FISTULA HEALING IS LOW AFTER FECAL DIVERSION SURGERY IN PERIANAL CROHN'S DISEASE
Sheeva Johnson*2, Jeffrey Ko2, Wissam J. Halabi1, Jesse L. Stondell2, Maneesh Dave2
1University of California Davis Division of Colon and Rectal Surgery, Sacramento, CA; 2University of California Davis Division of Gastroenterology and Hepatology, Sacramento, CA
Background: Perianal fistula are seen in up to 26% of patients with Crohn's disease and are often refractory to medical therapy (Shivashankar R. et al. Clin Gastro Hepatol, 15 (2017), p. 857-863). Fecal diversion is used to manage perianal fistula, with a meta-analysis showing 63% clinical improvement (Singh S. et al. Aliment Pharmacol Ther, 42 (2015), p. 783-92), however objective data on fistula healing rates, such as no fistula drainage despite gentle finger compression, exam under anesthesia (EUA), MRI, or endoscopic ultrasound, are often not reported. The aim of this study was to evaluate fistula healing, or closure of all individual draining fistulas, in complex perianal Crohn's disease after fecal diversion.
Methods: Patients with perianal Crohn's disease who underwent fecal diversion surgery from 6/1/2016-6/1/2020 with colorectal surgeons at a tertiary care center were selected through electronic medical record chart extraction using ICD-10 and CPT codes after IRB approval. Patients were followed through 9/1/2020. Fistula healing was determined by interval closure of fistulas through imaging or EUA.
Results: 11 patients with refractory perianal fistula underwent fecal diversion surgery from 6/1/2016-6/1/2020. Time to follow up was 4-24 months, with a mean of 11 months. 1 patient was lost to follow up. Mean age was 41 years, 5/11 were male. 10/11 patients were on biologic therapy at time of surgery, and 9/11 had tried more than one biologic. Type of fecal diversion performed was loop ileostomy (6/11), end ileostomy (3/11), loop colostomy (2/11). 4/10 (40%) had complete fistula healing, 6/10 (60%) had persistent fistula. 3/10 (30%) were readmitted within 90 days for complications (high ostomy output, bowel obstruction, and intraabdominal abscess). Most frequent complications observed were peristomal wounds/skin infection (3/10), high ostomy output/dehydration (2/10), bowel obstruction (1/10). Two patients underwent proctectomy (1 for persistent fistula, 1 for anal leakage).
Conclusion: Objective fistula closure is much lower with fecal diversion than anticipated by clinicians and was associated with significant stoma related morbidity.
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