managment of anal fistula in crohn disease
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Transcript of managment of anal fistula in crohn disease
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