title: Surgical Management of Fistula-in-ano Among Patients With Crohn's Disease: Analysis of Outcomes After Fistulotomy or Seton Placement-Single-Center Experience.
abstract: OBJECTIVE
  Fistula-in-ano is a common problem among patients with Crohn's disease and carries significant morbidity. We aimed to study the outcomes of surgical treatment of fistula-in-ano after fistulotomy or seton placement in patients with perianal fistulizing Crohn's disease.
  
  
  METHODS
  A retrospective observational study of 59 patients diagnosed with Crohn's disease, who were treated surgically for fistula-in-ano between 2010 and 2014 in our department. The assessment of disease complexity included a detailed physical examination, magnetic resonance imaging of the rectum, and examination under anesthesia. Outcomes for analysis included wound healing rate and postoperative incontinence.
  
  
  RESULTS
  High transsphincteric fistula was found in 44% of the patients, while mid or low transsphincteric fistulas were found in 51%. Three women (5%) had a rectovaginal fistula. All patients with high transsphincteric fistulas were treated with loose seton placement. Patients with mid- or low-level transsphincteric fistula were offered either fistulotomy or seton placement based on the clinical evaluation. The mean follow-up duration was 1.6 ± 1.1 years. In terms of recurrence, one patient treated with seton placement presented with recurrence 6 months after seton removal and one patient with fistulotomy failed to achieve wound healing. Minor incontinence was found in six patients treated with fistulotomy and in three patients treated with seton placement; however, this difference was not significant (chi-square = 1.723, df = 1, Monte-Carlo: p = 0.273).
  
  
  CONCLUSIONS
  Fistulotomy could achieve good results in terms of wound healing and incontinence in strictly selected patients with Crohn's disease suffering from low-lying transsphincteric fistulae. For more high-lying or complicated fistulae, seton placement is more appropriate. For high transsphincteric fistulae, the only option is placement of loose seton.
authors.affiliation: 1 2nd Department of Surgery, Aretaieion Hospital, University of Athens, Athens, Greece.
authors.forename: I
authors.initials: I
authors.lastname: Papaconstantinou
authors.affiliation: 1 2nd Department of Surgery, Aretaieion Hospital, University of Athens, Athens, Greece.
authors.forename: E
authors.initials: E
authors.lastname: Kontis
authors.affiliation: 2 1st Department of Radiology, Aretaieion Hospital, University of Athens, Athens, Greece.
authors.forename: V
authors.initials: V
authors.lastname: Koutoulidis
authors.affiliation: 3 Department of Gastroenterology, Evangelismos Hospital, Athens, Greece.
authors.forename: G
authors.initials: G
authors.lastname: Mantzaris
authors.affiliation: 1 2nd Department of Surgery, Aretaieion Hospital, University of Athens, Athens, Greece.
authors.forename: I
authors.initials: I
authors.lastname: Vassiliou
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000601:surgery*; D003424:Crohn Disease / Q000150:complications*; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Crohn’s disease; Fistula; anal; fistulotomy; seton