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P557. Complex perianal fistula eradication by mucosal advancement flap in IBD patients

Z. Serclova1, O. Ryska1, J. Kalvach1, J. Fulik2, 1Central Military Hospital, Department of Surgery, Prague 6, Czech Republic, 2University Hospital Bulovka, Department of Surgery, Prague 8, Czech Republic

Background

Perianal fistulas influence greatly the life of IBD patients. New methods of conservative treatment, including biological therapy, improve patients' quality of life, but don't lead towards the complete healing. Success rate of surgical treatment by closure of inner opening by Advancement Flap (AF) varies between 40–80%. We assume that pre-treatment with non-cutting setons, event. multiple drainages prevents residual abscesses, enables good timing of AF and may improve the results. The aim of the study was to evaluate the results of IBD patients, treated step by step by multiple drainages followed by advancement flap.

Methods

All IBD patients indicated for AF procedure for complex fistula in the period 6/2006–10/2012 were included in the retrospective analysis. After initial seton placement, re-drainage was performed in case of recurring abscesses or to simplify secondary fistula tracts. Afterwards fistula was eradicated by mucosal AF method. Concomitant medication was recorded. Continuing fistula secretion up to 3 months was assessed as a healing failure otherwise as a recurrence. Fisher's exact test was used for groups assessment.

Results

Fifty-three patients (36; 68% F/17; 32% M) in mean age of 34.3(±8.9) years, 48 (91%) with diagnosis of Crohn's disease and 5 (9%) ulcerative colitis were enrolled. Median number of drainages prior to the AF was 2 (1–9) during the period 11 (1–58) months. Primary healing of AF was achieved in 48 (91%) patients; afterwards 2/5 failed cases were successfully managed with repeated AF. Fistula recurred in 4 (7.5%) patients in 18 (4–32) months. One of these was successfully healed after repeated AF. Recto-vaginal fistula was recognised as a risk factor of surgical failure (RR: 12.3; CI95%: 1.5–100.5; p = 0.02). Smoking was not found as a risk factor of healing. There was a trend to healing failure in group of 33 pts. (66%) receiving biologic therapy (RR: 2.06; CI95%: 0.248–17.08; p = 0.504) and to lower recurrence rate (RR: 0.17; CI95%: 0.02–1.53; p = 0.115). Five patients had a stoma while AF surgery, 4/5 were later successfully closed. In 5 others a stoma needed to be performed during the follow-up (3 for the luminal disease).

Conclusion

Sequent surgical treatment of IBD perianal fistulas; long term drainages followed by AF; is effective in fistula eradication with low failure (9%) and recurrence (7.5%) rate. Totally 47 (89%) patients have healed AF and 45 (85%) live out of fistula and without the stoma in the median follow up of 21 (1–78) months.