Surgical and metabolic management of patients with external fistulas of the small intestine associated with Crohn's disease

In order to define more clearly the principles of surgical and metabolic management of patients with external small bowel fistulas in association with Crohn's disease, a consecutive series of 85 patients (26 with Crohn's disease) was studied. The patients were all managed by one surgeon and, in the last 60 patients, management was according to a standard protocol. In 19 cases, detailed metabolic studies (body composition, plasma proteins, and total energy expenditure) were conducted at intervals during the period of treatment . In 69 (82%) of the 85 patients, successful closure of the fistula was achieved (36 spontaneously, and 33 surgically), and the mortality rate was 16%. The overall results were similar for the Crohn's patients, except that spontaneous closure occurred significantly less often (in 4 of 26 patients). Two distinct types of Crohn's fistula were observed. In 10 patients, the fistula arose in the early postoperative period and was not associated with residual Crohn's disease. The pattern of behavior and overall results of treatment of these patients were the same as for non‐Crohn's patients. In 16 patients whose fistula arose from an area of Crohn's disease (6 postoperatively, 10 spontaneously after discharge of an abscess), spontaneous closure was not observed. Surgery was undertaken in 15 of these patients, and was successful in 14; one patient died . Studies of body stores of protein showed that massive losses (2% per day) occurred in patients in whom sepsis was uncontrolled, in spite of intravenous nutrition (IVN). Although the total energy expenditure of Crohn's patients was no different from that of non‐Crohn's patients (45 kcal/kg per day), studies of total body protein while the patients were being given IVN showed that, when active Crohn's disease remained in situ, the expected increase in body protein stores of about 1 kg did not occur . It is concluded that fistulas unassociated with residual Crohn's disease should be managed along conventional lines. Those fistulas arising from diseased small intestine all require surgery. This is performed after sepsis has been drained, metabolic deficits (but not necessarily deficits of body protein) have been corrected, and the anatomy of the fistula has been defined. The surgical procedure is a radical one involving complete dissection of the entire small intestine, resection of the bowel involved, and performance of a primary anastomosis .