VAGINAL FISTULA FOLLOWING RESTORATIVE PROCTOCOLECTOMY

Vaginal fistula (VF) is a devastating complication following restorati ve proctocolectomy. PURPOSE: This study was designed to examine the pe rioperative factors influencing the outcome and management of vaginal fistula. METHOD: Between October 1983 and September 1994, 526 women un derwent restorative proctocolectomy, Nineteen develop VF (3.6 percent) , and sis were referred from other institutions with this complication . These 25 women were followed for a minimum of nine months. RESULTS: Preoperative diagnosis of ulcerative colitis was made in 23 of the pat ients with VF (92 percent), and indeterminate colitis and familial ade nomatous polyposis was determined in the rest of tile patients. Postop eratively, 12 of the 23 women (52 percent) with a preoperative diagnos is of ulcerative colitis had clinical/pathologic findings of Crohn's d isease, and I woman was reclassified as having indeterminate colitis. Postoperative pelvic sepsis was significantly higher in women with VF than in those without VF (26.3 vs. 6.3 percent; P = 0.003). Median tim e until occurrence of VF following loop ileostomy closure was later fo r women with delayed findings of Crohn's disease at 16.5 (range, <1-72 ) months, compared with women without Crohn's disease at 0.5 (range, < 1-67) months (P < 0.05). Of the 163 women with handsewn anastomosis pe rformed at our institution, IZ developed VF (7.4 percent). In contrast , 7 of the 363 patients with stapled anastomosis had VF (1.9 percent; P = 0.003). Site of VI; was found at the anastomosis in 12 patients, b elow in 12 patients, and above in 1 patient. Presence of Crohn's disea se and anastomotic technique did not influence the site of VF. initial management of VF consisted of transanal repair in 20 patients (advanc ement flap, 12; direct repair, 6; and neoileoanal anastomosis, 2), set on in I patient, transabdominal approach in 1 patient, transvaginal in 1 patient, observation in 1 patient, and pouch excision in I patient. Of the 13 women without Crohn's disease, 12 had transanal repair (LO healed, I had recurrence, and 1 had pouch excision), acid 1 had succes sfully repair with transabdominal technique, for an overall success ra te of 84.6 percent. Of the 12 women with VF and delayed findings of Cr ohn's disease, transanal repair was performed on 9, 1 had pouch excisi on without repair, 1 had seton placement and pouch excision, and 1 und erwent observation. Transanal technique of repair in women with Crohn' s disease successfully healed three women (33.3 percent). Overall, of the 12 women with delayed findings of Crohn's disease, 6 had pouch exc ision, 3 had recurrences. and 3 healed. CONCLUSION: VF is an uncommon complication following restorative proctocolectomy and is associated w ith a high incidence of pelvic sepsis and handsewn anastomosis. Late p resentation of VF is more common with Crohn's disease and is associate d with a poor prognosis and pouch salvage rate. Transanal techniques a re an effective means of VF repair.