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Management of Anal Fistulae in Crohn’s disease. Bruce D George John Radcliffe Hospital Oxford. Penner and Crohn 1938 Perianal involvement in 33% (range 4-80%) Increased risk with increasingly distal inflammation 92% Crohn’s proctitis have perianal disease. Perianal Crohn’s disease.

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management of anal fistulae in crohn s disease

Management of Anal Fistulae in Crohn’s disease

Bruce D George

John Radcliffe Hospital

Oxford

perianal crohn s disease
Penner and Crohn 1938

Perianal involvement in 33% (range 4-80%)

Increased risk with increasingly distal inflammation

92% Crohn’s proctitis have perianal disease

Perianal Crohn’s disease
spectrum of crohn s anal pathology
Spectrum of Crohn’s anal pathology

Poor prognosis

Good prognosis

Fistulae

Deep cavitating ulcers

Skin tags

Fissures

Strictures

slide5
“Natural history of perianal Crohn’s disease. Ten year follow-up; a plea for conservatism.”

Buchmann et al 1980

109 patients

38% spontaneous fistula healing

treatment options
Metronidazole/ciprofloxacin

Azathioprine/6MP

Infliximab

Abscess drainage

Seton drain

Fistulotomy

Advancement flap

Defunctioning ileostomy

Proctectomy

Treatment Options
problems in surgical management
No random controlled trials

Extreme opinions

Different starting points

Different end points

Variable natural history

Changing medical therapy

Problems in Surgical Management
extreme views
J. Alexander-Williams 1976

“faecal incontinence is the result of aggressive surgeons and not progressive disease”

J. Graham Williams et al 1991

Fistula-in-ano in Crohn’s disease. Results of aggressive surgical treatment

Extreme views
problem of end points
Partial/complete healing of fistula

Duration of healing

Continence scores

Patient satisfaction

Radiological/clinical healing

Problem of “end-points”
slide10
MRI studies of fistula healing

Bell et al 2003

7 perianal fistula assessed pre and post infliximab (0,2,6)

4 healed, 2 no response, 1 partial response

1 healed clinically, but persisting on MRI

principles of management
Principles of Management
  • Thorough disease assessment
    • Clinical history and examination
    • Small bowel enema and colonoscopy
    • Ultrasound and MRI
    • EUA +/- biopsy
  • Tailoring of treatment to individual patient
aims of assessment
Detection of intestinal disease

Proctitis

Type of fistula(e)

Low/high

Undrained sepsis

Patients symptoms and expectations

Aims of assessment
principles of surgical treatment of of crohn s anal fistulae
First aid

Incision and drainage of abscess

Bridging treatment

Aims to convert acute uncontrolled situation into potentially curative situation

Quality of life based treatment

Attempt to heal fistula if symptomatic and realistic

4. Proctectomy and permanent stoma

Principles of Surgical Treatment of of Crohn’s Anal Fistulae
bridging treatment
Bridging treatment
  • Often involves loose seton drain
  • Allows patient to be established on immunomodulator
if bridging treatment going badly
If bridging treatment going badly
  • Check that sepsis drained adequately
    • MRI
  • Consider defunctioning stoma
  • Consider proctectomy
defunctioning ileostomy for perianal crohn s disease
Defunctioning ileostomy for perianal Crohn’s disease
  • to assist stabilisation
  • as “bridge” to proctocolectomy

18 patients defunctioned for severe perianal Crohn’s

1970-1997

15 acute remission

2 reversed with satisfactory function

Edwards et al 2000

quality of life based treatment
Controlled situation

No sepsis

Well patient

Seton in situ

Established on immunomodulator

Quality of Life Based Treatment

What are the treatment options?

treatment options19
Do nothing: long-term seton

Remove seton only

Remove seton and attempt to heal medically

Attempt to heal surgically

Combination medical and surgical treatment

Treatment Options
medical therapy to encourage fistula healing
Metronidazole

34-50% fistula healing in uncontrolled trials

High recurrence rates

Risk of peripheral neuropathy

Ciprofloxacin

No controlled studies

Medical therapy to encourage fistula healing
slide21
Azathioprine/ 6-mercaptopurine

22 of 41 fistulae healed with AZA/6MP

6 of 29 fistulae healed with placebo

odds ratio: 4.44

Pearson et al 1995

anti tumour necrosis factor alpha infliximab
Present et al 1999

94 patients of whom 85 (90%) had perianal fistulae

Reduction of 50% or more of number of draining fistulae

62% infliximab treated reached end point

26% placebo group reached end point

11% perianal abscess

Anti-tumour necrosis factor-alphainfliximab
surgery for low fistula
Surgery for low fistula

Simple fistulotomy

results of fistulotomy
Levien et al 1989

46 patients

29 healed, but 10 recurred

17 unhealed wounds

Williams et al 1991

41 fistulae in 33 patients

73% healed at 3 months

26 of 33 had no deterioration in continence

Scott and Northover 1996

81% “successful”

Results of fistulotomy
fistulotomy for low fistulae
60-80% healing of fistula

20-40% slow wound healing

10%-20% risk of recurrence

Small risk of incontinence

Most studies report better results if no proctitis

Fistulotomy for low fistulae
long term loose seton for high fistula
Williams et al 1991

11 of 23 good result (seton usually removed)

6 minor incontinence

5 ultimately requiring proctectomy

Scott and Northover 1996

23 of 27 good result (18 left in situ)

3 proctectomy, 1 chronic sepsis/pain

Long-term loose seton for high fistula
advancement flap for high fistulae
Advancement flap for high fistulae
  • Must be no proctitis
    • Joo et al 1998

19 0f 26 healed

combination therapy
Topstad et al 2003

Combined seton, infliximab and immunosuppression

67% complete healing + 19% partial healing

Regueiro and Mardini 2003

EUA/seton and infliximab versus infliximab alone

Improved results if infliximab therapy preceded by EUA and seton placement

Combination therapy
current protocol in oxford
EUA +/- seton drainage. Ensure no sepsis

Infliximab 0 and 2 weeks

Remove seton if necessary

Infliximab at 6 weeks

Current protocol in Oxford
proctectomy
To improve patients quality of life if “first aid, bridging and attempted healing treatments” inadequateProctectomy
summary of principles of surgical treatment of of crohn s anal fistulae
First aid

Incision and drainage of abscess

uncontroversial

Bridging treatment

Aims to convert acute uncontrolled situation into potentially curative situation

Seton and immunomodulator

Quality of life based treatment

Attempt to heal fistula if symptomatic and realistic (low and no proctitis)

Consider other options

4. Proctectomy and permanent stoma

Summary of Principles of Surgical Treatment of of Crohn’s Anal Fistulae