Less combination therapy and more fistulotomy in perianal fistulizing Crohn's disease in the elderly

This study aimed to describe Crohn's disease perianal fistulizing lesions in patients undergoing surgery over 60 years to compare clinical presentation, management and outcomes with those observed in younger patients.

Between January 2012 and December 2022, all patients over 60 years old who underwent a first surgical intervention for anal fistula at two medical centers were included. For each patient included, two younger patients who underwent the same surgical procedure during the same period in the same centers were matched for comparison.

Among 536 patients who underwent surgery, 6% (n = 30) aged over 60 years at first surgery were included. Compared with their younger counterparts, older patients had: i) a diagnosis of Crohn's disease and fistula more often in the same year: 63% vs 26%, p = 0.001; ii) combined therapy and anti-TNF alpha optimization less often (p = 0.0002 and p = 0.0001); iii) fewer surgical interventions: 3 vs 4.5, p = 0.008; iv) sparing surgery less frequently: 30% vs 58%, p = 0.01; v) fistulotomy more often: 27% vs 5%, p = 0.003. The rates of anal fistula closure were comparable between the two groups: 60% vs 62%, p = 0.93.

Synchronous diagnosis of anal fistula and Crohn's disease within the first year of care is not uncommon after 60 years of age, suggesting that Crohn's disease should not be overlooked in older individuals developing an anal fistula. Despite receiving less aggressive medical management due to age-related factors, elderly patients achieved similar fistula closure rates, through a more pragmatic surgical approach, including more fistulotomies in selected patients.