Perianal Fistulizing Crohns Disease Simple, Complex, Incision
and Drainage, Fistulotomy, Setons, Diversion or Proctectomy ? OH
MY!
Slide 2
24 yr old male with a 1 yr. h/o stricturing ileal disease s/p
ileocecetomy and rectosigmoid Crohns disease. He is currently on
Infliximab and Azathioprine but continues with recurrent and now
worsening perianal pain with severe throbbing discomfort and
swelling upon sitting especially for extended periods. Past MRI had
revealed incidentally a very small fluid collection. He has had
perianal discomfort on and off in the past treated with short
courses of antibiotics resulting in drainage with resolution of
swelling. He has discomfort on walking and especially sitting for
extended periods. Now referred to colorectal clinic for surgical
evaluation of persistent perirectal abscess/fistula. Case Study
Perianal Fistulizing Crohns
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What do we know? History h/o rectosigmoid disease and recurring
abscess. Symptoms throbbing pain, periodically drains purulence,
smells Testing MRI showing fluid collection Treatments Azathioprine
and Infliximab Cipro/flagyl QoL constant annoyance Difficulty
sitting, sometimes walking, recurring abscess, difficult when job
requires sitting in multiple meetings a day
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Perianal Abscess abscess
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What testing might be considered to evaluate abscess? Digital
exam feel fistula, induration, swelling - may be too painful MRI
helps delineate tracts and fluid collection, helps evaluate healing
may over report in some cases Anal Endosongraphy good to evaluate
tracts close to the anal canal but loss of resolution further away
Exam under anesthesia Very good to evaluate the area as usually
painful and note presence of fluid collections Kamm, M, NG.S 2008
Clin Gastroenterol and Hepatol 6:7-10
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Recent testing - MRI abd/pelvis Thickening rectal- sigmoid area
with left lateral rectal area with small fluid collection
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Exam Under Anesthesia Complex fistula opening was found in the
rectum on the left lateral aspect. Wire probe placed through the
opening and followed tract to an abscess cavity within the
sphincter muscles to the outside of the perineum. The abscess was
opened and purulent material drained through to the outside
opening.
Slide 8
fistula Abscess
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What surgical procedure would you recommend for this perianal
abscess? Incision and drainage Fistulotomy Seton placement
Diverting stoma
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Abscess is superficial outside the sphincter muscles! Schwartz,
D.A., J.H. Pemberton, and W.J. Sandborn, Diagnosis and treatment of
perianal fistulas in Crohn disease. Ann Intern Med, 2001. 135(10):
p. 906-18.
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Seton keeps the fistula track open so abscess drains Abscess is
within the sphincter muscles
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Preoperative discussions? What major risk should be discussed
related to perianal procedures? Incontinence - damage to sphincters
Perineal tissue destruction - scarring What postoperative
recommendations and patient education should you discuss for this
case? Hot sitz baths several times per day Use of butterfly or anal
incontinence pads to wick away moisture For a seton left in with a
circle tie: Move seton from side to side Sutured connection needs
to be outside tract Recommend leaving a tail on the seton so cannot
rotate inside the tract
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In Perineal Crohns Evolution toward upfront aggressive COMBINED
medical AND surgical therapy
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Surgery for Perianal Crohns Disease Combination Therapy Initial
Response (%) Recurrence (%) Time to Recurrence (Months) Infliximab
82793.6 EUA + Seton+ Infliximab 1004413 Regueiro M & Mardine H.
Inflammatory Bowel Diseases, March 2003, 9(2):98-103 ACCENT 2 trial
extended trial
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Antibiotics often help to decrease inflammation in the short
term Metronidazole and/or Ciprofloxacin Patients generally start
infliximab therapy after sepsis has been drained Often a seton is
left in to control drainage, prevent recurrent sepsis and allow
inflammation to resolve. Removal of a seton within a few weeks of
starting therapy is necessary to facilitate track healing! In
extensive complex fistulae may be longer Treatment of Perianal
Fistulae Causey, Marlin et al Gastroenterol April 5 ( 2013)
58-63
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Surgery for Crohns Disease Infliximab & Perineal Fistula
For perianal fistulizing CD, repeat doses of Infliximab improves
clinical and radiological outcomes, although complete radiologic
healing occurs in a minority of patients! Rasul I et al. Am J
Gastro2004:99:82-88
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Surgery for Perineal Crohns Disease Summary Setons prevent
sphincter damage by preventing recurrent abscess formation Presence
of active proctitis reduces chance of the fistula healing, thus
proctitis needs to be aggressively treated! Setons can be removed
after a couple doses of a biologic when the tract is healing or
left in long term if healing does not occur. If the tract appears
healed or dry the seton can be removed. The perineum is re-examined
regularly MRI If fecal incontinence develops, proctectomy is
discussed Kamm, M, NG.S 2008 Clin Gastroenterol and Hepatol
6:7-10
Slide 19
Cutting Seton elastic band Tightening can occur every 2-3 weeks
as tolerated. With each tightening, the seton cuts slowly through
the sphincter tissue and heals the tissue behind. Eventually the
seton falls out and has done its job! Chuang-Wei,Surgeon,1 June
2008 185-88
Case Study #2 25 y/o gentleman who was referred for evaluation
of uncontrolled perianal Crohn's disease originally noted symptoms
in high school of increased stools and progressed to LLQ abdominal
pain and diarrhea Colonoscopy in August 2011 which was notable for
perianal CD with multiple fissures, deep ulcerations in the distal
rectum as well as severe inflammation with ulceration extending up
to the splenic flexure. TI was normal. Initiated on prednisone,
mesalamine, and metronidazole. He was then started on adalimumab in
late 2011, but no loading doses. SHx: Works in a factory building
doors. States that normally he 'just comes home and goes to his
room' after work, does not socialize much. FHx: Denies family
history of IBD or CRC ROS: No F/C, No N/V. No SOB/CP. No HA. Denies
dysphoria. No abdominal pain, + perianal discomfort + diarrhea +
perianal skin wetness and lots of milky drainage. Patient smells of
sickness and clothes wet.
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He is notably despondent in the office and is not forthcoming
about how he is feeling, wearing a hat pulled over eyes, poor eye
contact and soft voice with paucity of words. He appears to be very
uncomfortable sitting but states he is definitely sitting fine!
Father does most of the talking.
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Perineal Fistulizing Disease Perianal fistulizing disease can
lead to substantial physical and emotional disease: Pain Discharge
Incontinence Perineal and genital disfigurement Slow resolution
even with treatment Patients often reluctant to seek medical care
Providers unfamiliar with nuances to manage the disease Causey,
Marlin et al Gastroenterol April 5 ( 2013) 58-63
MRI MRI : Changes in the descending colon and sigmoid colon
compatible with CD. Extensive perianal and rectal fistulas and
abscess collection extending into the gluteal soft tissues,
perineum and scrotal sac.
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Exam under anesthesia and setons
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Returns now for follow up visit: Since his EUA he has remained
on adalimumab, Ciprofloxacin, and metronidazole States he is
feeling 'better' with setons but has had persistent daily perianal
drainage, leakage/accidents of stool and has 5 BMs during day and
1-2 BMs at night. Still despondent, not sitting comfortably, not
eating as fear of bowel movements Clearly patient is not doing well
Perianal area will not heal with continued stool flow!
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Chance of fistulae and rectum healing given his severe
proctitis Diversion Stoma Need for removal of colon/rectum Quality
of life Depression Patient support network/education Patient
Discussion and Education
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Risk factors for Proctectomy 5 yr. Extensive fistula/abscess vs
simple 26% vs. 6% Severe Proctitis vs none or mild 37% vs. 10%
Severe proctitis and extensive fistula/abscess 46% proctectomy rate
Often Proctectomy performed only after a patient has had enough of
their disease! Causey, Marlin et al Gastroenterol April 5 ( 2013)
58-63
Slide 31
Diversion does not alter the course of the disease! Patients
undergoing diversion for perineal CD have