Pouch Vaginal Fistula

The symptoms of pouch-vaginal fistula consist of leakage of secretion or gas from the mucosa and/or faecal leakage through the vagina or the perineum. Its incidence is equal to approximately 5-10% of patients operated on for RP. The treatment depends on the severity of the symptoms. In the case of minimal symptoms, the application of a seton tie could be sufficient, even if long-term data on it does not exist [16].

In the case of incontinence, a defunctioning ileostomy can be performed and a seton tie can be inserted for drainage. Once the sepsis has been resolved, recanalisation will be possible. The insertion of a seton tie is probably the technique of choice in the presence of a cryptoglandular fistula. Ileostomy alone, in fact, is not in a position to guarantee satisfactory results [17].

Surgical procedures can be divided into abdominal and local. The first is concerned with abdominal revision and the advancement of the ileo-anal anastomosis. Local procedures, on the other hand, such as advancement flap repair and endoanal or endovaginal repair, precede fistulectomy.

It is obvious that the site of anastomosis influences surgical choice. According to some authors, in the presence of anastomosis in the distal rectum, it is possible to make a reconstruction and to perform a more distal anastomosis with success in 21 out of 26 patients [12, 16, 17]. In the case of a fistula that is derived from ileo-anal anastomosis, a local treatment is recommended.

Advancement flap repair determines success in 50% of cases. Transvaginal repair allows a direct access to the fistula avoiding sphincter damage. In one study, five patients out of seven obtained good results at a mean follow-up of 26 months [13]. Others authors have reported good results in 11 patients out of 14 at a mean follow-up of 18 months [18].

In reviewing the various results obtained with a transvaginal approach, the closing of the fistula has been demonstrated in 25 patients out of 35. Surgery with an abdominal approach is in a position to achieve good results in 80% of cases; with the per-ineal approach the percentage falls to 50% of cases [13,16, 19, 20].

A further condition that can lead to the removal of the ileal pouch is represented via malfunction. Such an event is responsible for 20-40% of failure of the pouch [9, 10]. Karoui [21] reports a removal rate of 35% for poor functioning (24 out of 58 removals) due to outlet obstruction in 10 patients and incontinence in 14 patients. The success rate after medical or surgical treatment is extremely variable in the literature, ranging between 33 and 100% of cases [9, 22]. Surgical treatment can consist of an exclusively transanal approach or a combined abdominoperineal approach, depending on the reason of dysfunction and technical feasibility [23]. The most frequent causes of malfunction are represented by mechanical obstruction, sphincter dysfunction, reduced capacity of the reservoir or by mucosal inflammation [24]. The majority of the patients with poor functioning have an evacuation frequency of 10 motions/24 h or more, often associated with emission of small volumes of faeces and the presence of urgency, incontinence and evacuation difficulties [24].

Outlet obstruction (OO), which alone is responsible for 18-48% of the malfunction of the ileal reservoir [9, 10], can be determined by various factors including stenosis of the pouch-anal anastomosis, a long efferent limb (LEL) in an S-shaped form or by the presence of a residual of rectal mucosa at the level of the pouch-anal anastomosis (retained rectal stump).

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