title: [Surgical options in the treatment of perianal Crohn's disease].
abstract: BACKGROUND
  About 40% of patients with Crohns disease (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 option.
  
  
  OBJECTIVE
  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 Crohns 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.
authors.affiliation: Università degli Studi di Milano, Dipartimento di Scienze Cliniche "Luigi Sacco", Ospedale Luigi Sacco, Azienda Ospedaliera e Polo Universitario, Milano.
authors.forename: P
authors.initials: P
authors.lastname: Danelli
authors.forename: C
authors.initials: C
authors.lastname: Bartolucci
authors.forename: G M
authors.initials: GM
authors.lastname: Sampietro
authors.forename: V
authors.initials: V
authors.lastname: Panizzo
authors.forename: A
authors.initials: A
authors.lastname: Sartani
authors.forename: G
authors.initials: G
authors.lastname: Maconi
authors.forename: E
authors.initials: E
authors.lastname: Parente
authors.forename: A M
authors.initials: AM
authors.lastname: Taschieri
mesh_terms: D000293:Adolescent; D000328:Adult; D001004:Anus Diseases / Q000209:etiology* / Q000601:surgery*; D003424:Crohn Disease / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged