Fistulating Crohn’s disease

1. Fistulating Crohn’s disease Paul Rooney Royal Liverpool Hospital

2. Classification • Type I. Primary crohn’s fistula arising de novo. • Type II. Secondary to failed crohn’s surgery

4. How Common? • 33% of Crohn’s • n=639 surgical pts • 290 fistula in 222pts • 69% pre op • 27% intra op (Michelassi 1993)

5. Site • Trans mural inflammation • Site dependant on affected segment • RIF 52% • Pelvis 12% • LIF 24%

6. Conservative management ? • Imfliximab, Azothiaprine,Tacrolimus, Thalidomide. n=26 3 doses of imfliximab 9 perianal 6 enterocutaneous 4 enteroenteric 3 rectovaginal 4 peristomal (Poritz 2002)

7. Conservative Management? • 14 pts required surgery post imfliximab • 6 still had fistula but declined surgery • No healing of intra abdominal disease (n=10) • Abdominal fistula/sepsis needs Surgery!

8. Surgical Strategy The Evidence: • n= 343 1008 anastamoses (1980-97) • Risk factors for post op fistula • 76 (13%) fistula/septic complications • Albumin <30 • Steroids • Abscess at surgery • Fistula at surgery

9. Septic Complication Rate • 4 risk factors 50% • 3 29% • 2 14% • 1 16% • 0 5% • (Yamamoto 2002 DCR)

10. Eradication of sepsis Nutrition Resection of Crohn’s bowel Fear of Death Fear of stoma Fear of loss of gut function (long term TPN) Decision Time

11. SNAP • S sepsis • N nutrition • A anatomy • P plan

12. Resection Anstamosis away from primary site of fistula Resection and exteriorization further surgery 6/12 Or drain, controlled fistula, further surgery when stable 6/12 Don’t regret making a stoma but tell the patient what you’re going to do Non septic Septic

15. Conclusion • Fistula and septic complications are common • Patient and surgeon must understand the risk of anastomosis • SNAP • Don’t be afraid to make a stoma