Multiple surgical approaches achieve rectovaginal Fistulas closure in two-thirds of Crohn's related cases

CLEVELAND CLINIC: A retrospective review published in the Journal of Crohn's and Colitis, JCC, determining outcomes of multiple surgical interventions for treating Crohn's related Rectovaginal Fistulas, concluded it to be effective in achieving closure in over two-thirds of cases.

Crohn's disease (CD) is a chronic inflammatory disorder characterized by a tendency for fistula formation. The symptoms include dyspareunia, perianal pain, vaginal irritation, and frequent genitourinary infections. This is the second most common cause of rectovaginal fistula (RVF), constituting up to 9 % and causing distress and social embarrassment.

The data show a lack of a universal procedure of choice. The treatment of RVF depends on severity, location, number, complexity, and association with stricturing intestinal disease. Surgical options for RVF repair have success rates and involve direct repair, fistulotomy, fibrin glue instillation, endorectal or vaginal advancement flap, abdominal procedures with colorectal or coloanal anastomosis, and epiploplasty.

"Crohn's-related RVF is challenging to treat", with limitations of ideal treatment while many technique proposals proved successful, as mentioned in the literature. There are many questions on RVF repair mentioned, "Whether Martius flap addition could improve outcomes after RVF repair or not? "and " Whether gracilis muscle transplant could be proposed for failed previous RVF repair or not? The literature mentions the recommendation of combined medical and surgical treatments.

Previous studies mentioned hopeful and enhanced outcomes from ongoing studies.

In women with CD, the incidence of RVF ranges from 10-20 %, which affects the quality of life. Considering this and adding precision data related to surgical outcomes, a study was conducted by a team of researchers led by Dr. Ana M Otero-Piñeiro, MD, Ph.D. from the Department of Colorectal Surgery at the Digestive Disease Surgical Institute of Cleveland Clinic. The team aimed to determine the surgical outcomes of single and repeat operative interventions.

The critical points of the study are:

• The review was conducted for patients who underwent surgery between 1995 to 2021.
• The data collection was related to patient demographics, treatment, surgical intervention, postoperative outcomes, and fistula outcomes.
• 166 patients underwent 360 operations with a mean age of 42.8 years.
• The smoking history was recorded as 34 patients were current and 58 were former smokers.
• A local approach using fibrin glue, fistulotomy/fistulectomy, or seton placement was performed commonly in 44.5 % of patients. (n=160).
• The transvaginal/transanal approach was performed in 31.4 % (n=113) of patients with an advancement flap repair (including Martius advancement flap) and episoproctotomy, a transabdominal approach in 27.2% (n=98) of patients including proctectomy or redo anastomosis.
• The gracilis muscle interposition was finally performed in 2.2% of patients. (n=8)
• The operative interventions per patient had a median number of 2 procedures.
• The rate of healing of the fistula per patient was 71.7%.
• The median follow-up period was 5.5 years.
• The healing was impaired in former smoking with an Odds Ratio of 0.52 with a p-value of 0.014.
• The healing in seton insertion had an OR of 0.42 and a p-value of 0.012, indicating impaired healing.

The team finally concluded, "Multiple surgical approaches are successful in achieving RVF closure in two-thirds of Crohn's related cases."

The co-author Dr. Xue Jia, MA, from the Department of General Surgery, Statistics at the Digestive Disease Surgical Institute, added, "Healing is impaired in smoking and seton insertion and must be considered and avoided."

The study focused on the life quality of women as reoperations and recurrences of RVF adversely impact anal continence and life quality.

References:

Ana M Otero-Piñeiro, MD Ph.D., Xue Jia, MA, Karina E Pedersen, Tracy Hull, MD, Jeremy Lipman, MD, Stefan Holubar, MD, Scott R Steele, MD MBA, Amy L Lightner, MD, Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice, Journal of Crohn's and Colitis, 2022; jjac151,