Pouch Fistulae

Fistula originating from the ileoanal anastomosis or the pouch itself is a serious complication. The incidence varies between 5% and 17% and depends on the accuracy and duration of follow-up [44, 45]. It often requires further surgery and may alter ultimate functional outcome and lead to pouch excision. Fis-tulae may occur to the perineum, vagina, bladder or abdominal wall skin. Aetiologic factors include anas-tomotic dehiscence, pelvic sepsis, surgical experience, localised ischaemia, entrapment of the posterior vaginal wall in the stapling device and Crohn's disease. Pelvic sepsis is probably the major predisposing factor. Patients may be asymptomatic, some may have only minor symptoms whereas others may have disabling symptoms. Symptoms consist of purulent discharge and flatus or stool passing through the vagina, perineum or abdominal wall. Diagnosis is based on history and physical examination and may be confirmed by examination under anaesthesia. Other diagnostic modalities may be used to assess the tract, including endoanal ultrasound, pouchography, fistulography, CT and MRI. Initial management includes local procedures to drain the sepsis, and Crohn's disease must be excluded [46]. Most pouch-perineal fistulae originate from the ileoanal anastomosis. When superficial, these fistulae can be managed by fistulotomy. If the fistula is transsphinc-teric, it can be managed by staged fistulotomy using a seton or by a pouch advancement procedure. At our clinic, nine patients (7.6%) had a perineal fistula at a mean follow-up of 57 months. All were treated by staged fistulotomy. In none of these patients was the diagnosis changed to Crohn's disease.

Pouch-vaginal fistula (PVF) occurs in 6.3% (range 3-16%) of women who undergo IPAA [47]. Symptoms are discharge of flatus and faeces through the vagina. PVF are classified in relation to the ileoanal anastomosis (above, below or at the anastomosis), and management is challenging. Diversion may be considered in order to alleviate symptoms and control sepsis. Several surgical procedures have been described for the repair of PVF with variable success rates [48, 49]. Local procedures, such as transvaginal repair or endoanal ileal advancement flap, are appropriate for low fistulae whereas combined abdominoperineal procedures should be considered for high fistulae. Overall, more than 50% of patients maintain a functioning pouch without fistula recurrence, and about 20% require pouch excision [50]. Among the pouch clinic patients, four developed a PVF: two occurred early after a one-stage IPAA and were successfully treated by loop ileostomy. The other two patients had very mild symptoms and refused surgery.

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