Successful complex therapy of Crohn disease induced recto-vaginal fistula

Introduction: The surgical therapy of Crohn induced perianal fistulas provide little success for the surgeon. This is especially true for recto-vaginal fistulas.

Case-report: We diagnosed Crohn disease at a 48 years old lady in 2006. The disease affected all the colon but the final 5cm-s of the rectum. After the colonoscopy she developed acute abdomen and we had to perform laparotomy. During the operation we found rupture of the cecum and concomitant peritonitis. The right side of the colon was removed and a ileostomy was was constructed. At that stage we recognized her recto-vaginal fistula which was 1cm in diameter and was situated 4cm from the anal verge. The established elementary diet, mesalasine, azatioprine and methylprednisolone treatment was ineffective in respect of the fistula. Thus the closure of the ileostomy was impossible. Procto-colectomy with abdominoperineal excision was considered. But the distal 10cm of the rectum was spared -apart from the fistula- so we decided further active treatment. She was given 5 cycles if infliximab therapy and we proceeded with surgery. A Lehoczky-type fascio-cutaneous flap was used to close the fistula in December 2007– with success. After the operation she received further infliximab maintenance therapy. We removed the diseased left colon in August 2008 and constructed a ileo-rectostomy with the intact 10cm rectal stump. She is continent, she has 3–5 bowel movement per day and has no recurrent recto-vaginal fistula.

Conclusion: In selected cases recto-vaginal fistulas in Crohn disease can be treated with the hope of success. It requires close cooperation between gastroenterologists and surgeons.