The operative management of fistulous Crohn's disease.

In 100 consecutive patients with fistulous Crohn's disease who were managed surgically during a 12 year period, a 96 per cent closure rate was obtained with only a 1 per cent 30 day mortality rate. En bloc resection of the diseased intestine and fistula with primary anastomosis was the preferred treatment, but temporary exteriorization of the intestinal ends was undertaken in patients compromised by extensive sepsis or profound hypoalbuminemia. In 43 patients, there were 70 secondary intestinal defects caused by the fistula eroding into otherwise healthy intestine. The majority of these defects were successfully closed by primary suture; however, three secondary duodenal defects, treated by primary suture alone, failed to heal and fistulas recurred. As a result, two of these patients died of overwhelming sepsis. Since adopting closure or protection of duodenal defects by a jejunal serosal patch, this problem has not arisen again. One defect in the sigmoid colon treated by primary suture also had recurrence of fistula, probably because the repair lay adjacent to an abscess cavity. Temporary loop colostomy is now used to protect repairs of defects in the sigmoid colon undertaken in the presence of local sepsis.