Colocutaneous Fistulae

Fistulae are a very frequent manifestation of CD, affecting 35% of patients. They is one of the sub-phe-notypes of the disease manifesting as intestinal perforation, abscess formation and fistulae formation. Perineal fistulae make up most of cases and affect 20% [42]. Fistulae can be divided into internal and external, of which internal fistulae emerge in 5-10% of patients, while external fistulae emerging in the rest [43]. Colocutaneous fistulae are a type of external fistulae with an internal opening located anywhere in the inflamed large intestine. The fistula tract begins at the abdominal wall, and continues until it ends as an external opening on the skin. The symptoms include a constant or periodical flow of intestinal, festering, or a combination of intestinal and festering contents from the external opening of the fistula tract. Certain fistulae lack manifestation.

Treatment of colocutaneous fistulae depend on the clinical manifestations, symptoms and complications. Conservative treatment of choice is 5-ASA (mesalazine), metronidazole and ciprofloxacin. Colocutaneous fistulae are not related to any absorption disturbances and do not cause severe symptoms, therefore the first-line treatment should be a conservative one [27]. Initial treatment with 5-ASA, metronidazole and ciprofloxacin has a beneficial effect, and despite the fact that in the majority of cases it does not lead to complete healing, it considerably decreases the symptoms and improves the quality of the patient's life [44]. Increasing evidence shows that corticosteroids should not be used in fistulous CD. When patients are non-responsive to 5-ASA, metronidazole and ciprofloxacin therapy, the immunomodulators (6-mercaptopurine or azathio-prine) should be considered. This line of therapy was effective in 54-65% of cases, and was followed by complete fistula closing in 31-39% of patients [45-47]. Chimeric monoclonal antibody anti-TNF (infliximab) is new and promising type of therapy that shows high effectiveness in fistulae resistant to 5-ASA, antibiotics and immunomodulators. Complete healing of fistulae has been observed in 24-55% with a simultaneous slight risk for side effects [48-52]. The external fistulae show better responsiveness to infliximab (69%) when compared to the internal fistulae (13%) [22]. External fistulae including perianal fistulae respond best to the therapy (78%), while 38% of abdominal-wall fistulae respond well to infliximab [53]. Infliximab should be recommended in the treatment of both external and internal asymptomatic fistulae that are unresponsive to the application of other medications due to low toxicity and safety of usage [54].

Septic complications of the colocutaneous fistulae are indications for immediate surgical intervention. A decision to undertake surgical treatment should also be made in the case of those fistulae resistant to conservative treatment, and when the outflow of intestinal contents causes maceration of the skin creating discomfort and lowering the patient's quality of life. The type of surgical procedure depends mostly on the image obtained after laparotomy. The aim of the procedure should always be resection of the fistula and the involved portion of intestine along with the removal of the entire fistula tract and external opening. Elective procedures should be conducted possibly at the time of remission and not sooner than 3-6 months from the time of severe onset of symptoms [27]. Some authors point out a high rate of recurrence following segmental resection [55], some present satisfactory results with only 13% of recurrences and with an average time of 27 months until recurrence.

resection of the large intestine caused by Crohn's disease [52], whereas a surveillance period that lasted 10 years showed a 66% chance [60], and a surveillance period of 14 years showed an 86% chance for recurrence [60]. The types of surgical procedures performed on the large intestine include segmental resection, left and right hemicolectomy, sigmoid resection and anterior rectal resection, colectomy with ileo-rectal anastomosis, colectomy with ileostomy and proctocolectomy. Interpretation of the results can be difficult because inclusion criteria in some trials are not homogenous; therefore, patients with segmental resection are enrolled in the same group with those who underwent subtotal colectomy with ileostomy or just stoma formation (61-63). The latest reports show that recurrence following segmental resection required repeated surgical treatment in 30-49% of patients [21, 61, 64]. The lowest level of recurrence at 15% has been noted for patients after right-sided hemicolectomies [61]. Recurrence following subtotal colectomy with ileostomy has been recorded as being between 41 and 64% [64-66]. Recurrence following subtotal colectomy with ileostomy is much lower and has been recorded at 18.5% [64] and 30% [67], respectively. The best results have been noted for the cases of stapled end-to-end anastomoses, which have reduced the rate of recurrence to as low as 3% [68], and side-to-side anastomosis with a recurrence level at 2% [69].

The most important factor creating the risk of postoperative recurrence is found to be cigarette smoking [70, 71]. Quitting smoking after the surgery decreases the risk of recurrence [72]. Another independent factor influencing recurrence is the sub-phe-notype of the disease. The sub-phenotype connected with perforation and fistula creation, is believed to be at a higher risk of recurrence following resection [73]. It has been proven that the application of 5-ASA (mesalazine) as well as metronidazole and ornidazole influences the lowering of risk for early recurrence [70, 74]. Wide stapled anastomoses may also reduce recurrences following surgery, but it requires further evaluation and additional randomised trials [70].

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