Jean K. Ritchie

Anovaginal and rectovaginal fistulas in Crohn's disease.

Between 1957 and 1985, 886 women with Crohns disease and an intact distal large bowel were seen at St. Marks Hospital. Ninety of these patients developed a fistula between the vagina and anus or rectum at an average of 34 years. The track of the fistula was clearly documented in 80 patients and was extrasphincteric or suprasphincteric in 36, transsphincteric in 42 (high 13, low 29), and superficial in two. Of the 90 patients, 12 (13 percent) were managed throughout without recourse to surgery. Twelve (13 percent) had the fistula laid open or drainage of an abscess as the only surgery. Twelve (13 percent) underwent repair of the fistula and, of these, eight remain symptomatically cured. One has had further symptoms but no surgery while three later underwent proctectomy for rectal disease. In eight patients the colon was removed and the rectum defunctioned and in 34 the rectum was excised as the initial surgery after development of the fistula. The remaining 12 (13 percent) underwent later proctectomy for rectal disease of failed conservative management of the fistula. Extensive colonic involvement, rectal disease, or associated anal lesions were the main reasons for rectal excision in 38 patients. In only ten was the rectovaginal fistula a prominent indication for proctectomy. As medical treatment, repair, or other local surgery were successful in one third of the patients, these options should always be considered in the first instance.

Internal fistulas in Crohn's disease.

There is doubt about the timing of surgery for patients with internal fistulas in Crohns disease. Although immediate operative intervention for all patients has been advocated, such a policy has not always been followed at St. Marks Hospital. Between 1971 and 1982, 83 internal fistulas were identified in 59 patients with Crohns disease. Fifty-nine fistulas arose primarily from the small intestine and involved another segment of the bowel, five were between large bowel and duodenum, and three between areas of large bowel. Sixteen fistulas (ten from ileum and six from large bowel) involved the bladder. Thirty-six patients with 54 fistulas underwent immediate surgical treatment. Fifteen patients with 20 fistulas required surgery later. There was one postoperative death among the 51 patients treated surgically and one late death unrelated to the treatment of the fistula. Of the remaining 49 surgically treated patients, 46 were traced and remain well, six after further surgery. Eight patients with nine fistulas (four involving the bladder) were treated at St. Marks without operation. One later required surgery elsewhere for an enterocutaneous fistula, but the remaining seven patients are well. This study suggests that the presence of an internal fistula, even if it involves the bladder, is not an absolute indication for immediate surgery and that the severity of the symptoms should dictate the treatment policy.

Resection and sutured peranal anastomosis for carcinoma of the rectum

Resection and peranal suture is now an accepted technique for low rectal carcinoma; however, long-term results of large numbers are not known. Eighty-four patients who had this procedure at a specialist institution between 1972 and 1985 are reviewed. There was a low operative mortality (2.4 percent), but a high complication rate with pelvic sepsis in 34 (40.5 percent) and anastomotic dehiscence (either partial or complete) in 40 (47.6 percent). The crude five-year survival rate was 56 percent. Isolated local recurrence occurred in seven patients (9.2 percent) and in a further seven patients it was associated with systemic recurrence. The functional results were satisfactory with 92 percent of assessed patients having three or less bowel actions per day. Subsequent incontinence occurred in 8 of the 60 patients assessed and 5 of these needed proximal diversion. For patients in whom the only alternative is abdominoperineal excision of the rectum, these results confirm that there is no disadvantage in terms of potential cure and that the functional results are acceptable.

Sexual function and perineal wound healing after intersphincteric excision of the rectum for inflammatory bowel disease

The technique of intersphincteric excision of the rectum in patients with inflammatory bowel disease was introduced with the aim of avoiding postoperative sexual dysfunction and, combined with primary perineal suture, should decrease morbidity from delayed perineal wound healing. In a series of 98 patients so treated at St. Marks Hospital, permanent sexual dysfunction from sympathetic nerve damage occurred in one male patient among 23 aged 60 years or less assessed postoperatively. No patient exhibited evidence of permanent parasympathetic nerve damage. Primary healing of the perineal wound was successful in 50 per cent of the cases and in 69 per cent the wound healed within three months of operation. It is suggested that this combination of operative techniques significantly decreases morbidity from rectal excision compared with more extensive procedures and should be more widely adopted.