Surgical Management of Fistula-in-ano Among Patients With Crohn’s Disease: Analysis of Outcomes After Fistulotomy or Seton Placement—Single-Center Experience

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.

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“…This risk is comparable in the short and long terms. These data are in line with previous reports [18,19]. Some words of caution are needed.…”

Section: Discussionsupporting

confidence: 92%

Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors

et al. 2020

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“…Few reports of CD patients treated with DDS have been published. [7][8][9][10][11][12][13][14][15] Although all have consistently highlighted the safety of DDS in regards to effects on anal sphincter control, short-term success rates vary from 59% to 100% with longer follow-up revealing a high (35%-44%) incidence of recurrent sepsis. [7][8][9][10][11][12] Our data are consistent with these reported long-term outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Interestingly, there have been few modern reports on the use of DDS in CD, possibly reflecting the effectiveness of biologic therapy in promoting fistula healing and the use of new surgical treatments such as LIFT which have been reported to be safe in CD patients with anal stenosis, active proctitis, or anal canal ulceration. 3,4,[13][14][15] It is interesting to speculate that the reported effectiveness of stem cell therapy for these fistulas 5 might continue to reduce the need for DDS in CD. Defining clinical variables that predict outcomes of DDS in CD is important both for patient prognostication and guiding surgical approach.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Definitive Draining Seton Placement for Complex Anal Fistula in Crohn’s Disease

Mujukian

Zaghiyan

Banayan

et al. 2020

The American Surgeon

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Definitive draining seton (DDS) alone is an accepted treatment for complex refractory anal fistulas in Crohn’s disease (CD). We evaluated the long-term success of DDS in CD patients. DDS was defined as draining seton placed definitively for at least 12 months. Primary end point was clinical response (CR) defined as a lack of induration, pain, swelling, abscess recurrence, or unintended dislodgement. The study cohort of 23 patients had a median age of 29 (range; 9-61) years and included 14 males (61%). Reasons for DDS included anal stenosis (n = 9; 39%), active proctitis (n = 9; 39%), and/or anal canal ulceration (n = 9; 39%). Median number of setons was 2 (range; 1-6) and 65% had multiple fistula tracts. Almost all patients (n = 22; 96%) were on a biologic postoperatively. At 12-month follow-up, only 39% (n = 9) had a CR. The remaining 14 patients failed due to new abscess formation (n = 6; 26%), new fistula formation (n = 6; 26%), and seton dislodgement (n = 2; 9%). Six (26%) patients required fecal diversion. No patients required proctectomy. DDS for complex CD fistula results in a mediocre CR with many patients developing recurrent abscess/fistula or requiring diversion despite biologic therapy.

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“…In a case series led by Kelly et al, 7% (14/200) had spontaneous resolution of the fistula tract with seton placement alone [1]. The study by Papaconstantinou et al reported improvement in all 25 cases of mid-or low-level trans-sphincteric fistula in CD, with recurrence six months after seton removal in one patient, and minor incontinence was found in 12% (3/25) [26]. Incontinence rates associated with loose setons have been significantly lower, varied from 5-17%, compared to cutting setons [27,28].…”

Section: Seton Placementmentioning

confidence: 99%

Comparison of the Efficacy of the Various Treatment Modalities in the Management of Perianal Crohn’s Fistula: A Review

Feroz

Ahmed

Muralidharan³

et al. 2020

Cureus

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Crohn's disease (CD) is a transmural inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal (GI) tract. With the disease's progression, adhesions and transmural fissuring, intraabdominal abscesses, and fistula tracts may develop. An anal fistula (or fistula-in-ano) is a chronic abnormal epithelial lined tract communicating the anorectal lumen (internal opening) to the perineal or buttock skin (external opening). The risk of fistula development varies from 14%-38%. It can cause significant morbidity, which adversely impacts the quality of life. It is mostly believed that an anal crypt gland infection causes anal abscesses, leading to fistula development. Crohn's disease's pathogenesis involves Th1 and Th17 hypersensitivity due to an unknown antigen within the intestinal mucosa. Evidence to support this review was gathered via the Pubmed database. Search terms used were combinations of "Perianal fistula," "seton," "immunotherapy." Studies were reviewed and cross-referenced for additional reports. Setons are surgical thread loops passed from the external to the internal opening of the fistula tract and exteriorized through the anorectal canal, facilitating abscess drainage and inciting a local inflammatory reaction, thus promoting the resolution of the fistula. Biologicals such as anti-tumor necrosis factor (TNF) antibody (infliximab, adalimumab, certolizumab), anti-IL-12/23 (ustekinumab), and anti-α₄β₇ integrin antibody (vedolizumab) have been approved for Crohn's disease targeting the Th1/Th17-mediated inflammation. Other therapeutic modalities are fistulotomy, cyanoacrylate glue, bioprosthetic plugs, mucosal advancement flap, ligation of inter-sphincteric fistula tract (LIFT), diverting stoma, proctectomy, video-assisted anal fistula treatment (VAAFT), and fistula laser closure (FiLaC). Our review found that chronic seton therapy should be the primary approach, especially if the patient has a perianal abscess. It has a low incidence of re-intervention, recurrent abscess formation, and side-branching of the fistulous tract, with preservation of the fistulous tract's patency and cost-effectiveness. The major disadvantage of seton therapy is the discomfort and time to achieve stability. Among the biologicals, infliximab is the only therapy which has a statistically significant effect on the healing rate of perianal Crohn's fistula compared to placebo, but the major disadvantage associated with anti-TNF as sole therapy is high re-intervention rate, prolong maintenance therapy, high recurrence rate, and severe side effects. We hypothesize that the two aspects should be addressed concurrently to increase the fistula healing or closure rate. First, the seton should be used as initial therapy to maintain tract patency to allow abscess drainage and minimize the intestinal flora colonization within the tract mucosa, thereby leukocytic infiltration and propagation of inflammation within the tract. The second aspect that has to be considered is that we should target the initial stimulation of the T...

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Surgical Management of Fistula-in-ano Among Patients With Crohn’s Disease: Analysis of Outcomes After Fistulotomy or Seton Placement—Single-Center Experience

Cited by 20 publications

References 20 publications

Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors

Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors

Outcomes of Definitive Draining Seton Placement for Complex Anal Fistula in Crohn’s Disease

Comparison of the Efficacy of the Various Treatment Modalities in the Management of Perianal Crohn’s Fistula: A Review

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