Opzioni chirurgiche nel trattamento della malattia di Crohn a localizzazione perianale



Ann. Ital. Chir., LXXIV, 6, 2003

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(CD) have a perianal involvement. Despite the recent introduction
of anti-TNF antibody, this therapy has uncertain
long-term results and surgery still remains a major treatment
Aims & Methods: This study relates our experience in surgical
management of perianal CD without anti-TNF treatment.
From July 92 to February 02, 37 patients with perianal
Crohn’s disease were treated, 43 underwent local operations
or faecal diversion for fistulas and/or abscesses.
Patients not requiring surgery or in therapy with anti-TNF·
were excluded from the study. We analysed the outcome of
surgical treatment for perianal CD.
Results: Male to female ratio was 1:0.6, median age was
36,9 years (range 17-62). Perianal disease included 32
fistulas (16 trans-sphincteric, 2 superficial, 2 ano-vaginal,
10 multiple and complex, 2 horseshoe) and 7 abscesses (5
perianal, 2 ischio-rectal). Local surgery included 1 abscess
drainage, 5 abscess drainage and fistula incision with seton
insertion, 2 fistulotomy, 9 partial fistulectomy and seton
insertion. At surgery, 40% of patients were ongoing a medical
treatment with 5-ASA and/or antibiotics, 40% with
steroids and/or immunosoppressors, 15% only with 5-ASA
and 5% no ongoing treatment. The horseshoe fistulas were
managed with a fistulotomy and seton insertion. One
patient with ano-vaginal fistula required proctectomy and
the other one total proctocolectomy. Patients treated by diverting
colonostomy (3) had fistula recurrence after its closure
in 100%. 20% of patients required total proctocolectomy
and ileostomy for extensive intestinal disease. Of the
27 patients undergoing seton insertion or fistulotomy none
had faecal incontinence due to the operation and 38% had
a 1 year recurrence.
Conclusions: Perianal CD is a heterogeneous entity, therefore
its management is still controversial. Moreover, a
high percentage of patients (18% in our series) requires a
major surgery due to the extension and seriousness of rectal
involvement. In our survey only 12 patients (39%),
with trans-sphincteric fistula, could have been theoretically
treated with anti-TNF. We wonder if the cost-and-benefit
of this medical treatment justifies its application on
patients that could undergo a surgical treatment with good
long term results.


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