACKGROUND: Despite improvement in surgical techniques and stapling devices during the last 10 years, colorectal anastomoses are still prone to leakage. The purpose of this study was to assess the performance and safety of stapled anastomoses in rectal surgery and to identify factors that influence the occurrence of anastomotic leaks. STUDY DESIGN: A review was undertaken of 1,014 patients who underwent stapled anastomoses to the rectum or anal canal for colorectal cancer or benign disease between 1989 and 1995 in a tertiary care institution. Indications for operations, comorbidities at admission, preoperative bowel preparation, stapler size, intraoperative events, associated surgical procedures, and clinical outcomes were tested for any association with anastomotic leak. RESULTS: A double stapled technique was used in 154 patients and a conventional single stapler technique was used in 860. Postoperative mortality was 1.6%, and the overall morbidity was 18.4%. Clinically apparent anastomotic leak developed in 29 patients (2.9%). Anastomotic dehiscence occurred in 22 of 284 patients (7.7%) after low stapling (within 7 cm from the anal verge) and in 7 of 730 patients (1%) after high stapling (p < 0.001). Diabetes mellitus, use of pelvic drainage, and duration of surgery were significantly related to the occurrence of anastomotic leak by the univariate analysis. Multivariate regression analysis identified an anastomotic distance from the anal verge within 7 cm as the only variable related to the occurrence of postoperative leak (p < 0.001). CONCLUSION: Low anastomoses were associated with a leak rate greater than with high colorectal anastomoses. We conclude that anastomoses to the rectum using the circular stapler can be done with low mortality and morbidity.

Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease.

BACKGROUND: Since its introduction in the early 1980s, strictureplasty (SXP) has become a viable option in the surgical management of obstructing small bowel Crohn's disease. Questions still remain regarding its safety and longterm durability in comparison to resection. Precise indications and contraindications to the procedure are also not well defined. STUDY DESIGN: A retrospective review of all patients undergoing SXP for obstructing small bowel Crohn's disease at the Cleveland Clinic between 1984 and 1999 was conducted. A total of 314 patients underwent a laparotomy that included the index SXP The total number of SXPs performed was 1,124, with a median of two (range 1 to 19) per patient. Sixty-six percent of patients underwent a synchronous bowel resection. Recurrence was defined as the need for reoperation. Followup information was determined by personal interviews, phone interviews, or both. RESULTS: The overall morbidity rate was 18%, with septic complications occurring in 5% of patients. Preoperative weight loss (p = 0.004) and older age (p = 0.008) were found to be significant predictors of morbidity. The surgical recurrence rate was 34%, with a median followup period of 7.5 years (range 1 to 16 years). Age was found to be a significant predictor of recurrence (p = 0.02), with younger patients having a shorter time to reoperation. CONCLUSIONS: This large series of patients with longterm followup confirms the safety and efficacy of strictureplasty in patients with obstructing small bowel Crohn's disease. The 18% morbidity and 34% operative recurrence rates compare favorably with reported results of resective surgery. Caution should be used in patients with preoperative weight loss, because they experienced higher complication rates. Although young patients seem to follow an accelerated course, SXP remains indicated as part of an overall strategy to conserve intestinal length.

Surgical approaches to low anovaginal fistula in Crohn's disease.

BACKGROUND: Anovaginal fistula due to Crohn's disease can be surgically repaired in some women. The purpose of this study was to analyze the types of fistula along with the features that point to success or failure in treating these patients. METHODS: Women with anovaginal fistula and Crohn's disease treated surgically by one surgeon from 1988 to 1992 were retrospectively studied. RESULTS: Forty-eight women underwent treatment for anovaginal fistula caused by Crohn's disease. This represented 55% of the total patients seen for anovaginal fistula from all causes. Nine patients had severe anorectal and/or colonic disease and underwent total proctocolectomy with ileostomy. Four other patients had seton placement only. The remaining 35 patients underwent transanal repair of their fistula and are the basis of this study. Three types of flap repairs were performed: curvilinear advancement rectal flap (n = 24), linear advancement rectal flap (n = 6), and advancement sleeve flap (n = 5). The type of surgery selected depended on the associated anal and colorectal disease. Diverting ileostomies were used in nine patients with a successful outcome in eight. Healing occurred with the initial repair in 19/35 (54%). An additional five patients underwent successful repeat procedures for an overall success rate of 24/35 (68%). CONCLUSION: Surgical closure of anovaginal can be offered to selected women with Crohn's disease, thus avoiding a permanent stoma in this group. The type of flap chosen for repair depends on the characteristics of the fistula.