Should immunomodulation therapy alter the surgical management in patients with rectovaginal fistula and Crohn's disease?

BACKGROUND: Rectovaginal fistula in Crohn's disease is challenging for both healthcare providers and patients. The impact of immunomodulation therapy on healing after surgery is unclear. OBJECTIVE: The purpose of this study was to examine whether immunomodulation therapy impacts healing after surgery for rectovaginal fistula in Crohn's disease. DESIGN: This was a retrospective analysis with a follow-up telephone survey. SETTINGS: The study was conducted at two major tertiary referral centers. PATIENTS: All of the patients who underwent rectovaginal fistula repair from 1997 to 2013 at our centers were included. MAIN OUTCOME MEASURES: A χ 2 test and logistical regression analysis were used to study treatment outcomes according to type of procedure, recent use of immunosuppressives, and number of previous attempted repairs. Age, BMI, smoking, comorbidities, previous vaginal delivery/obstetric injury, use of probiotics, diverting stoma, and use of seton were also analyzed. RESULTS: A total of 120 (62%) patients were contacted, and 99 (51%) of them agreed to participate in the study. Mean follow-up after surgical repair was 39 months. Procedures included advancement flap (n = 59), transvaginal repair (n = 14), muscle interposition (n = 14), episioproctotomy (n = 6), sphincteroplasty (n = 3), and other (n = 3); overall, 63% of patients experienced healing. Sixty-eight patients underwent recent immunomodulation therapy but did not exhibit statistical significance in outcome after surgical repair. In the subset of patients with fistula related to obstetric injury, a 74% (n = 26) healing rate after surgical repair was observed. Age, BMI, diabetes mellitus, use of steroids, probiotics, seton before repair, fecal diversion, and number of repairs did not affect healing. LIMITATIONS: This was a retrospective analysis; the high volume tertiary referral inflammatory bowel disease centers studied may not be reflective of rectovaginal fistula presentation, treatment, or results in all patients, and the 3-year follow-up may not be sufficiently long. CONCLUSIONS: Despite a relatively low success rate (63%) in healing after surgical repair of a rectovaginal fistula, the recent use of immunomodulation therapy did not negatively impact healing. However, tissue interposition techniques had the highest success rates.