Impact of perineal Crohn's disease on utilization of care in the absence of modifiable predictors of treatment failure

The burden of perineal Crohn's disease (PCD) remains poorly characterized, and many patients ultimately require fecal diversion or proctectomy. Our goal was to characterize the clinical course of patients presenting with perineal Crohn's disease, focusing on the cohort of patients ultimately requiring fecal diversion, and identify modifiable predictors for this unfortunate outcome. We performed a retrospective review of 81 consecutive patients who underwent 172 operations to address complications of PCD. Diverted patients were compared to those who did not require diversion in regard to demographics, surgical procedure, postoperative infliximab, and presence of proctitis (chi square, t tests). Logistic regression was utilized to predict the need for fecal diversion. The number of visits needed to undergo care for this condition was quantified. Eight-one patients underwent a total of 172 surgical procedures and had a total of 2713 outpatient visits (range 1-118) to address symptoms of perineal Crohn's disease. Following first intervention, only 57.1 % healed at 3 months. These rates were highest in patients treated with fistulotomies and were not impacted by whether patients received postoperative infliximab (p = 0.703). Patients (23.5 %) underwent three or more surgical procedures to control their PCD and ultimately only 60 % healed without diversion, which was performed in 19 (23.5 %) patients. Patients undergoing more than three operations (OR = 10.9, p = 0.006) and women with rectovaginal fistula (OR = 3.88, p < 0.01) were at a high risk for diversion. Modifiable factors such as infliximab, smoking, proctitis, and surgery aimed at closing the internal anal opening did not alter outcome. In the patients with perineal Crohn's, complex fistulas healing rates appear to be independent of postoperative infliximab or procedures aimed at closing the internal anal opening. Those who do not heal require numerous specialist visits.