QS207 - Fistulotomy in Crohn’s Disease: Friend or Foe?

Purpose/Background: Fistulotomy is a highly effective surgical treatment for non-complex anal fistulae. However, concerns exist regarding disruption of the anal sphincter muscles and the risk of incontinence. Crohn’s disease (CD) patients are at increased risk for developing perianal fistulae, often recurrent, as well as fecal incontinence due to chronic perianal disease. As a result, CD is considered a contraindication for fistulotomy, especially in patients with submuscular involvement. We aimed to evaluate fistulotomy outcomes in patients with CD.

Methods/Interventions: We performed a single-center retrospective review of adult patients with CD who underwent a fistulotomy between 1999 and 2022. Data was collected using an electronic medical record review. Data included patient demographics, CD characteristics, perianal disease characteristics, fistulotomy short ( < 30 days) and long-term (>30 days) outcomes, pre- and post-fistulotomy immunomodulating medication use, and functional outcomes at the most recent follow-up. Fistulotomy was classified as superficial if no sphincter muscle was involved, low fistulotomy if < 10% of muscles were involved, and high fistulotomy if >10% of muscles were involved. Fistulotomy not connecting internal and external opening (partial fistulotomy) or those without an internal opening in the anal canal were excluded. Data represent median (interquartile range) or frequency (proportion).

Results/Outcomes: A total of 43 adult patients were included: 29 (67.4%) male, age 34 (28 - 42) years at fistulotomy, and a follow-up time of 4.3 years (2;5.9) after fistulotomy. Prior interventions included draining seton (n=21, 48.8%), partial fistulotomy (n=4, 17.4%), or no prior surgery (n=11, 25.6%). Fistulotomies were subcutaneous (n=28, 65.1%), low-transsphincter (n=7, 16.3%), low-intersphincteric (n=2, 4.7%), and low-unspecified (n=6, 14%). Short-term complications included pain (n=9, 20.9%), bleeding (n=2, 4.7%), keyhole deformity (n=1, 2.3%), seepage (n=1, 2.3%), and no complication (n=25, 58.1%). Long-term complications included bleeding (n=1, 2.3%), keyhole deformity (n=1, 2.3%), non-healing wounds (n=1, 2.3%), stricture (n=1, 2.3%), recurrence of abscess at the same location (n=3, 7%), reoperation at the same fistula (n=5, 11.6%), and no complication (n=32, 74.4%). At the last follow-up, 41 patients (95.3%) reported resolution of symptoms related to the treated fistula. There were no reports of incontinence. At the time of fistulotomy, patients were on biologic therapy (n=21, 48.8%), immunomodulators (n=7, 16.3%), or no medication (n=15, 34.8%). After fistulotomy, patients remained on the same medical management (n=20, 46.5%), switched agents (n=9, 20.9%), discontinued an agent (n=7, 16.3%), or initiated therapy (n=7, 16.3%). Nine patients (20.9%) had a second superficial fistulotomy, and three (7%) had a second low fistulotomy. Complications from the second fistulotomy included a non-healing wound (2.3%) and persistent pain (2.3%) in the superficial group.

Conclusion/Discussion: Our data suggests that patients with CD may safely undergo fistulotomy for anal fistulas that are superficial or involve minimal sphincter muscle. No incontinence has been reported, although a longer follow-up period may be required in patients with uncontrolled disease.