Fistulating Crohn’s diseaseFistulating Crohn’s disease

Paul RooneyPaul RooneyRoyal Liverpool HospitalRoyal Liverpool Hospital

ClassificationClassification

Type I. Primary crohn’s fistula arising de Type I. Primary crohn’s fistula arising de novo.novo.Type II. Secondary to failed crohn’s Type II. Secondary to failed crohn’s surgerysurgery

How Common?How Common?

33% of Crohn’s33% of Crohn’sn=639 surgical ptsn=639 surgical pts290 fistula in 222pts290 fistula in 222pts69% pre op69% pre op27% intra op27% intra op

(Michelassi 1993)(Michelassi 1993)

SiteSite

Trans mural Trans mural inflammationinflammationSite dependant on Site dependant on affected segmentaffected segmentRIF 52%RIF 52%Pelvis 12%Pelvis 12%LIF 24%LIF 24%

Conservative management ?Conservative management ?

Imfliximab, Azothiaprine,Tacrolimus,Imfliximab, Azothiaprine,Tacrolimus,Thalidomide.Thalidomide.n=26 3 doses of imfliximabn=26 3 doses of imfliximab9 perianal9 perianal6 enterocutaneous6 enterocutaneous4 enteroenteric4 enteroenteric3 rectovaginal3 rectovaginal4 peristomal4 peristomal (Poritz 2002)(Poritz 2002)

Conservative Management?Conservative Management?

14 pts required surgery post imfliximab14 pts required surgery post imfliximab6 still had fistula but declined surgery6 still had fistula but declined surgeryNo healing of intra abdominal disease No healing of intra abdominal disease (n=10)(n=10)Abdominal fistula/sepsis needs Surgery!Abdominal fistula/sepsis needs Surgery!

Surgical Strategy The Evidence:Surgical Strategy The Evidence:

n= 343 1008 anastamoses (1980-97)n= 343 1008 anastamoses (1980-97)Risk factors for post op fistulaRisk factors for post op fistula76 (13%) fistula/septic complications76 (13%) fistula/septic complicationsAlbumin <30Albumin <30SteroidsSteroidsAbscess at surgeryAbscess at surgeryFistula at surgeryFistula at surgery

Septic Complication RateSeptic Complication Rate

4 risk factors4 risk factors 50%50%3 3 29%29%22 14%14%11 16%16%00 5% 5%

(Yamamoto 2002 DCR)(Yamamoto 2002 DCR)

Decision TimeDecision Time

Eradication of sepsisEradication of sepsisNutritionNutritionResection of Crohn’s Resection of Crohn’s bowelbowel

Fear of DeathFear of DeathFear of stomaFear of stomaFear of loss of gut Fear of loss of gut function (long term function (long term TPN)TPN)

SNAPSNAP

SS sepsissepsisNN nutritionnutritionAA anatomyanatomyPP planplan

Non septicNon septic SepticSeptic

ResectionResectionAnstamosis away Anstamosis away from primary site of from primary site of fistulafistula

Resection and Resection and exteriorization further exteriorization further surgery 6/12surgery 6/12Or drain, controlled Or drain, controlled fistula, further surgery fistula, further surgery when stable 6/12when stable 6/12Don’t regret making a Don’t regret making a stoma but tell the stoma but tell the patient what you’re patient what you’re going to dogoing to do

ConclusionConclusion

Fistula and septic complications are Fistula and septic complications are commoncommonPatient and surgeon must understand the Patient and surgeon must understand the risk of anastomosisrisk of anastomosisSNAPSNAPDon’t be afraid to make a stomaDon’t be afraid to make a stoma