Oxford

Colorectal

Management of Anal Fistulae in Crohn’s disease

Bruce D George

John Radcliffe Hospital

Oxford

Oxford

Colorectal

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

Oxford

Colorectal

Spectrum of Crohn’s anal pathology

Good prognosis

Poor prognosis

Skin tags

Fissures

Fistulae

Strictures

Deep cavitating ulcers

Oxford

Colorectal

Spectrum of Crohn’s Anal Fistulae

Oxford

Colorectal

• “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

Oxford

Colorectal

Treatment Options

• Metronidazole/ciprofloxacin

• Azathioprine/6MP

• Infliximab

• Abscess drainage

• Seton drain

• Fistulotomy

• Advancement flap

• Defunctioning ileostomy

• Proctectomy

Oxford

Colorectal

Problems in Surgical Management

• No random controlled trials

• Extreme opinions

• Different starting points

• Different end points

• Variable natural history

• Changing medical therapy

Oxford

Colorectal

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

Oxford

Colorectal

Problem of “end-points”

• Partial/complete healing of fistula

• Duration of healing

• Continence scores

• Patient satisfaction

• Radiological/clinical healing

Oxford

Colorectal

• 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

Oxford

Colorectal

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

Oxford

Colorectal

Aims of assessment

• Detection of intestinal disease–Proctitis

• Type of fistula(e)– Low/high

–Undrained sepsis

• Patients symptoms and expectations

Oxford

Colorectal

Principles of Surgical Treatment of of Crohn’s Anal Fistulae

1. First aidIncision and drainage of abscess

2. Bridging treatmentAims to convert acute uncontrolled situation into potentially curative situation

3. Quality of life based treatmentAttempt to heal fistula if symptomatic and realistic

4. Proctectomy and permanent stoma

Oxford

Colorectal

First Aid Surgery

Oxford

Colorectal

Bridging treatment

• Often involves loose seton drain

• Allows patient to be established on immunomodulator

Oxford

Colorectal

If bridging treatment going badly

• Check that sepsis drained adequately– MRI

• Consider defunctioning stoma

• Consider proctectomy

Oxford

Colorectal

Defunctioning ileostomy for perianal Crohn’s disease

– to assist stabilisation– as “bridge” to

proctocolectomy

18 patients defunctioned for severe perianal Crohn’s1970-199715 acute remission2 reversed with satisfactory function

Edwards et al 2000

Oxford

Colorectal

Quality of Life Based Treatment

• Controlled situation–No sepsis

–Well patient

–Seton in situ

–Established on immunomodulator

What are the treatment options?

Oxford

Colorectal

Treatment Options

• Do nothing: long-term seton

• Remove seton only

• Remove seton and attempt to heal medically

• Attempt to heal surgically

• Combination medical and surgical treatment

Oxford

Colorectal

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

Oxford

Colorectal

• 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

Oxford

Colorectal

Anti-tumour necrosis factor-alphainfliximab

• 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

Oxford

Colorectal

Surgery for low fistula

Simple fistulotomy

Oxford

Colorectal

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”

Oxford

Colorectal

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

Oxford

Colorectal

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

Oxford

Colorectal

Advancement flap for high fistulae

• Must be no proctitis

– Joo et al 1998

19 0f 26 healed

Oxford

Colorectal

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

Oxford

Colorectal

Current protocol in Oxford

• EUA +/- seton drainage. Ensure no sepsis

• Infliximab 0 and 2 weeks

• Remove seton if necessary

• Infliximab at 6 weeks

Oxford

Colorectal

Proctectomy

• To improve patients quality of life if “first aid, bridging and attempted healing treatments” inadequate

Oxford

Colorectal

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

1. First aidIncision and drainage of abscess

uncontroversial

2. Bridging treatmentAims to convert acute uncontrolled situation into potentially curative situation

Seton and immunomodulator

3. Quality of life based treatmentAttempt to heal fistula if symptomatic and realistic (low and no proctitis)

Consider other options

4. Proctectomy and permanent stoma