Superficial Fistulotomy for Non-Transsphincteric Fistulae in Perianal Crohn’s Disease: Do They Heal?

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Oscar Hernandez Dominguez, Janell Holloway, Anuradha Bhama, Benjamin L. Cohen, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7376465/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Fistulotomy is highly effective (> 90%) for cryptoglandular fistula-on-ano, but fistulotomy in perianal Crohn’s disease (pCD) is limited due to increased risk of recurrent fistulae, diarrhea, and fecal incontinence. We hypothesized superficial fistulotomy resulted in wound healing in most patients. Method We conducted a single-center retrospective review of adult patients with pCD who underwent fistulotomy from 1999–2022. Baseline characteristics, pCD characteristics, and short- and long-term surgical and functional outcomes were reported. Matched-pair Wilcoxon signed-rank test was used to compare continuous data. Results A total of 43 adult pCD patients underwent fistulotomy and were included: 29 (67.4%) males, age of 34 (28–42) years, and a follow-up time of 4.3 years. Prior interventions included draining setons (48.8%) and partial fistulotomy (17.4%); 25.6% had no prior surgery. Fistulotomies were subcutaneous (65.1%), low transsphincteric (16.3%), intersphincteric (4.7%), and unspecified (14%). Short-term complications included pain (20.9%), bleeding (4.7%), and seepage (2.3% each), and 58.1% of the patients had no complications. Long-term complications included bleeding, keyhole deformity, non-healing wounds, and anal stricture (2.3% each), and 60.5% did not experience long-term complications. At the last follow-up, 41 (95.3%) patients had complete healing of the fistulotomy site. Conclusion Fistulotomy was safe in select patients with fistulizing pCD and superficial fistulas with little or no sphincter involvement. We observed that fistulotomy was associated with wound healing, decreased drainage, and social restrictions in most patients, suggesting that this is a viable and safe option for this at-risk group. Fistulotomy fecal incontinence perianal Crohn’s disease inflammatory bowel disease fistula-in-ano Figures Figure 1 Figure 2 INTRODUCTION Crohn's disease (CD) is a persistent inflammatory condition affecting the gastrointestinal tract, marked by inflammation that may penetrate the intestinal mucosa and anal canal, resulting in complications such as perianal abscesses and fistulae. Many patients with CD suffer from a fistulizing phenotype, and the rate of perianal CD (pCD) varies between 17% and 34% among individuals with CD. 1 , 2 This disease can have an overall detrimental impact on patients’ quality of life (QoL) owing to symptoms such as chronic local pain, discharge, and fecal incontinence. Until recently, clear guidance on pCD therapy in clinical practice has been fragmented, and work by the pCD Treatment Optimization and Classification (TOpCLass) Consortium represents a major advance toward synchronizing clinical practice for fistulizing pCD. 3 , 4 Typically, the first-line medical treatment of pCD includes a combination of antibiotics, biologics, and immunomodulator therapies to alleviate inflammation and facilitate the healing of perianal fistulas. 5 However, medical management alone can lead to a loss of treatment response in up to half of the patients and recurrence of fistulas. 6 Although there have been significant developments in the medical treatment of perianal CD, including stem cell therapy, surgical intervention remains a crucial component of the therapeutic strategy, with most individuals with pCD requiring perianal surgery. 2 Surgical management relies on surgical drainage of abscesses, control of fistulas with seton drains, and subsequent fistula repair after optimization of medical management. It is no longer advisable to rely solely on chronic seton treatment for pCD, therefore other surgical approaches have become increasingly important. 7 Fistulotomy (Fig. 1 ) is an effective treatment option for cryptoglandular-related perianal fistulas; however, special consideration must be given to patients with pCD because of the risk of incontinence in those prone to recurrent fistulae and chronic diarrhea related to intestinal inflammation and loss of small bowel length. Fecal incontinence, which negatively impacts health-related QoL, has been reported in 59% of patients with pCD. 8 , 9 Additionally, aggressive surgical treatment for pCD may increase the risk of incontinence, reported in up to 23% of patients undergoing anorectal surgery for pCD. 9 Other concerns with surgery include wound healing problems and anal stricture. Patients with uncontrolled pCD have a high risk of fistula recurrence, raising concerns that they may require repeated surgical procedures that compromise the anal sphincter or result in anal stenosis. However, more recent studies have reported that patients with pCD can have positive outcomes, such as high healing rates, low recurrence rates, and low risk of incontinence after fistulotomy. As a result, specialists have advocated reconsideration of avoiding these procedures in selected patients with pCD. 10 – 14 Nevertheless, many surgeons continue to avoid fistulotomies in patients with pCD because of the lack of long-term data. Therefore, the long-term effects of fistulotomy on the functionality of patients with pCD should be explored further. Therefore, we performed a retrospective analysis of consecutive adult patients who underwent fistulotomy for pCD and assessed short- and long-term outcomes, such as functionality and incontinence, to determine whether fistulotomy may be safely considered a viable option for select patients with pCD. We hypothesized superficial fistulotomy resulted in wound healing in most patients. METHODS We performed an Institutional Review Board-approved retrospective review of consecutive adult pCD patients who underwent fistulotomy between January 1999 and November 2022 at our center. Patients were identified using International Classification of Diseases (ICD-9 and − 10) codes for CD (555.0 and K-50, respectively) and the common procedural terminology (CPT) codes for fistulotomy (46270, 46275, 46280, and 46285) to identify the index fistulotomy. Patients with anovaginal or rectovaginal fistulae, ulcerative colitis (UC), or indeterminate colitis were excluded. Patients who were first diagnosed with UC and later diagnosed with CD were included. Patients with ileal pouch-anal anastomosis (IPAA) were excluded. Retrospective chart review was used to review clinical notes and collect variables including patient demographics and baseline characteristics, including details regarding date of diagnosis of CD, pCD characteristics, prior treatments and operations, fistula location and characteristics, short ( 30 days) outcomes of fistulotomy, pre- and post-fistulotomy use of immunomodulatory medications, reoperations, and functional outcomes (including incontinence) at the most recent follow-up. If a second fistulotomy was performed, its location and complications were also recorded. Fistulas were categorized according to a modified Parks’ classification (Fig. 2) based on surgical findings and imaging; the modification includes superficial fistulae that do not include any sphincter muscle. 15 Imaging of the fistula included examination under anesthesia (EUA) prior to fistulotomy, magnetic resonance imaging (MRI), endoscopy, and computed tomography (CT). Fistulotomy was broadly categorized based on the operative records of the operating surgeon and the length of the anal sphincter below the internal opening of the fistula. It was categorized as follows: “superficial” if no sphincter muscle was involved, “low fistulotomy” if 10% of the muscles were involved. Patients who underwent partial fistulotomy (i.e. , those in whom the external openings (EO) were not connected to the internal opening (IO) were (designated as partial fistulotomy) or those without IO in the anal canal were excluded. The onset of new symptoms of incontinence to flatus, liquid, or solid stool in the postoperative period after fistulotomy in the absence of diarrhea was used as a marker of functional impairment caused by fistulotomy. Fecal incontinence was extracted from clinic/medical visit notes and chart reviews. Healing of the pCD fistula on the date of the last clinical encounter was defined as a clinical note reporting a healed fistula or a normal perianal examination. Medications were classified as immunomodulators (azathioprine and 6-mercaptopurine), budesonide, or biologic therapies, such as tumor necrosis factor inhibitors (TNFi), including infliximab, adalimumab, certolizumab pegol, and other biologics, including vedolizumab and ustekinumab. Descriptive statistics were computed for all variables, including the mean (standard deviation) or median (interquartile range) for continuous factors and frequency (%) for categorical variables. A matched-pair Wilcoxon signed-rank test was used to compare continuous data. Estimated median group differences were reported with 2- and 1-sided p-values, with p-values < 0.05 considered significant. All analyses were performed using R version 3.1.2 ( www.R-project.org ). RESULTS A total of 43 adult patients with pCD met the inclusion criteria of the study. Demographics and baseline characteristics of the study participants are shown in Table 1 . Twenty-nine patients were men (67.4%); median age at the time of fistulotomy was 34 years (28–42). Eight patients (18.6%) had a family history of CD, and 25 (58.14%) had additional pCD stigmata, including anal fissures (20.9%), skin tags (18.6%), anal ulcers (14%), and anal strictures (2.3%). Patients were diagnosed with CD a median of 7 (IQR, 1-18.5) years before fistulotomy. The predominant fistula symptoms were mucopurulent drainage (74.4%), painful bowel movements (72.1%), and bloody drainage (22%). At the time of fistulotomy, 21 (48.8%) patients were receiving biologics, including infliximab (11.6%), ustekinumab (11.6%), adalimumab (9.3%), vedolizumab (9.3%). Non-biologic monotherapy included mesalamine (7%), budesonide (4.7%), methotrexate (2.3%), and azathioprine (2.3%). Fifteen patients (34.9%) were not receiving medical treatment for CD at the time of fistulotomy. The medical management of pCD before and after fistulotomy was summarized in Table 2 . Patients remained on the same medical management (48.8%), switched agents (16.3%), discontinued all therapies (14%), or initiated therapy (20.9%). The fistula characteristics and fistulotomy details of the treated fistulas are presented in Table 3 . Prior to fistulotomy, surgical treatment of pCD predominantly included incision and drainage (65.1%), loose draining seton placement (51.2%), and partial fistulotomy (25.6%). Twelve patients (27.9%) had no history of prior surgery. Prior surgical treatment of fistulas that underwent fistulotomy included seton placement (48.8%), incision and drainage (46.5%), partial fistulotomy (n = 4, 17.4%), and no surgical treatment (n = 11, 25.6). The duration of the draining seton placement was 5.4 months (IQR, 2.1–14.8) before the fistulotomy. The evaluation of fistulas predominantly included EUA (34.8%) and MRI (30.2%). Eighteen patients (41.9%) had multiple fistulas at the time of fistulotomy. Only two (4.7%) fistulotomies were performed in the anterior midline, while the rest were performed in the posterior midline (27.9%), right laterality (39.5%), or left laterality (28%). The fistulotomies were subcutaneous (65.1%), low transsphincteric (16.3%), low intersphincteric (4.7%), or not specified in the operative report (n = 6, 14%). During a median follow-up time of 4.3 (2-5.6) years after fistulotomy, 25 patients (58.1%) did not have any short-term complications. Short-term complications potentially related to fistulotomy included pain that required additional medical evaluation, such as clinic visits, emergency department visits, and pain prescriptions (n = 9, 20.9%). Additional short-term complications included bleeding (n = 2, 4.7%) and seepage (n = 1, 2.3%). The long-term complications included non-healing wounds (n = 1, 2.3%) and anal strictures (n = 1, 2.3%). Twenty-six patients (60.5%) did not experience any long-term complications. Five (11.6%) patients required at least one additional surgical procedure to address the fistula or fistulotomy sites. One patient (2.3%) continued to have blood/mucopurulent drainage, and one (2.3%) had persistent skin irritation/local dermatitis at the site of the fistulotomy. Almost all patients (n = 41, 95.3%) showed clinical healing of the fistula at last follow-up (Table 4 ). Functional outcomes before and after fistulotomy were not significantly different in terms of nocturnal seepage (2 vs. 0, p = 0.08), nocturnal incontinence (1 vs. 1, p = 0.5), and fecal urgency (3 vs. 1, p = 0.08). Additionally, anal strictures due to fistulotomy were not significantly different between the groups (2 vs. 2, p = 0.92). Fewer patients reported daytime leakage without pad use (3 vs. 0, p = 0.04) and social restrictions (4 vs. 1, p = 0.04) after fistulotomy than before fistulotomy. After fistulotomy, compared to before fistulotomy, more patients reported no functional complaints after fistulotomy: 86% vs. 74%, p = 0.05 (Table 5 ). None of the patients in this series required proctectomy owing to adverse outcomes related to fistulotomy. However, almost half (n = 21, 48.8%) of the patients underwent at least one subsequent surgical procedure for pCD after the index surgery. Table 5 shows that a minority of patients (n = 5, 11.6%) with severe pCD required subsequent fecal diversion owing to the progression of pCD. Other long-term adverse outcomes included wound deformities (n = 3, 7%), strictures (n = 1, 2.3%), and incontinence (n = 1, 2.3%). Nine (20.9%) patients underwent a second superficial fistulotomy and three (7%) underwent a second low fistulotomy. The median time from the index to the second fistulotomy was 9.2 months. The median follow-up interval after the second fistulotomy was 23.1 (7.2, 38.2) months. Complications from the second fistulotomy included non-healing wounds (n = 1, 8.3%), pain (n = 1, 8.3%), and mucopurulent drainage (n = 1, 8.3%). No patient reported incontinence related to the second fistulotomy, and nine patients (75%) were asymptomatic ( Supplementary Table ). DISCUSSION Fistulizing pCD is a challenging condition to treat owing to the recurrent and chronic nature of the disease, which can significantly diminish a patient's QoL. Despite advances in medical management, including the use of biologics, small molecules, and stem cell therapy, surgical intervention remains an important adjunctive treatment option. However, fistulotomy has traditionally been avoided in patients with pCD because of concerns regarding the risk of incontinence in this at-risk patient population. This study demonstrated that primary superficial and low sphincter fistulotomies in select patients with pCD have very low rates of short- and long-term complications, particularly those resulting in permanent sphincter injury, and resulted in improved clinical outcomes and wound healing in 95% of the patients. In our study, we also observed that the functional outcomes after fistulotomy were either similar or improved. We observed no reported worsening of fecal incontinence after the procedure. Although the cohort was small, patients who underwent multiple fistulotomies had similar safety and function-preserving outcomes. This study suggests that fistulotomies in patients with pCD may be safely considered for anal fistulas that are superficial or involve minimal sphincter muscle involvement. Fistulotomy for pCD remains a contentious treatment strategy because of the risk of fecal incontinence and decreased healing time. However, recent studies have indicated that fistulotomy may be effective in certain cases. 14 The Crohn's & Colitis Foundation of America, European Crohn’s and Colitis Organization (ECCO), and American Society of Colon and Rectal Surgeons (ASCRS) suggest that fistulotomy can be a safe and effective treatment for selected low-lying fistulas in pCD. 16 , 17 , 18 Our study corroborates these recommendations, as the fistulotomies in our series demonstrated low short- and long-term complications, no negative long-term functional complications, and high healing rates. A study by Sangwan et al . evaluated 35 patients with Crohn’s who underwent fistulotomy, and none experienced fecal incontinence in the immediate postoperative period as a direct result of the operation. 12 Our study echoes their findings, but we also discovered that incontinence and other functional outcomes did not develop at 4.3 years follow up. Additionally, our study found that fistulotomy was effective, with a 95% clinical fistula healing rate. Our findings agree with recent literature showing fistulotomy for superficial or simple fistulas without proctitis tends to heal well and more effectively than with medical management and conservative seton surgery alone. 6 , 7 , 13 , 14 , 18 – 20 The successful treatment rates achieved in this series were possibly due to the patients receiving a personalized multimodal treatment strategy that included medical therapy to achieve fistula healing and low recurrence. In this study, medical treatment, including biological therapy, was tailored to the individual patient's pCD, which may have improved the fistula healing rates. Approximately 30% of the patients in our study were on TNFi therapy, and another 20% were on other biologics. Recent research has suggested that continuing biological therapy may be beneficial for disease control and facilitate perineal wound healing without increasing postoperative infections. 21 – 24 Studies have suggested that the class of biologic medications may be switched to improve fistula healing and reduce pCD recurrence after fistulotomy. 25 In our study, approximately 20% of patients underwent a change in their biologic medication after fistulotomy. Further studies are necessary to determine whether changing the class of biologic medication is as effective in pCD as it is in colonic diseases. MRI is another potential strategy for individualizing pCD treatments. A retrospective analysis evaluated the predictive value of the degree of fibrosis and disease activity (MAGNIFI-CD index) and showed that post-treatment MRI grading MAGNIFI-CD index was accurate in predicting long-term clinical closure and seems valuable in follow-up of pCD. 26 Recent studies have suggested that MRI should be standardized to measure pCD outcomes in adult and pediatric patients. 27 , 28 In our series, MRI was not standardized and was performed in less than a third of patients and may be related to the ease of access for EUA at our center; however, improving MRI utilization for pCD patients may be an area of further improvement, especially as MRI indices become standardized and comparable between studies. 29 Our results align with recent evidence indicating that fistulotomy requires the coordinated involvement of medical and surgical disciplines in order to provide a thorough assessment and treatment plan tailored to the individual scenario and patient goals. 30 , 31 A critical factor in selecting a suitable treatment for pCD fistulas is a patient's history of prior fistulotomy. Repeated procedures to treat recurrent fistulas in patients with pCD may ultimately harm the sphincter and lead to incontinence. Papaconstantinou et al . reported that patients undergoing fistulotomy should be carefully selected, with a history of previous fistulotomy being a significant consideration to avoid further treatment. 19 However, there is a paucity of literature analyzing the outcomes of patients with pCD after multiple fistulotomies. In our series, 12 patients underwent a second fistulotomy for superficial or low fistula. Complications related to sphincter disturbance were few, with only one patient reporting wound healing disturbances and no patient with incontinence related to the fistulotomy. Although there were no serious complications of a second fistulotomy in our series to justify the absolute avoidance of the procedure, as previously suggested, it must be noted that our series was small, and the follow-up time was only 23 months. However, these patients were carefully selected at an IBD referral center and underwent multidisciplinary evaluation and treatment. The strengths of this study include its sample size, which is larger than that reported thus far, the duration of follow-up, and the functional outcomes. However, our study had some limitations. First, the sample was limited to patients from a single IBD referral center, which may have introduced selection bias in patients referred to the institution. Surgeons selected patients they deemed to be good candidates for fistulotomy based on clinical characteristics and acumen. Second, fistula healing was defined as a documented physical examination of a healed fistula or normal perianal examination. Given the retrospective nature of this study, validated scales or MRI scans were not used to confirm the healing rate, which may have demonstrated the persistence or recurrence of the fistula. Additionally, the study lacked a validated scale for incontinence or functional outcomes, and this information was extracted from outpatient visits. Although this is one of the largest series of fistulotomies in patients with pCD, the number of patients remains small, especially those who underwent preoperative proctitis or a second fistulotomy. This limitation restricted our ability to draw definitive conclusions regarding the outcomes of various medical regimens for treating preoperative proctitis. Almost half of the patients later developed proctitis, all of whom required at least one other pCD-related surgery. However, only one of these patients reported incontinence, which was present even before the index fistulotomy. Ultimately, five patients required diversion, but none required diversion due to incontinence. Additionally, due to the retrospective nature of the study, specific descriptions of the preoperative status of the anal canal were limited. Finally, we did not compare the outcomes between patients with cryptoglandular-related fistulas. Despite these limitations, our study contributes to the ongoing debate regarding the management of pCD with fistulotomy. In conclusion, we observed that patients with non-transsphincteric pCD fistulae may safely undergo careful fistulotomy for superficial or minimal sphincter-involving anal fistulas. Fistulotomy was associated with improved functional outcomes, including less drainage and no fistulotomy-related fecal incontinence, and resulted in wound healing in the majority of patients. These findings suggest that fistulotomy is a viable option and is not contraindicated in carefully selected patients with pCD. Given the risk of recurrence, caution should be exercised when performing perianal surgery for pCD, and patients should be referred to an IBD center when the pathology or optimal management is unclear. Declarations Compliance with Ethical Standards Conflict of Interest: The authors declare no conflicts of interest. Author SH receives research funding from the Crohn's & Colitis Foundation and American Society of Colon and Rectal Surgeons. The remaining authors have no conflicts of interest to disclose or funding. Ethics Approval This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Cleveland Clinic approved this study. Consent to participate Informed consent is not required as retrospective chart review was anonymized, and the submission does not include images that may identify the person. Funding This study received no specific funding. Originality : This study is original, written without the use of generative AI, has not been published elsewhere, and was presented at the American Society of Colon and Rectal Surgeons Annual Scientific Meeting on June 1–4, 2024, Baltimore, MD, USA. AI : During the preparation of this work, the author used PaperPal to proofread the grammar and punctuation. After using this tool/service, the author(s) reviewed and edited the content as needed and took full responsibility for the publication’s content. Author Contribution O.HD, J.H and S.H wrote the main manuscript text. O.HD., S.H., B.C., were responsible for conceptualization. O.HD., and J.H. were responsible for data curation. B.J., L.D., A.K., O.L., J.L., and S.H validated, analyzed data, and reviewed and edited manuscript. Acknowledgement The authors are grateful to our Cleveland Clinic Medical Illustrator Joseph Pangrace BFA, CMI, for his expertise and contribution of new artwork contained in this article. 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Systematic Review and Meta-Analysis: Preoperative Vedolizumab and Postoperative Complications in Patients with IBD. Southern Medical Journal . 2021;114:98–105. Bachour SP, Shah RS, Joseph A, et al. Change in Biologic Class Promotes Endoscopic Remission Following Endoscopic Postoperative Crohn’s Disease Recurrence. J Clin Gastroenterol .. Epub ahead of print November 27, 2023. DOI: 10.1097/mcg.0000000000001943 . Van Rijn KL, Meima-Van Praag EM, Bossuyt PM, et al. Fibrosis and MAGNIFI-CD Activity Index at Magnetic Resonance Imaging to Predict Treatment Outcome in Perianal Fistulizing Crohn’s Disease Patients. J Crohn’s Colitis . 2022;16:708–716. Richard N, Derinck A, Bridoux V, et al. Which magnetic resonance imaging feature is associated with treatment response in perianal fistulizing Crohn’s disease? Abdom Radiol .. Epub ahead of print 2024. DOI: 10.1007/s00261-024-04238-3 . Crowley E, Ma C, Guizzetti L, et al. Recommendations for Standardizing MRI-based Evaluation of Perianal Fistulizing Disease Activity in Pediatric Crohn’s Disease Clinical Trials. Inflamm Bowel Dis . 2024;30:357–369. Vuyyuru SK, Solitano V, Singh S, et al. Scoring Indices for Perianal Fistulising Crohn’s Disease: A Systematic Review. J Crohn’s Colitis .. Epub ahead of print 2023. DOI: 10.1093/ecco-jcc/jjad214 . Geldof J, Iqbal N, Warusavitarne J, et al. The Essential Role of a Multidisciplinary Approach in Inflammatory Bowel Diseases: The Essential Role of a Multidisciplinary Approach in Inflammatory Bowel Diseases: Combined Medical-Surgical Treatment in Complex Perianal Fistulas in CD. Clin Colon Rectal Surg . 2022;35:21. Kotze PG, Shen B, Lightner A, et al. Modern management of perianal fistulas in Crohn’s disease: Future directions. Gut . 2018;67:1181–1194. Tables Table 1. Patient demographics and baseline characteristics (N=43). Variable N=43 (100%) Males 29 (67.4%) BMI, kg/m 2 24.3 (21.7 - 30.1) Age at fistulotomy, years 34 (28 - 42) CD diagnosis to pCD diagnosis, years 1 (0 - 10.5) CD diagnosis to fistulotomy, years 7 (1 - 18.5) Diagnosis changed from UC to CD 3 (7.0%) Comorbidities None Obesity Depression/anxiety Smoker Hypertension Diabetes mellitus Venous thromboembolism Cancer, any Coronary artery disease Congestive heart failure Chronic obstructive pulmonary disease 16 (37.2%) 10 (23.3%) 9 (20.9%) 5 (11.6%) 5 (11.6%) 3 (7.0%) 2 (4.7%) 2 (4.7%) 1 (2.3%) 1 (2.3%) 1 (2.3%) Family History of IBD Crohn’s disease Ulcerative colitis 8 (18.6%) 1 (2.3%) Other pCD stigmata Anal fissure Skin tag Anal ulcer Anal stricture 9 (20.9%) 8 (18.6%) 6 (14.0%) 2 (2.3%) Preoperative fistula symptoms Mucopurulent drainage Pain with bowel movements Bloody drainage Skin dermatitis/irritation Fever Stool drainage 32 (74.4%) 31 (72.1%) 10 (23.3%) 7 (16.3%) 3 (7.0%) 2 (4.7%) Surgical Treatment of prior pCD Abscess incision and drainage Loose seton Partial fistulotomy Cutting seton Fistula plug LIFT ERAF Fibrin glue No prior surgery 28 (65.1%) 22 (51.2%) 11 (25.6%) 2 (4.7%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 12 (27.9%) Data are presented as frequency (proportion) or median (interquartile range). BMI: Body mass index; CD: Crohn’s disease; UC: ulcerative colitis; pCD: perianal CD; ERAF: endorectal advancement flap; LIFT: Ligation of intersphincteric fistula. Table 2 . Medical therapy for pCD at the time of and after fistulotomy (N=43). Variable Before After Biologics No biologic Any Infliximab Ustekinumab Adalimumab Vedolizumab Upadacitinib 22 (51.2%) 21 (48.8%) 5 (11.6%) 5 (11.6%) 4 (9.3%) 4 (9.3%) 0 (0.0%) 15 (34.9%) 28 (65.1%) 5 (11.6%) 7 (16.3%) 6 (14.0%) 3 (7.0%) 1 (2.3%) Non-biologic medical therapy Mesalamine Budesonide Methotrexate Azathioprine 3 (7.0%) 2 (4.7%) 1 (2.3%) 1 (2.3%) 2 (4.7%) 0 (0.0%) 0 (0.0%) 1 (2.3%) Combined medical therapy Infliximab + 6-MP Adalimumab + 6-MP Infliximab + Sulfasalazine Infliximab + Azathioprine Infliximab + Mesalamine 1 (2.3%) 1 (2.3%) 1 (2.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.3%) 2 (4.7%) Same medical management - 21 (48.8%) Switched agents - 7 (16.3%) Discontinued all therapy - 6 (14.0%) Initiated therapy - 9 (20.9%) Data are presented as frequency (proportion). 6-MP: 6-mercaptopurine. Table 3. Index fistula evaluation and treatment details (N=43). Variable N=43 (100%) Fistula treatment prior to fistulotomy, same fistula Medical Seton Incision and drainage Partial fistulotomy No treatment 28 (65.1%) 21 (48.8%) 20 (46.5%) 4 (17.4%) 11 (25.6%) Seton to Fistulotomy, months (n=21) 5.4 (2.1;14.8) Location of Seton Placement (n=21) Transsphincteric Intersphincteric Submuscular, not specified Not specified 6 (14.0%) 4 (17.4%) 1 (2.3%) 10 (23.3%) Work-up of Fistula Exam under anesthesia Magnetic resonance imaging Computed tomography Colonoscopy 15 (34.8%) 13 (30.2%) 4 (17.4%) 2 (4.7%) Fistula Internal Opening Distal to dentate Anal verge Dentate Not specified 19 (44.2%) 6 (14.0%) 5 (11.6%) 13 (30.2%) Fistulotomy Location Posterolateral Anterolateral Posterior midline Anterior midline 15 (34.8%) 14 (32.5%) 12 (27.9%) 2 (4.7%) Multiple Fistulas 18 (41.9%) Fistulotomy Type Superficial/Subcutaneous Low Fistulotomy (<10% muscle fibers) Any external anal sphincter divided Submuscular, sphincter not specified Internal anal sphincter divided 28 (65.1%) 15 (34.8%) 7 (16.3%) 6 (14.0%) 2 (4.7%) Fistulotomy to last follow up, years 4.3 (2.0 - 5.9) Data are presented as frequency (proportion) or median (interquartile range). Table 4 . Short (30-day) outcomes after fistulotomy, N=43. Fistulotomy Complications Short-term N=43 (%) Long-term N=43 (%) None 25 (58.1%) 26 (60.5%) Any 18 (41.9%) 17 (39.5%) Bleeding 2 (4.7%) 1 (2.3%) Keyhole deformity 0 (0.0%) 1 (2.3%) Non-healing wounds 0 (0.0%) 1 (2.3%) Pain 9 (20.9%) 5 (11.6%) Mucopurulent Drainage 6 (14.0%) 5 (11.6%) Seepage 1 (2.3%) 0 (0.0%) Fecal diversion 0 (0.0%) 0 (0.0%) Stricture 0 (0.0%) 1 (2.3%) Recurrence of abscess 0 (0.0%) 3 (7.0%) Incontinence 0 (0.0%) 0 (0.0%) Re-operation on same fistula Once 0 (0.0%) 3 (7.0%) Multiple 0 (0.0%) 2 (4.7%) Fistulotomy healing at last follow-up 41 (95.3%) Symptoms: Bloody drainage - 1 (2.3%) Symptoms: Skin irritation/dermatitis - 1 (2.3%) Other pCD related surgeries post-fistulotomy 1 2 3+ - - - 7 (16.3%) 6 (14.0%) 8 (18.6%) Crohn’s proctitis and/or treatment complication Non-healing wounds Fecal diversion Stricture Incontinence - - - - 2 (4.7%) 5 (11.6%) 1 (2.3%) 1 (2.3%) Data are presented as frequency (proportion) or median (IQR). Table 5. Functional outcomes and anal stricture before and after index fistulotomy (N = 43) Variable Before fistulotomy After fistulotomy p-value No complaints 32 (74.4%) 37 (86.0%) 0.05 Day Fecal incontinence 0 (0.0%) 0 (0.0%) -- Night leakage 2 (4.7%) 0 (0.0%) 0.08 Night incontinence 1 (2.3%) 1 (2.3%) 0.5 Day leakage with pad use 1 (2.3%) 1 (2.3%) 0.5 Day leakage w/o pad use 3 (7.0%) 0 (0.0%) 0.04 Fecal urgency 3 (7.0%) 1 (2.3%) 0.08 Social restrictions due to function 4 (9.3%) 1 (2.3%) 0.04 Anal stricture 2 (4.7%) 2 (4.7%) 0.92 Data are presented as frequency (proportion). Additional Declarations No competing interests reported. Supplementary Files SupplementalTable.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Nov, 2025 Reviews received at journal 30 Oct, 2025 Reviews received at journal 22 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviewers invited by journal 05 Sep, 2025 Editor assigned by journal 21 Aug, 2025 Submission checks completed at journal 16 Aug, 2025 First submitted to journal 14 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7376465","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":510915961,"identity":"2fdd2373-bd6e-4928-a469-23edd0f59a79","order_by":0,"name":"Oscar Hernandez Dominguez","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Oscar","middleName":"Hernandez","lastName":"Dominguez","suffix":""},{"id":510915962,"identity":"fbbdd47f-7587-4201-9c70-b9b84baa6cdd","order_by":1,"name":"Janell Holloway","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Janell","middleName":"","lastName":"Holloway","suffix":""},{"id":510915963,"identity":"c4cbbeda-27cc-4a38-9abc-ea2975efee35","order_by":2,"name":"Anuradha Bhama","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Anuradha","middleName":"","lastName":"Bhama","suffix":""},{"id":510915964,"identity":"2c895f44-6a90-4879-be98-94c31840c25c","order_by":3,"name":"Benjamin L. Cohen","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"L.","lastName":"Cohen","suffix":""},{"id":510915965,"identity":"3f08a811-e156-48b9-9c48-dfc2707d82d5","order_by":4,"name":"Leonardo Duraes","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Leonardo","middleName":"","lastName":"Duraes","suffix":""},{"id":510915966,"identity":"3b013a9f-b01d-43ae-b7e9-8ab06a4e2a01","order_by":5,"name":"Arielle Kanters","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Arielle","middleName":"","lastName":"Kanters","suffix":""},{"id":510915967,"identity":"6bd31e5b-7b17-44d9-ae4c-176358031680","order_by":6,"name":"Olga Lavryk","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Olga","middleName":"","lastName":"Lavryk","suffix":""},{"id":510915968,"identity":"d35b53e1-1fbc-4a69-b8c5-2cae91de48fa","order_by":7,"name":"Jeremy Lipman","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"Jeremy","middleName":"","lastName":"Lipman","suffix":""},{"id":510915969,"identity":"5181020a-15bb-4657-841e-169e910e308f","order_by":8,"name":"David Liska","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Liska","suffix":""},{"id":510915970,"identity":"03253958-de4a-47c1-8e3d-dc651fed6b0c","order_by":9,"name":"Stefan D. Holubar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAs0lEQVRIiWNgGAWjYBACAwbmBmYgLcfAwPiAWC2MYC3GDAzMBqRpSWwgWos5e2ObdEFNXXp/+2EGho97aglrsew52CY949jh3BlnkhkYZzw7ToTDbiS2SfOwHcjdIMF/gJnnwDFitfyrSzeQYGYgQQtvG3MCVEsNEVrOHGy2ntl32BDkl4MzDhwgQsvx5oO3C77VyfO3H2Z88OFAHWEtKABoxWEStQABqbaMglEwCkbBSAAApYE6KvMsqIEAAAAASUVORK5CYII=","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":true,"prefix":"","firstName":"Stefan","middleName":"D.","lastName":"Holubar","suffix":""}],"badges":[],"createdAt":"2025-08-14 19:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7376465/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7376465/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91109169,"identity":"d4b5957d-8b2e-46da-9bba-ea5eaf8d1c88","added_by":"auto","created_at":"2025-09-11 16:06:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":413805,"visible":true,"origin":"","legend":"\u003cp\u003eFistulotomy. The left panel depicts cauterization of anal sphincter muscle fibers for transphincteric and intersphincteric fistulas. The right panel depicts superficial fistulotomy of subcutaneous fistula.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7376465/v1/f19c096dd69a607921b46988.png"},{"id":91109175,"identity":"c3c43a85-70d8-48c7-8c95-1848b78680b0","added_by":"auto","created_at":"2025-09-11 16:06:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":407676,"visible":true,"origin":"","legend":"\u003cp\u003eModified Park classification of perianal fistulae.\u003c/p\u003e\n\u003cp\u003efootnotes: A, intersphincteric and superficial subcutaneous fistula.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7376465/v1/64656b5f388a18c470b9a569.png"},{"id":91111471,"identity":"3f84b065-59ef-4e0f-91ff-db3608ced49f","added_by":"auto","created_at":"2025-09-11 16:30:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1999098,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7376465/v1/f42f46b2-76bf-4644-9b1c-b74a86e7567e.pdf"},{"id":91109170,"identity":"6b4c1e57-ce8a-4a42-9f49-da3462153fde","added_by":"auto","created_at":"2025-09-11 16:06:37","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15001,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-7376465/v1/407e9d3c82211a7935273731.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Superficial Fistulotomy for Non-Transsphincteric Fistulae in Perianal Crohn’s Disease: Do They Heal?","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCrohn's disease (CD) is a persistent inflammatory condition affecting the gastrointestinal tract, marked by inflammation that may penetrate the intestinal mucosa and anal canal, resulting in complications such as perianal abscesses and fistulae. Many patients with CD suffer from a fistulizing phenotype, and the rate of perianal CD (pCD) varies between 17% and 34% among individuals with CD.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e This disease can have an overall detrimental impact on patients\u0026rsquo; quality of life (QoL) owing to symptoms such as chronic local pain, discharge, and fecal incontinence.\u003c/p\u003e\u003cp\u003eUntil recently, clear guidance on pCD therapy in clinical practice has been fragmented, and work by the pCD Treatment Optimization and Classification (TOpCLass) Consortium represents a major advance toward synchronizing clinical practice for fistulizing pCD.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Typically, the first-line medical treatment of pCD includes a combination of antibiotics, biologics, and immunomodulator therapies to alleviate inflammation and facilitate the healing of perianal fistulas.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, medical management alone can lead to a loss of treatment response in up to half of the patients and recurrence of fistulas.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Although there have been significant developments in the medical treatment of perianal CD, including stem cell therapy, surgical intervention remains a crucial component of the therapeutic strategy, with most individuals with pCD requiring perianal surgery.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Surgical management relies on surgical drainage of abscesses, control of fistulas with seton drains, and subsequent fistula repair after optimization of medical management. It is no longer advisable to rely solely on chronic seton treatment for pCD, therefore other surgical approaches have become increasingly important.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFistulotomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) is an effective treatment option for cryptoglandular-related perianal fistulas; however, special consideration must be given to patients with pCD because of the risk of incontinence in those prone to recurrent fistulae and chronic diarrhea related to intestinal inflammation and loss of small bowel length. Fecal incontinence, which negatively impacts health-related QoL, has been reported in 59% of patients with pCD.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Additionally, aggressive surgical treatment for pCD may increase the risk of incontinence, reported in up to 23% of patients undergoing anorectal surgery for pCD.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Other concerns with surgery include wound healing problems and anal stricture. Patients with uncontrolled pCD have a high risk of fistula recurrence, raising concerns that they may require repeated surgical procedures that compromise the anal sphincter or result in anal stenosis. However, more recent studies have reported that patients with pCD can have positive outcomes, such as high healing rates, low recurrence rates, and low risk of incontinence after fistulotomy. As a result, specialists have advocated reconsideration of avoiding these procedures in selected patients with pCD.\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Nevertheless, many surgeons continue to avoid fistulotomies in patients with pCD because of the lack of long-term data. Therefore, the long-term effects of fistulotomy on the functionality of patients with pCD should be explored further.\u003c/p\u003e\u003cp\u003eTherefore, we performed a retrospective analysis of consecutive adult patients who underwent fistulotomy for pCD and assessed short- and long-term outcomes, such as functionality and incontinence, to determine whether fistulotomy may be safely considered a viable option for select patients with pCD. We hypothesized superficial fistulotomy resulted in wound healing in most patients.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e We performed an Institutional Review Board-approved retrospective review of consecutive adult pCD patients who underwent fistulotomy between January 1999 and November 2022 at our center. Patients were identified using International Classification of Diseases (ICD-9 and \u0026minus;\u0026thinsp;10) codes for CD (555.0 and K-50, respectively) and the common procedural terminology (CPT) codes for fistulotomy (46270, 46275, 46280, and 46285) to identify the index fistulotomy. Patients with anovaginal or rectovaginal fistulae, ulcerative colitis (UC), or indeterminate colitis were excluded. Patients who were first diagnosed with UC and later diagnosed with CD were included. Patients with ileal pouch-anal anastomosis (IPAA) were excluded.\u003c/p\u003e\u003cp\u003eRetrospective chart review was used to review clinical notes and collect variables including patient demographics and baseline characteristics, including details regarding date of diagnosis of CD, pCD characteristics, prior treatments and operations, fistula location and characteristics, short (\u0026lt;\u0026thinsp;30 days) and long-term (\u0026gt;\u0026thinsp;30 days) outcomes of fistulotomy, pre- and post-fistulotomy use of immunomodulatory medications, reoperations, and functional outcomes (including incontinence) at the most recent follow-up. If a second fistulotomy was performed, its location and complications were also recorded.\u003c/p\u003e\u003cp\u003eFistulas were categorized according to a modified Parks\u0026rsquo; classification (Fig.\u0026nbsp;2) based on surgical findings and imaging; the modification includes superficial fistulae that do not include any sphincter muscle.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Imaging of the fistula included examination under anesthesia (EUA) prior to fistulotomy, magnetic resonance imaging (MRI), endoscopy, and computed tomography (CT). Fistulotomy was broadly categorized based on the operative records of the operating surgeon and the length of the anal sphincter below the internal opening of the fistula. It was categorized as follows: \u0026ldquo;superficial\u0026rdquo; if no sphincter muscle was involved, \u0026ldquo;low fistulotomy\u0026rdquo; if\u0026thinsp;\u0026lt;\u0026thinsp;10% of muscles were involved, and \u0026ldquo;high fistulotomy\u0026rdquo; if\u0026thinsp;\u0026gt;\u0026thinsp;10% of the muscles were involved. Patients who underwent partial fistulotomy \u003cem\u003e(i.e.\u003c/em\u003e, those in whom the external openings (EO) were not connected to the internal opening (IO) were (designated as partial fistulotomy) or those without IO in the anal canal were excluded.\u003c/p\u003e\u003cp\u003eThe onset of new symptoms of incontinence to flatus, liquid, or solid stool in the postoperative period after fistulotomy in the absence of diarrhea was used as a marker of functional impairment caused by fistulotomy. Fecal incontinence was extracted from clinic/medical visit notes and chart reviews. Healing of the pCD fistula on the date of the last clinical encounter was defined as a clinical note reporting a healed fistula or a normal perianal examination. Medications were classified as immunomodulators (azathioprine and 6-mercaptopurine), budesonide, or biologic therapies, such as tumor necrosis factor inhibitors (TNFi), including infliximab, adalimumab, certolizumab pegol, and other biologics, including vedolizumab and ustekinumab.\u003c/p\u003e\u003cp\u003eDescriptive statistics were computed for all variables, including the mean (standard deviation) or median (interquartile range) for continuous factors and frequency (%) for categorical variables. A matched-pair Wilcoxon signed-rank test was used to compare continuous data. Estimated median group differences were reported with 2- and 1-sided p-values, with p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant. All analyses were performed using R version 3.1.2 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.R-project.org\" target=\"_blank\"\u003ewww.R-project.org\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.R-project.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 43 adult patients with pCD met the inclusion criteria of the study. Demographics and baseline characteristics of the study participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Twenty-nine patients were men (67.4%); median age at the time of fistulotomy was 34 years (28\u0026ndash;42). Eight patients (18.6%) had a family history of CD, and 25 (58.14%) had additional pCD stigmata, including anal fissures (20.9%), skin tags (18.6%), anal ulcers (14%), and anal strictures (2.3%). Patients were diagnosed with CD a median of 7 (IQR, 1-18.5) years before fistulotomy. The predominant fistula symptoms were mucopurulent drainage (74.4%), painful bowel movements (72.1%), and bloody drainage (22%). At the time of fistulotomy, 21 (48.8%) patients were receiving biologics, including infliximab (11.6%), ustekinumab (11.6%), adalimumab (9.3%), vedolizumab (9.3%). Non-biologic monotherapy included mesalamine (7%), budesonide (4.7%), methotrexate (2.3%), and azathioprine (2.3%). Fifteen patients (34.9%) were not receiving medical treatment for CD at the time of fistulotomy. The medical management of pCD before and after fistulotomy was summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Patients remained on the same medical management (48.8%), switched agents (16.3%), discontinued all therapies (14%), or initiated therapy (20.9%).\u003c/p\u003e\u003cp\u003eThe fistula characteristics and fistulotomy details of the treated fistulas are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Prior to fistulotomy, surgical treatment of pCD predominantly included incision and drainage (65.1%), loose draining seton placement (51.2%), and partial fistulotomy (25.6%). Twelve patients (27.9%) had no history of prior surgery. Prior surgical treatment of fistulas that underwent fistulotomy included seton placement (48.8%), incision and drainage (46.5%), partial fistulotomy (n\u0026thinsp;=\u0026thinsp;4, 17.4%), and no surgical treatment (n\u0026thinsp;=\u0026thinsp;11, 25.6). The duration of the draining seton placement was 5.4 months (IQR, 2.1\u0026ndash;14.8) before the fistulotomy. The evaluation of fistulas predominantly included EUA (34.8%) and MRI (30.2%). Eighteen patients (41.9%) had multiple fistulas at the time of fistulotomy. Only two (4.7%) fistulotomies were performed in the anterior midline, while the rest were performed in the posterior midline (27.9%), right laterality (39.5%), or left laterality (28%). The fistulotomies were subcutaneous (65.1%), low transsphincteric (16.3%), low intersphincteric (4.7%), or not specified in the operative report (n\u0026thinsp;=\u0026thinsp;6, 14%).\u003c/p\u003e\u003cp\u003eDuring a median follow-up time of 4.3 (2-5.6) years after fistulotomy, 25 patients (58.1%) did not have any short-term complications. Short-term complications potentially related to fistulotomy included pain that required additional medical evaluation, such as clinic visits, emergency department visits, and pain prescriptions (n\u0026thinsp;=\u0026thinsp;9, 20.9%). Additional short-term complications included bleeding (n\u0026thinsp;=\u0026thinsp;2, 4.7%) and seepage (n\u0026thinsp;=\u0026thinsp;1, 2.3%). The long-term complications included non-healing wounds (n\u0026thinsp;=\u0026thinsp;1, 2.3%) and anal strictures (n\u0026thinsp;=\u0026thinsp;1, 2.3%). Twenty-six patients (60.5%) did not experience any long-term complications. Five (11.6%) patients required at least one additional surgical procedure to address the fistula or fistulotomy sites. One patient (2.3%) continued to have blood/mucopurulent drainage, and one (2.3%) had persistent skin irritation/local dermatitis at the site of the fistulotomy. Almost all patients (n\u0026thinsp;=\u0026thinsp;41, 95.3%) showed clinical healing of the fistula at last follow-up (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFunctional outcomes before and after fistulotomy were not significantly different in terms of nocturnal seepage (2 vs. 0, p\u0026thinsp;=\u0026thinsp;0.08), nocturnal incontinence (1 vs. 1, p\u0026thinsp;=\u0026thinsp;0.5), and fecal urgency (3 vs. 1, p\u0026thinsp;=\u0026thinsp;0.08). Additionally, anal strictures due to fistulotomy were not significantly different between the groups (2 vs. 2, p\u0026thinsp;=\u0026thinsp;0.92). Fewer patients reported daytime leakage without pad use (3 vs. 0, p\u0026thinsp;=\u0026thinsp;0.04) and social restrictions (4 vs. 1, p\u0026thinsp;=\u0026thinsp;0.04) after fistulotomy than before fistulotomy. After fistulotomy, compared to before fistulotomy, more patients reported no functional complaints after fistulotomy: 86% vs. 74%, p\u0026thinsp;=\u0026thinsp;0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNone of the patients in this series required proctectomy owing to adverse outcomes related to fistulotomy. However, almost half (n\u0026thinsp;=\u0026thinsp;21, 48.8%) of the patients underwent at least one subsequent surgical procedure for pCD after the index surgery. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows that a minority of patients (n\u0026thinsp;=\u0026thinsp;5, 11.6%) with severe pCD required subsequent fecal diversion owing to the progression of pCD. Other long-term adverse outcomes included wound deformities (n\u0026thinsp;=\u0026thinsp;3, 7%), strictures (n\u0026thinsp;=\u0026thinsp;1, 2.3%), and incontinence (n\u0026thinsp;=\u0026thinsp;1, 2.3%). Nine (20.9%) patients underwent a second superficial fistulotomy and three (7%) underwent a second low fistulotomy. The median time from the index to the second fistulotomy was 9.2 months. The median follow-up interval after the second fistulotomy was 23.1 (7.2, 38.2) months. Complications from the second fistulotomy included non-healing wounds (n\u0026thinsp;=\u0026thinsp;1, 8.3%), pain (n\u0026thinsp;=\u0026thinsp;1, 8.3%), and mucopurulent drainage (n\u0026thinsp;=\u0026thinsp;1, 8.3%). No patient reported incontinence related to the second fistulotomy, and nine patients (75%) were asymptomatic (\u003cb\u003eSupplementary Table\u003c/b\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFistulizing pCD is a challenging condition to treat owing to the recurrent and chronic nature of the disease, which can significantly diminish a patient's QoL. Despite advances in medical management, including the use of biologics, small molecules, and stem cell therapy, surgical intervention remains an important adjunctive treatment option. However, fistulotomy has traditionally been avoided in patients with pCD because of concerns regarding the risk of incontinence in this at-risk patient population. This study demonstrated that primary superficial and low sphincter fistulotomies in select patients with pCD have very low rates of short- and long-term complications, particularly those resulting in permanent sphincter injury, and resulted in improved clinical outcomes and wound healing in 95% of the patients.\u003c/p\u003e\u003cp\u003eIn our study, we also observed that the functional outcomes after fistulotomy were either similar or improved. We observed no reported worsening of fecal incontinence after the procedure. Although the cohort was small, patients who underwent multiple fistulotomies had similar safety and function-preserving outcomes. This study suggests that fistulotomies in patients with pCD may be safely considered for anal fistulas that are superficial or involve minimal sphincter muscle involvement.\u003c/p\u003e\u003cp\u003eFistulotomy for pCD remains a contentious treatment strategy because of the risk of fecal incontinence and decreased healing time. However, recent studies have indicated that fistulotomy may be effective in certain cases.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The Crohn's \u0026amp; Colitis Foundation of America, European Crohn\u0026rsquo;s and Colitis Organization (ECCO), and American Society of Colon and Rectal Surgeons (ASCRS) suggest that fistulotomy can be a safe and effective treatment for selected low-lying fistulas in pCD.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Our study corroborates these recommendations, as the fistulotomies in our series demonstrated low short- and long-term complications, no negative long-term functional complications, and high healing rates.\u003c/p\u003e\u003cp\u003eA study by Sangwan \u003cem\u003eet al\u003c/em\u003e. evaluated 35 patients with Crohn\u0026rsquo;s who underwent fistulotomy, and none experienced fecal incontinence in the immediate postoperative period as a direct result of the operation.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Our study echoes their findings, but we also discovered that incontinence and other functional outcomes did not develop at 4.3 years follow up. Additionally, our study found that fistulotomy was effective, with a 95% clinical fistula healing rate. Our findings agree with recent literature showing fistulotomy for superficial or simple fistulas without proctitis tends to heal well and more effectively than with medical management and conservative seton surgery alone.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe successful treatment rates achieved in this series were possibly due to the patients receiving a personalized multimodal treatment strategy that included medical therapy to achieve fistula healing and low recurrence. In this study, medical treatment, including biological therapy, was tailored to the individual patient's pCD, which may have improved the fistula healing rates. Approximately 30% of the patients in our study were on TNFi therapy, and another 20% were on other biologics. Recent research has suggested that continuing biological therapy may be beneficial for disease control and facilitate perineal wound healing without increasing postoperative infections.\u003csup\u003e\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Studies have suggested that the class of biologic medications may be switched to improve fistula healing and reduce pCD recurrence after fistulotomy.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e In our study, approximately 20% of patients underwent a change in their biologic medication after fistulotomy. Further studies are necessary to determine whether changing the class of biologic medication is as effective in pCD as it is in colonic diseases.\u003c/p\u003e\u003cp\u003eMRI is another potential strategy for individualizing pCD treatments. A retrospective analysis evaluated the predictive value of the degree of fibrosis and disease activity (MAGNIFI-CD index) and showed that post-treatment MRI grading MAGNIFI-CD index was accurate in predicting long-term clinical closure and seems valuable in follow-up of pCD.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Recent studies have suggested that MRI should be standardized to measure pCD outcomes in adult and pediatric patients.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e In our series, MRI was not standardized and was performed in less than a third of patients and may be related to the ease of access for EUA at our center; however, improving MRI utilization for pCD patients may be an area of further improvement, especially as MRI indices become standardized and comparable between studies.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Our results align with recent evidence indicating that fistulotomy requires the coordinated involvement of medical and surgical disciplines in order to provide a thorough assessment and treatment plan tailored to the individual scenario and patient goals.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA critical factor in selecting a suitable treatment for pCD fistulas is a patient's history of prior fistulotomy. Repeated procedures to treat recurrent fistulas in patients with pCD may ultimately harm the sphincter and lead to incontinence. Papaconstantinou \u003cem\u003eet al\u003c/em\u003e. reported that patients undergoing fistulotomy should be carefully selected, with a history of previous fistulotomy being a significant consideration to avoid further treatment.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e However, there is a paucity of literature analyzing the outcomes of patients with pCD after multiple fistulotomies. In our series, 12 patients underwent a second fistulotomy for superficial or low fistula. Complications related to sphincter disturbance were few, with only one patient reporting wound healing disturbances and no patient with incontinence related to the fistulotomy. Although there were no serious complications of a second fistulotomy in our series to justify the absolute avoidance of the procedure, as previously suggested, it must be noted that our series was small, and the follow-up time was only 23 months. However, these patients were carefully selected at an IBD referral center and underwent multidisciplinary evaluation and treatment.\u003c/p\u003e\u003cp\u003eThe strengths of this study include its sample size, which is larger than that reported thus far, the duration of follow-up, and the functional outcomes. However, our study had some limitations. First, the sample was limited to patients from a single IBD referral center, which may have introduced selection bias in patients referred to the institution. Surgeons selected patients they deemed to be good candidates for fistulotomy based on clinical characteristics and acumen. Second, fistula healing was defined as a documented physical examination of a healed fistula or normal perianal examination. Given the retrospective nature of this study, validated scales or MRI scans were not used to confirm the healing rate, which may have demonstrated the persistence or recurrence of the fistula. Additionally, the study lacked a validated scale for incontinence or functional outcomes, and this information was extracted from outpatient visits. Although this is one of the largest series of fistulotomies in patients with pCD, the number of patients remains small, especially those who underwent preoperative proctitis or a second fistulotomy. This limitation restricted our ability to draw definitive conclusions regarding the outcomes of various medical regimens for treating preoperative proctitis. Almost half of the patients later developed proctitis, all of whom required at least one other pCD-related surgery. However, only one of these patients reported incontinence, which was present even before the index fistulotomy. Ultimately, five patients required diversion, but none required diversion due to incontinence. Additionally, due to the retrospective nature of the study, specific descriptions of the preoperative status of the anal canal were limited. Finally, we did not compare the outcomes between patients with cryptoglandular-related fistulas. Despite these limitations, our study contributes to the ongoing debate regarding the management of pCD with fistulotomy.\u003c/p\u003e\u003cp\u003eIn conclusion, we observed that patients with non-transsphincteric pCD fistulae may safely undergo careful fistulotomy for superficial or minimal sphincter-involving anal fistulas. Fistulotomy was associated with improved functional outcomes, including less drainage and no fistulotomy-related fecal incontinence, and resulted in wound healing in the majority of patients. These findings suggest that fistulotomy is a viable option and is not contraindicated in carefully selected patients with pCD. Given the risk of recurrence, caution should be exercised when performing perianal surgery for pCD, and patients should be referred to an IBD center when the pathology or optimal management is unclear.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompliance with Ethical Standards\u003c/h2\u003e\n\u003cp\u003eConflict of Interest: The authors declare no conflicts of interest. Author SH receives research funding from the Crohn\u0026apos;s \u0026amp; Colitis Foundation and American Society of Colon and Rectal Surgeons. The remaining authors have no conflicts of interest to disclose or funding.\u003c/p\u003e\n\u003ch2\u003eEthics Approval\u003c/h2\u003e\n\u003cp\u003eThis retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Cleveland Clinic approved this study.\u003c/p\u003e\n\u003ch2\u003eConsent to participate\u003c/h2\u003e\n\u003cp\u003eInformed consent is not required as retrospective chart review was anonymized, and the submission does not include images that may identify the person.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study received no specific funding.\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOriginality\u003c/span\u003e: This study is original, written without the use of generative AI, has not been published elsewhere, and was presented at the American Society of Colon and Rectal Surgeons Annual Scientific Meeting on June 1\u0026ndash;4, 2024, Baltimore, MD, USA.\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAI\u003c/span\u003e: During the preparation of this work, the author used PaperPal to proofread the grammar and punctuation. After using this tool/service, the author(s) reviewed and edited the content as needed and took full responsibility for the publication\u0026rsquo;s content.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eO.HD, J.H and S.H wrote the main manuscript text. O.HD., S.H., B.C., were responsible for conceptualization. O.HD., and J.H. were responsible for data curation. B.J., L.D., A.K., O.L., J.L., and S.H validated, analyzed data, and reviewed and edited manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors are grateful to our Cleveland Clinic Medical Illustrator Joseph Pangrace BFA, CMI, for his expertise and contribution of new artwork contained in this article.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data used in this study are not publicly available but can be provided upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchwartz DA, Loftus E V, Tremaine WJ, et al. The natural history of fistulizing Crohn\u0026rsquo;s disease in Olmsted County, Minnesota. \u003cem\u003eGastroenterology\u003c/em\u003e. 2002;122:875\u0026ndash;880.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsai L, McCurdy JD, Ma C, et al. 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Change in Biologic Class Promotes Endoscopic Remission Following Endoscopic Postoperative Crohn\u0026rsquo;s Disease Recurrence. \u003cem\u003eJ Clin Gastroenterol\u003c/em\u003e.. Epub ahead of print November 27, 2023. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/mcg.0000000000001943\u003c/span\u003e\u003cspan address=\"10.1097/mcg.0000000000001943\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Rijn KL, Meima-Van Praag EM, Bossuyt PM, et al. Fibrosis and MAGNIFI-CD Activity Index at Magnetic Resonance Imaging to Predict Treatment Outcome in Perianal Fistulizing Crohn\u0026rsquo;s Disease Patients. \u003cem\u003eJ Crohn\u0026rsquo;s Colitis\u003c/em\u003e. 2022;16:708\u0026ndash;716.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRichard N, Derinck A, Bridoux V, et al. Which magnetic resonance imaging feature is associated with treatment response in perianal fistulizing Crohn\u0026rsquo;s disease? \u003cem\u003eAbdom Radiol\u003c/em\u003e.. Epub ahead of print 2024. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00261-024-04238-3\u003c/span\u003e\u003cspan address=\"10.1007/s00261-024-04238-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrowley E, Ma C, Guizzetti L, et al. Recommendations for Standardizing MRI-based Evaluation of Perianal Fistulizing Disease Activity in Pediatric Crohn\u0026rsquo;s Disease Clinical Trials. \u003cem\u003eInflamm Bowel Dis\u003c/em\u003e. 2024;30:357\u0026ndash;369.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVuyyuru SK, Solitano V, Singh S, et al. 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Modern management of perianal fistulas in Crohn\u0026rsquo;s disease: Future directions. \u003cem\u003eGut\u003c/em\u003e. 2018;67:1181\u0026ndash;1194.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003ePatient demographics and baseline characteristics (N=43).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"423\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=43 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMales\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;29 (67.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e24.3 (21.7 - 30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at fistulotomy, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e34 (28 - 42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCD diagnosis to pCD diagnosis, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1 (0 - 10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCD diagnosis to fistulotomy, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e7 (1 - 18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis changed from UC to CD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;None\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Obesity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Depression/anxiety\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Smoker\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hypertension\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Diabetes mellitus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Venous thromboembolism\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cancer, any\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Coronary artery disease\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Congestive heart failure\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Chronic obstructive pulmonary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (37.2%)\u003c/p\u003e\n \u003cp\u003e10 (23.3%)\u003c/p\u003e\n \u003cp\u003e9 (20.9%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily History of IBD\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Crohn\u0026rsquo;s disease\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ulcerative colitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (18.6%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther pCD stigmata\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Anal fissure\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSkin tag\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAnal ulcer\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAnal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (20.9%)\u003c/p\u003e\n \u003cp\u003e8 (18.6%)\u003c/p\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003cp\u003e2 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative fistula symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMucopurulent drainage\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePain with bowel movements\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eBloody drainage\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSkin dermatitis/irritation\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFever\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Stool drainage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (74.4%)\u003c/p\u003e\n \u003cp\u003e31 (72.1%)\u003c/p\u003e\n \u003cp\u003e10 (23.3%)\u003c/p\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Treatment of prior pCD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Abscess incision and drainage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Loose seton\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Partial fistulotomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cutting seton\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Fistula plug\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;LIFT\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;ERAF\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Fibrin glue\u003c/p\u003e\n \u003cp\u003eNo prior surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (65.1%)\u003c/p\u003e\n \u003cp\u003e22 (51.2%)\u003c/p\u003e\n \u003cp\u003e11 (25.6%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e12 (27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (proportion) or median (interquartile range). BMI: Body mass index; CD: Crohn\u0026rsquo;s disease; UC: ulcerative colitis; pCD: perianal CD; ERAF: endorectal advancement flap; LIFT: Ligation of intersphincteric fistula.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Medical therapy for pCD at the time of and after fistulotomy (N=43).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"474\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBiologics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No biologic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Any\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Infliximab\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ustekinumab\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Adalimumab\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Vedolizumab\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Upadacitinib\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (51.2%)\u003c/p\u003e\n \u003cp\u003e21 (48.8%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e4 (9.3%)\u003c/p\u003e\n \u003cp\u003e4 (9.3%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (34.9%)\u003c/p\u003e\n \u003cp\u003e28 (65.1%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-biologic medical therapy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Mesalamine\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Budesonide\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Methotrexate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Azathioprine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCombined medical therapy\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Infliximab + 6-MP\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Adalimumab + 6-MP\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Infliximab + Sulfasalazine\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Infliximab + Azathioprine\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Infliximab + Mesalamine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSame medical management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e21 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSwitched agents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiscontinued all therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitiated therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e9 (20.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (proportion). 6-MP: 6-mercaptopurine.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Index fistula evaluation and treatment details (N=43).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=43 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistula treatment prior to fistulotomy, same fistula\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Medical\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Seton\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Incision and drainage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Partial fistulotomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (65.1%)\u003c/p\u003e\n \u003cp\u003e21 (48.8%)\u003c/p\u003e\n \u003cp\u003e20 (46.5%)\u003c/p\u003e\n \u003cp\u003e4 (17.4%)\u003c/p\u003e\n \u003cp\u003e11 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeton to Fistulotomy, months (n=21)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5.4 (2.1;14.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of Seton Placement (n=21)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Transsphincteric\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Intersphincteric\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Submuscular, not specified\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Not specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003cp\u003e4 (17.4%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e10 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork-up of Fistula\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Exam under anesthesia\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Magnetic resonance imaging\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Computed tomography\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Colonoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (34.8%)\u003c/p\u003e\n \u003cp\u003e13 (30.2%)\u003c/p\u003e\n \u003cp\u003e4 (17.4%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistula Internal Opening\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Distal to dentate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Anal verge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Dentate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Not specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (44.2%)\u003c/p\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e13 (30.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistulotomy Location\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Posterolateral\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Anterolateral\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Posterior midline\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Anterior midline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (34.8%)\u003c/p\u003e\n \u003cp\u003e14 (32.5%)\u003c/p\u003e\n \u003cp\u003e12 (27.9%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple Fistulas\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e18 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistulotomy Type\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Superficial/Subcutaneous\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Low Fistulotomy (\u0026lt;10% muscle fibers)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Any external anal sphincter divided\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Submuscular, sphincter not specified\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Internal anal sphincter divided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (65.1%)\u003c/p\u003e\n \u003cp\u003e15 (34.8%)\u003c/p\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistulotomy to last follow up, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.3 (2.0 - 5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (proportion) or median (interquartile range).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Short (\u0026lt; 30-day) and long-term (\u0026gt;30-day) outcomes after fistulotomy, N=43.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"501\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistulotomy Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShort-term\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=43 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLong-term\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=43 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e25\u0026nbsp;(58.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e26 (60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e18 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e17 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Keyhole deformity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Non-healing wounds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 (20.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mucopurulent Drainage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Seepage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Fecal diversion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Recurrence of abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRe-operation on same fistula\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Once\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Multiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistulotomy healing at last follow-up \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e41\u0026nbsp;(95.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Symptoms: Bloody drainage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Symptoms: Skin irritation/dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther pCD related surgeries post-fistulotomy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;3+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003cp\u003e8 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrohn\u0026rsquo;s proctitis and/or treatment complication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Non-healing wounds\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Fecal diversion\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Stricture\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (proportion) or median (IQR).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eFunctional outcomes and anal stricture before and after index fistulotomy (N = 43)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003efistulotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter fistulotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNo complaints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e32 (74.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e37 (86.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDay Fecal incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNight leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNight incontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDay leakage with pad use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDay leakage w/o pad use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eFecal urgency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eSocial restrictions due to function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e4 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eAnal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (proportion).\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Fistulotomy, fecal incontinence, perianal Crohn’s disease, inflammatory bowel disease, fistula-in-ano","lastPublishedDoi":"10.21203/rs.3.rs-7376465/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7376465/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFistulotomy is highly effective (\u0026gt;\u0026thinsp;90%) for cryptoglandular fistula-on-ano, but fistulotomy in perianal Crohn\u0026rsquo;s disease (pCD) is limited due to increased risk of recurrent fistulae, diarrhea, and fecal incontinence. We hypothesized superficial fistulotomy resulted in wound healing in most patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a single-center retrospective review of adult patients with pCD who underwent fistulotomy from 1999\u0026ndash;2022. Baseline characteristics, pCD characteristics, and short- and long-term surgical and functional outcomes were reported. Matched-pair Wilcoxon signed-rank test was used to compare continuous data.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 43 adult pCD patients underwent fistulotomy and were included: 29 (67.4%) males, age of 34 (28\u0026ndash;42) years, and a follow-up time of 4.3 years. Prior interventions included draining setons (48.8%) and partial fistulotomy (17.4%); 25.6% had no prior surgery. Fistulotomies were subcutaneous (65.1%), low transsphincteric (16.3%), intersphincteric (4.7%), and unspecified (14%). Short-term complications included pain (20.9%), bleeding (4.7%), and seepage (2.3% each), and 58.1% of the patients had no complications. Long-term complications included bleeding, keyhole deformity, non-healing wounds, and anal stricture (2.3% each), and 60.5% did not experience long-term complications. At the last follow-up, 41 (95.3%) patients had complete healing of the fistulotomy site.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFistulotomy was safe in select patients with fistulizing pCD and superficial fistulas with little or no sphincter involvement. We observed that fistulotomy was associated with wound healing, decreased drainage, and social restrictions in most patients, suggesting that this is a viable and safe option for this at-risk group.\u003c/p\u003e","manuscriptTitle":"Superficial Fistulotomy for Non-Transsphincteric Fistulae in Perianal Crohn’s Disease: Do They Heal?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 16:06:32","doi":"10.21203/rs.3.rs-7376465/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-10T11:28:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T16:59:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-22T22:14:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339659776940095960737569741007958017094","date":"2025-09-13T07:26:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137623662721940092940849383990680466258","date":"2025-09-05T17:01:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T10:06:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-21T13:18:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-16T04:06:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2025-08-14T19:03:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"291c88d0-3087-4f51-ac49-d22f109c0a3d","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T21:08:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 16:06:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7376465","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7376465","identity":"rs-7376465","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}