Abstract
The purpose of this study is to demonstrate that repetitive minor surgical procedures allow for a high rate of permanent closure of perianal fistulas in patients with Crohn’s disease (CD). Patients with perianal fistulizing CD (PFCD) who underwent perianal surgery at the University Hospital of Muenster between 2003 and 2018 were assessed for fistula characteristics and surgical procedures. We included 45 patients (m:f = 28:17) with a mean age of 27 years at first fistula appearance. Of these, 49% suffered from a complex fistula. An average of 4.2 (1–14) procedures were performed, abscess incisions and fistula seton drainages included. Draining setons were left in place for 5 (1–54) months, until fistula closure. Final surgical techniques were fistulotomy (31.1%), seton removal with sustained biological therapy (26.7%), Anal Fistula Plug (AFP) (17.8%), Over-The Scope-Clip proctology (OTSC) (11.1%), and mucosa advancement flap (4.4%). In 8.9% of cases, the seton was kept as permanent therapy. The time from first to last surgery was 18 (0–182) months and the median follow-up time after the last surgery was 90 (15–200) months. The recurrence rate was 15.5% after 45 (17–111) months. Recurrent fistulas healed after another 1.86 (1–2) surgical re-interventions. The final success rate was 80%. Despite biological treatment, PFCD management remains challenging. However, by repeating minor surgical interventions over a prolonged period of time, high permanent healing rates can be achieved.
Highlights
Perianal fistulas are a frequent problem in Crohn’s disease (CD) patients: population-based studies demonstrate that approximately every fifth CD patient suffers from perianal fistulas and that this risk is even higher in case of colorectal manifestation [1,2]
From a total of 76 CD patients with perianal fistula, 31 patients were excluded in accordance with our exclusion criteria, leaving a cohort of 45 patients
The first appearance of perianal fistula was diagnosed at a median age of 27 and the most frequent manifestations of CD outside the perianal area were localized in the ileocolon (L3, n = 18, 40%)
Summary
Perianal fistulas are a frequent problem in CD patients: population-based studies demonstrate that approximately every fifth CD patient suffers from perianal fistulas and that this risk is even higher in case of colorectal manifestation [1,2]. PFCD is mostly present in patients under 30 years old and associated with symptoms, such as perianal pain and purulent or fecal discharge. In case of chronic inflammation, the destruction of the anal sphincter and perianal scars can lead to fecal incontinence [1]. These symptoms, especially in combination with further CD-associated complaints, such as abdominal pain, diarrhea, and weight loss, may cause physical exhaustion, psychological distress, a reduction in sexual function and, a significant impairment of the quality of life in patients. Complex fistulas are characterized by a high course towards the sphincter, more than one external opening, and clinical symptoms of a perianal abscess
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