Rectovaginal Fistulas in Crohn Disease Lead to Debilitating Outcomes Despite Treatment

Rectovaginal fistulas are refractory to advanced therapy in patients with Crohn disease.

Despite medical advancements, rectovaginal fistulas (RVF) continue to be refractory to therapeutics, resulting in around one-third of patients with concomitant Crohn disease (CD) and RVF requiring proctectomy, according to study results presented at the Advances in Inflammatory Bowel Diseases (AIBD) 2022 conference, held from December 5 to 7, 2022, in Orlando, Florida.

Approximately 10% of patients with CD develop rectovaginal or anovaginal fistulizing disease that often is refractory to medical therapies, with inconsistent responsiveness to surgical interventions. Patients often need long-term immunosuppression and demonstrate an increased risk for proctectomy.

Researchers conducted a large, multicenter, retrospective, cohort study from January 1996 to September 2021 across 3 tertiary centers to describe strategies used to treat RVF and assess long-term outcomes following treatment.

Researchers reviewed medical records and identified 416 patients with CD-related RVF via ICD-9 and ICD-10 codes and terms in clinical documentation referring to RVF. At CD and RVF diagnosis, patients had a mean age (SD) of 28.5[14.5] and 38.4[14.5] years, respectively. Additionally, most patients were White (85%) and had a mean body mass index (BMI) of 25.1[7.1] at the time of RVF diagnosis.

The most predominant CD phenotype was ileocolonic (56.2%) followed by inflammatory (41.2%) and penetrating (38.2%) presentations, and 65.8% of patients presented with complex fistulas.

Despite therapeutic advances, RVF remains a devastating complication of CD with [one-third] of patients requiring rectum removal with a permanent stoma.

When analyzing previous procedures or exposures, researchers observed that 90% of the cohort received corticosteroid treatment and 75.5% received thiopurine treatment prior to diagnosis of RVF. Over half (60.2%) of patients had undergone small bowel or colon resections before RVF diagnosis; 26.4% reported prior ostomy during their CD disease history.

Strategies for treatment of RVF included:

  • medical therapies (23.1%), including biologics, although many patients in the cohort already had exposure to anti-tumor necrosis factor (TNF) biologics (74.3%), anti-integrins (17.5%), and anti-interleukin 12/23 medications (IL-12/23) (14.1%)
  • rectovaginal seton placement (single in 41.7% and multiple in 45.8% of patients)
  • minor procedures such as fistulotomy, fibrin glue, or fistula plug injection (11.4%)
  • LIFT or advancement flap procedures (13.3%), and
  • layered primary closure or omental, gracilis, or Martius flap procedures (14.3%).

Outcomes following treatment included:

  • successful repair of the RVF resulting in complete absence of vaginal discharge (12.7%)
  • diverting ostomy during follow-up (56%), or
  • proctectomy or proctocolectomy with end ileostomy (31.9%).

“Despite therapeutic advances, RVF remains a devastating complication of CD with [one-third] of patients requiring rectum removal with a permanent stoma,” the study authors wrote.

References:

Barros L, Friton J, Onken B, et al. Rectovaginal fistulas in Crohn’s disease: A large multicenter cohort study. Abstract presented at: AIBD 2022; December 5-7, 2022; Orlando, FL. Abstract 89.