Management and Treatment of Fistulas after Surgical Treatment of Ulcerative Colitis

Ileal-pouch fistulas after total proctocolectomy and pouch-anal anastomosis are a rare and overwhelming complication for patients and a challenging problem for surgeons. In patients with ileal pouch-anal anastomosis (IPAA), fistulous tracts can originate at any level of the pouch and anal canal, and they can extend into any adjacent hollow organs or to the skin. Even though several studies have assessed pouch-vaginal fistula formation, little has been published regarding overall perianal fistula formation after restorative proctocolectomy. Pouch-anal or pouch-vaginal fistulas may occur at any time following restorative proctocolectomy, with an incidence of 2.6–14%, depending on the length of the follow-up. A fistula after ileoanal pouch construction may occur in the form of a leak in the early period, but it is more frequently seen as a late complication some months after the procedure. In the majority of cases, the ileoanal anastomosis is the origin of early fistulas presenting with pelvic and perianal sepsis, and most likely associated with the technical aspects of the operation. Several operative techniques have been described to control perianal sepsis and, ultimately, heal the fistulous tract; however, due to the individual complexity of the fistulas, optimal management continues to be controversial. In patients with pouch-anal and pouch-vaginal fistulas, pouch failure, defined as a definitive ileostomy with or without pouch excision, remains high and is reported in 21–30% of patients with fistulas; however, the factors contributing to pouch excision remain poorly defined.