Management of Anal Fistulae in Crohn

1
Management of Anal Fistulae in Crohns disease

• Bruce D George
• John Radcliffe Hospital
• Oxford

2
Perianal Crohns disease

• Penner and Crohn 1938
• Perianal involvement in 33 (range 4-80)
• Increased risk with increasingly distal
  inflammation
• 92 Crohns proctitis have perianal disease

3
Spectrum of Crohns anal pathology
Poor prognosis
Good prognosis
Fistulae
Deep cavitating ulcers
Skin tags
Fissures
Strictures
4
Spectrum of Crohns Anal Fistulae
5

• Natural history of perianal Crohns disease. Ten
  year follow-up a plea for conservatism.
• Buchmann et al 1980

109 patients
38 spontaneous fistula healing
6
Treatment Options

• Metronidazole/ciprofloxacin
• Azathioprine/6MP
• Infliximab

• Abscess drainage
• Seton drain
• Fistulotomy
• Advancement flap
• Defunctioning ileostomy
• Proctectomy

7
Problems in Surgical Management

• No random controlled trials
• Extreme opinions
• Different starting points
• Different end points
• Variable natural history
• Changing medical therapy

8
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 Crohns disease. Results of
  aggressive surgical treatment

9
Problem of end-points

• Partial/complete healing of fistula
• Duration of healing
• Continence scores
• Patient satisfaction
• Radiological/clinical healing

10

• 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

11
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

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Aims of assessment

• Detection of intestinal disease
• Proctitis
• Type of fistula(e)
• Low/high
• Undrained sepsis
• Patients symptoms and expectations

13
Principles of Surgical Treatment of of Crohns
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

14
First Aid Surgery
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Bridging treatment

• Often involves loose seton drain
• Allows patient to be established on
  immunomodulator

16
If bridging treatment going badly

• Check that sepsis drained adequately
• MRI
• Consider defunctioning stoma
• Consider proctectomy

17
Defunctioning ileostomy for perianal Crohns
disease

• to assist stabilisation
• as bridge to proctocolectomy
• 18 patients defunctioned for severe perianal
  Crohns
• 1970-1997
• 15 acute remission
• 2 reversed with satisfactory function
• Edwards et al 2000

18
Quality of Life Based Treatment

• Controlled situation
• No sepsis
• Well patient
• Seton in situ
• Established on immunomodulator

What are the treatment options?
19
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

20
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

21

• 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

22
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

23
Surgery for low fistula
Simple fistulotomy
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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

25
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

26
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

27
Advancement flap for high fistulae

• Must be no proctitis
• Joo et al 1998
• 19 0f 26 healed

28
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

29
Current protocol in Oxford

• EUA /- seton drainage. Ensure no sepsis
• Infliximab 0 and 2 weeks
• Remove seton if necessary
• Infliximab at 6 weeks

30
Proctectomy

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

31
Summary of Principles of Surgical Treatment of of
Crohns 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