Contemporary Surgical Management of Ileosigmoid Fistulas in Crohn’s Disease: A Systematic Review and Meta-analysis
Background:
Ileosigmoid fistula (ISF) is a common complication of Crohn’s disease that is often diagnosed intraoperatively. Surgical management varies, including rates of laparoscopic surgery, primary repair vs sigmoid resection, and diversion rates. This variability highlights the need for a systematic review of the current literature.
Methods:
We conducted a systematic review of the literature by searching MEDLINE, EMBASE, Scopus, and the Cochrane Library. All searches covered the period from the inception of each respective database through August 6, 2024. Studies reporting the preoperative, intraoperative, and postoperative courses of patients with ileosigmoid fistulas were included. We specifically compared outcomes for patients who underwent ostomy vs no ostomy, laparoscopic vs open surgery, and primary repair vs resection. The quality of cohort studies was assessed using the Newcastle-Ottawa Scale (NOS), while the Joanna Briggs Institute’s checklist was used for the case series.
Results:
From an initial search of 128 articles, 17 were selected for full-text review. Ultimately, 6 studies met the inclusion criteria—English language and published after 2000—including 5 retrospective cohort studies and 1 prospective case series, comprising a total of 493 patients. These studies were published between 2009 and 2024. Substantial heterogeneity was observed in surgical approaches and outcomes. The pooled estimate for proportion of ISF performed laparoscopically was 44.0% (95% CI: 0.21 - 0. 69, I<sup>2</sup> = 95%). The pooled estimate for primary repair was 41.3% (95% CI: 0.28 - 0.56, I<sup>2</sup> = 90%). Overall, 145 (29%) ileosigmoid fistulas were identified preoperatively, while emergency surgery and diversion rates varied from 5.7% to 57% and 11.9% to 57%, respectively. Postoperatively, the pooled leak rate was 8.34% (95% CI: 0.06 - 0.11, I<sup>2</sup> = 21%). There was no significant difference in leak rates between primary repair and resection groups (pooled <italic>P =</italic> 0.22), and resection was associated with a longer hospital stay (pooled <italic>P =</italic> 0.007). Two studies found a significant association between sigmoid resection and diversion (pooled <italic>P =</italic> 0.0002), and additional small bowel resection was linked to higher diversion rates (pooled <italic>P =</italic> 0.003).
Conclusions:
This review highlights significant variability in the surgical management of ileosigmoid fistulas in Crohn’s disease, underscoring the need for standardized guidelines. A multicenter study is recommended as a first step towards developing evidence-based guidelines.
