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P295. What is our success on complex perianal fistula healing in the clinic? From antibiotic to combined anti-TNF based treatment, ending with or without ileostomy

Y. Erzin1, A. Ercaliskan2, I. Hatemi1, D. Eyice2, B. Baca3, N. Demir1, A.F. Celik1, 1Istanbul University Cerrahpasa Medical Faculty, Gastroenterology, Istanbul, Turkey, 2Istanbul University Cerrahpasa Medical Faculty, Internal Medicine, Istanbul, Turkey, 3Istanbul University Cerrahpasa Medical Faculty, General Surgery, Istanbul, Turkey

Background

Our aim was to determine overall treatment (Tx) success and factors influencing the medical Tx (MedTx) response in complex perianal fistulas (Cpfis).

Methods

patients' charts between 1999–13 retrospectively were reviewed. There were 51/705 (7%) CD patients with Cpfis. All patients were treated with different combinations of antibiotics, azathioprine (AZA) and anti-TNFs but our aim was to put them on triple MedTx if there was no drug intolerance. In case of an abscess, drainage and seton was applied remaining between 3 to 6 mo. in case of no recurrence. Tx success was stratified as complete discharge cessation or additional closure of external orifice, and ultimately radiological disappearance by MRI. In case of MedTx failure a diverting stoma was applied. Age, sex, disease duration, location, behaviour, rectal involvement, age at fistula onset, fistula duration, number of fistula, smoking, number of setons, duration of each MedTx, time with seton, total durations of drugs, and type of surgery was noted. Each patient's fistula status at the last visit was determined and re-opening and re-closing events and closure time after seton removal were noted.

Results

There were 51 Cpfis pts., 20 (39%) being female with a mean age of 35.66±11.66 yrs. The mean fistula follow-up time was 41.68±31.31 mo., 19/51 (37%) patients had one fistula the remaining multiple. 34 patients (66%) were complicated by abscesses and loose seton was applied to 30/34 (88%), four of them with permanent setons for repeating abscesses. During whole follow up 50 abscesses (12 of them while having a seton) were observed. Fistula closure after seton removal was achieved between 1–21 (median 8) mo. Ileostomy was performed in 14 (28%) patients and fistula closure was achieved in only 4/14 (30%) between 2–9 mo. At the last visit 27/51 (53%) were in remission, and only 7/51 (14%) achieved radiological. The follow up Tx time was significantly longer in response-positive group (50.33 vs. 31.95 mo., p = 0.031), and total anti-TNF Tx time significantly correlated with Tx success (r = −0.339, p = 0.021). An age-sex adjusted Cox regression analysis disclosed total anti-TNF Tx time as the only independent predictor of Tx response (p = 0.001).

Table (abstract P295)
Response positiveResponse negativep
n%n%
Age of the fistula in months36.4±30.5 32.5±20.1NS
Gender (Female/male)12/1544.5%/55.5%8/1633%/66%NS
Rectal involvement (absent/present)12/1544.5%/55.5%11/1346%/54%NS
Treatment duration (follow up) (mo)2750.3±36.32431.9±21.20.031
Number of fistula (1/2/3/4)12/10/4/144%/37%/15%/4%7/9/8/029%/38%/33%/0NS
Perianal abscess during follow up (no/yes)12/1545%/55%5/1921%/79%0.074
Total anti-TNF duration (mo)2431.5±192219.4±10.80.011
Total AZA duration (mo)2035.1±26.12221.6±11.50.040
Total antiobiotic duration (mo)2711.1±10.32414.3±10.4NS

Conclusion

Anti-TNFs necessary for even small success of complex fistula closure. Clinical response rate within the mean 41 mo. of follow up was 53% with it's own re-opening risk. Only 14% had radiological tract closure reaching our ultimate aim. Long term antibiotic use either solo or combined did not show any effect on perianal fistula closure.