INCIDENCE, DIAGNOSIS, AND TREATMENT OF ENTERIC AND COLORECTAL FISTULAS IN PATIENTS WITH CROHNS-DISEASE

Objective The authors review their experience, evaluating the incidenc e and examining the various modalities employed in the diagnosis and t reatment of patients with Crohn's disease complicated by fistulae. Sum mary Background Data Although common, internal and external fistulae i n Crohn's disease may pose challenging problems to the surgeon. Method s Of 639 patients who underwent surgical treatment at the University o f Chicago between 1970 and 1988 for complications of Crohn's disease, 222 patients (34.7%) were found to have 290 intraabdominal fistulae. R esults A fistula was diagnosed preoperatively in 154 patients (69.4%), intraoperatively in 60 (27%), and only after examination of the speci men in 8 (3.6%). The fistula represented the primary or single indicat ion for surgical treatment in 14 patients (6.3%) and one of several in dications in the remaining patients. Of 165 patients with an abdominal mass or abscess, 69 (41.8%) had a fistula. All patients underwent res ection of the diseased intestinal segment; 160 (73.1%) with primary an astomosis and the remaining 62 with a temporary or permanent stoma. Th e fistula was directly responsible for a stoma in only 16 patients (7. 2%) and was never responsible for a permanent stoma. Resection of the diseased bowel achieved en bloc removal of the fistula in 145 cases. R emoval of 93 additional fistulae required resection of the diseased bo wel segment along with closure of a fistulous opening on the stomach o r duodenum (n = 14), bladder (n = 35), or rectosigmoid (n = 44). When the fistula drained through a vaginal cuff (n = 4), the opening was le ft to close by secondary intention; when the fistula opened through th e abdominal wall (n = 46), the fistulous tract was debrided. In the re maining two entero-salpingeal fistulae, en bloc resection of the invol ved salpinx accomplished complete removal of the fistula. There was a dehiscence of one duodenal and one bladder repair; 14 patients (6%) ex perienced postoperative septic complications and one patient died. Con clusions Fistulae are diagnosed preoperatively in 69% of cases and can be suspected in as many as 42% of patients with an abdominal mass. Fi stulae are the primary or single indication for surgical treatment and are directly responsible for a stoma only in a few patients. Treatmen t, based on resection of the diseased bowel and extirpation of the fis tula, can be accomplished with minimal morbidity and mortality.