A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated.
Data collected in this study support data in the literature. Analysis of longitudinal data analysed by simple models and complex models suggest that the ES therapy had a positive and significant effect on pain reduction (VAS) and on the improvement of ulcer healing process in terms of the PUSH tool total index compared with conventional treatment, and may have induced a significant acceleration of the wound-healing process.
There is a high reported incidence of persistent perineal sinus after proctectomy for inflammatory bowel disease. The cause and prevention are discussed. In a consecutive series, persistent perineal sinuses occurred in 4 of 17 patients with Crohn's colitis, and in none of 20 patients with ulcerative or unclassified colitis (1 died soon after operation). The technique is described for patients with a sinus persisting for more than 6 months, using total excision, primary closure, and suction drainage. Six of 7 patients so treated healed primarily and the seventh healed within 2 weeks. In males, sexual dysfunction was often decreased.
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