SURGICAL-MANAGEMENT OF ILEOSIGMOID FISTULAS IN CROHNS-DISEASE

Ileosigmoid fistulas are found in Crohn's disease and may present a su rgical dilemma. PURPOSE: This study was designed to examine surgical p ractice to determine types of intervention, enumerate complications, a nd elicit guidelines for surgical management. METHOD: The medical reco rds of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed. RESULTS: Ninety patients (44 men) were studied . A preoperative diagnosis of ileosigmoid fistula was made in 77 perce nt of patients. Sigmoid repair was performed in 43 patients (47.8 perc ent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13 .3 percent) underwent more extensive procedures, and 3 patients (3.3 p ercent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection grou ps were similar with respect to age, length of Crohn's disease, and pr eoperative symptoms. There was no significant difference between group s in the incidence of postoperative complications; there were no posto perative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significa nt purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflam mation from active Crohn's disease. CONCLUSION: Contrast studies ident ified 77 percent of ileosigmoid fistulas preoperatively. Performing re pair rather than resection does not increase the risk of complications , if standard surgical principles are followed. Preoperative or intrao perative endoscopy assists the surgical evaluation of the sigmoid.