Surgical treatment of anoperineal Crohn's disease: Can abdominoperineal resection be predicted?

Background: Anoperineal Crohn's disease (APCD) runs an unpredictable course . Although this course is relatively benign in most patients, some will eve ntually require abdominoperineal resection (APR). The aim of this study was to identify prognostic factors of long-term APR in patients with APCD. Study Design: From 1980 to 1996, 119 patients were operated on for APCD (me an +/- SD age 30 +/- 13 years; range 11 to 96 years). Patients were divided into two groups: those undergoing APR and patients without APR at the end of followup. The following prognostic criteria were studied: (1) age at ons et of Crohn's disease (CD) and at the first manifestation of APCD, gender A PCD as the first manifestation of CD, and interval between the onset of CD and the first manifestation of APCD; (2) for the first manifestation of APC D, the type and number of lesions and the results of surgical treatment; an d (3) associated intestinal localizations of CD and the type and number of manifestations of APCD during followup. Results: Mean followup from the first manifestation of APCD was 93 months ( range 1 to 398 months). At the end of followup, 30 patients had undergone A PR (25%). Logistic regression analysis showed that four criteria seemed to be associated with an increased risk of APR: age at first APCD (p < 0.02), fistula as the first manifestation of APCD (p < 0.04), more than three APCD lesions during followup (p < 0.01), and rectal involvement by CD (p < 0.00 0001). When, as in eight patients, these criteria were all present, APR was performed during followup in 100% of patients. In the absence of all four criteria (eight patients), APR was never performed. Conclusions: This study allowed us to identify patients with APCD at high r isk of APR. For these patients, early prevention of CD recurrence should be attempted by aggressive medical therapy. (J Am Coll Surg 1999;189: 171-176 . (C) 1999 by the American College of Surgeons).