Multiple Surgical Interventions Improves Outcomes for Crohn’s Related Rectovaginal Fistulas

Ana M. Otero-Pineiro, MD, PhD

Smoking is 1 of the key factors that could lead to Crohn’s disease-related rectovaginal fistulas.

A team, led by Ana M. Otero-Pineiro, MD, PhD, Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, determined outcomes of single and repeat operative interventions of patients with Crohn’s disease-related rectovaginal fistulas.

Approximately 10-20% of women with Crohn’s disease have rectovaginal fistula , which significantly affects their quality of life.

Reviewing the Data

In the retrospective review, the investigators examined adult patients with a Crohn’s disease-related rectovaginal fistula who underwent an operation between 1995-2021. The investigators collected data on patient demographics, Crohn’s disease related medical treatment, surgical intervention, postoperative outcomes, and fistula outcomes.

The study included 166 patients who underwent 360 operations with a mean age of 42.8 years.

In addition, 20.7% (n = 34) patients were current smokers and 35.4% (n = 58) of participants were former smokers.

Procedures

A local approach using fibrin glue, fistulomy/fistulectomy or seton placement was the most commonly performed procedure , occurring in 44.5% (n = 160) of patients, followed by a transvaginal/transanal approach (31.4%; n = 113) with an advancement flap repair, with an advancement flap repair (including Martius advancement flap) and episoproctotomy, a transabdominal approach (27.2%; n = 98) including proctectomy or redo anastomosis and finally gracilis muscle interposition (2.2% n = 8).

The median number of operative interventions per patient was 2 procedures and the overall fistula healing rate per patient was 71.7% (n = 119) at a median follow-up of 5.5 years.

The investigators identified several factors that impaired healing, including former smoking (OR, 0.52; 95% CI, 0.31-0.87; P = 0.014) and seton insertion (OR, 0.42; 95% CI, 0.21-0.83; P = 0.012).

“Over two-thirds of Crohn’s related rectovaginal fistulas can achieve closure with multiple surgical interventions,” the authors wrote. “Smoking and seton usage negatively impact healing rates and should be avoided.”

Social Media and Fistulas

Patient’s with Crohn’s perianal fistulae (CPF) has an increased burden of quality of life and financial concerns over treatments.

However, it can be difficult for researchers and clinicians to understand this true burden, but social media can offer a truer glimpse at what is occurring.

Crohn’s perianal fistulae can affect the physical, emotional, and social wellbeing of patients, reducing their overall quality of life. However, there is not much data available from studies on how patients navigate the challenges tied to the complications of Crohn’s disease and how the individual perceives the value of treatments.

A team, led by Carine Khalil, PhD, Cedars Sinai Medical Center, used social media to examine how patients with Crohn’s perianal fistulae rate their experience and express concerns to assess its impact on behavior and wellbeing in data presented during the Crohn’s and Colitis Congress 2022 Annual Meeting.

Overall, 4 main themes and several subthemes emerged.

For example, 38% of posts involved patients seeking peer-support and information about CPF symptoms, treatments, diet, experimental therapies, natural remedies, and patients’ apprehension regarding treatments.

In addition, 30% of the posts focused on the biopsychosocial burden of the disease, while patients reported pain and constant discomfort, psychological effects, including stress symptoms, distress, and fear. This also included the social impact on work and intimate relationships.

Another theme was users discussing treatment challenges, which was seen in 21% of posts. This included financial challenges, unsuccessful procedures and treatments, recurrence of CPF post-treatment, and a lack of information of treatments.

The final theme, found in 15% of posts, involved patient experience with medications and surgeries, including efficacy of treatments, side effects, and complications.

The study, “Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice,” was published online in the Journal of Crohn’s and Colitis.