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P653 Ligation of the intersphincteric fistula tract vs. endorectal advancement flap for high perianal fistulas in Crohn’s disease: a retrospective cohort study

E. van Praag*1, M. Stellingwerf1, J. van der Bilt1, K. Gecse2, W. Bemelman1, C. Buskens1

1Amsterdam UMC, Surgery, Amsterdam, The Netherlands, 2Amsterdam UMC, Gastroenterology, Amsterdam, The Netherlands

Background

The ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF) procedures are well-established, sphincter preserving procedures, for closure of high perianal fistulas. As surgical closure is not commonly offered in patients with Crohn’s fistulas, long-term data are limited. The aim of this study was to compare outcomes after both procedures in Crohn’s patients.

Methods

In this retrospective cohort study, all consecutive Crohn’s patients ≥18 years treated with LIFT or AF between 2007 and February 2018 were included. Primary outcome was clinical healing defined as closure of external fistula opening without discharge. Secondary outcomes included radiological healing evaluated by MRI, recurrence, newly developed postoperative incontinence, prospective Vaizey Incontinence Score and global subjective change in continence (improved, unchanged or deteriorated). A clinical minimally important difference (MID) for improvement in the Vaizey Incontinence Score was determined using a clinical anchor-based method to assess the clinical relevance of changes in this score.

Results

Forty procedures in 37 patients (35.1% male, median age 33.9, LIFT: 19, AF: 21) were included. A non-significant trend was seen towards higher clinical healing percentages after LIFT compared with AF (89.5% vs. 60.0%; p = 0.065). The overall radiological healing and recurrence rates were not significantly different between LIFT and AF (52.6% vs. 47.6%; p = 0.752, 21.1% vs. 19.0%; P>0.999, respectively). In AF a trend was seen towards higher clinical healing percentages after anti-TNF/immunomodulator use (75.0% vs. 37.5%; p = 0.104).

Newly developed postoperative incontinence was not significantly different (LIFT: 15.8% vs. AF: 21.4%; P>0.999). Interestingly, 22.2% had improved continence postoperatively (LIFT: 31.6% vs. AF: 11.8%; p = 0.236), and the global change question demonstrated improved continence in 47.4% (LIFT: 52.9% vs. AF: 42.9%; p = 0.612). The mean total Vaizey score prior to surgery, was 6.8 (SD 4.8) and after surgery this decreased to 5.3 (SD 5.0) (p = 0.067). The MID was calculated to be 2.92 and five patients with a deteriorated continence, all after AF (23.8%), reported a difference of more than 2.92 points and were therefore clinically relevant.

Conclusion

In Crohn’s high-perianal fistulas the clinical and radiological healing, recurrence and incontinence rates are not significantly different between LIFT and AF. However, clinical healing rates seem higher after LIFT, and incontinence rates seem lower. Furthermore, the global change question demonstrated that the majority of patients actually benefitted from surgical intervention with respect to continence.