VM02 - Cloacal Repair in a Pelvic Pouch Patient

Purpose/Background: Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for refractory ulcerative colitis with excellent functional results. A pouch-vaginal fistula is an infrequent complication. The management of these fistulas is difficult, and failure can result in significant deformity of the anus and perineum.

Methods/Interventions: We present a case of a 25-year-old female with medically refractory ulcerative colitis who underwent a pelvic pouch procedure. Three months following ileostomy reversal, she developed a low pouch-vaginal fistula in the absence of pelvic sepsis. She was trialed on Ustekinumab, underwent seton placement, and ultimately a perineal procedure that failed. This resulted in a cloaca-like deformity with exposed pouch mucosa. Due to persistent urgency, pain, and incontinence related to the procedure failure, she underwent an end-loop ileostomy.

Results/Outcomes: The method we chose to repair this problem mirrors a repair of a 4th degree obstetrical tear but done in Kraske position. After incising along the scarred transverse edge of the anoperineum, both sides of the anal sphincter are isolated with care to avoid injury to the pudendal nerves during the lateral dissection. The dissection is carried cephalad in the pouch-vaginal septum such that an overlapping sphincteroplasty will lay flat. The anoderm is first reapproximated with 3-0 absorbable vertical mattress sutures, ensuring approximation of the dentate line. The sphincteroplasty is then performed in vest-over-pants fashion using 2-0 delayed absorbable sutures. The muscle tail is reinforced using 2-0 suture, and the wound is closed side-to-side leaving a small opening on the vaginal side to promote drainage.

These techniques are reviewed in the supplemental video.

Conclusion/Discussion: A cloacal deformity from a failed anorectal vaginal fistula in any woman is difficult to manage and can lead to exposed rectal mucosa and fecal incontinence. The problem is magnified for a patient with a pelvic pouch due to the normal defecation pattern of multiple loose stools daily. This rare problem in a woman with a pelvic pouch can be surgically addressed with the type of meticulous repair described here, done with a diverting ileostomy.