title: Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn's disease.
abstract: BACKGROUND
  Due to the considerable variety in the clinical presentation of anorectal and rectovaginal fistulas in Crohn's disease, data on treatment results for each type of fistula are limited. The aim of this study was to summarize the results after surgical treatment of such fistulas in a large consecutive series of patients.
  
  
  METHODS
  All patients with anorectal or rectovaginal fistula due to Crohn's disease requiring surgery in our institution between 1991 and 2001 were extracted from a prospective database. A standardized telephone interview was conducted and patients were followed in our outpatient clinic, the department of internal medicine, or at their gastroenterologist. Type of fistula and interventions were classified and analyzed. Recurrence-free time intervals were estimated for each type of fistula and for the different surgical procedures. The influence of the surgical procedure, the number of operations performed, and the correlation to other localizations of the disease were analyzed in regard to the recurrence rate.
  
  
  RESULTS
  From 777 patients with Crohn's disease undergoing surgery between 1991 and 2001, 147 had anorectal or rectovaginal fistula (292 operations). Ninety-eight percent of them also had Crohn's disease in the colon or rectum compared to only 21% of patients without a fistula (p value <0.001). Over long-term follow-up, 29 patients (20%) required proctectomy. Submucosal fistulas needed major surgery in only 14% of cases compared to 56% of cases with rectovaginal fistulas. After 5 years, complex fistulas showed a strong trend towards a higher recurrence rate after surgery than simple submucosal fistulas (45.6% vs. 18.8%, p = 0.079). Whereas recurrences occurred over the whole observation period in the group of patients with complex fistulas, there was no further recurrence in patients with submucosal fistulas 13 months after surgery. In rectovaginal fistulas, additional levatorplasty showed no advantage over standard endorectal advancement flap.
  
  
  CONCLUSIONS
  Long-term follow-up demonstrates that recurrence rates after repair of complex fistulas for Crohn's disease are high and continuously increase over time. Submucosal fistulas have the best outcome; after 13 months without recurrence, definite cure can be expected.
authors.affiliation: Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Löffler
authors.forename: Thilo
authors.initials: T
authors.lastname: Welsch
authors.forename: Stefanie
authors.initials: S
authors.lastname: Mühl
authors.forename: Ulf
authors.initials: U
authors.lastname: Hinz
authors.forename: Jan
authors.initials: J
authors.lastname: Schmidt
authors.forename: Peter
authors.initials: P
authors.lastname: Kienle
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000473:pathology / Q000601:surgery*; D003424:Crohn Disease / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012006:Rectovaginal Fistula / Q000150:complications* / Q000601:surgery*; D012007:Rectum / Q000473:pathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome