The medical, nutritional and surgical treatment of fistulae in Crohn's disease.

Of a total 44 patients with Crohn's disease, 10 patients with 9 internal and 15 external fistulae, some of which were recurrent, were analyzed at the Department of Surgery, Yokohama City University between 1973 and 1988. Twenty-two fistulae were treated with medical and nutritional therapy using either total parenteral or enteral hyperalimentation by which the closure rate of the internal and external fistulae was 0 (0/9) and 42 per cent (9/14), respectively. The nutritional status of all the patients with fistulae treated by nutritional therapy improved, especially those whose fistulae were closed. However, 8 of 9 internal fistulae and 5 of 15 external fistulae finally required resection of the fistula with the distal stenotic bowel segment. The re-opening rate of fistulae following successful medical/nutritional therapy and surgical therapy was 88.9 per cent (8/9) and 53.8 per cent (7/13), respectively, and the mean interval until recurrence was shorter in the patients who underwent medical and nutritional therapy (4.5 months) than in those who underwent surgical therapy (19.4 months). Thus, using medical and nutritional therapy, none of the internal fistulae were closed, but 9 of 14 external fistulae were. The optimal management of internal fistulae is therefore thought to be bowel resection to include the distal stenotic lesion, while medical and nutritional therapy is thought to be of value for external fistulae.