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Long-term healing after complex anal fistula repair in patients with Crohn’s disease

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Techniques in Coloproctology Aims and scope Submit manuscript

Abstract

Background

Complex anal fistula in Crohn’s disease (CD) poses a challenging problem. We sought to evaluate long-term surgical healing of complex anal fistula in CD through the two robust repair options—ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF).

Methods

A single-center retrospective study was conducted evaluating long-term healing rates in patients with CD with complex anal fistula undergoing LIFT or AF in 2008–2018. Fistula healing was defined as closure of external wounds, cessation of drainage and absence of pain. Short-term and long-term healing rates were compared. Cox proportional hazards model was performed to identify independent predictors of fistula healing.

Results

The study cohort included 60 CD patients undergoing LIFT (n = 38) or AF (n = 22). The AF group included 8 dermal flaps. Patients having LIFT were younger (35 years vs 43 years; p = 0.007), more likely to have a seton at the time of repair (92% vs 68%; p = 0.03) and less likely to have had prior repair attempts (34% vs 68%; p = 0.02). Short-term fistula healing occurred in 65% (n = 39) of the overall study cohort. However, at final follow-up, median 36 months (range 6–192 months), only 46% (n = 28) of repaired fistulas were healed. Considering the overall status of the cohort’s perianal health at final follow-up, including both repaired, secondary or novel anal fistulas, only 50% (n = 30) of all patients in the cohort had all fistula sites healed and maintained bowel continuity at final follow-up. On Cox proportional hazards analysis, LIFT independently predicted long-term fistula healing (hazard ratio 2.3; 95% confidence interval 1.1–4.9; p = 0.03). Only a small number of patients (n = 5; 8%) required fecal diversion (n = 3) and/or proctectomy (n = 2).

Conclusions

Repair of complex anal fistula in CD results in modest healing rates. LIFT independently predicts long-term healing. However, these results must be taken in context, considering differences in patient and fistula characteristics between groups. These results ought to be kept in mind when counseling CD patients with complex anal fistula.

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Funding

None declared. The authors have no relevant disclosures and source of financial support was none. The authors have no disclosures of funding for this work from any of the following organizations: National Institute of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); and others.

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Authors and Affiliations

  1. Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA

    A. Mujukian, A. Truong, P. Fleshner & K. Zaghiyan

Authors
  1. A. Mujukian
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  2. A. Truong
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  3. P. Fleshner
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  4. K. Zaghiyan
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Contributions

Per the International Committee of Medical Journal Editors (ICMJE) guidelines. Angela Mujukian: Substantial contributions to acquisition, analysis, or interpretation of data, original drafting; revision for critically important intellectual content, final approval of the version to be published, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Adam Truong: substantial contributions to acquisition, analysis, or interpretation of data, revision for critically important intellectual content, final approval of the version to be published, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Phillip Fleshner: substantial contributions to conception and design of the work, revision for critically important intellectual content, final approval of the version to be published, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Karen Zaghiyan: substantial contributions to conception and design of the work; acquisition, analysis or interpretation of data, drafting and revision for critically important intellectual content, final approval of the version to be published, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to K. Zaghiyan.

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Mujukian, A., Truong, A., Fleshner, P. et al. Long-term healing after complex anal fistula repair in patients with Crohn’s disease. Tech Coloproctol 24, 833–841 (2020). https://doi.org/10.1007/s10151-020-02238-1

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