FISTULOTOMY AFTER ILEOANAL POUCH: IS IT EVER SAFE?
Oscar Hernandez Dominguez*, Nicole E. Brooks, Eddy Lincango, Megan Obi, Arielle E. Kanters, Emre Gorgun, Jeremy M. Lipman, Hermann Kessler, Michael Valente, David Liska, Scott Steele, Tracy L. Hull, Stefan D. Holubar
Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Intro
Anal fistulas are classified and treated based on the position of the fistula tract relative to the anal sphincter muscles. Surgical treatment seeks to eliminate the epithelialized tract while also preserving anal sphincter function. Fistulotomy is a highly effective surgical treatment for simple anal fistulas. However, there is a lack of evidence on the use of fistulotomy in patients with ileal pouch-anal anastomosis (IPAA), generally considered a contraindication to fistulotomy. Therefore, our aim was to determine the safety, efficacy, and functional outcomes after fistulotomy used selectively in IPAA patients.
Methods
A retrospective review of all adult patients with an IPAA who underwent fistulotomy at our institution between January 1999 and August 2022 was performed. Data were collected from a prospective IPAA registry and supplemental chart review. Data included demographics, fistula characteristics, postoperative complications, recurrence, reoperations, resolution of fistula, and IPAA functional outcomes at the most recent follow-up.
Results
49 adult patients were included. The study cohort included 28 males (57%), the median age at fistulotomy was 45 years (range 23-70), median time from IPAA to fistula symptoms was 114.5 months (range, 2.6 to 450.2). Prior to fistulotomy, 24 patients (49%) had seton placement, 16 (33%) had drainage of abscess, and 5 patients (10%) had nonoperative therapy. Etiology of fistula was cryptoglandular (n=24, 49%), perianal Crohn's (n=17, 35%), IPAA anastomosis leak (n=7, 14%), and fissure (n=3, 6%). Fistula class was superficial (n=26, 53%), intersphincteric (n=15, 31%), and low transsphincteric (n=8, 16%). Anal fistulas were evaluated with MRI in 10 (20%) and CT in 11 (22%) patients. Fistulotomies were performed in the left anterior (n=18, 37%), right anterior (n=12, 24%), left posterior (n=7, 14%), right posterior (n=7, 14%), and posterior midline (n=5, 10%). Short-term complications included bleeding (n=2, 4%), and perianal sepsis (n=1, 2%). During a median follow-up time of 36 months (range 0-135.4) after fistulotomy, long-term complications included recurrence/new fistula (n=13, 26.5%), reoperation (n=9, 18%), and keyhole deformity (n=2, 4%). Functional IPAA outcomes included seepage (n=6, 12%) and fecal incontinence (n=2, 4%); no anal stricture was reported. Three patients (6%) required a temporary fecal diversion and 2 (4%) required IPAA excision, all of whom had been diagnosed with Crohn's. Thirty-seven (75%) of patients had complete resolution after fistulotomy with an intact functioning pouch.
Conclusion
Our data suggest that select patients with IPAA may safely undergo fistulotomy for anal fistulas that are superficial or involve minimal sphincter muscle. Pouch functional outcomes were minimally affected by fistulotomy in patients that did not have recurring fistula and abscess or Crohn's disease.
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