Sarkis ELKHOURY M'D'

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Sarkis ELKHOURY M.D. Tripoli, July 2005
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Normal Anatomy
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Perianal Lesions in CD
Type of lesion Number of patients ()
Skin tag 75 (37) Fissure 38 (19) Low
fistula 40 (20) High fistula 12 (6)
Rectovaginal fistula 6 (3) Perianal abscess
32 (16) Ischiorectal abscess 8 (4)
Intersphincteric abscess 7 (3) Supralevator
abscess 6 (3) Anorectal stricture 9 (9)
Hemorrhoids 15 (7) Anal ulcer 12 (12)
Total patients 110 (54)
Keighley MR et al. Int J Colorectal Dis
19861104107.
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Types of Anorectal Fistulas
(A) A superficial fistula track
(B) An intersphincteric fistula track
(C) A high transsphincteric fistula track
(D) A suprasphincteric fistula track
(E) An extrasphincteric fistula track
(F) A low transsphincteric fistula track
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Epidemiology
Frequency 14 38 in adults 13 in
adolescents Cumulative 12 at 1
year Frequency 15 at 5 years 21 at 10
years 26 at 20 years
Farmer RG et al. Gastroenterology
197568627635. Williams DR et al. Dis Colon
Rectum 1981242224. Marks CG et al. Br J Surg
198168525527.
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Relation to diseases extension
Frequency Intestinal lesions 12 Ileum
15 Ileum Colon 41 Colon without
rectum 92 Colon Rectum
Hellers G et al. Gut 198021525527.
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Association with intraabdominal fistulas
Site Number of Patients Risk Ileum 1686 0.8
2.2 Colon 1655 2.6 4.6 P lt 0.0001
Am J Gastroenterol 20051001547-1549.
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Diagnosis
Techniques Accuracy Exam Under G anesthesia
90 Fistulography CT SCAN MRI 76 -
100 Anorectal EUS 56 - 100
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Lunniss PJ et al. Dis Colon Rectum
199437708718. Haggett PJ et al. Gut
199536407410. De Souza NM et al. Dis Colon
Rectum 199639926934. Schwartz DA et al.
Gastroenterology 200112110641072.
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Measurement of fistula disease activity
Categories affected by fistulas Score
Discharge 0 - 4 Pain/restriction of
activities 0 - 4 Restriction of sexual
activity 0 - 4 Type of perianal disease 0 -
4 Degree of induration 0 - 4
Irvine EJ et al. J Clin Gastroenterol
1995202732.
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Fistula drainage assessment
End point Definition Closure Closure of
individual fistulas defined as no fistula
drainage despite gentle finger compression.
Improvement Improvement defined as a decrease
from baseline in the number of open draining
fistulas of 50 for at least 2 consecutive
visits (i.e., at least 4 weeks). Remission
Remission defined as closure of all fistulas
that were draining at baseline for at least 2
consecutive visits (i.e., at least 4 weeks).
Present DH et al. NEJM 199934013981405.
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Treatment
Medical treatment. Surgical treatment.
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Medical Treatment
Antibiotics 6-MP Azathioprine Cyclosporin
A Tacrolimus Infliximab
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Antibiotics
Metronidazole /or Ciprofloxacin. No controlled
studies. Recurrence after arrest of
treatment. Rapid onset of response. Side effects
(Metronidazole). Improvement in must
patients, but healing in 50 of patients.
Turunen U. et al. Gastroenterology
1993104A793 Solomon MJ et al. Can J
Gastroenterol 19937571573. Jakobovits J et al.
Am J Gastroenterol 198479533540. Bernstein LH.
Gastroenterology 198079357365.
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6-MP Azathioprine
No controlled trials. No differences with
placebo. Complete fistula closure 31 -
38. Partial response 54 - 77. Late onset of
response. Relapse after arrest of treatment.
Present DH et al. N Engl J Med 1980302981987. K
orelitz BI et al. Dig Dis Sci 1985305864. OBri
en JJ et al. Gastroenterology 19911013946.
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Cyclosporin A
No controlled studies. Dose 4 7.6 mg/kg/d
IV Response within 7 days. Relapse after oral Cy
A discontinuation. Complete response
44. Overall response 88. Side effects .
Hanauer SB et al. Am J Gastroenterol
199388646649. Present DH et al. Dig Dis Sci
199439374380. ONeill J et al.
Gastroenterology 1997112A1056. Egan LJ et al.
Am J Gastroenterol 199893442448.
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Tacrolimus
A single small placebo-controlled trial (43
patients). Dose 0.2 mg/kg/d PO. Response Tacrol
imus Placebo P 50 Closure
43 8 0.004 100 Closure 10
8 0.86 Side effects 38
0 0.008
Sandborn WJ et al. Gastroenterology
2003125380388.
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Infliximab
Optimal dose 5 mg/kg ( at 0, 2 6 weeks). Must
be associated with 6 MP or AZA. Complete healing
(100 closure) 55. Patial healing (50
closure) 68. Median duration of healing 3
months. Development of perianal
abscess. Maintenance treatment Loss of response
after 40 weeks. Complete closure at 54 weeks
39.
Present DH et al. NEJM 199934013981405.
Sands B et al. Gastroenterology 2002122A81.
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Surgical treatment
Fistulotomy Fistulectomy Flap anorectal,
vaginal Seton cutting or non cutting Intestinal
diversion Primary closure
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Low fistulas
A- Superficial B- Low transsphincteric C- Low
intersphincteric
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Low fistulas
20 studies, 462 patients treated by fistulotomy
GASTROENTEROLOGY 200312515081530
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Low fistulas
Results of the 21 studies Healing
rates 59 100 Recurrence rates 0
41 Incontinence rates 0 50 Proctectomy
rates 6 60
GASTROENTEROLOGY 200312515081530
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Low fistulas
Recommendations Fistulotomy in the absence of
rectal inflammation. Non cutting seton in the
presence of rectal inflammation.
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High fistulas
A High Inter sphincteric B High Tran
ssphincteric C Supra sphincteric D Extra
sphincteric
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High fistulas
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High fistulas
Results of the 29 studies Healing
rates 25 100 Recurrence rates 20 - 75
Incontinence rates 0 66 Proctectomy
rates 0 60
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Rectovaginal fistulas
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Rectovaginal fistulas
Results of the 33 studies Healing
rates 25 100 Proctectomy rates 10 70
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Rectovaginal fistulas
Recommendations
Avoid fistulotomy (Sphincter injury risk). Avoid
non cutting seton (unless there is a rectovaginal
abscess). Possible techniques Primary
closure. Transanal advancement
flap. transvaginal advancement flap.
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Management of patients
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