Management of Anal Fistulae in Crohn�s disease

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					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                             Poor
prognosis                        prognosis


                 Fistulae     Deep cavitating
Skin tags
                              ulcers
      Fissures   Strictures

                                        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   •   Abscess drainage
• Azathioprine/6MP              •   Seton drain
• Infliximab                    •   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 aid
      Incision and drainage of abscess


2. Bridging treatment
      Aims to convert acute uncontrolled situation into potentially curative situation


3. Quality of life based treatment
      Attempt to heal fistula if symptomatic and realistic
                                                                         Oxford
4. Proctectomy and permanent stoma
                                                                            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’s
      1970-1997
      15 acute remission
      2 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-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

                                                  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                         Oxford
   – 81% “successful”

                                                     Colorectal
         Fistulotomy for low fistulae

• 60-80% healing of fistula

• 20-40% slow wound healing

• 10%-20% risk of recurrence

• Small risk of incontinence

                                               Oxford
• Most studies report better results if no proctitis

                                                 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 aid
      Incision and drainage of abscess
      uncontroversial
2. Bridging treatment
      Aims to convert acute uncontrolled situation into potentially curative situation
      Seton and immunomodulator
3. Quality of life based treatment
      Attempt to heal fistula if symptomatic and realistic (low and no proctitis)
      Consider other options                                            Oxford
4. Proctectomy and permanent stoma

                                                                            Colorectal

				
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