Clinical Course of Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease: A Multicenter Case Series of 24 Patients

Hannah W Fiske; Chung Sang Tse; Badr Al-Bawardy; Pooja Magavi; Gauree Gupta Konijeti; Eric Mao; Sean Fine; Alyssa Parian; Mark Lazarev; Samir A Shah

doi:10.1093/crocol/otae065

Clinical Course of Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease: A Multicenter Case Series of 24 Patients

Crohns Colitis 360. 2024 Nov 27;6(4):otae065. doi: 10.1093/crocol/otae065. eCollection 2024 Oct.

Authors

Hannah W Fiske¹, Chung Sang Tse², Badr Al-Bawardy^{3

4

5}, Pooja Magavi⁶, Gauree Gupta Konijeti⁶, Eric Mao⁷, Sean Fine⁸, Alyssa Parian⁹, Mark Lazarev⁹, Samir A Shah¹⁰

Affiliations

¹ Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
² Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
³ Department of Internal Medicine, Division of Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
⁴ College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
⁵ Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA.
⁶ Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, CA, USA.
⁷ Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA, USA.
⁸ Division of Gastroenterology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
⁹ Division of Gastroenterology & Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA.
¹⁰ Gastroenterology Associates Inc. (Powered by GI Alliance), The Warren Alpert Medical School of Brown University, Providence, RI, USA.

Abstract

Background: Isolated complex perianal fistulas, without luminal evidence of inflammatory bowel disease in the gastrointestinal tract, pose diagnostic and treatment dilemmas for gastroenterologists and colorectal surgeons. For patients who develop recurrent complex fistulas, a presumptive diagnosis of Crohn's disease may be made. It is unclear whether these cases of isolated perianal disease in the absence of luminal inflammation truly represent isolated severe cryptoglandular fistulas or rather an early presentation of Crohn's disease. We aimed to investigate the clinical course and outcomes of patients with isolated complex perianal fistulas.

Methods: In this retrospective multicenter case series across 6 institutions in the United States, we report the clinical course of patients with isolated recurrent complex perianal fistulas, including their diagnostic evaluation, medical and surgical therapies, and clinical outcomes.

Results: All patients (n = 24) required incision and drainage of perirectal abscesses. The majority received setons (n = 19, 79%), more intensive surgical interventions (n = 15, 62.5%, including fistulotomy/sphincterotomy, advancement flap, and ligation of the intersphincteric fistula tract), antibiotics (n = 17, 71%), and biologic therapy (n = 16, 67%). Nine patients (37.5%) underwent a combined medical-surgical approach with biologics and intensive surgical intervention. Despite surgical and/or medical management, active symptomatic complex perianal fistulas persisted in 58% (n = 14) of patients at follow-up (median 5.5 years, interquartile range 2.5-10 years); symptom remission was achieved in 21% (n = 5), and fistula closure in 21% (n = 5).

Conclusions: These cases highlight a multidisciplinary and multimodal approach when treating isolated complex perianal fistulas and their propensity to persist despite the incorporation of advanced therapies.

Keywords: inflammatory bowel disease; isolated perianal Crohn’s disease; perianal fistula.