No abstract

Rectal flap advancement is a satisfactory option for the therapeutic management of anal fistula, including CD populations. Fistula drainage is needed before performing this surgical technique.

Therapeutic strategies for perianal fistulizing CD require robust anatomical and healing evaluations. Combined strategies using biologics to improve both drainage and secondary closure of the fistula tracts merit further study.

Aim The medico‐surgical strategy for the treatment of perianal fistulizing Crohn's disease (CD) following surgical drainage remains challenging and debated. Our aims were to describe the failure rate of therapeutic interventions after drainage of the fistula tract and determine the factors associated with failure to optimize medico‐surgical strategies. Method All consecutive patients with perianal fistulizing CD who underwent surgical drainage with at least a 12‐week follow‐up were included. Failure was defined as the occurrence of at least one of the following items: abscess recurrence, purulent discharge from the tract, visible external opening and further drainage procedure(s). Results One hundred and sixty‐nine patients were included. The median follow‐up was 4.0 years. The cumulative failure rates were 20%, 30% and 36% at 1, 3 and 5 years, respectively. The cumulative failure rates in patients who had sphincter‐sparing surgeries or seton removal were significantly higher than in those who had a fistulotomy. Anterior fistula [hazard ratio (HR) = 2.52 (1.13–5.61), P = 0.024], supralevator extension [HR = 20.78 (3.38–127.80), P = 0.001] and the absence or discontinuation of immunosuppressants after anal drainage [HR = 3.74 (1.11–12.5), P = 0.032] were significantly associated with failure in the multivariate analysis model. Conclusion Combined strategies for perianal fistulizing CD lead to a failure rate of 36% at 5 years. Where advisable, fistulotomy may be preferred because it has a lower rate of recurrence. The benefits of immunosuppressants require a dedicated prospective randomized trial.

Aim To compare the rate of failure of radiofrequency thermocoagulation for anal fistula with that of rectal advancement flap in a case‐matched study. Method Patients who underwent radiofrequency treatment were compared with age‐ and sex‐matched patients with Crohn's disease (CD) who underwent a rectal flap procedure. Fistula features, general characteristics and the main clinical events were recorded in a prospective database. Failure was defined by at least one of following: abscess, purulent discharge, visible external opening or further drainage procedure. Results A total of 62 patients [median age 45 (range 36.8–57.5) years; 22 women, 40 men; 22 with CD] were analysed. The failure rate of radiofrequency treatment was higher than that of rectal flap treatment (74.2% vs 32.2%; P = 0.004). The cumulative probabilities of failure of the radiofrequency treatment were 53.8% (38.8–68.3), 71.8% (55.3–84.0) and 87.4% (70.6–95.3) at 3, 6 and 12 months, respectively. Three patients in the radiofrequency group required drainage for an abscess and one had severe thermal ulceration. The Cox proportional hazards regression model (surgical procedure, obesity, CD) showed rectal flap treatment [3.48 (1.60–8.07); P = 0.001] and CD [2.60 (1.16–6.41); P = 0.02] to be the main independent predictors of healing. Conclusion Radiofrequency thermocoagulation is a less satisfactory sphincter‐sparing treatment for the management of anal fistula than a rectal flap procedure.