1. Fistulating Crohn’s disease Paul Rooney Royal Liverpool Hospital

2. Classification Type I. Primary crohn’s fistula arising de novo. Type II. Secondary to failed crohn’s surgery

4. How Common? 33% of Crohn’s n=639 surgical pts 290 fistula in 222pts 69% pre op 27% intra op (Michelassi 1993)

5. Site Trans mural inflammation Site dependant on affected segment RIF 52% Pelvis 12% LIF 24%

6. Conservative management ? Imfliximab, Azothiaprine,Tacrolimus, Thalidomide. n=26 3 doses of imfliximab 9 perianal 6 enterocutaneous 4 enteroenteric 3 rectovaginal 4 peristomal(Poritz 2002)

7. Conservative Management? 14 pts required surgery post imfliximab 6 still had fistula but declined surgery No healing of intra abdominal disease (n=10) Abdominal fistula/sepsis needs Surgery!

8. Surgical Strategy The Evidence: n= 343 1008 anastamoses (1980-97) Risk factors for post op fistula 76 (13%) fistula/septic complications Albumin <30 Steroids Abscess at surgery Fistula at surgery

9. Septic Complication Rate 4 risk factors50% 3 29% 214% 116% 0 5% (Yamamoto 2002 DCR)

10. Decision Time Eradication of sepsis Nutrition Resection of Crohn’s bowel Fear of Death Fear of stoma Fear of loss of gut function (long term TPN)

11. SNAP Ssepsis Nnutrition Aanatomy Pplan

12. Non septicSeptic Resection Anstamosis away from primary site of fistula Resection and exteriorization further surgery 6/12 Or drain, controlled fistula, further surgery when stable 6/12 Don’t regret making a stoma but tell the patient what you’re going to do

15. Conclusion Fistula and septic complications are common Patient and surgeon must understand the risk of anastomosis SNAP Don’t be afraid to make a stoma