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20-11-2023 | Crohn's Disease | Original Article

Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn’s Disease: Experience of a Tertiary Center

Authors: Ana M. Otero-Piñeiro, Tracy Hull, Stefan Holubar, Karina E. Pedersen, Nihal Aykun, Megan Obi, Robert Butler, Scott R. Steele, Amy L. Lightner

Published in: Journal of Gastrointestinal Surgery

Abstract

Background

The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis.

Objective

Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn’s disease phenotype of the pouch.

Design

Retrospective cohort study of a prospectively maintained, IRB-approved database.

Settings/Patients

Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn’s-related perianal disease.

Interventions

Two hundred thirty-one operations for perianal or anovaginal fistula(s).

Main Outcome and Measures

Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure.

Results

Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m². More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03–0.43, p = 0.001). Overall pouch failure rate was 12.1%.

Limitations

Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset.

Conclusions

Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.

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Title: Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn’s Disease: Experience of a Tertiary Center
Authors: Ana M. Otero-Piñeiro
Tracy Hull
Stefan Holubar
Karina E. Pedersen
Nihal Aykun
Megan Obi
Robert Butler
Scott R. Steele
Amy L. Lightner
Publication date: 20-11-2023
Publisher: Springer US
Keywords: Crohn's Disease
Ileostomy
Ulcerative Colitis
Published in: Journal of Gastrointestinal Surgery
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-023-05603-1

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Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn’s Disease: Experience of a Tertiary Center

Abstract

Background

Objective

Design

Settings/Patients

Interventions

Main Outcome and Measures

Results

Limitations

Conclusions

Keynote Webinar | Spotlight on Diet and Diabetes

Springer Medicine

Abstract

Background

Objective

Design

Settings/Patients

Interventions

Main Outcome and Measures

Results

Limitations

Conclusions

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