Rectovaginal Fistulas in Crohn Disease Lead to Debilitating Outcomes Despite Treatment

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.

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.