Advertisement

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes

  • Author Footnotes
    1 equal contribution
    Gianluca Pellino
    Correspondence
    Corresponding author at: Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy and Vall d'Hebron University Hospital, Barcelona, Spain.
    Footnotes
    1 equal contribution
    Affiliations
    Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy

    Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
    Search for articles by this author
  • Author Footnotes
    1 equal contribution
    Valerio Celentano
    Footnotes
    1 equal contribution
    Affiliations
    Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom

    Department of Surgery and Cancer. Imperial College, London, United Kingdom
    Search for articles by this author
  • Danilo Vinci
    Affiliations
    Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
    Search for articles by this author
  • Francesco Maria Romano
    Affiliations
    Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
    Search for articles by this author
  • Agnese Pedone
    Affiliations
    Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
    Search for articles by this author
  • Vincenzo Vigorita
    Affiliations
    Department of General and Digestive Surgery, University Hospital Complex of Vigo, Vigo, Spain

    General Surgery Research Group, SERGAS-UVIGO, Galicia Sur Health Research Institute [IIS Galicia Sur], Vigo, Spain
    Search for articles by this author
  • Giuseppe Signoriello
    Affiliations
    Section of Statistic, Department of Mental Health and Public Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
    Search for articles by this author
  • Francesco Selvaggi
    Affiliations
    Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
    Search for articles by this author
  • Guido Sciaudone
    Affiliations
    Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
    Search for articles by this author
  • Author Footnotes
    1 equal contribution

      Abstract

      Background

      Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

      Aims

      To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

      Methods

      A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

      Results

      34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

      Conclusion

      PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Digestive and Liver Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Colombo F
        • Sahami S
        • de Buck Van Overstraeten A
        • Tulchinsky H
        • Mege D
        • Dotan I
        • Foschi D
        • Leo CA
        • Warusavitarne J
        • D'Hoore A
        • Panis Y
        • Bemelman W
        • Sampietro GM
        Restorative proctocolectomy in elderly IBD patients: a multicentre comparative study on safety and efficacy.
        J Crohns Colitis. 2017 Jun 1; 11 (PMID: 27927720): 671-679https://doi.org/10.1093/ecco-jcc/jjw209
        • Mege D
        • Colombo F
        • Stellingwerf ME
        • Germain A
        • Maggiori L
        • Foschi D
        • Buskens CJ
        • de Buck van Overstraeten A
        • Sampietro G
        • D'Hoore A
        • Bemelman W
        • Panis Y
        Risk factors for small bowel obstruction after laparoscopic ileal pouch-anal anastomosis for inflammatory bowel disease: a multivariate analysis in four expert centres in Europe.
        J Crohns Colitis. 2019 Mar 26; 13 (PMID: 30312385): 294-301https://doi.org/10.1093/ecco-jcc/jjy160
        • Sampietro GM
        • Colombo F
        • Frontali A
        • Baldi CM
        • Carmagnola S
        • Cassinotti A
        • Dell'Era A
        • Massari A
        • Molteni P
        • Dilillo D
        • Fociani P
        • Tonolini M
        • Maconi G
        • Fiorina P
        • Corsi F
        • Bianco R
        • Nebuloni M
        • Zuccotti G
        • Ardizzone S
        • Foschi D.
        Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. a prospective study on safety, efficacy and long-term results.
        Dig Liver Dis. Dec 2018; 50 (Epub 2018 May 21. PMID: 29914803): 1283-1291https://doi.org/10.1016/j.dld.2018.05.009
        • Colombo F
        • Pellino G
        • Selvaggi F
        • Corsi F
        • Sciaudone G
        • Sampietro GM
        • Foschi D.
        Minimally invasive surgery and stoma-related complications after restorative proctocolectomy for ulcerative colitis. a two-centre comparison with open approach.
        Am J Surg. Apr 2019; 217 (Epub 2018 Jul 24. PMID: 30054005): 682-688https://doi.org/10.1016/j.amjsurg.2018.07.028
        • Fazio VW
        • Tekkis PP
        • Remzi F
        • et al.
        Quantification of risk for pouch failure after Ileal pouch anal anastomosis surgery.
        Ann Surg. 2003; 238: 605-614
      1. Body mass index and complications following major gastrointestinal surgery: a prospective, international cohort study and meta-analysis. EuroSurg Collaborative.
        Colorectal Dis. Aug 2018; 20 (Epub 2018 Jul 9. PMID: 29897171): O215-O225https://doi.org/10.1111/codi.14292
        • Pellino G
        • Sciaudone G
        • Miele E
        • et al.
        Functional outcomes and quality of life after restorative proctocolectomy in paediatric patients: a case–control study.
        Gastroenterol Res Pract. 2014; 340341
        • Pellino G
        • Sciaudone G
        • Candilio G
        • et al.
        Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly.
        BMC Surg. 2013; : S9
        • Rottoli M
        • Tanzanu M
        • Di Candido F
        • Colombo F
        • Frontali A
        • Chandrasinghe PC
        • Pellino G
        • Frasson M
        • Warusavitarne J
        • Panis Y
        • Sampietro GM
        • Spinelli A
        • Poggioli G.
        Risk factors for locally advanced cancer associated with ulcerative colitis: results of a retrospective multicentric study in the era of biologics.
        Dig Liver Dis. Jan 2020; 52 (Epub 2019 Sep 30. PMID: 31582324): 33-37https://doi.org/10.1016/j.dld.2019.08.024
        • Liberati A
        • Altman DG
        • Tetzlaff J
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. Oct 2009; 62 (Epub 2009 Jul 23. PMID: 19631507): e1-34https://doi.org/10.1016/j.jclinepi.2009.06.006
      2. Ryan R, Hill S. How to GRADE the Quality of the Evidence. Cochrane Consumers and Communication Group; 2016. ProMed –mail website. http://cccrg.cochrane.org/author-resources. Version 3.0. December 2016.

        • Arai K
        • Koganei K
        • Kimura H
        • et al.
        Incidence and outcome of complications following restorative proctocolectomy.
        Am J Surg. Jul 2005; 190 (PMID: 15972169): 39-42https://doi.org/10.1016/j.amjsurg.2005.05.001
        • Burke D
        • van Laarhoven CJ
        • Herbst F
        • et al.
        Transvaginal repair of pouch-vaginal fistula.
        Br J Surg. Feb 2001; 88 (PMID: 11167874): 241-245https://doi.org/10.1046/j.1365-2168.2001.01663.x
        • Cohen Z
        • Smith D
        • McLeod R.
        Reconstructive surgery for pelvic pouches.
        World J Surg. Apr 1998; 22 (PMID: 9523514): 342-346
        • Devesa JM
        • Devesa M
        • Velasco GR
        • et al.
        Benign rectovaginal fistulas: management and results of a personal series.
        Tech Coloproctol. Jun 2007; 11 (Epub 2007 May 25. PMID: 17510743): 128-134https://doi.org/10.1007/s10151-007-0342-1
        • Fahad H
        • Dulai PS
        • Shen B
        • et al.
        Hyperbaric oxygen therapy is effective in the treatment of inflammatory and Fistulizing pouch complications.
        Clin Gastroenterol Hepatol. Jun 2021; 19 (Epub 2020 Jun 19. PMID: 32565291): 1288-1291https://doi.org/10.1016/j.cgh.2020.06.029
        • Fazio VW
        • Wu JS
        • Lavery IC.
        Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment.
        Ann Surg. Oct 1998; 228 (PMID: 9790348; PMCID: PMC1191541): 588-597https://doi.org/10.1097/00000658-199810000-00015
        • Gajsek U
        • McArthur DR
        • Sagar PM.
        Long-term efficacy of the button fistula plug in the treatment of Ileal pouch-vaginal and Crohn's-related rectovaginal fistulas.
        Dis Colon Rectum. Aug 2011; 54 (PMID: 21730789): 999-1002https://doi.org/10.1097/DCR.0b013e31821df266
        • Gonsalves S
        • Sagar P
        • Lengyel J
        • et al.
        Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of Ileal pouch-vaginal and rectovaginal fistulas.
        Dis Colon Rectum. Nov 2009; 52 (PMID: 19966636): 1877-1881https://doi.org/10.1007/DCR.0b013e3181b55560
        • Groom JS
        • Nicholls RJ
        • Hawley PR
        • et al.
        Pouch-vaginal fistula.
        Br J Surg. Jul 1993; 80 (PMID: 8369945): 936-940https://doi.org/10.1002/bjs.1800800750
        • Heriot AG
        • Tekkis PP
        • Smith JJ
        • et al.
        Management and outcome of pouch-vaginal fistulas following restorative proctocolectomy.
        Dis Colon Rectum. Mar 2005; 48 (PMID: 15747067): 451-458https://doi.org/10.1007/s10350-004-0902-7
        • Johnson PM
        • O'Connor BI
        • Cohen Z
        • et al.
        Pouch-vaginal fistula after ileal pouch-anal anastomosis: treatment and outcomes.
        Dis Colon Rectum. Jun 2005; 48 (PMID: 15868243): 1249-1253https://doi.org/10.1007/s10350-004-0872-9
        • Keighley MR
        • Grobler SP.
        Fistula complicating restorative proctocolectomy.
        Br J Surg. Aug 1993; 80 (PMID: 8402069): 1065-1067https://doi.org/10.1002/bjs.1800800849
        • Kjaer MD
        • Kjeldsen J
        • Qvist N.
        Poor outcomes of complicated pouch-related fistulas after Ileal pouch-anal anastomosis surgery.
        Scand J Surg. Sep 2016; 105 (Epub 2015 Oct 27. PMID: 26508126): 163-167https://doi.org/10.1177/1457496915613648
        • Korsgen S
        • Nikiteas N
        • Ogunbiyi OA
        • et al.
        Results from pouch salvage.
        Br J Surg. Mar 1996; 83 (PMID: 8665197): 372-374https://doi.org/10.1002/bjs.1800830325
        • Lee PY
        • Fazio VW
        • Church JM
        • et al.
        Vaginal fistula following restorative proctocolectomy.
        Dis Colon Rectum. Jul 1997; 40 (PMID: 9221847): 752-759https://doi.org/10.1007/BF02055426
        • MacLean AR
        • O'Connor B
        • Parkes R
        • et al.
        Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results.
        Dis Colon Rectum. Jul 2002; 45 (PMID: 12130874): 880-886https://doi.org/10.1007/s10350-004-6321-y
        • Mallick IH
        • Hull TL
        • Remzi FH
        • et al.
        Management and outcome of pouch-vaginal fistulas after IPAA surgery.
        Dis Colon Rectum. Apr 2014; 57 (PMID: 24608306): 490-496https://doi.org/10.1097/DCR.0000000000000094
        • O'Kelly TJ
        • Merrett M
        • Mortensen NJ
        • et al.
        Pouch-vaginal fistula after restorative proctocolectomy: aetiology and management.
        Br J Surg. Sep 1994; 81 (PMID: 7953422): 1374-1375https://doi.org/10.1002/bjs.1800810943
        • Raval MJ
        • Schnitzler M
        • O'Connor BI
        • et al.
        Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis.
        Ann Surg. Nov 2007; 246 (PMID: 17968167): 763-770https://doi.org/10.1097/SLA.0b013e31814539b1
        • Rius J
        • Nessim A
        • Nogueras JJ
        • et al.
        Gracilis transposition in complicated perianal fistula and unhealed perineal wounds in Crohn's disease.
        Eur J Surg. Mar 2000; 166 (PMID: 10755336): 218-222https://doi.org/10.1080/110241500750009311
        • Ryoo SB
        • Oh HK
        • Han EC
        • et al.
        Complications after ileal pouch-anal anastomosis in Korean patients with ulcerative colitis.
        World J Gastroenterol. Jun 21 2014; 20 (PMID: 24966620; PMCID: PMC4064095): 7488-7496https://doi.org/10.3748/wjg.v20.i23.7488
        • Sagar PM
        • Dozois RR
        • Wolff BG.
        Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease.
        Dis Colon Rectum. Aug 1996; 39 (PMID: 8756845): 893-898https://doi.org/10.1007/BF02053988
        • Sagar RC
        • Thornton M
        • Herd A
        • et al.
        Transvaginal repair of recurrent pouch-vaginal fistula.
        Colorectal Dis. Dec 2014; 16 (PMID: 25204796): O440-O442https://doi.org/10.1111/codi.12775
        • Sapci I
        • Akeel N
        • DeLeon MF
        • et al.
        What is the best surgical treatment of pouch-vaginal fistulas?.
        Dis Colon Rectum. May 2019; 62 (PMID: 30614849): 595-599https://doi.org/10.1097/DCR.0000000000001313
        • Shah NS
        • Remzi F
        • Massmann A
        • et al.
        Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy.
        Dis Colon Rectum. Jul 2003; 46 (PMID: 12847365): 911-917https://doi.org/10.1007/s10350-004-6684-0
        • Tran KT
        • Kuijpers HC
        • van Nieuwenhoven EJ
        • et al.
        Transposition of the rectus abdominis muscle for complicated pouch and rectal fistulas.
        Dis Colon Rectum. Apr 1999; 42 (PMID: 10215049): 486-489https://doi.org/10.1007/BF02234173
        • Troja A
        • Käse P
        • El-Sourani N
        • et al.
        Treatment of recurrent rectovaginal/pouch-vaginal fistulas by gracilis muscle transposition - a single center experience.
        J Visc Surg. Dec 2013; 150 (Epub 2013 Oct 18. PMID: 24144724): 379-382https://doi.org/10.1016/j.jviscsurg.2013.08.002
        • Tsujinaka S
        • Ruiz D
        • Wexner SD
        • et al.
        Surgical management of pouch-vaginal fistula after restorative proctocolectomy.
        J Am Coll Surg. Jun 2006; 202 (Epub 2006 Apr 21. PMID: 16735205): 912-918https://doi.org/10.1016/j.jamcollsurg.2006.02.014
        • Viazis N
        • Giakoumis M
        • Koukouratos T
        • et al.
        One-year infliximab administration for the treatment of chronic refractory pouchitis.
        Ann Gastroenterol. 2011; 24 (PMID: 24713783; PMCID: PMC3959330): 290-293
        • Viscido A
        • Habib FI
        • Kohn A
        • et al.
        Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis.
        Aliment Pharmacol Ther. May 15 2003; 17 (PMID: 12755839): 1263-1271https://doi.org/10.1046/j.1365-2036.2003.01535.x
        • Wexner SD
        • Ruiz DE
        • Genua J
        • et al.
        Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients.
        Ann Surg. Jul 2008; 248 (PMID: 18580205): 39-43https://doi.org/10.1097/SLA.0b013e31817d077d
        • Wexner SD
        • Rothenberger DA
        • Jensen L
        • et al.
        Ileal pouch vaginal fistulas: incidence, etiology, and management.
        Dis Colon Rectum. Jun 1989; 32 (PMID: 2676425): 460-465https://doi.org/10.1007/BF02554497
        • Zinicola R
        • Wilkinson KH
        • Nicholls RJ.
        Ileal pouch-vaginal fistula treated by abdominoanal advancement of the Ileal pouch.
        Br J Surg. Nov 2003; 90 (PMID: 14598427): 1434-1435https://doi.org/10.1002/bjs.4314
        • Zmora O
        • Tulchinsky H
        • Gur E
        • et al.
        Gracilis muscle transposition for fistulas between the rectum and urethra or vagina.
        Dis Colon Rectum. Sep 2006; 49 (PMID: 16752191): 1316-1321https://doi.org/10.1007/s10350-006-0585-3
        • Pellino G
        • Vinci D
        • Signoriello G
        • et al.
        Long-term bowel function and fate of the ileal pouch after restorative proctocolectomy in patients with Crohn's Disease: A systematic review with metanalysis and metaregressio.
        J Crohn Colitis. Mar 13 2020; 14 (PMID:31412119): 418-427https://doi.org/10.1093/ecco-jcc/jjz146
        • Hyman H
        • Umanskiy K
        Difficult decisions in colorectal surgery, difficult decisions in surgery: an evidence-based approach, Chapter 8.
        (editors) Springer International Publishing, Switzerland2017
        • Raval MJ
        • Schnitzler M
        • O'Connor BI
        Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis.
        Ann Surg. 2007; 246: 763-770
        • Rottoli M
        • Vallicelli C
        • Boschi L
        • Cipriani R
        • Poggioli G.
        Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn's disease a risk factor for failure? A prospective cohort study.
        Updates Surg. Dec 2018; 70 (Epub 2018 Jul 7. PMID: 29982963): 485-490https://doi.org/10.1007/s13304-018-0558-9
        • Frontali A
        • Rottoli M
        • Chierici A
        • Poggioli G
        • Panis Y.
        Rectovaginal fistula: risk factors for failure after graciloplasty-A bicentric retrospective European study of 61 patients.
        Colorectal Dis. Aug 2021; 23 (Epub 2021 Apr 27. PMID: 33851506): 2113-2118https://doi.org/10.1111/codi.15673
        • Tekkis PP
        • Fazio VW
        • Remzi F
        • et al.
        Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy.
        Br J Surg. Oct 2005; 92 (PMID: 15988792): 1270-1276https://doi.org/10.1002/bjs.5071
        • Breen EM
        • Schoetz Jr, DJ
        • Marcello PW
        • et al.
        Functional results after perineal complications of ileal pouch-anal anastomosis.
        Dis Colon Rectum. Jun 1998; 41 (PMID: 9645736): 691-695https://doi.org/10.1007/BF02236254
        • Gaertner WB
        • Witt J
        • Madoff RD
        • et al.
        Ileal pouch fistulas after restorative proctocolectomy: management and outcomes.
        Tech Coloproctol. Nov 2014; 18 (Epub 2014 Jul 19. PMID: 25037072): 1061-1066https://doi.org/10.1007/s10151-014-1197-x
        • Emile SH
        • Gilshtein H
        • Wexner SD.
        Outcome of Ileal pouch-anal anastomosis in patients with indeterminate colitis: a systematic review and meta-analysis.
        J Crohns Colitis. Jul 30 2020; 14 (PMID: 31912129): 1010-1020https://doi.org/10.1093/ecco-jcc/jjaa002
        • Meagher AP
        • Farouk R
        • Dozois RR
        • et al.
        J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients.
        Br J Surg. Jun 1998; 85 (PMID: 9667712): 800-803https://doi.org/10.1046/j.1365-2168.1998.00689.x
        • Fleshman JW
        • Cohen Z
        • McLeod RS
        • et al.
        The ileal reservoir and ileoanal anastomosis procedure. Factors affecting technical and functional outcome.
        Dis Colon Rectum. Jan 1988; 31 (PMID: 3366021): 10-16https://doi.org/10.1007/BF02552562
        • Francone TD
        • Champagne B.
        Considerations and complications in patients undergoing Ileal pouch anal anastomosis.
        Surg Clin North Am. Feb 2013; 93 (PMID: 23177068): 107-143https://doi.org/10.1016/j.suc.2012.09.004
        • Selvaggi F
        • Pellino G.
        Pouch-related fistula and intraoperative tricks to prevent it.
        Tech Coloproctol. Feb 2015; 19 (Epub 2015 Jan 4. PMID: 25557442): 63-67https://doi.org/10.1007/s10151-014-1257-2
        • Reza LM
        • Lung PFC
        • Lightner AL
        • et al.
        Perianal fistula and the Ileoanal pouch - different aetiologies require distinct evaluation.
        Colorectal Dis. Oct 2020; 22 (Epub 2020 May 14. PMID: 32304181): 1436-1439https://doi.org/10.1111/codi.15074
        • Wong WD
        • Rothenberger DA
        • Goldberg SM.
        Ileoanal pouch procedures.
        Curr Probl Surg. Mar 1985; 22 (PMID: 3922680): 1-78https://doi.org/10.1016/0011-3840(85)90017-6
        • Lolohea S
        • Lynch AC
        • Robertson GB
        • et al.
        Ileal pouch-anal anastomosis-vaginal fistula: a review.
        Dis Colon Rectum. Sep 2005; 48 (PMID: 15991061): 1802-1810https://doi.org/10.1007/s10350-005-0079-8
        • Maslekar S
        • Sagar PM
        • Harji D
        • et al.
        The challenge of pouch-vaginal fistulas: a systematic review.
        Tech Coloproctol. Dec 2012; 16 (Epub 2012 Sep 6. PMID: 22956207): 405-414https://doi.org/10.1007/s10151-012-0885-7
        • Mizrahi Ido
        • Wexner Steven D.
        Management of pouch-vaginal fistulas. Difficult decisions in colorectal surgery.
        Springer, Cham2017: 53-63https://doi.org/10.1007/978-3-319-40223-9_7
        • Machin M
        • Younan HC
        • Slesser AAP
        • Mohsen Y.
        Systematic review on the management of Ileoanal pouch-vaginal fistulas after restorative proctocolectomy in the treatment of ulcerative colitis.
        Colorectal Dis. Jan 2021; 23 (Epub 2020 Sep 12. PMID: 32810915): 34-51https://doi.org/10.1111/codi.15318