Laser ablation of complex perianal fistulas preserves continence and is a rectum-sparing alternative in Crohn's disease patients.

A 20-year review of the inflammatory bowel disease surgical database of the author was analyzed for Crohn's disease (CD) patients who had a surgical approach to perianal fistula disease (PAD). Of 333 patients with CD operated between July 1977 and February 1997, 51 had procedures for PAD (15.3%), and 7 of these patients had laser ablation of severe, debilitating complex PAD (13.7%). These patients have traditionally been treated by diverting ileostomy or proctectomy with permanent diversion. Others have advocated conservative management with long-term antibiotics, staged operations, and insertion of multiple loose setons to promote drainage. This technique was adapted from the laser procedure now advocated for severe hydradenitis suppurativa. The hand-held CO2 laser was used to unroof all fistulas external to the external sphincter. Fistulas were identified by probing. Infected granulation tissue was removed by laser ablation until normal fat or muscle was revealed. Intersphincteric abscesses were unroofed, and a single seton was placed around the external sphincter for all but submucous fistulas. Patients were usually operated as outpatients with pain control effected with oral and transnasal agents. A laparoscopically performed temporary diverting ileostomy was used in one early patient in the series. Patients were followed, and progress was documented by physical examination and photographs. Quality of life was assessed. All patients improved remarkably from their preoperative state. The 4 patients in the group operated more than 1 year before this review have all demonstrated complete healing. The three more recent patients are in various stages of healing. Continence was preserved in 7 of 7 patients. No patient has required rectal excision. Recurrence thought to be related to associated hydradenitis has occurred in 1 patient. Laser ablation is a valuable technique in the management of patients with severe, debilitating complex PAD complicating CD. It effectively eradicates the septic tracks and pockets while preserving sphincter function. It obviates the need for diversion with or without proctectomy.