Management of Pouch-Vaginal Fistulae - experience from our institution.
Sivathondan PC., Bloemendaal A., Travis S., Mortensen N., George BD.
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-TNF drugs. METHOD: All patients presenting for management of PVF to our surgical service between 2007 and 2016 were studied. Median duration of follow up from diagnosis of PVF was 6 years. Details of original pouch surgery, timing of presentation of PVF, management and final outcome were recorded. Primary outcome was gastrointestinal (GI) continuity (as defined by presence or absence of a stoma). RESULTS: A total of 23 patients were identified ( median age 45 years) of whom 9 had pelvic sepsis at the time of original pouch surgery. Management included local surgical repair, defunctioning ileostomy, pouch excision and anti-TNF therapy. Gastrointestinal continuity was achieved in 12 patients (52%). Healing of 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 7 maintained GI continuity. Patients with late presentation PVF (60 months or longer post-surgery) 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.