Download PDF
Clin Colon Rectal Surg 2001; 14(2): 117-128
DOI: 10.1055/s-2001-15849
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Management of Anorectal Crohn's Fistulas

David E. Beck
  • Department of Colon and Rectal Surgery, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, LA
Further Information

Publication History

Publication Date:
31 December 2001 (online)

Also available at
    Permissions and Reprints

ABSTRACT

The evaluation and management of anorectal fistulas in Crohn's disease remails a challenging delemma. An adequate evaluation delineates the extent of disease and guides therapy to alleviate symptoms while avoiding untoward side effects. Therapeutic options have evolved over the last few decades and vary from medical therapy to operative techniques. Medical therapy includes antibiotics and immunomodulators. Drainage setons or catheters offer long-term palliation without the risk of incontinence. Cautiously aggressive surgery, including fistulotomy and advancement flaps, allow significant symptomatic improvement. A protective temporary loop ileostomy may be a useful adjunct in some patients, especially in cases of redo flap surgery. If proctectomy is required, an intersphincteric dissection optimizes the chance for wound healing. An algorithm is presented to guide diagnosis and treatment.

KEYWORD

Crohn's disease - fistulas - anorectal - fistulo-in-ano

REFERENCES

  • 1 Alabaz O, Weiss E G. Anorectal Crohn's disease. In: Beck DE, Wexner SD, eds. Fundamentals of Anorectal Surgery, 2nd ed London: WB Saunders 1998: 498-509
    Search in Google Scholar
  • 2 Nivatvongs S, Gordon P H. Crohn's disease. In: Gordon PH, Nivarvongs S, eds. Principles and Practice of Surgery for the Colon, Rectum, and Anus, 2nd ed St. Louis: Quality Medical Publishing 1999: 907-974
    Search in Google Scholar
  • 3 Penner A, Crohn B B. Perianal fistulae as a complication of regional enteritis.  Ann Surg . 1938;  108 867
    CrossrefPubMedSearch in Google Scholar
  • 4 Williamson P R, Hellinger M D, Lorach S W, Ferrara A. Twenty-year review of the surgical management of perianal Crohn's disease.  Dis Colon Rectum . 1995;  38 389-392
    CrossrefPubMedSearch in Google Scholar
  • 5 Pescatori M, Interisano A, Basso L. Management of perianal Crohn's disease: results of a multicenter study in Italy.  Dis Colon Rectum . 1995;  38 121-124
    PubMedSearch in Google Scholar
  • 6 Alexander-Williams J. The management of intestinal fistulae.  Helv Chir Acta . 1994;  60 1025-1029
    PubMedSearch in Google Scholar
  • 7 Schoetz Jr J D. Gastroduodenal Crohn's disease.  Prospect Colon Rectal Surg . 1992;  5 145-152
    PubMedSearch in Google Scholar
  • 8 Law P J, Talbot R W, Bartman C I, Northover J MA. Anal endosonography in the evaluation of perianal sepsis and fistula in ano.  Br J Surg . 1989;  76 752-755
    PubMedSearch in Google Scholar
  • 9 Deen K I, Williams J G, Hutchinson R. Fistulas in ano: endoanal ultrasonographic assessment assists decision making for surgery.  Gut . 1994;  35 391-394
    PubMedSearch in Google Scholar
  • 10 Yang Y K, Wexner S D, Nogueras J J. The role of anal ultrasound in the assessment of benign anorectal disease.  Coloproctology . 1993;  5 260-264
    PubMedSearch in Google Scholar
  • 11 Ratto C, Gentile E, Merico M. How can the assessment of fistula-in-ano be improved.  Dis Colon Rectum . 2000;  43 1375-1382
    PubMedSearch in Google Scholar
  • 12 Seow-Choen F, Burnett S, Bartram C I, Nicholls R J. Comparison between anal endosonography and digital examination in the evaluation of anal fistulae.  Br J Surg . 1991;  78 445-447
    PubMedSearch in Google Scholar
  • 13 Lunniss P J, Barker P G, Sultan A H. Magnetic resonance imaging of fistula-in-ano.  Dis Colon Rectum . 1994;  37 708-718
    PubMedSearch in Google Scholar
  • 14 Haggett P J, Moore N R, Shearman J D. Pelvic and perineal complications of Crohn's disease: assesment using magnetic resonance imaging.  Gut . 1995;  36 407-410
    PubMedSearch in Google Scholar
  • 15 Tjandra J I, Sissons G R. Magnetic resonance imaging facilitates assessment of perianal Crohn's disease.  Aust NZ J Surg . 1994;  64 470-474
    PubMedSearch in Google Scholar
  • 16 Orsoni P, Barthet M, Portier F. Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn's disease.  Br J Surg . 1999;  86 360-364
    CrossrefPubMedSearch in Google Scholar
  • 17 Jenss H, Starlinger M, Skaleij M. Magnetic resonance imaging in perianal Crohn's disease.  Lancet . 1992;  340 1286
    PubMedSearch in Google Scholar
  • 18 Van Beers B, Grandin C, Kartheuser A. MRI of complicated anal fistulae: comparison with digital examination.  J Comput Tomogr . 1994;  18 87-90
    PubMedSearch in Google Scholar
  • 19 Beckingham I J, Spencer J A, Ward J. Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano.  Br J Surg . 1996;  83 1396-1398
    PubMedSearch in Google Scholar
  • 20 deSouza N M, Hall A S, Puni R. High resolution magnetic resonance imaging of the anal sphincter using a dedicated endoanal coil. Comparison of magnetic resonance imaging and surgical findings.  Dis Colon Rectum . 1996;  39 926-934
    PubMedSearch in Google Scholar
  • 21 Kuijpers H C, Schulpen T. Fistulography for fistula-in-ano: is it useful?.  Dis Colon Rectum . 1985;  28 103-104
    PubMedSearch in Google Scholar
  • 22 Weisman R I, Orsay C P, Pearl R K, Abcarian H. The role of fistulography in fistula in ano: report of five cases.  Dis Colon Rectum . 1991;  34 181-184
    PubMedSearch in Google Scholar
  • 23 Schratter-Sehn A U, Lochs H, Vogelsang H, Schurawitzki H. Endoscopic ultrasonography versus computed tomography in the differential diagnosis of perianorectal complications in Crohn's disease.  Endoscopy . 1993;  25 582-586
    PubMedSearch in Google Scholar
  • 24 Stein R B, Hanauer S B. Medical therapy for inflammatory bowel disease.  Gastroenterol Clin North Am . 1999;  28 297-321
    CrossrefPubMedSearch in Google Scholar
  • 25 Bernstein L H, Frank M S, Brandt L J, Boley S J. Healing of perineal Crohn's disease with metronidazole.  Gastroenterology . 1980;  79 357-365
    PubMedSearch in Google Scholar
  • 26 Hanauer S B, Meyers S, Sachar D B. The pharmacology of anti-inflammatory drugs in inflammatory bowel disease. In: Kirsner JB, Shorter RG, eds. Inflammatory Bowel Disease, 4th ed Baltimore: Williams & Wilkins 1995: 643-663
    Search in Google Scholar
  • 27 Praentera C, Zannoli F, Scribano M L. An antibiotic regimen for the treatment of active Crohn's disease. A randomized, controlled clinical trial of metronidazole plus ciprofloxacin.  Am J Gastroenterol . 1996;  91 328-332
    PubMedSearch in Google Scholar
  • 28 Turunen U, Farkkila V, Valtonen V. Long-term outcome of ciprofloxacin treatment in severe perianal or fistulous Crohn's disease.  Gastroenterology . 1993;  104 A793
    PubMedSearch in Google Scholar
  • 29 Kirschner B S. Safety of azathioprine and 6-mercaptopurine in pediatric patients with inflammatory bowel disease.  Gastroenterology . 1998;  115 813-821
    PubMedSearch in Google Scholar
  • 30 Korelitz B I, Adler D J, Mendelsohn R A, Sacknoff A L. Long-term experience with 6-mercaptopurine in the treatment of Crohn's disease.  Am J Gastroenterol . 1993;  88 1198-1205
    PubMedSearch in Google Scholar
  • 31 Korelitz B I, Present D H. Favorable effect of 6-mercaptopurine on fistulae of Crohn's disease.  Dig Dis Sci . 1985;  30 58-64
    CrossrefPubMedSearch in Google Scholar
  • 32 Van Dullemen M H, Van Deventer J H S, Hommes D W. Treatment of Crohn's disease with anti-tumor necrosis factor chimeric monoclonal antibody (cA2).  Gastroenterology . 1995;  109 129-135
    PubMedSearch in Google Scholar
  • 33 Targan S R, Hanauer S B, Van Deventer J H S. A short-term study of chimeric monoclonal antibody cA2 to tumor necrosis factor alpha for Crohn's disease. Crohn's disease cA2 Study Group.  N Engl J Med . 1997;  337 1029-1035
    CrossrefPubMedSearch in Google Scholar
  • 34 Beck D E, Fazio V W, Lavery I L. Catheter drainage of ischiorectal abscesses.  South Med J . 1988;  81 444-446
    PubMedSearch in Google Scholar
  • 35 Halme L, Sainio A P. Factors related to frequency, type, and outcome of anal fistulas in Crohn's Disease.  Dis Colon Rectum . 1995;  38 55-59
    CrossrefPubMedSearch in Google Scholar
  • 36 Williams J G, Rothenberger D A, Nemer F D, Goldberg S M. Fistula-in-ano in Crohn's disease. Results of aggressive surgical treatment.  Dis Colon Rectum . 1991;  34 378-384
    CrossrefPubMedSearch in Google Scholar
  • 37 Kennedy H L, Zegarra J P. Fistulotomy without external sphincter division for high anal fistulae.  Br J Surg . 1990;  77 898-901
    CrossrefPubMedSearch in Google Scholar
  • 38 Cronkite E T, Lozner E L, Deaver J M. Use of thrombin and fibrinogen in skin grafting.  JAMA . 1944;  124 976-978
    PubMedSearch in Google Scholar
  • 39 Hjortrup A, Moesgaard F, Kjaergard J. Fibrin adhesive in the treatment of perineal fistulas.  Dis Colon Rectum . 1991;  34 752-754
    CrossrefPubMedSearch in Google Scholar
  • 40 Abel M E, Chiu Y S, Russell T R, Volpe P A. Autologous fibrin glue in the treatment of rectovaginal and complex fistulas.  Dis Colon Rectum . 1993;  36 447-449
    CrossrefPubMedSearch in Google Scholar
  • 41 Cintron J R, Park J J, Orsay C P. Repair of fistulas-in-ano using fibrin adhesive: Long-term follow-up.  Dis Colon Rectum . 2000;  43 944-950
    CrossrefPubMedSearch in Google Scholar
  • 42 Venkatesh K S, Ramanujam P. Fibrin glue application in the treatment of recurrent anorectal fistulas.  Dis Colon Rectum . 1999;  42 1136-1139
    CrossrefPubMedSearch in Google Scholar
  • 43 Park J J, Cintron J R, Orsay C P. Repair of chronic anorectal fistulae using commercial fibrin sealant.  Arch Surg . 2000;  135 166-169
    CrossrefPubMedSearch in Google Scholar
  • 44 Ramirez R, Beck D E. Use of Tisseel fibrin sealant for complex fistulas using conscious sedation.  Dis Colon Rectum . 2000;  43 A51-52
    PubMedSearch in Google Scholar
  • 45 Marks C G, Ritchie J K, Lockhart-Mummery H E. Anal fistulas in Crohn's disease.  Br J Surg . 1981;  68 525-527
    PubMedSearch in Google Scholar
  • 46 Nordgren S, Fasth S, Hulten L. Anal fistulas in Crohn's disease: incidence and outcome of surgical treatment.  Int J Colorectal Dis . 1992;  7 214-218
    CrossrefPubMedSearch in Google Scholar
  • 47 Scott N A, Nair A, Hughes L E. Anovaginal and rectovaginal fistula in patients with Crohn's disease.  Br J Surg . 1992;  79 1379-1380
    CrossrefPubMedSearch in Google Scholar
  • 48 Jones I T, Fazio V W, Jagelman D G. The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum.  Dis Colon Rectum . 1987;  30 919-923
    CrossrefPubMedSearch in Google Scholar
  • 49 Wise Jr E W, Aguilar P S, Padmanabhan A. Surgical treatment of low rectovaginal fistulas.  Dis Colon Rectum . 1991;  34 271-274
    CrossrefPubMedSearch in Google Scholar
  • 50 Makowiec F, Jehle E C, Becker H D, Starlinger M. Clinical course after transanal advancement flap repair of perianal fistulas in Crohn's disease.  Br J Surg . 1995;  82 603-606
    PubMedSearch in Google Scholar
  • 51 Lewis P, Bortolo D C. Treatment of transsphincteric fistulae by full thickness anorectal advancement flap.  Br J Surg . 1990;  77 1187-1189
    PubMedSearch in Google Scholar
  • 52 Hyman N. Endoanal advancement flap repair for complex anorectal fistulas.  Am J Surg . 1999;  178 337-340
    CrossrefPubMedSearch in Google Scholar
  • 53 Ozuner G, Hull T L, Cartmill J, Fazio V W. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas.  Dis Colon Rectum . 1996;  39 10-14
    PubMedSearch in Google Scholar
  • 54 Lowry A C, Thorson A G, Rothenberger D A, Goldberg S M. Repair of simple rectovaginal fistulas.  Influence of previous repairs. Dis Colon Rectum . 1988;  31 676-678
    PubMedSearch in Google Scholar
  • 55 Joo J S, Weiss E G, Nogueras J J, Wexner S D. Endorectal advancement flap in perianal Crohn's disease.  Am Surg . 1998;  64 147-150
    PubMedSearch in Google Scholar
  • 56 Strong S, Fazio V W. The surgical management of Crohn's disease. In: Kirsner JB, ed. Inflammatory Bowel Disease Philadelphia: WB Saunders; 2000: 658-709
    Search in Google Scholar
  • 57 Lentner A, Wienert V. Long-term, indwelling setons for low transsphincteric and intersphincteric anal fistulas: experience with 108 cases.  Dis Colon Rectum . 1996;  39 1097-1101
    PubMedSearch in Google Scholar
  • 58 Koganei K, Sugita A, Harada H. Seton treatment for perianal Crohn's fistulas.  Surg Today . 1995;  25 32-36
    CrossrefPubMedSearch in Google Scholar
  • 59 Scott H J, Northover J M. Evaluation of surgery for perianal Crohn's fistulas.  Dis Colon Rectum . 1996;  39 1039-1043
    PubMedSearch in Google Scholar
  • 60 Zelas P, Jagelman D G. Loop ileostomy in the management of Crohn's colitis in the debilitated patient.  Ann Surg . 1980;  191 164-168
    PubMedSearch in Google Scholar
  • 61 Harper P H, Kettlewell M G, Lee E C. The effect of split ileostomy on perianal Crohn's disease.  Br J Surg . 1982;  69 608-610
    PubMedSearch in Google Scholar
  • 62 Post S, Herfanth C, Schumacher H. Experience with ileostomy and colostomy in Crohn's disease.  Br J Surg . 1995;  82 1629-1633
    PubMedSearch in Google Scholar
  • 63 Cola B, Feralla S, Marzo C. La localizzazione ano-perianale della malattia di Crohn: trattamento erisultati. In: Delami GG, ed. Attalita Chirgiche Nelle Malattie del Colon-Retto-Ano Verona: Bi & Gi Publishers 1992: 256
    Search in Google Scholar
  • 64 McKee R F, Keenan R A. Perianal Crohn's disease. Is it all bad news?.  Dis Colon Rectum . 1996;  39 136-142
    PubMedSearch in Google Scholar
  • 65 Fuhrman G M, Larach S W. Experience with perirectal fistulas in patients with Crohn's disease.  Dis Colon Rectum . 1989;  32 847-848
    PubMedSearch in Google Scholar
  • 66 Sohn N, Korelitz B I, Weinstein M A. Anorectal Crohn's disease: definitive surgery for fistulas and recurrent abscesses.  Am J Surg . 1980;  139 394-397
    CrossrefPubMedSearch in Google Scholar
  • 67 Morrison J G, Gathright Jr B J, Ray J E. Surgical management of anorectal fistulas in Crohn's disease.  Dis Colon Rectum . 1989;  32 492-496
    CrossrefPubMedSearch in Google Scholar
  • 68 Levien D H, Surrell J, Mazier W P. Surgical treatment of anorectal fistula in patients with Crohn's disease.  Surg Gynecol Obstet . 1989;  169 133-136
    PubMedSearch in Google Scholar
  • 69 Wolff B G, Culp C E, Beart Jr W R. Anorectal Crohn's disease: a long-term perspective.  Dis Colon Rectum . 1985;  28 709-711
    PubMedSearch in Google Scholar
  • 70 Moon H K, Caminer D, Boyd B. Unhealed perineal wounds. In: Wexner SD, Vernava AM III, eds. Clinical Decision Making in Colorectal Surgery New York: Igaku-Shoin 1995: 217-223
    Search in Google Scholar
  • 71 Kodner I J. Perianal Crohn's disease. In: Allan RN, Rhodes JM, Hanauer SB, et al., eds. Inflammatory Bowel Diseases Edinburgh: Churchill-Livingstone 1997: 863-872
    Search in Google Scholar