Crohn's Disease Complicated by Ileosigmoid Fistula - Synchronous Resection or Primary Sigmoid Repair, One or Two-stage Procedure? A systematic review of the literature and prospective case series.

Introduction: Although ileosigmoid fistulas (ISFs) in Crohn's disease (CD) are rare they can be quite challenging, especially for the inexperienced surgeons. Furthermore, current guidelines offer no clear recommendation regarding the surgical strategy in such cases. A systematic review of the literature to determine the best surgical strategy and a prospective case series are presented herein.

Materials And Methods: The systematic review was performed according to PRISMA guidelines. A single-center prospective data-base from January 1, 2014 to August 20, 2019 is presented. Age, duration of CD, and the rates of ISF, emergency, preoperative diagnosis, type of surgery, type of stoma, and complications were analyzed and a prospective case series.

Results: Eleven of 69 papers with a total of 505 patients were included in the systematic analysis. The rate of ISF was 3-5% of all CD patients. The combined preoperative detection rate of all modalities was 71%. Primary repair was performed in 42% of the cases; the rate of stoma was 31.5% with a similar proportion in primary repair and sigmoid resection.In the presented series, 35 of 176 patients with CD were operated (51% in an emergency setting). There were 7 cases with ISFs (4% of all and 20% of the operated patients). Preoperative diagnosis was made at 57%. Primary repair was performed in 71%, and a two-stage intervention with a stoma - in 58% of patients.

Conclusions: Primary repair should be attempted in all cases in which the sigmoid colon is disease-free or is not involved in the adja-cent abscess. The synchronous resections are not a mandatory indication for the stoma, but rather a tailored approach is recommended with an evaluation of the risk factors. Based on the available literature, no clear recommendation regarding the type of stoma can be made.