From 1994 to 2004 we treated 672 patients with anal fistulae, of whom 59 (8.8%) had Crohn's disease. The male-to-female ratio was found to be 0.31 in Crohn's disease and 2.48 in idiopathic fistulae. The mean age of the Crohn's patients was 34 and 45 years for the idiopathic fistula patients. On average, the Crohn's patients had twice as many fistulae and they were generally more complex and the proportion of rectovaginal fistulae was higher at 14.2% vs. 2%. The most frequent operations used in idiopathic fistulae were fistulotomy or fistulectomy (71.8%), advancing flap (27.7%) and glue sealant (0.5%). In Crohn's disease the respective proportions of these three techniques were fistulotomy (10.2%), advancing flap (71.2%) and glue sealant (18.6%). The median failure rates were quite different: idiopathic fistulae (8.7%) and Crohn's fistulae (40.5%). One must always be aware that early success may be followed by later recurrence, so scrupulous follow-up is necessary. The main reason for using the advancing flap technique is to preserve the anal profile and to maintain continence. However, even if there is a recurrence, the potentially long intervals without perineal sepsis are a benefit to the patient in their own right. As a summary of our work in this chapter we propose a non-exhaustive algorithm for the treatment of perineal Crohn's disease (Fig. 9).
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