Mario H. Mueller, Matthias Geis, Markus Kueper, Michael Kasparek, Joerg Glatzle, Ekkehard Jehle, Martin Kreis, Tilman Zittel, Dep. of General Surgery, University of Tuebingen, Tuebingen, Germany

Introduction: Perianal lesions, which may vary from asymptomatic skin tags to severe, debilitating perianal destruction and sepsis are common in patients with Crohn's disease. Severe perianal disease may subside with fecal diversion, thereby avoiding proctectomy. We investigated the overall risk of permanent stoma carriage in perianal Cohn's disease and tried to identify risk factors predicting permanent stoma carriage. Methods: A total of 97 consecutive patients presented with anorectal Crohn's disease for the first time in our outpatient department between 1992 and 1995. 92/97 patients (95%) could be followed up and were evaluated by a standardized questionnaire with respect to the recurrence of perianal abscesses or fistula, and surgical treatment including fecal diversion of Crohn's disease over the years. Risk analysis was done for the following characteristics: gender, perianal or anovaginal fistulas, abscess formation, anal stricture, incontinence and abdominal surgery (AS). The median interval between the first diagnosis of Crohn's disease and last follow-up was 15.8 years (range 8-37 years). Results: 83 of 92 patients (92%) required AS during follow-up, and a total of 227 abdominal operations had to be performed. 21 patients (23%) required temporary fecal diversion, and in 30 patients (33%) a permanent stoma became necessary. The median time from first diagnosis of Crohn's disease to permanent fecal diversion was 8.5 years (range 0-23 years). Complex abcess formations (including severe perianal sepsis) required a permanent stoma in 36%, complex perianal fistulas in 38%, and anovaginal fistulas in 54%. Anovaginal fistulas, complex perianal fistulas and subtotal colectomy significantly increased the risk of a permanent stoma (p<0.05). Discussion: Patients with perianal Crohn's disease carried a high risk for AS, and one third eventually required a permanent fecal diversion. Anovaginal fistulas, complex perianal fistulas or a previous subtotal colectomy indicated an increased risk for a permanent stoma.