P475 What is our success on complex perianal fistulae healing under optimal medical treatment ending up with ileostomy?
Y. Erzin*1, A. Ercaliskan1, I. Hatemi1, B. Baca2, N. Demir1, K. Bal1, A.F. Celik1
1Istanbul University Cerrahpasa Medical Faculty, Gastroenterology, Istanbul, Turkey, 2Istanbul University Cerrahpasa Medical Faculty, General Surgery, Istanbul, Turkey
Our aim was to determine overall success rate of ileostomy in patients with complex perianal fistulas (Cpfis) that are under optimal medical Tx (MedTx) with anti-TNF based regimens combined with antibiotics and/or azathioprine (AZA) and find out predictors of ileostomy.
IBD patients' charts between 1999-14 retrospectively were reviewed. There were 60/762 (8%) 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 were 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, time with seton, total durations of drugs, and type of surgery were noted. Each patient's fistula status at the last visit was noted. Ileostomy procedure only was performed after recommendation of our IBD council together with the patient's acceptance
Comparisons between complex perianal fistulae patients with and without ileostomy
|Patients with ileostomy (n=16)||Patients without ileostomy (n=44)||P|
|Age||41.12 ± 13.78||35.54 ± 10.53||NS|
|Age at fistulae onset||35.43 ± 13.78||31.79 ± 9.92||NS|
|Disease duration(yrs)||13.25 ± 6.7||7.54 ± 6.71||0.005|
|Fistula duration (mo)||69.81 ± 35.61||38.93 ± 24.47||0.000|
|Number of fistulae tracts||2.25 ± 1.13||1.72 ± 0.78||0.048|
|Time spent under seton (mo)||28.6 ± 17.74||15.73 ± 10||0.006|
|Rectal involvemen t(%)||81||48||0.02|
|Luminal activity (%)||83||39||0.011|
There were 60 Cpfis pts., 25(42%) being female with a mean age of 37.03 ± 11.63 yrs. Sixteen out of 60 patients (27%) underwent an ileostomy after MedTx failure but none of them due to anal stricture or incontinence. Overall success rate after ileostomy was 8/16 (50%) but radiological healing rate was just 4/16 (25%). The need for ileostomy significantly was more common among women and patients with rectal involvement and luminal active disease despite optimal MedTx. The duration of CD and fistulae, number of fistulae and time under seton significantly were higher among patients ending up with ileostomy (Table 1). Cox-regression analysis disclosed none of the above mentioned parameters as independent predictors of an ileostomy.
This study stresses the actual ongoing problem with complex perianal fistula closure in CD despite evolving MedTx modalities even when ending up with diverting stoma. However, we can not ignore the possibility of ileostomy related optimal results regarding the fistula closure in early cases who are under better clinical and endoscopic conditions.