Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1621_Библиотеки_им_академика_М_И_Перельмана.pdf
106
List of Recommendations
1. Evaluate patients with complex perianal Crohn’s disease with MRI or EAUS in
conjunction with examination under anesthesia to assess proximal disease and
anatomy of the perianal disease (strong recommendation based on moderate
quality evidence).
2. For patients with complex perianal Crohn’s disease complicated by sepsis, the
initial step is to drain all abscesses and place loose setons in identiable stulas
(strong recommendation based on low quality evidence).
3. Patients with refractory perianal symptoms and septic complications requiring
recurrent surgical intervention, and patients with signicantly impacted quality
of life despite combined seton and medical management should be counseled to
consider fecal diversion with a loop ileostomy (strong recommendation based on
low quality evidence).
4. Counseling regarding temporary fecal diversion should include discussion about
a possible permanent ostomy given low rates of continuity restoration (moderate
recommendation based on moderate quality evidence).
5. Discussion about permanent diversion is especially pertinent for patients with
proximal disease who have or are at risk for rectal stenosis (strong recommenda-
tion based on moderate quality evidence).
Personal View oftheData
In our search, no studies directly compared seton placement with diversion in
similar patient populations. Clinically, these surgical strategies are used in a step-
wise approach. Drainage of any infectious source and seton placement are the rst
stage of perianal Crohn’s disease treatment. This is completed in conjunction with
medical treatment, specically anti-TNF biologic therapy. If seton placement
with concurrent maximized medical management fails, then diversion is consid-
ered. The discussion of diversion is based on the severity of complications, includ-
ing the frequency of surgical interventions for perianal Crohn’s disease, fecal
incontinence, patient discomfort, and the combined effect of these complications
on the patient’s quality of life. Proceeding with diversion is a joint decision
between patient, surgeon, and the gastroenterologist. The decision is based on
exhaustion of combined seton and medical therapy, and the potential for improv-
ing quality of life [77].
Diversion with a loop ileostomy is generally discussed as an initial temporizing
measure that allows treatment of perianal disease with biologic agents in the absence
of continued irritation from the fecal stream. However, temporary diversion has
been shown to be reversed in as few as 17% of patients [39, 43]. Therefore, patients
should be made aware that a temporary loop ileostomy may result in permanent
diversion with or without conversion to proctectomy.
S. Khaitov and A. Ofshteyn
107
References
1. Platell C, Mackay J, Collopy B, Fink R, Ryan P, Woods R. Anal pathology in patients with
Crohn’s disease. ANZ J Surg. 1996;66(1):5–9. https://doi.org/10.1111/j.1445-2197.1996.
tb00690.x.
2. Lapidus A, Bernell O, Hellers G, Löfberg R.Clinical course of colorectal Crohn’s disease:
a 35-year follow-up study of 507 patients. Gastroenterology. 1998;114(6):1151–60.. http://
www.ncbi.nlm.nih.gov/pubmed/9609751. Accessed 5 June 2018.
3. Schwartz DA, Loftus EV, Tremaine WJ, etal. The natural history of stulizing Crohn’s disease
in Olmsted County, Minnesota. Gastroenterology. 2002;122(4):875–80. http://www.ncbi.nlm.
nih.gov/pubmed/11910338. Accessed 17 June 2018.
4. Michelassi F, Melis M, Rubin M, Hurst RD. Surgical treatment of anorectal complica-
tions in Crohn’s disease. Surgery. 2000;128(4):597–603. https://doi.org/10.1067/
msy.2000.108779.
5. Bell SJ, Williams AB, Wiesel P, Wilkinson K, Cohen RCG, Kamm MA.The clinical course of
stulating Crohn’s disease. Aliment Pharmacol Ther. 2003;17(9):1145–51. http://www.ncbi.
nlm.nih.gov/pubmed/12752351. Accessed 17 June 2018.
6. Ardizzone S, Maconi G, Colombo E, Manzionna G, Bollani S, Bianchi Porro G.Perianal s-
tulae following iniximab treatment: clinical and endosonographic outcome. Inamm Bowel
Dis. 2004;10(2):91–6.. http://www.ncbi.nlm.nih.gov/pubmed/15168807. Accessed 17 June
2018.
7. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB. AGA technical review on peri-
anal Crohn’s disease. Gastroenterology. 2003;125(5):1508–30. https://doi.org/10.1016/j.
gastro.2003.08.025.
8. Irvine EJ.Usual therapy improves perianal Crohn’s disease as measured by a new disease
activity index. McMaster IBD Study Group. J Clin Gastroenterol. 1995;20(1):27–32.. http://
www.ncbi.nlm.nih.gov/pubmed/7884173. Accessed 17 June 2018.
9. Sostegni R, Daperno M, Scaglione N, Lavagna A, Rocca R, Pera A.Review article: Crohn’s
disease: monitoring disease activity. Aliment Pharmacol Ther. 2003;17(Suppl 2):11–7. http://
www.ncbi.nlm.nih.gov/pubmed/12786607. Accessed 17 June 2018.
10. van Dongen LM, Lubbers EJ.Perianal stulas in patients with Crohn’s disease. Arch Surg.
1986;121(10):1187–90.. http://www.ncbi.nlm.nih.gov/pubmed/3767650. Accessed 17 June
2018.
11. Bernard D, Morgan S, Tassé D.Selective surgical management of Crohn’s disease of the anus.
Can J Surg. 1986;29(5):318–21.. http://www.ncbi.nlm.nih.gov/pubmed/3756650. Accessed 17
June 2018.
12. Radcliffe AG, Ritchie JK, Hawley PR, Lennard-Jones JE, Northover JM.Anovaginal and rec-
tovaginal stulas in Crohn’s disease. Dis Colon Rectum. 1988;31(2):94–9.. http://www.ncbi.
nlm.nih.gov/pubmed/3338350. Accessed 17 June 2018.
13. Fry RD, Shemesh EI, Kodner IJ, Timmcke A.Techniques and results in the management of
anal and perianal Crohn’s disease. Surg Gynecol Obstet. 1989;168(1):42–8.. http://www.ncbi.
nlm.nih.gov/pubmed/2909131. Accessed 17 June 2018.
14. Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM.Seton treatment of high anal
stulae. Br J Surg. 1991;78(10):1159–61. https://doi.org/10.1002/bjs.1800781004.
15. Scott NA, Nair A, Hughes LE.Anovaginal and rectovaginal stula in patients with Crohn’s
disease. Br J Surg. 1992;79(12):1379–80.. http://www.ncbi.nlm.nih.gov/pubmed/1486446.
Accessed 18 July 2018
16. Pescatori M, Interisano A, Basso L, etal. Management of perianal Crohn’s disease. Results of
a multicenter study in Italy. Dis Colon Rectum. 1995;38(2):121–4.. http://www.ncbi.nlm.nih.
gov/pubmed/7851164. Accessed 17 June 2018.
11 Management ofSevere Anoperineal Disease
108
17. Koganei K, Sugita A, Harada H, Fukushima T, Shimada H. Seton treatment for perianal
Crohn’s stulas. Surg Today. 1995;25(1):32–6. https://doi.org/10.1007/BF00309382.
18. Sangwan YP, Schoetz DJ, Murray JJ, Roberts PL, Coller JA.Perianal Crohn’s Disease Results
of Local Surgical Treatment. Dis Colon Rectum. 1996;39(5):529–35. https://doi.org/10.1007/
BF02058706.
19. Scott HJ, Northover JM. Evaluation of surgery for perianal Crohn’s stulas. Dis Colon
Rectum. 1996;39(9):1039–43.. http://www.ncbi.nlm.nih.gov/pubmed/8797656. Accessed 18
July 2018
20. Makowiec F, Jehle C, Becker H-D, Starlinger M.Perianal abscess in Crohn’s disease. 1997.
https://insights.ovid.com/crossref?an=00003453-199740040-00011. Accessed 14 July
2018.
21. Régimbeau J-M, Panis Y, Marteau P, Benoist S, Valleur P.Surgical treatment of anoperineal
crohn’s disease: can abdominoperineal resection be predicted? 1999. https://ac.els-cdn.com/
S1072751599000927/1-s2.0-S1072751599000927-main.pdf?_tid=435c0c76-74ea-496d-
a29c-7b7d08933d70&acdnat=1531592691_ce33ece4e3fb4bf114a25cad6a9a4263. Accessed
14 July 2018.
22. Takesue Y, Ohge H, Yokoyama T, Murakami Y, Imamura Y, Sueda T.Long-term results of
seton drainage on complex anal stulae in patients with Crohn’s disease. J Gastroenterol.
2002;37(11):912–5. https://doi.org/10.1007/s005350200153.
23. Shinozaki M, Koganei K, Fukushima T.Simultaneous anus and bowel operation is preferable
for anal stula in Crohn’s disease. J Gastroenterol. 2002;37(8):611–6. https://doi.org/10.1007/
s005350200097.
24. Thornton M, Solomon MJ.Long-term indwelling seton for complex anal stulas in Crohn’s
disease. Dis Colon Rectum. 2005;48(3):459–63. https://doi.org/10.1007/s10350-004-0830-6.
25. Mueller MH, Geis M, Glatzle J, etal. Risk of fecal diversion in complicated perianal Crohn’s
disease. J Gastrointest Surg. 2007;11(4):529–37. https://doi.org/10.1007/s11605-006-0029-3.
26. van Koperen PJ, Saruddin F, Bemelman WA, Slors JFM. Outcome of surgical treatment
for stula in ano in Crohn’s disease. Br J Surg. 2009;96(6):675–9. https://doi.org/10.1002/
bjs.6608.
27. Löfer T, Welsch T, Mühl S, Hinz U, Schmidt J, Kienle P.Long-term success rate after sur-
gical treatment of anorectal and rectovaginal stulas in Crohn’s disease. Int J Color Dis.
2009;24(5):521–6. https://doi.org/10.1007/s00384-009-0638-x.
28. Lozynskyy YS.Treatment algorithms in the case of perianal complications of Crohn’s disease.
Dig Dis. 2009;27:565–70. https://doi.org/10.1159/000233299.
29. Rehg KL, Sanchez JE, Krieger BR, Marcet JE.Fecal diversion in perirectal stulizing Crohn’s
disease is an underutilized and potentially temporary means of successful treatment. Am Surg.
2009;75(8):715–8.. http://www.ncbi.nlm.nih.gov/pubmed/19725296. Accessed 13 July 2018.
30. Galis-Rozen E, Tulchinsky H, Rosen A, etal. Long-term outcome of loose seton for com-
plex anal stula: a two-centre study of patients with and without Crohn’s disease. Color Dis.
2010;12(4):358–62. https://doi.org/10.1111/j.1463-1318.2009.01796.x.
31. Molendijk I, Nuij VJAA, van der Meulen-de Jong AE, Janneke van der Woude
C.Disappointing durable remission rates in complex Crohnʼs disease stula. Inamm Bowel
Dis. 2014;20(11):2022–8. https://doi.org/10.1097/MIB.0000000000000148.
32. Papaconstantinou I, Kontis E, Koutoulidis V, Mantzaris G, Vassiliou I.Surgical management
of stula-in-ano among patients with Crohn’s disease: analysis of outcomes after stulotomy
or seton placement—single-center experience. Scand J Surg. 2017;106(3):211–5. https://doi.
org/10.1177/1457496916665763.
33. Harper PH, Kettlewell MG, Lee EC.The effect of split ileostomy on perianal Crohn’s disease.
Br J Surg. 1982;69(10):608–10.. http://www.ncbi.nlm.nih.gov/pubmed/7127043. Accessed 17
June 2018.
34. Grant DR, Cohen Z, McLeod RS.Loop ileostomy for anorectal Crohn’s disease. Can J Surg.
1986;29(1):32–5. http://www.ncbi.nlm.nih.gov/pubmed/3940583. Accessed 17 June 2018.
S. Khaitov and A. Ofshteyn
109
35. Yamamoto T, Allan RN, Keighley MR.Effect of fecal diversion alone on perianal Crohn’s
disease. World J Surg. 2000;24(10):1258–62.. discussion 1262–3. http://www.ncbi.nlm.nih.
gov/pubmed/11071472. Accessed 13 July 2018.
36. Edwards CM, George BD, Jewell DP, Warren BF, Mortensen NJ, Kettlewell MG. Role
of a defunctioning stoma in the management of large bowel Crohn’s disease. Br J Surg.
2000;87(8):1063–6. https://doi.org/10.1046/j.1365-2168.2000.01467.x.
37. Régimbeau JM, Panis Y, Cazaban L, et al. Long-term results of faecal diversion for refrac-
tory perianal Crohn’s disease. Color Dis. 2001;3(4):232–7. http://www.ncbi.nlm.nih.gov/
pubmed/12790965. Accessed 18 July 2018
38. Spivak J, Landers CJ, Vasiliauskas EA, et al. Antibodies to I2 predict clinical response to
fecal diversion in Crohnʼs disease. Inamm Bowel Dis. 2006;12(12):1122–30. https://doi.
org/10.1097/01.mib.0000235833.47423.d7.
39. Hong MKH, Craig Lynch A, Bell S, etal. Faecal diversion in the management of perianal Crohn’s
disease. Color Dis. 2011;13(2):171–6. https://doi.org/10.1111/j.1463-1318.2009.02092.x.
40. Sauk J, Nguyen D, Yajnik V, etal. Natural history of perianal Crohnʼs disease after fecal diversion.
Inamm Bowel Dis. 2014;20(12):2260–5. https://doi.org/10.1097/MIB.0000000000000216.
41. Mennigen R, Heptner B, Senninger N, Rijcken E.Temporary fecal diversion in the manage-
ment of colorectal and perianal Crohn’s disease. Gastroenterol Res Pract. 2015;2015:1–5.
https://doi.org/10.1155/2015/286315.
42. Gu J, Valente MA, Remzi FH, Stocchi L. Factors affecting the fate of faecal diversion in
patients with perianal Crohn’s disease. Color Dis. 2015;17(1):66–72. https://doi.org/10.1111/
codi.12796.
43. Singh S, Ding NS, Mathis KL, etal. Systematic review with meta-analysis: faecal diversion
for management of perianal Crohn’s disease. Aliment Pharmacol Ther. 2015;42(7):783–92.
https://doi.org/10.1111/apt.13356.
44. Martí-Gallostra M, Myrelid P, Mortensen N, Keshav S, Travis SPL, George B.The role of a
defunctioning stoma for colonic and perianal Crohn’s disease in the biological era. Scand J
Gastroenterol. 2017;52(3):251–6. https://doi.org/10.1080/00365521.2016.1205127.
45. Bafford AC, Latushko A, Hansraj N, Jambaulikar G, Ghazi LJ.The use of temporary fecal
diversion in colonic and perianal Crohn’s disease does not improve outcomes. Dig Dis Sci.
2017;62(8):2079–86. https://doi.org/10.1007/s10620-017-4618-7.
46. Topstad DR, Panaccione R, Heine JA, Johnson DRE, MacLean AR, Buie DW.Combined seton
placement, iniximab infusion, and maintenance immunosuppressives improve healing rate
in stulizing anorectal Crohnʼs disease. Dis Colon Rectum. 2003;46(5):577–83. https://doi.
org/10.1007/s10350-004-6611-4.
47. Regueiro M, Mardini H.Treatment of perianal stulizing Crohn’s disease with iniximab
alone or as an adjunct to exam under anesthesia with seton placement. Inamm Bowel Dis.
2003;9(2):98–103.. http://www.ncbi.nlm.nih.gov/pubmed/12769443. Accessed 15 July 2018.
48. van der Hagen SJ, Baeten CG, Soeters PB, Russel MGVM, Beets-Tan RG, van Gemert
WG. Anti-TNF-α (iniximab) used as induction treatment in case of active proctitis in a
multistep strategy followed by denitive surgery of complex anal stulas in Crohn’s dis-
ease: a preliminary report. Dis Colon Rectum. 2005;48(4):758–67. https://doi.org/10.1007/
s10350-004-0828-0.
49. Hyder SA, Travis SPL, Jewell DP, McC Mortensen NJ, George BD. Fistulating anal
Crohnʼs disease: results of combined surgical and iniximab treatment. Dis Colon Rectum.
2006;49(12):1837–41. https://doi.org/10.1007/s10350-006-0656-5.
50. Gaertner WB, Decanini A, Mellgren A, etal. Does iniximab infusion impact results of opera-
tive treatment for Crohnʼs perianal stulas? Dis Colon Rectum. 2007;50(11):1754–60. https://
doi.org/10.1007/s10350-007-9077-3.
51. Guidi L, Ratto C, Semeraro S, etal. Combined therapy with iniximab and seton drainage for
perianal stulizing Crohn’s disease with anal endosonographic monitoring: a single-centre
experience. Tech Coloproctol. 2008;12(2):111–7. https://doi.org/10.1007/s10151-008-0411-0.
52. Tougeron D, Savoye G, Savoye-Collet C, Koning E, Michot F, Lerebours E. Predicting
factors of stula healing and clinical remission after iniximab-based combined therapy
11 Management ofSevere Anoperineal Disease
110
for perianal stulizing Crohn’s disease. Dig Dis Sci. 2009;54(8):1746–52. https://doi.
org/10.1007/s10620-008-0545-y.
53. Sciaudone G, Di Stazio C, Limongelli P, etal. Treatment of complex perianal stulas in Crohn
disease: iniximab, surgery or combined approach. Can J Surg. 2010;53(5):299–304.. http://
www.ncbi.nlm.nih.gov/pubmed/20858373. Accessed 18 July 2018
54. Tanaka S, Matsuo K, Sasaki T, etal. Clinical advantages of combined seton placement and
iniximab maintenance therapy for perianal stulizing Crohn’s disease: when and how were
the seton drains removed? Hepato-Gastroenterology. 2010;57(97):3–7.. http://www.ncbi.nlm.
nih.gov/pubmed/20422862. Accessed 14 July 2018
55. Alvarez JA, Bermejo F, Algaba A, Hernandez MP, Grau M. Surgical repair and biological
therapy for fecal incontinence in Crohn’s disease involving both sphincter defects and complex
stulas. J Crohns Colitis. 2011;5(6):598–607. https://doi.org/10.1016/j.crohns.2011.06.004.
56. Hotokezaka M, Ikeda T, Uchiyama S, Tsuchiya K, Chijiiwa K. Results of seton drain-
age and iniximab infusion for complex anal Crohn’s disease. Hepato-Gastroenterology.
2011;58(109):1189–92.. http://www.ncbi.nlm.nih.gov/pubmed/21937376. Accessed 18 July
2018
57. Gaertner WB, Madoff RD, Spencer MP, Mellgren A, Goldberg SM, Lowry AC.Results of
combined medical and surgical treatment of recto-vaginal stula in Crohn’s disease. Color Dis.
2011;13(6):678–83. https://doi.org/10.1111/j.1463-1318.2010.02234.x.
58. Roumeguère P, Bouchard D, Pigot F, etal. Combined approach with iniximab, surgery, and
methotrexate in severe stulizing anoperineal Crohnʼs disease: results from a prospective
study. Inamm Bowel Dis. 2011;17(1):69–76. https://doi.org/10.1002/ibd.21405.
59. Duff S, Sagar PM, Rao M, Dolling S, Sprakes M, Hamlin PJ. Iniximab and surgi-
cal treatment of complex anal Crohn’s disease. Color Dis. 2012;14(8):972–6. https://doi.
org/10.1111/j.1463-1318.2011.02811.x.
60. Antakia R, Shorthouse AJ, Robinson K, Lobo AJ.Combined modality treatment for com-
plex stulating perianal Crohn’s disease. Color Dis. 2013;15(2):210–6. https://doi.
org/10.1111/j.1463-1318.2012.03124.x.
61. Kotze PG, Albuquerque IC, da Luz Moreira A, Tonini WB, Olandoski M, Coy CSR.Perianal
complete remission with combined therapy (seton placement and anti-TNF agents) in Crohn’s
disease: a Brazilian multicenter observational study. Arq Gastroenterol. 2014;51(4):284–9.
https://doi.org/10.1590/S0004-28032014000400004.
62. Bor R, Farkas K, Bálint A, etal. Efcacy of combined anti-TNF-alpha and surgical therapy in
perianal and enterocutaneous stulizing Crohn’s disease– clinical observations from a tertiary
Eastern European center. Scand J Gastroenterol. 2015;50(2):182–7. https://doi.org/10.3109/00
365521.2014.936033.
63. Haennig A, Staumont G, Lepage B, etal. The results of seton drainage combined with anti-
TNFα therapy for anal stula in Crohn’s disease. Color Dis. 2015;17(4):311–9. https://doi.
org/10.1111/codi.12851.
64. Yardımcı S, Kara YB, Attaallah W, Uğurlu MÜ, Yeğen ŞC.Seton drainage combined with anti-
tnf therapy for perianal stulizing Crohn’s disease, single center experience. Marmara Med J.
2016;29(2):79. https://doi.org/10.5472/MMJoa.2902.03.
65. Schwartz DA, Wang A, Ozbay B, etal. Comparison of health care utilization and costs between
patients with perianal stulizing Crohn’s disease treated with biologics with or without pre-
vious seton placement. Inamm Bowel Dis. 2017;23(10):1860–6. https://doi.org/10.1097/
MIB.0000000000001243.
66. Orkin BA, Telander RL.The effect of intra-abdominal resection or fecal diversion on perianal
disease in pediatric Crohn’s disease. J Pediatr Surg. 1985;20(4):343–7. http://www.ncbi.nlm.
nih.gov/pubmed/4045658. Accessed 17 June 2018.
67. Rosen MJ, Moulton DE, Koyama T, et al. Endoscopic ultrasound to guide the combined
medical and surgical management of pediatric perianal Crohnʼs disease. Inamm Bowel Dis.
2010;16(3):461–8. https://doi.org/10.1002/ibd.21067.
S. Khaitov and A. Ofshteyn
111
68. Hukkinen M, Pakarinen MP, Piekkala M, Koivusalo A, Rintala R, Kolho K-L.Treatment of
complex perianal stulas with seton and iniximab in adolescents with Crohn’s disease. J
Crohns Colitis. 2014;8(8):756–62. https://doi.org/10.1016/j.crohns.2014.01.001.
69. Mattioli G, Pio L, Arrigo S, etal. Cone-like resection, stulectomy and mucosal rectal sleeve
partial endorectal pull-through in paediatric Crohn’s disease with perianal complex stula. Dig
Liver Dis. 2015;47(8):658–62. https://doi.org/10.1016/j.dld.2015.05.003.
70. Seemann NM, King SK, Elkadri A, Walters T, Fish J, Langer JC.The operative management of
children with complex perianal Crohn’s disease. J Pediatr Surg. 2016;51(12):1993–7. https://
doi.org/10.1016/j.jpedsurg.2016.09.021.
71. Present DH, Rutgeerts P, Targan S, etal. Iniximab for the Treatment of Fistulas in Patients
with Crohn’s Disease. N Engl J Med. 1999;340(18):1398–405. https://doi.org/10.1056/
NEJM199905063401804.
72. de Groof EJ, Sahami S, Lucas C, Ponsioen CY, Bemelman WA, Buskens CJ. Treatment of
perianal stula in Crohn’s disease: a systematic review and meta-analysis comparing seton
drainage and anti-tumour necrosis factor treatment. Color Dis. 2016;18(7):667–75. https://doi.
org/10.1111/codi.13311.
73. Marzo M, Felice C, Pugliese D, etal. Management of perianal stulas in Crohn’s disease: an
up-to-date review. World J Gastroenterol. 2015;21(5):1394. https://doi.org/10.3748/wjg.v21.
i5.1394.
74. Sahni VA, Ahmad R, Burling D.Which method is best for imaging of perianal stula? Abdom
Imaging. 2008;33(1):26–30. https://doi.org/10.1007/s00261-007-9309-y.
75. Ziech M, Felt-Bersma R, Stoker J. Clinical imaging. Imaging of perianal stulas. YJCGH.
2009;7:1037–45. https://doi.org/10.1016/j.cgh.2009.06.030.
76. Kasparek MS, Glatzle J, Temeltcheva T, Mueller MH, Koenigsrainer A, Kreis ME.Long-term
quality of life in patients with Crohnʼs disease and perianal stulas: inuence of fecal diver-
sion. Dis Colon Rectum. 2007;50(12):2067–74. https://doi.org/10.1007/s10350-007-9006-5.
77. Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS, pCD Collaborators. Surgical man-
agement of stulating perianal Crohn’s disease–AUK survey. Color Dis. 2017;19(3):266–73.
https://doi.org/10.1111/codi.13462.
11 Management ofSevere Anoperineal Disease
113
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_12
C. Twum-Barima, BSc (Hons), MBChB, MRCS · P. Tozer, BSc (Hons), MBChB, MRCS (*)
Robin Phillips Fistula Research Unit, St Mark’s Hospital, London and Imperial College
London, London, UK
e-mail: philtozer@nhs.net
12
Management ofAno/Rectovaginal
Fistula
CharleneTwum-Barima andPhilTozer
Introduction
Fistulas to the vagina from the anus or low rectum are variously called anovaginal
and rectovaginal stula (RVF) and the latter phrase will be used throughout this
chapter. RVF’s are a devastating problem producing severe symptoms in many
cases. They occur more commonly in Crohn’s disease than in the general popula-
tion, with a prevalence of 10% and mean age of onset of 34years in a series of 886
patients [1]. A population based survey from Minnesota found that 35% of Crohn’s
disease patients had stulas and 9% of these were RVF’s [2]. RVF’s are more com-
monly associated with colonic (23%) than small bowel (3.5%) Crohn’s disease [3,
4]. A variety of techniques are used in managing Crohn’s disease related RVF’s. In
this chapter, the literature pertaining to surgical treatment of an RVF complicating
Crohn’s disease is reviewed and is followed by recommendations and opinions
(Table12.1).
Table 12.1 PICO question
PICO table
Population Intervention Comparator
Outcomes
Management of ano/
rectovaginal stula
Pts with Crohn’s
disease
repair stoma Recurrent stula,
quality of life
114
Search Strategy
A comprehensive literature search of the Cochrane, EMBASE and MEDLINE data-
bases was performed to identify all relevant English-language publications over the
last 20years. Key search terms included: ‘rectovaginal stula,’ ‘anovaginal stula,’
‘Crohn’s’ and ‘surgery’ (and variants). Studies were excluded if they reported fewer
than 3 patients with Crohn’s RVF, or did not study surgical intervention (reparative
or ostomy formation), describe outcomes in Crohn’s patients separately from other
etiologies or consider stula healing and/or quality of life assessment as outcomes.
Conference proceedings were excluded. Only the most recent study was included if
similar studies from the same institution were encountered. The references of the
included studies were reviewed to identify additional studies.
Results
Almost all published studies are observational and retrospective in nature. No stud-
ies directly compare reparative surgery with ostomy formation. Reparative surgical
options reported include gracilis interposition, advancement ap repair (i.e. rectal,
vaginal), Martius ap, episioproctotomy, abdominal approaches including Soave-
type coloanal pull-through, and novel approaches including glue, plug, mesh inter-
position, stem cell injection and fat injection. Ostomy formation was performed in
three situations: temporarily to “protect” a repair; permanently to reduce symptoms
by defunctioning the rectum and therefore the stula, or; as part of an ablative oper-
ation (e.g. proctectomy).
Studies either tend to be of a single technique with multiple etiologies, or mul-
tiple techniques with a single etiology, or multiple techniques in multiple etiologies.
Many studies had only a small number of Crohn’s disease RVF’s treated by a par-
ticular technique and comparison between techniques is therefore difcult. It was
not always possible to determine the precise number of Crohn’s disease RVF
patients undergoing a particular technique. Most studies measured healing of the
stula as an outcome although assessment was performed at various time points
using multiple methods. Quality of life scoring was rarely reported. Heterogeneity
in etiology, stula morphology, surgical technique, previous repair attempts, and
outcome measurement limits the strength of the recommendations that follow
(Table12.2).
Few series of gracilis interposition contain three or more Crohn’s disease RVF
patients. Most include recurrent stulas and utilize fecal diversion. In one study,
three of nine patients’ RVF healed and one became sufciently small with reduced
symptoms such that no further treatment was required [5]; these four patients had
their stomas successfully reversed. Quality of life assessments were not reported. In
a study of gracilis interposition for RVF’s and rectourethral stulas, repair of
Crohn’s disease-related stulas was reported as “successful” but only one of the
three RVF’s healed [7]. Another study reporting 11 patients with Crohn’s disease
RVF’s treated with gracilis interposition found that all had healed and had their
C. Twum-Barima and P. Tozer
115
stoma reversed, although the follow-up interval was just a few months in one-half of
the patients [6] and medical treatment was not described.
One study of gracilis interposition for multiple etiologies reported quality of life
outcomes in addition to healing, which occurred in 4 of 5 (80%) Crohn’s disease
patients [8]. Quality of life was reported for all 8 RVF’s. Seven of eight women had
been sexually active before surgery but only four remained so afterwards. All four
had a healed stula. One noted reduced libido and two complained of dyspareunia,
but three of the four said they were satised with their sex-related quality of life.
Studies reporting outcomes from advancement ap repair also suffer from het-
erogeneity. For example, one study with 6 Crohn’s disease RVF patients used 5
vaginal advancement aps and 1 rectal advancement ap [11]. In the vaginal ap
patients, one was bolstered by porcine small intestinal submucosa-derived mesh,
one by gracilis interposition, and three by Martius aps, with only one patient hav-
ing follow-up longer than 4months. It is difcult in this context to dene advance-
ment ap success rates. Several studies include Crohn’s disease RVF’s but do not
report their outcomes separately from the RVF’s of other etiologies or anorectal
Table 12.2 Studies evaluating reparative techniques for Crohn’s disease RVF
Study
Patients Intervention(s) Outcome(s)
Quality
of evidence
Wexner (2008)
[5]
9 CD
RVF
Gracilis 3/9 (33%)
healed
Low
Furst (2008) [6] 11 CD
RVF
Gracilis 11/11 healed Low
Ulrich (2009)
[7]
3 CD
RVF
Gracilis 1/3 (33%)
healed
Low
Lefevre (2009)
[8]
5 CD
RVF
Gracilis 4/5 (80%)
healed
Low
Rottoli (2018)
[9]
8 CD
RVF
Gracilis 6/8 (75%)
healed
Low
Jarrar (2011)
[10]
12 CD
RVF
Rectal adv ap 5/12 (42%)
healed
Low quality
Nosti (2013)
[11]
6 CD
RVF
5 Vaginal adv ap, 1 rectal adv
ap, (4+Martius/Gracilis)
4/6 (67%)
healed
Very low
Songne (2007)
[12]
7 CD
RVF
Martius ap 8/8 (100%)
healed
Very low
Pitel (2011) [13] 8 CD
RVF
Martius ap 4/8 (50%)
healed
Low
Schwandner
(2009) [14]
9 CD
RVF
Rectal adv ap & Surgisis
mesh
7/9 (78%)
healed
Low
Mege (2016)
[15]
4 CD
RVF
Biological mesh (Strattice) 2/4 (50%)
healed
Low
Gajsek (2011)
[16]
8 CD
RVF
Button plug 4/8 (50%)
healed
Low
Garcia-Arranz
(2016) [17]
5 CD
RVF
Allogeneic stem cell transplant 3/5 (60%)
healed
Very low
Norderval
(2018) [18]
7 CD
RVF
Autologous fat graft injection 6/7 (86%)
healed
Low
12 Management ofAno/Rectovaginal Fistula
116
stulas to the perineum. One study that carefully described 12 Crohn’s disease
RVF’s found a primary healing rate of RVF managed by rectal advancement ap of
42% [10], rising to 83% after up to 3 attempts. Across the entire cohort, continence
and quality of life were similar before and after surgery. However, the “inconti-
nence” associated with the stula and true anal incontinence associated with the
surgical insult to the internal anal sphincter are not disentangled in this study and so
the true impact of this surgical technique on continence and any related impact on
quality of life cannot be determined.
Two studies analyzed the Martius ap technique in a variety of patients. One
study reported 8 Crohn’s disease RVF patients and found that the stula healed in
one-half [13]. Fecal incontinence (Wexner score), sexual quality of life [Female
Sexual Function Index (FSFI)], and overall quality of life [Short Form-12 (SF-12)
Health Survey] were analyzed for the entire group but results in the Crohn’s disease
RVF group were not separately presented. Fecal diversion was also used in several
patients and was maintained in at least one-half of the Crohn’s disease patients. An
earlier study described healing of all (7/7) Crohn’s disease RVF’s, but two of the
seven patients went on to proctectomy for “non-RVF” indications and the details are
unclear [12].
The generally poor outcomes associated with RVF repair, often reported as
worse in patients with Crohn’s disease, coupled with the morbidity of the operations
and postoperative symptoms, have prompted a slew of novel techniques, usually
aimed to be less invasive but more effective.
The over the scope clip (OTSC) has been used in Crohn’s disease RVF’s in two
studies of mixed stulas and etiologies. In one, [19] the success rate in the Crohn’s
disease RVF group was not described and in the other [20], only two Crohn’s dis-
ease RVF patients were included and neither healed.
Two studies reported biological mesh interposition in at least 3 Crohn’s disease
RVF patients. Porcine skin-derived mesh was used in 4 diverted patients in one
study [15]. Two patients’ RVF’s fully healed, one failed to heal, and the other was
converted to a rectoperineal stula. In another study, porcine small intestinal
submucosa- derived mesh was used and 7 of 9 (78%) Crohn’s disease RVF patients’
stulas were healed at the end of follow up [14].
A submucosal tissue-derived stula plug specically designed for stulas to the
vagina was used in 8 Crohn’s disease RVF’s without fecal diversion [16]. At nal
follow-up, 4 of 8 (50%) stulas were healed. Plug dislodgement led to several fail-
ures, and repairs in smokers and repeat procedures were always unsuccessful.
Allogeneic stem cells have been used to treat anal stulas arising in Crohn’s
disease in a large multicenter randomized controlled trial [21]. A phase I–II study
[17] from the same Spanish group found that 3 of 5 (60%) Crohn’s disease RVF
patients maintained a healed stula at 1-year follow-up. Autologous fat implanta-
tion led to healing of Crohn’s disease RVF’s in one study, in which 6 of 7 patients
(86%) had no stula at nal follow-up [18]. Repeat procedures, fecal diversion, and
medical treatment occurred but were not specied.
Several mixed series have been published that include Crohn’s disease RVF’s
treated with several different surgical techniques. In many it is impossible to
C. Twum-Barima and P. Tozer