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DOP087. Only one third of Crohn's disease patients have sustained remission of perianal fistulas

I. Molendijk1, V.J. Nuij2, A.E. van der Meulen-de Jong1, C.J. van der Woude2, 1Leiden University Medical Center, Gastroenterology and Hepatology, Leiden, Netherlands, 2Erasmus University Medical Center, Gastroenterology and Hepatology, Rotterdam, Netherlands

Background

Despite more potent drugs and advanced surgical techniques the treatment of perianal fistulizing Crohn's disease (CD) remains challenging. With this study we aimed to assess the different treatment strategies used in perianal CD and their effect on remission (no discharge on history and physical examination), response (decrease of discharge, pain and bleeding from the fistula tract) and relapse.

Methods

Patients (pts) with perianal fistulizing CD visiting the Erasmus MC University hospital between the 1–1–1980 and the 1–1–2000 were identified through hospital system search. Exclusion criteria were: diagnosis CD after fistula diagnosis, perianal fistulas that commenced <0.5 yrs after surgery or delivery, follow-up <0.5 yrs, no data on fistula complexity. Demographics, fistula characteristics and all received medical and surgical treatments aimed and the outcome of these strategies were noted. The Mann–Whitney U-test and the Fisher's exact test were used to determine association between variables.

Results

In total 232 pts were identified (98 men; 42.2%). Median age at CD diagnosis was 22.8 yrs (4.0–68.7) and the median duration of CD was 16.9 yrs (0.6–46.5). CD localization was: upper GI tract (4.7%), small bowel (6.9%), ileocecal (15.1%), large bowel (37.9%), small and large bowel (28.9%), whole GI (0.9%) and isolated perianal disease (5.6%). In 41.1% there was rectal involvement. Follow-up was median 10.0 yrs (0.5–37.5). Fistula diagnosis was at a median age of 29.4 yrs (9.1–77.3), time to fistula was <10 yrs of CD diagnosis in 78.9%. Median duration to fistula formation was 7.0 yrs (0.7–38.0). Complex fistula (according to Sandborn criteria) were present in 78.0%. Medical treatment (antibiotics, steroids, immunosuppressants, anti-TNF) commenced in 79.7% of the pts and in 53.2% surgery (colectomy, fistulectomy, stoma, rectum amputation) was performed. Remission rate was 69.8% after a median duration of 2.3 yrs (0–25.3). Pts with simple fistulas had a higher remission rate (88.2% vs. 64.6%; p < 0.001). Involvement of the rectum was not associated with a lower remission rate in both simple and complex fistulas (p = 0.321 vs. p = 0.255). Anti-TNF therapy did not alter remission rate in simple fistulas, however complex fistulas healed significantly less often after anti-TNF treatment (p = 0.012). Initially healed fistulas recurred in 26.7% in case of simple fistulas and in 41.9% in case of complex fistulas (p = 0.051) with an overall rate of 37.7%.

Conclusion

Only one third of perianal fistulizing CD pts had a sustained remission after conventional treatment strategies. Simple fistulas were more likely to heal than complex fistulas and less of these healed fistulas relapsed. Rectum involvement was not associated with lower remission rates.