Should Immunomodulation Therapy Alter the Surgical Management in Patients With Rectovaginal Fistula and Crohn’s Disease?

Narang, Rahul; Hull, Tracy L.; Perrins, Steven; García, José Sebastian; Wexner, Steven D.

doi:10.1097/dcr.0000000000000614

Cited by 15 publications

(22 citation statements)

References 35 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Failure to heal after a direct repair with a flap necessitates more challenging subsequent surgery due to the presence of fibrosis, which makes local tissues unfit for a new repair . All types of local repair should be avoided in cases of acutely or chronically inflamed local tissue as well as when patients are contemporaneously medically treated .…”

Section: Discussionmentioning

confidence: 99%

Use of the Martius advancement flap for low rectovaginal fistulas

Trompetto¹,

Luc²,

Novelli

et al. 2019

Colorectal Disease

View full text Add to dashboard Cite

Aim The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short‐ and long‐term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues. Method Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien–Dindo classification. Quality of life (SF‐12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre‐ and postoperatively. Results The mean follow‐up was 42 ± 29 months (range 3–101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45–70 min), and the median hospital stay was 3.5 days (range 3–5 days). No major complications occurred. Pre‐ and postoperative CCIS did not differ [1 (range 0–3.5)]. The postoperative SF‐12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001). Conclusion The Martius procedure should be considered as the first‐line method of treatment in carefully selected cases of LRVF.

show abstract

Section: Discussionmentioning

confidence: 99%

Use of the Martius advancement flap for low rectovaginal fistulas

Trompetto¹,

Luc²,

Novelli

et al. 2019

Colorectal Disease

View full text Add to dashboard Cite

show abstract

“…RVFs related to CD are challenging for surgeons, and a very high propensity to recur is observed, with published rates ranging from 25% to 80% [ 7 , 21 , 22 ]. An optimal medical or surgical control of local and distant CD acute/subacute manifestations must be achieved.…”

Section: Discussionmentioning

confidence: 99%

Martius’ flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn’s disease, endometriosis and a mullerian anomaly

Gallo

Luc²,

Clerico³

et al. 2017

BMC Surg

View full text Add to dashboard Cite

BackgroundRectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn’s disease that negatively affects patients’ social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options.Case presentationWe describe a 31-year-old female patient with a Crohn’s disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient’s medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius’ flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy.ConclusionMartius’ flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn’s disease.The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate.

show abstract

“…28 The long-term outcomes of temporary fecal diversion, including rates of attempted and successful restoration of bowel continuity and need for additional surgery such as In the setting of CD-related rectovaginal fistula, a recent series of 120 patients demonstrated that the use of fecal diversion did not affect healing, but tissue interposition techniques had the highest success rates. 32 In a further series of 51 patients with rectovaginal fistula, 60% of patients treated with preoperative fecal diversion healed, and 51% of patients treated with nondiverted repairs healed. 33 While anorectal stricture is often considered an indication for definitive ostomy formation, a recent series of 102 patients demonstrated stricture healing in 59% at a median follow-up period of 2.8 years with 19 patients requiring definitive ostomy.…”

Section: Ostomy Formation For Management Of Perianal Fistulating Diseasementioning

confidence: 93%

Role of Fecal Diversion in Complex Crohn's Disease

Burke

2019

Clinics in Colon and Rectal Surgery

View full text Add to dashboard Cite

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.

show abstract

Should Immunomodulation Therapy Alter the Surgical Management in Patients With Rectovaginal Fistula and Crohn’s Disease?

Abstract: Despite a relatively low success rate (63%) in healing after surgical repair of a rectovaginal fistula, the recent use of immunomodulation therapy did not negatively impact healing. However, tissue interposition techniques had the highest success rates.

Cited by 15 publications

References 35 publications

Use of the Martius advancement flap for low rectovaginal fistulas

Use of the Martius advancement flap for low rectovaginal fistulas

Martius’ flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn’s disease, endometriosis and a mullerian anomaly

Role of Fecal Diversion in Complex Crohn's Disease

Contact Info

Product

Resources

About