Anal fistulas in Crohn's disease: Incidence and outcome of surgical treatment

Abstract

The incidence and prognosis of anal fistulas were investigated in a prospective study comprising 136 patients operated on for Crohn's disease. The incidence of anal fistulas was 27 of 136 (20%), in patients with classical disease 12 of 68 (18%), and in those with Crohn's colitis 15 of 68 (22%). A fistula preceded the intestinal manifestation of the disease in 6 patients. At the time of diagnosis of Crohn's disease anal fistulas were observed in 19 cases, including 3 of the 6 with early onset which had resisted treatment and remained active. Five patients developed anal lesions during the course of the disease, all but 2 in temporal relationship to an intestinal recurrence. Of the 27 patients with anal fistulas, 11 were of the low-anal type, whereas 14 were anorectal. Conventional laying open of the fistula was undertaken in all patients with classical Crohn's disease in close conjunction with resection of the intestinal disease. On local surgical treatment 10 of 12 (89%) healed with preservation of continence. Four recurrent fistulas occurring in conjunction with intestinal recurrence also healed uneventfully. Laying open was undertaken in 11 of the 15 patients with colitis. Healing was obtained in only 4 of these patients. In the remaining 4 severe colitis indicated immediate proctocolectomy. Occurrence of fistulas involved a significant delay in perineal healing after proctectomy. It is concluded that traditional laying open of an anal fistula in patients with classical Crohn's disease is followed by high rate of uneventful healing. In contrast, local surgical treatment of anal fistulas complicating Crohn's colitis is usually unsuccessful.(ABSTRACT TRUNCATED AT 250 WORDS)

CARD15 Mutations and Perianal Fistulating Crohn’s Disease: Correlation and Predictive Value of Antibiotic Response

“…It may be thought that the best response to antibiotics observed in these patients could be related to factors other than CARD15 genotype [2,[42][43][44]. This was ruled out by demonstrating no significant differences between patients with and without CARD15 variants in relation to other factors with a OR odds ratio, CI confidence interval * Calculated for the probability of response to antibiotics in patients without mutations compared with patients with mutations Dig Dis Sci potential effect on the response.…”

Anti-TNF-α (Infliximab) Used as Induction Treatment in Case of Active Proctitis in a Multistep Strategy Followed by Definitive Surgery of Complex Anal Fistulas in Crohn's Disease: A Preliminary Report

“…Several reports demonstrate rates of recurrence of approximately 20 percent after surgical treatment of these fistulas. [1][2][3][4][5] Complex fistulas are defined as high transsphincteric, intersphincteric, extrasphincteric, and suprasphincteric fistulas and fistulas with multiple openings above the dentate line. Some authors characterize fistulas as complex if there is any active rectal Crohn's disease irrespective of the course taken by the fistula track.…”

“…To facilitate drainage and to cause less perianal pain, noncutting setons can be used, threaded through the internal opening at the site of the dentate line and through the fistula to the opening in the perianal skin. 3,5,[10][11][12][13][14] When there is no evidence of rectal and anal disease and the surgeon has ascertained the absence of any abscess, a definitive surgical approach to treatment of the fistula can be undertaken. A patient with a low fistula can be treated by a fistulotomy.…”

“…[8][9][10][14][15][16] The recurrence rate of high complex perianal fistulas in patients with Crohn's disease varies between 25 and 50 percent. 1,3,5,[7][8][9][10]12,[14][15][16][17][18] In the presence of active perianal and rectal Crohn's disease, medical therapy including antibiotics, immunosuppressive agents, and anti-TNF-␣ is frequently used to reduce the perianal symptoms. Surgical techniques to reduce the activity of the perianal and rectal Crohn's disease and to prevent recurrent abscesses include noncutting setons and deviating stomas.…”

Imaging techniques and combined medical and surgical treatment of perianal Crohn’s disease

“…In these cases, there will be persistent discharge of mucopurulent material due to persistent inflammation, but it will be reduced, and the patient's quality of life will be improved if compared to a situation of recurrent abscesses. The patient is furthermore not exposed to the risk of fecal incontinence caused by cone-like fistulectomy, particularly if the procedure is repeated [76,77]. On the other hand, if fistulectomy is not performed, this increases the possibility of missing secondary tracts, which, as already mentioned, are considered a risk factor for recurrence and reoperation [31,32].…”