De Carlo Giulia, Belkovsky Mikhael, Lavryk Olga Lavryk, Kanters Arielle, Falloon Katherine, Naseer Maliha, Braga-Neto Manuel, Qazi Taha, Cohen Benjamin, Lipman Jeremy, Liska David, Hull Tracy, Holubar Stefan
Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.
Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.
Surgery. 2025 Nov;187:109638. doi: 10.1016/j.surg.2025.109638. Epub 2025 Aug 21.
Pouch-related fistulas occur in 5% to 12% of patients with ileal pouch-anal anastomosis. Although cryptoglandular and Crohn-related fistulas are commonly treated with endorectal advancement flaps, the use of pouch-advancement flaps has not been previously reported in isolation. Our aim was to evaluate the outcomes of pouch-advancement flaps in the management of pouch-related fistulas and compare the outcomes of pouch-vaginal and pouch-perineal fistulas.
We retrospectively reviewed all patients with ileal pouch-anal anastomosis who underwent pouch-advancement flap surgery at our center. Our primary endpoint was sustained fistula healing after pouch-advancement flap surgery without the need for additional surgery at any time during long-term follow-up.
Thirty patients met our inclusion criteria: 14 (46.7%) presented with pouch-perineal fistula, 14 (46.7%) with pouch-vaginal fistula, and 2 (6.6%) with both. Multibranched complex fistulas were diagnosed in 6 patients (20%). In 9 patients (30%), the pouch-advancement flap was protected with diverting loop ileostomy. After a median follow-up period of 25.7 months (range 4.8-43.1 months), the pouch-advancement flap was initially successful in 19 patients (63%), with no difference between pouch-perineal and pouch-vaginal fistulas (P = 1.0). After the initial healing, 14 of 19 patients (73.7% or 46% overall) had sustained healing, while 5 of 19 (26.3%) had fistula recurrence. Fecal diversion and other fistula characteristics were not associated with pouch-advancement flap healing (P = 1.0).
Pouch-advancement flaps were initially successful in two thirds, with a recurrence rate after initial healing of 26.3%, regardless of whether they were pouch-perineal or pouch-vaginal. The role of fecal diversion before pouch advancement flap remains unclear, and larger, multicentric collaborative studies are needed to clarify its role.
回肠袋肛管吻合术后，5%至12%的患者会出现与袋相关的瘘管。尽管隐窝腺性瘘管和克罗恩病相关瘘管通常采用直肠内推进皮瓣治疗，但此前尚未有单独使用袋推进皮瓣的报道。我们的目的是评估袋推进皮瓣治疗与袋相关瘘管的效果，并比较袋阴道瘘和袋会阴瘘的治疗效果。
我们回顾性分析了在本中心接受袋推进皮瓣手术的所有回肠袋肛管吻合术患者。我们的主要终点是袋推进皮瓣手术后瘘管持续愈合，且在长期随访期间无需进行任何额外手术。
30例患者符合纳入标准：14例（46.7%）为袋会阴瘘，14例（46.7%）为袋阴道瘘，2例（6.6%）两者均有。6例患者（20%）诊断为多分支复杂性瘘管。9例患者（30%）的袋推进皮瓣采用转流性回肠造口术保护。中位随访期为25.7个月（范围4.8 - 43.1个月），19例患者（63%）的袋推进皮瓣最初成功，袋会阴瘘和袋阴道瘘之间无差异（P = 1.0）。初次愈合后，19例患者中的14例（73.7%，总体为46%）实现了持续愈合，而19例中的5例（26.3%）出现了瘘管复发。粪便转流和其他瘘管特征与袋推进皮瓣愈合无关（P = 1.0）。
袋推进皮瓣最初成功率为三分之二，初次愈合后的复发率为26.3%，无论其为袋会阴瘘还是袋阴道瘘。在袋推进皮瓣手术前进行粪便转流的作用仍不明确，需要开展更大规模的多中心协作研究来阐明其作用。
