Introduction 1 2 6 7 13 10 13 14 15 16 19 We investigated the overall risk of a permanent stoma in patients with severe perianal Crohn’s disease and tried to identify risk factors predicting permanent stoma carriage. Methods Patients A total of 102 consecutive patients with Crohn’s disease presented with the first manifestation of a perianal fistula or a perianal abscess in our outpatient department between 1992 and 1995. Patients were investigated in Trendelenburg’s position by perianal inspection, proctoscopy, rectoscopy, and rigid sigmoidoscopy. Endoanal ultrasound was performed in case of suspected perianal abscess formation, and MRI was conducted of the pelvic floor in case of complicated fistulizing disease or intrapelvic abscess formation. All patients were documented prospectively. Follow-up data of 97 patients (95%) were available by a standardized questionnaire mailed to the patients and by a standardized chart review. There were 50 female and 47 male patients (ratio 1.06:1) with a median age of 23 years (range 8–51 years). Patients were evaluated with respect to the recurrence of perianal abscesses, fistulas, or surgical treatment of Crohn’s disease over the years. The median interval between the first diagnosis of Crohn’s disease and last follow-up was 16 years (range 8–37 years). Four patients had isolated small intestinal disease, 11 patients had isolated colonic disease, and 82 patients had small intestinal and colonic disease. 20 21 A variety of factors, such as sex of the patient, perianal fistula, rectovaginal fistula, abscess formation, anal stricture, fecal incontinence, or abdominal surgery were evaluated with regard to their predictive character for permanent stoma carriage by univariate and multivariate analysis. Statistical Analysis P Results Overall Risk of Permanent Fecal Diversion 1 1 2 Figure 1 n  Table 1 n   Patients Temporary Stoma Permanent Stoma Overall 97 51 (53%) 30 (31%) Abscess  formation 75 32 (43%) 21 (28%) Simple abscess formation 33 (44%) 13 (39%) 7 (21%) Complex abscess formation 42 (56%) 23 (55%) 15 (36%) Fistulas 88 51 (58%) 26 (30%) Simple perianal fistulas 42 (48%) 17 (40%) 8 (19%) Complex perianal fistulas 46 (52%) 34 (74%) 23 (50%) Rectovaginal fistulas 26 (54% of ♀) 18 (69% of 26) 14 (54% of 26) Overlap between abscess formation and presence of fistulas exists, and abscesses led to fecal diversion in combination with fistulas only. Table 2 n   Patient Number Permanent Stoma (% of Patients) Small Bowel Procedures Stricturplasty 7 0 Small bowel resection because of stenosis 23 0 Small bowel resection because of enteroenteric fistula 7 0 Anastomosis resection because of inflammatorystenosis 30 0 Stoma revision 4 0 Large bowel procedures Segmental colon resection 14 0 Right-sided colon resection 20 4 (20) Ileocecal resection 68 24 (35) Subtotal colon resection 35 21 (60) Left-sided colon resection 6 5 (83) Rectal resection 13 12 (92) Patients that required small bowel resections carried no risk of fecal diversion, whereas patients with colon resections carried an increased risk of fecal diversion. Abscess Formation 21 2 1 Figure 2 n n P  Perianal and Rectovaginal Fistulas 1 Thirty-four of 97 patients (35%) developed anal strictures, whereas fecal incontinence was documented in 12 patients (12%) during the follow-up. In 14 of 34 patients (41%) with anal stricture, a permanent fecal diversion became necessary, whereas 10 of 12 patients (83%) suffering from fecal incontinence required a permanent stoma. Abdominal Surgery 2 n n P P 3 P 3 Table 3 Abdominal Procedures per Patient and Percentage of Patients with Abdominal Surgery Abdominal Procedures Median (25–75%) Patients with Abdominal Surgery (%) P Permanent fecal diversion 3 (2–4) 100 P Without permanent fecal diversion 1 (1–3)   Temporary fecal diversion 3 (2–4.25) 80 P Without temporary fecal diversion 1 (0–2.5)   Anal stricture 2 (1–4) 60 n.s. Without anal stricture 2 (1–3)   Incontinence 2 (2–4.5) 10 n.s. Without incontinence 2 (1–3)   P Figure 3 Treatment algorithm for patients with complicated perianal Crohn’s disease.  Temporary Fecal Diversion 23 Risk Factors Predictive of a Permanent Fecal Diversion Univariate Analysis P P P 3 P P P 4 Table 4 Risk Factors for Permanent Fecal Diversion by Univariate and Multivariate Analysis in Patients with Complicated Perianal Crohn’s Disease Risk Factors Univariate Analysis Multivariate Analysis Permanent Fecal Diversion (%) P OR 95% CI P Rectal resection 92 P 30 5–179 P Fecal incontinence 83 P 21 3–165 P Subtotal colectomy 60 P    Rectovaginal fistulas 54 P    Temporary fecal diversion 51 p 8 2–35 P Complex perianal fistulas 54 P 5 2–18 P Multivariate Analysis P P P P 4 Discussion 19 24 25 19 22 23 22 26 21 26 28 19 21 23 29 19 22 23 30 31 23 32 23 33 23 34 34 23 23 19 19 18 23 35 18 36 37 38 38 15 18 38 39 18 40 18 41 22 33 33 43 44 45 46 48 48 45 44 46 48 47 24 44 49 50 51 51 21 22 50