Contemporary surgical management for ileosigmoid fistulas in Crohn's disease

Abstract

Background: Current diagnostic modalities and surgical treatments for ileosigmoid fistulas (ISF) in Crohn's disease (CD) are not well characterized.

Methods: ISF patients operated during 2000-2007 in a prospectively collected CD surgery database were included. Disease extent, diagnostic studies, medications, and smoking status were retrospectively reviewed.

Results: One hundred four CD patients with ISF (median age 37) underwent ileocolic resection (75 open, 29 laparoscopic). Sigmoid colon was treated with primary repair (26), segmental resection (71), and subtotal colectomy (7). Thirty-eight patients required additional surgery for CD manifestations (ileovesical fistula (11), enterocutaneous fistula (11), and synchronous small bowel disease (22)). Overall sensitivity of studies for ISF detection was 63% (66/104) (colonoscopy 35% (31/89), CT scan 41% (31/76), fluoroscopy 53% (31/58)). Stoma diversion (53 patients, 51%) occurred more with open surgery (81% vs. 63%, p = 0.04), intraoperative ureteral stents (28% vs. 2%, p < 0.0001), additional small bowel procedures (42% vs. 18%, p = 0.008), longer overall length of stay (10 vs. 6 days, p < 0.0001), preoperative steroid use > or =20 mg prednisone (40% vs. 18%, p = 0.02), and preoperative albumin < or =3.5 gm/dl (43% vs. 22%, p = 0.02). Mortality was nil. Overall morbidity was 37% with anastomotic leak 4%. Neither was affected by stoma diversion, laparoscopy use, or sigmoid colon treatment.

Conclusions: While most ISF in CD are found preoperatively, some are still incidental surgical findings. Sigmoid resection and primary repair have comparable morbidity if appropriately individualized. Laparoscopic treatment is acceptable in select cases without added morbidity.