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What Are theTreatment Options
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forPainful Anal Fissure inPatients
withCrohn’s Disease?
MichaelA.Valente
Introduction
Perianal manifestations of Crohn’s disease (CD) disease are usually chronic in
nature, and often characterized by waxing and waning symptoms. The goals of
treatment are typically achieved through multimodal management, which minimizes surgical intervention and preserves the sphincter complex [1–3]. While there
is a broad spectrum of severity of perianal CD, even the perceived minor issue of
ssuring of the anus can present the clinician and patient with difcult decisions in
management.
Fissures are identied in approximately 20 to 40% of patients with CD and
although they are often painless, 40–85% are associated with pain [1–3].
Additionally, persistent, unhealed ssures can lead to perianal abscess and stulae
in up to 20% of patients with CD; this presents quality of life issues for the patient
and a treatment dilemma for the surgeon [2].
When chronic anal ssures in patients without CD fail to respond to conservative
measures, lateral internal sphincterotomy (LIS) is performed with a high degree of
success and limited morbidity. In the setting of active anorectal CD, however, even
a minor anorectal procedure may carry an enhanced risk of morbidity, including
wound complications, anorectal/pelvic sepsis, stulous disease and incontinence [1,
4]. Thus, a signicant degree of caution must be applied when managing the refrac-
tory painful ssure in the setting of CD.
3
M. A. Valente (*)
University of Arizona, Surgical Oncology, Tucson, AZ, USA
e-mail: vnfons@lsuhsc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_3
39
40
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M. A. Valente
Search Strategy
A comprehensive literature search of EMBASE, MEDLINE, Cochrane Database of
Collected Research and PubMed was performed to identify all of the Englishlanguage publications related to the treatment outcomes of anal ssure, Crohn’s
disease, and perianal Crohn’s disease from 1990–2022. Key search terms included
“anal ssure,” “Crohn’s disease,” “perianal Crohn’s disease,” “inammatory bowel
disease,” “lateral internal sphincterotomy,” Botulinum toxin,” and Botox.” Table3.1
summarizes the population, intervention, comparator, and key outcomes (PICO) for
the patient population.
Results
Over the last three to four decades, there has been a paucity of studies on perianal
Crohn’s disease associated ssure-in-ano. A review of the most pertinent literature
is summarized in Table 3.2, with the quality of the studies evaluated using the
GRADE system. The studies in the literature are all retrospective with low patient
numbers, with little power and no standardization of outcomes.
D’Ugo and colleagues reviewed 41 patients with Crohn’s associated ssures and
found that medical therapy was effective in 66% of patients over a 37-month follow up. Fourteen patients went on to have either lateral internal sphincterotomy or botulinum toxin injection in the internal anal sphincter, with or without ssurectomy.
The overall complication rate was 57%. However, in patients with conrmed active
Crohn’s disease of the anal canal/rectum, Botox was performed instead of LIS and
therefore, there is no true comparison between Botox and LIS in known CD
patients [2].
Similarly, Lozynskyy etal. reported a 75% healing rate with medical management in CD patients and reported they had not performed surgical treatment of a
ssure associated with CD in the last 5years of their study [5]. Fleshner and colleagues compared medical versus surgical management of CD anal ssures and
reported a 49% ssure healing rate with medical management alone, with the majority of healing in acute and painless ssures. They then compared ssure healing
rates when after patients underwent anorectal procedures versus bowel resection for
proximal disease. They showed an 88% healing rate with anorectal procedures (LIS,
ssurectomy) versus 43% healing rate with proximal bowel resection for active ileal
or colonic CD.Additionally, the authors reported that abscess or stula formation
Table 3.1 PICO table for Crohn’s disease-associated painful anal ssure
Patient population
Patients with
Crohn’s disease
and painful anal
ssure
Intervention Comparator
Lateral internal
sphincterotomy
(LIS)
Conservative medical
management
(including Botox
injection)
Key outcomes
Morbidity, pain
resolution, healing, need
for additional
intervention(s)
3 What Are the Treatment Options for Painful Anal Fissure in Patients with Crohn’s…
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Quality of
evidence
(GRADE)
Morbidity
(%) surgical
treatment
57.1 Very low
Healing (%)
surgical
management
Healing (%)
medical
management
65.8 78.5%
quality
(recurrences)
quality
41
Table 3.2 Literature reported outcomes and quality of evidence
Outcome
classication
Healing rate,
complication
rate
Healing rate 75 NR NR Very low
Medical management (27),
surgical treatment (Botox/
ssurectomy vs LIS; 14)
surgical treatment
Patients (n) Interventions (n)
41, CD (22 with
denitive
diagnosis)
60 CD Medical management (45),
Study
D’Ugo
(2013) [2]
Lozynskyy
(2009) [5]
Healing rate 50 67 NR Low quality
(Maslyak’s method; 15)
Medical management (35),
surgical treatment (LIS,
ssurectomy, bowel
resection; 15 (8 anorectal))
56 CD (49
symptomatic)
Fleshner
(1995) [6]
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arises from the base of an unhealed ssure in 26% of all patients, with no signicant
difference between the medical and surgical groups [6].
Several additional retrospective studies have been performed but very little outcome data exists. For example, Wolkomir etal. evaluated 25 CD patients undergoing 27 procedures for anal ssure. However, they did not directly report on the
healing or complication rates in their study. They did describe a mean follow up of
greater than 7 years and noted that 22 patients (88%) had a healed wound by
2 months; however, 11 patients subsequently developed anorectal pathology of
whom three developed recurrent ssure and 2 went on to proctectomy (secondary to
progression of primary disease, not due to surgery) [7]. Similarly, Sangwan etal.
studied 21 patients with anal ssure of whom six underwent LIS and one underwent
ssurectomy. However, again, no outcome data was reported in this study [8].
Although it is stated in many review articles that LIS should be reserved for
patients without active anorectal CD [1, 3, 4, 9, 10], active CD simply has not been
assessed as a study variable in any recent literature. This may be because it is
assumed to be unsafe to proceed with LIS in the setting of active CD.However, this
assumption may not be valid, especially in the era of biologic treatment for CD, and
should be validated in future studies.
M. A. Valente
Recommendations
Painful anal ssures in Crohn’s disease that do not respond to conservative measures may be treated with Botulinum toxin injection and/or lateral internal sphincterotomy. (Evidence: low; Recommendation: weak)
Surgical intervention for anal ssure may pose increased morbidity in patients
with active anorectal CD. (Evidence: low; Recommendation: weak)
There is a paucity of literature evaluating medical versus surgical management of
Crohn’s disease associated ssures. Additionally, the literature to date consists of
low to very low quality retrospective studies with incomplete outcome data. To further clarify the treatment algorithm in the presence of active perianal Crohn’s disease, new, well-designed studies are needed, especially those comparing Botox to
LIS in patients who have failed conservative medical management.
Personal View
First and foremost, the distinction between patients with a painful anal ssure that
has concurrent abdominal CD versus a patient that has a painful anal ssure in the
setting of active anorectal/perianal CD must be elucidated. The pathophysiology of
painful anal ssures in patients with abdominal CD without active anorectal disease
is similar to common ssures in the general population; they are caused by internal
sphincter muscle spasm/hypertonicity, secondary to trauma to the anoderm from
frequent, loose bowel movements. In patients without active anorectal disease, the
treatment algorithm is essentially the same as for patients without a diagnosis of
3 What Are the Treatment Options for Painful Anal Fissure in Patients with Crohn’s…
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Crohn’s disease
with painful
fissure
43
Crohn’s disease
calcium channel
blocker cream
Not healed
No active
anorectal
Nitroglycerin/
Or
LIS
Active anorectal
Crohn’s disease
Multidisciplinary
management of
Crohn’s disease
And
Not healed
Not healed
Not healed
Nitroglycerin/
calcium channel
blocker cream
Botox injection
in internal
sphincter
Continued
Crohn’s
management
+ Active disease
Consider fecal
diversion
Botox injection
in internal
sphincter
− Active disease
Fig. 3.1 Algorithm for management of ssure associated with Crohn’s disease. (From: IBD: management of a painful anal ssure and skin tags in patients with Crohn’s disease)
CD.Medical management is rst line and includes optimization of bowel habits to
minimize diarrhea (treat the proximal Crohn’s disease, loperamide, ber supplements) and a trial of topical calcium channel blocker or similar smooth muscle
relaxant (nitroglycerin is discouraged due to poor side effect prole). In the event of
an unhealed ssure, Botox injection (50–100 Units) delivered directly into the internal sphincter muscle, or LIS may be performed (Fig.3.1). Additionally, it should be
noted that painless anal ssures in patients with CD should not undergo surgery and
biologics should be utilized, as the vast majority of these will heal after starting
medical treatment.
In the setting of active anorectal CD, multidisciplinary treatment should be standard and medical management (i.e., biologics) should be considered rst line treatment, in addition to the conservative management regimen as aforementioned. The
majority of these painful ssures will heal with conservative measures, albeit it may
take considerably longer to achieve than in typical ssure patients and recurrences
are commonplace.
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M. A. Valente
When a CD painful ssure has failed aggressive medical management, Botox
(50–100units) can be injected. Additionally, the injection of 40–80mg/ml of triamcinolone (Kenalog) into any anorectal inammatory strictures and /or inammation
is often performed. If Botox injection does not result in healing of the ssure, continued aggressive medical management should be undertaken and a repeat injection
of Botox/steroid may be contemplated. Lateral internal sphincterotomy should be
contemplated and performed in refractory cases that have failed all other options.
Depending on the amount of active inammation, a closed or open approach may be
employed, but a closed approach is potentially more desirable due to the smaller
wound that is created. The patients are begun on an antibiotic regimen postoperatively (i.e., oral metronidazole) and seen in early post-operative period for
wound examination.
Consideration for temporary fecal diversion or proctectomy is considered a last
resort to palliate symptoms. In the author’s experience, there is often additional anal
pathology present, such as severe stulizing disease and/or anorectal stenosis,
which in conjunction with painful ssures, may make fecal diversion or proctectomy necessary. However, temporary fecal diversion for these anorectal ailments is
often not temporary in over 70–80% of cases, and hence, proctectomy with permeant diversion should be contemplated and discussed with the patient early on in
cases of severe, refractory disease [11].
References
1. Bolshinsky V, Church J.Management of Complex Anorectal and Perianal Crohn's disease.
Clin Colon Rectal Surg. 2019 Jul;32(4):255–60.
2. D’Ugo S, Franceschilli L, Cadeddu F, etal. Medical and surgical treatment of haemorrhoids
and anal ssure in Crohn’s disease: a critical appraisal. BMC Gastroenterol. 2013;13(1):13–47.
3. Mahmoud NN, Halwani Y, Montbrun S, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal
RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP.Current management of
perianal Crohn’s disease. Curr Probl Surg. 2017 May;54(5):262–98.
4. Lu KU, Hunt SR. Surgical management of Crohn’s disease. Surg Clin North Am.
2013;93(1):167–85.
5. Lozynskyy YS.Treatment algorithms in the case of perianal complications of Crohn’s disease.
Dig Dis. 2009;27(4):565–70.
6. Fleshner PR, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC.Anal ssure in
Crohn’s disease: a plea for aggressive management. Dis Colon Rectum. 1995;38(11):1137–43.
7. Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal ssures in
Crohn’s disease. Dis Colon Rectum. 1993;36(6):545–7.
8. Sangwan YP, Schoetz DJ, Murray JJ, Roberts PL, Coller JA.Perianal Crohn’s disease. Results
of local surgical treatment. Dis Colon Rectum. 1996;39(5):529–35.
9. Singh B, George BD, McC Mortensen NJ.Surgical therapy of perianal Crohn’s disease. Dig
Liver Dis. 2007;39(10):988–92.
10. Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR. Clinical practice
guideline for the Management of Anal Fissures. Dis Colon Rectum. 2017 Jan;60(1):7–14.
11. Gu J, Valente MA, Remzi FH, Stocchi L. Factors affecting the fate of faecal diversion in
patients with perianal Crohn's disease. Color Dis. 2015 Jan;17(1):66–72.
Elective Surgical Management
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inPatients withUlcerative Colitis: How
Many Stages?
RogerD.Hurst
Introduction
For the last three decades restorative proctocolectomy with J-pouch ileoanal anastomosis has been the primary treatment for ulcerative colitis patients who require
surgery. While most patients requiring surgery for ulcerative colitis are young and
are at baseline in good health, many are at least temporarily debilitated from either
severity of disease, infection, malnutrition, obesity, or from side effects of immunosuppressant medications. These factors can greatly increase the risk for poor surgical outcomes both in the short and long term. Even when conditions are optimized,
the ileoanal anastomosis is known to be a high risk anastomosis with frequent leaks
and pelvic sepsis. Leak rates for the procedure are reported to be between 5 and
14% [1]. This high risk for anastomotic dehiscence was recognized early in the
development of the procedure and strategies have been implemented in the hopes of
diminishing the risks and consequences of poor anastomotic healing. For these reasons performing the operation multiple stages was the initial standard approach.
However, the absolute need for staging has been questioned and many have advocated for a strategy of omitting the approach of multiple stages in selected cases and
some have advocated for omitting staging in almost all cases [2–4]. This chapter
will review the current available evidence to support the need for staging of the
operations for the treatment of ulcerative colitis.
The ileo-anal procedure can be performed in either a single stage, two-step, or
three-step approach [5, 6]. The decision points for the staging center around two
separate issues. (Tables 4.1 and 4.2).
4
R. D. Hurst (*)
Department of Surgery, University of Chicago, Chicago, IL, USA
e-mail: rhurst@surgery.bsd.uchicago.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_4
45
46
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Table 4.1 Is diversion prefered with ileal pouch-anal anastomosis?
Pt population
Ulcerative colitis
patients undergoing
ileo-anal procedure
Table 4.2 Should total colectomy with ileostomy preceed ileal pouch-anal anastomsis?
Pt population
Ulcerative colitis
patients undergoing
initial surgery
Intervention Comparator
Omission of
diverting stoma
Intervention Comparator
Total abdominal
colectomy as initial
operation
Diversion of
fecal stream
Ileo-anal
anastomosis as
initial operation
Outcomes studied
Anastomotic leaks, pelvic
sepsis, long-term function, cost,
length of hospital stay
Outcomes studied
Anastomotic leaks, pelvic
sepsis, long-term function,
cost, length of hospital stay
R. D. Hurst
1. When constructing the ileal pouch-anal reservoir and performing the ileoanal
anastomosis should the fecal stream be diverted from the pouch and the anastomosis with a loop ileostomy to allow for healing?
2. In patients who are temporarily debilitated, should a total abdominal colectomy
with end ileostomy and de-functionalized Hartmann’s pouch be performed to
allow for physiologic recovery prior to undertaking the more risky reservoir construction and ileoanal anastomosis?
This chapter will review each of these controversies.
Search Strategy
A Medline Ovid database search was performed on publications from 1985 through
November 2022 comparing ileal pouch-anal anastomosis with or without diverting
loop ileostomy. MeSH search headings utilized: restorative proctocolectomy, ileoanal, ileo-anal anastomosis, ileal pouch, ileal reservoir, ileostomy, and loop ileostomy. References found from these articles were also searched and reviewed.
Additionally “Find Citing Articles” function was utilized as a citation index to further enhance the extent of the search.
Results
Diverting Loop Ileostomy
Multiple reports have been published regarding the value of diverting loop ileostomy when performing pouch construction and creating the ileoanal anastomosis.
No denitive conclusive study exists as each of these studies is awed by either a
lack of adequate numbers, poor study design, or signicant bias. Many studies are
retrospective reports comparing only highly selected cases. Case control studies do
exist, but again in most instances these studies involve highly selected patients or
4 Elective Surgical Management inPatients withUlcerative Colitis: How Many Stages?
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Table 4.3 Studies supporting the use of diverting stomas
Patients
Patients
Author
Cohen, Z etal. [7] 1992 Retrospective,
Tjandra, J, etal. [8] 1993 Matched controls 50 50 Moderate
Williamson, MER, etal. [9] 1997 Selected 50 50 Low
Kienle P, etal. [10] 2003 Prospective
Weston-Petrus [11] 2008 Meta-analysis Moderate
Mennigen, R, etal. [12] 2011 Selected,
Date Study type
selected
cohort, Selected
retrospective
with stoma
87 71 Low
27 32 Low
89 33 Low
without
stoma
Quality of
evidence
47
insufcient numbers. Add to this, the results of these studies have been conicting.
Some studies suggesting an increased risk for anastomotic leaks and pelvic sepsis
when the diverting stoma is omitted [7–12] while other studies suggest that the presence of the stoma does not affect the rate of anastomotic complications [13–31].
The studies supporting and opposing the use of a temporary diverting stoma are
listed in Tables 4.3 and 4.4.
A common design strategy employed in many of these reports is to allow the
operative surgeon to make a judgment regarding the need for the loop ileostomy
(Those with “selected” study designs as designated in Tables 4.3 and 4.4). This
decision by the surgeon is made as a judgment regarding the risk for anastomotic
complications. The surgeon therefore decides who is at high risk and in places these
patients in the diverted group and patients judged to be a low risk are placed in the
un-diverted group. While this strategy may well be a reasonable approach in the
management of patients undergoing surgery for ulcerative colitis, when applied to a
clinical study this method of patient selection creates bias such that interpretation of
the results can be difcult. Thus by design such selective cannot conclusively demonstrate that there is no benet from the loop ileostomy. The absence of a difference
between the two groups may result from the loop ileostomy effectively taking high
risk patients and decreasing their risk to that of the lower risk group. So from these
studies using a selected approach, one can really only claimed that patients judged
to be at low risk for anastomotic complications will do as well as a high risk cohort
when the loop ileostomy is omitted. Additionally, it is important to note that there
are several studies with results that would indicate that even in patients selected in
this manner, those without a loop ileostomy have an inferior outcome [7, 9, 12].
There is only one randomized controlled trial looking at the value of diverting
loop ileostomy in restorative proctocolectomy [16]. But this study was markedly
underpowered with only 23 patients in the loop ileostomy group and 22 patients in
the un-diverted group. In each group there is only one incidence of anastomotic leak
and even with this study the patients that were randomized had been preselected by
the operating surgeon as having had a low risk for anastomotic leak.
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Table 4.4 Studies supporting omission of diverting stoma
Patients
Patients
Author
Everett WG, etal.
[13]
Matikainen M,
etal. [14]
Galandiuk S, etal
[15]
Grobler SP, etal.
[16]
Sagar PM, etal
[17]
Gorne SR, etal
[18]
Gullberg K, etal.
[19]
Hainsworth PJ,
etal. [20]
Antos, F, etal.
[21]
Dolgin SE, etal.
[22]
Mowschenson
PM, etal. [23]
Heuschen UA,
etal. [24]
Lepisto A, etal.
[25]
Ikeuchi H, etal.
[26]
Remzi FH, etal
[27]
Joyce, MR [28] 2010 Retrospective 715 120 Low
Gray BW, etal.
[29]
Sahami, etal [30] 2016 Retrospective 305 316 Low
Olecki, etal. [31] 2022 Retrospective, selected 323 91 Low
Date Study type
1990 Selected 35 29 Low
1990 Consecutive 21 25 Low
1991 Retrospective matched
controls, selected
1992 Randomized control
study, selected
1992 Consecutive, selected 28 30 Very low
1995 Retrospective, selected 69 74 Low
1995 Consecutive 7 13 Low
1998 Selected 30 72 Low
1999 Selected 20 23 Low
1999 Consecutive,
Prospective
nonrandomized
2000 Retrospective, selected 28 102 Low
2001 Matched controls,
selected
2002 Retrospective 154 332 Moderate
2005 Retrospective, selected 92 150 Low
2006 Retrospective, selected 1725 277 Low
2012 Selected 28 22 Low
with stoma
37 37 Low
23 22 Low
14 16 Low
144 57 Moderate
without
stoma
Quality of
evidence
R. D. Hurst
Perhaps the best available study to suggest that loop ileostomy may not be necessary is a matched-pair controlled study conducted by Heuschen etal. [24] In this
study 57 patients in the study group (no diversion) were compared to 114 matched
controls. Heuschen et al. found no signicant differences in early complications
including pouch related septic complications. Conversely, Tjandra, et al., also
reported a study with matched controls with 50 patients in each group and found a
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