Recto-vaginal fistulas in Crohn's patients can be successfully managed by aggressive systemic treatment and advancement flaps

Abstract

• Introduction: Recto-vaginal fistulas are a dreadful complication of Crohn's disease for which no consensus exists regarding optimal treatment. The aim of the study was to identify possible medical and surgical variables that may determine outcome. Patients and Methods: 43 patients with a symptomatic recto-vaginal fistula, 33 with Crohn's disease (mean age: 35.7 yrs) and 10 without (mean age: 38.5 yrs) were studied retrospectively. All patients were initially treated with a seton drainage. Fistula surgery included vaginal advancement flaps (n=18), rectal advancement flaps (n=9) and sphincter repairs (n=6). Variables that were studied included: presence of Crohn's disease, proctitis, azathioprine treatment, vaginal vs rectal advancement flap and fecal diversion. Results: The recto-vaginal fistula was successfully closed in the non-Crohn and Crohn patients in 90% (mean follow-up: 21.2 mths) and 72.2% (mean follow-up: 31.5 mths) resp. (NS). Aggravation of incontinence was reported in none of the patients. Crohn patients treated with azathioprine for proctitis showed a higher success rate of fistula surgery, 84% as compared to the patients who didn't receive azathioprine, 57% (p=0.1). In Crohn's patients recurrence rates following rectal and vaginal flaps were comparable, 33.3% and 27.7%, resp. Success rate of fistula surgery was higher in Crohn's patients with fecal diversion, 90% as compared to those treated with medical colostomy, 61.9% (p=0.1). In conclusion: The majority of recto-vaginal fistulas in Crohn's patients can successfully be managed with systemic treatment and a subsequent advancement flap. Treatment with azathioprine and fecal diversion, but not the initial presence of proctitis or the type of advancement flap seem to influence outcome.