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Chapter 16

Crohn Anorectal Disease

JAMES CHURCH

Perioperative Considerations

The principles of the management of perianal symptoms in patients with Crohn disease

Define the status of the proximal bowel.

Colonoscopy Esophagogastroduodenoscopy Magnetic resolution enterography (MRE)/Computed tomography enterography (CTE)

± Small bowel follow-through (MRE/CTE preferred) Is there active Crohn disease? If there is, it needs to be managed either medically or surgically. Medical treatment will often help perineal Crohn disease (Crohn disease within the tissues of the perineum). Has the patient had bowel resections?

If so, do they have diarrhea as a result and does this make them

prone to incontinence? This will exacerbate perianal symptoms.

Use of agents to slow motility, and/or bulk formers, may help.

Define the status of the anal sphincters.

What is the status of the anal sphincters? Has there been previous surgery? Childbirth?

If anal ultrasound is available, this is worth adding to the

assessment.

A thin perineum in a woman will not support flap repair of anterior

fistulas (including rectovaginal fistulas) and is an indication for one

of the following: perineoplasty, Martius flap, and gracilis flap.

Is there sepsis? If so, control it.

This will usually need an examination under anesthesia (EUA) to fully and completely assess the low rectum, anus, and the perineum. During this examination, carefully check the perianal skin for fluctuance or asymmetry.

If there is a swelling, it can be aspirated; and if pus is obtained, the

collection is incised and drained.

Openings that are already draining can be gently probed, but

remember that hidradenitis is associated with perianal Crohn disease

and an opening in the perianal skin could be from this, or a fistula

(Fig. 16-1).

FIGURE 16-1 The ravages of perianal hidradenitis suppurativa in a patient

with colonic Crohn disease.

Openings that track to the dentate line are anal fistulas. These should

be adequately drained with either a vessel loop seton or a Penrose

drain or both (Fig. 16-2).

FIGURE 16-2 Draining anterior extensions of a perianal fistula using Penrose

drains, while the primary track is drained by vessel loop setons.

Search the tracks for extensions, cavities, or sinuses, and make sure

that everything is drained or unroofed. If the symptoms and cellulitis do not settle down during the 24 hours after EUA, then another EUA is indicated. If the sepsis still cannot be controlled by local means, then fecal diversion is indicated.

Is there perineal Crohn disease?

Perineal Crohn disease is an infiltration of the perineal tissue by Crohn disease. It is associated with a characteristic clinical appearance, and

the majority of cases have perineal granulomas reported on biopsy. Perineal Crohn disease is a contraindication to incisional surgery, as wounds don’t heal (Fig. 16-3A and B).

FIGURE 16-3 A. An unhealed perianal wound in a patient with perineal Crohn

disease. This wound had been present for over a year. Biopsy of the perineum revealed typical granulomas. B. Perineal Crohn disease: Unhealed wound from fistulotomy performed a year previously.

Perineal Crohn disease usually responds well to biologic treatment, and this can prepare the region for successful local repair.

Sterile Instruments/Equipment

Equipment used for anorectal cases are as follows:

Anal retractors, fiberoptic lighted: small, medium, and large

Hill-Ferguson retractors: often used for perianal cases placed in lithotomy position Pratt bivalve anal retractor Right-angle retractors

Set of Lockhart-Mummery fistula probes Set of curettes 00-silk ties Silicon, radio-opaque yellow (mini) vessel loop, 1.3 mm wide and 0.9 mm thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick Monopolar electrocautery

We routinely use 40 cut/60 coagulation settings, pure or blend. A needle tip may be used for endorectal advancement flap.

Pezzer (mushroom) drains, size ranging from 10 to 32Fr

¼ and ½ in Penrose drains Hydrogen peroxide diluted 50-50 with sterile normal saline, placed in a 10-mL syringe with a 14-gauge angiocatheter or a blunt-tip needle

Positioning

Positioning of the patient is dependent on the site of the external and internal opening(s), with prone jackknife being optimal for anterior internal opening and lithotomy for fistulas with a posterior internal opening.

In lithotomy:

Emphasis on ergonomics cannot be understated. The edge of the

operating table may need to be moved in the caudal direction, to

ensure that the chair and feet of the operating surgeon are not

restricted by the base of the operating table. In addition, the patient’s

buttocks overhanging the edge of the operating table. In prone jackknife:

We place two shoulder rolls under the chest (taking special care to

protect the breasts) and a foam pillow (Kraske roll) under the pelvis

(taking special care to protect the genitals from pressure injury).

We typically secure the patient with a belt to prevent inadvertent

rolling.

We use tape to laterally retract the buttocks, with or without

benzoin.

Excessive tape traction will result in iatrogenic tearing (fissuring) of the anoderm—avoid.

Technique Anal Tags (Figure 16-4)

FIGURE 16-4 Elephant ear skin tags in a patient with perianal Crohn disease.

Classic “elephant ear” tags are a sign of perineal Crohn disease and should not be excised.

Symptomatic tags in the absence of perineal Crohn disease can be removed, but only after bowel habits are normalized as much as possible.

Anal Stenosis (Figure 16-5)

FIGURE 16-5 Perianal Crohn disease with anal stenosis.

Anal stenosis in patients with Crohn disease can be due to chronic diarrhea from short bowel syndrome, chronic scarring from healed anal disease, a Crohn-related stricture, sepsis, or a cancer. EUA with biopsy should determine the cause. Secondary stenosis due to chronic diarrhea doesn’t need to be treated, as long as the diarrhea is now “normal.” Strictures due to scars can be dilated and injected with steroid. (kenalog 40mg/1cc, diluted with 4cc saline) Septic strictures are treated by drainage of the sepsis with or without fecal diversion, and malignant strictures treated on their merits, according to the stage of the cancer.

Anal Fissure (Figure 16-6)

FIGURE 16-6 Perianal Crohn disease with deep-wide–based anal fissure.

If patients with Crohn disease develop a typical painful anal fissure, they are candidates for treatment with the usual ointments (diltiazem and nifedipine), and if these are ineffective, a judicious sphincterotomy.

The pain is from internal sphincter spasm, and sphincterotomy will resolve the fissure.

A painless fissure in a patient with Crohn disease is concerning for perineal Crohn disease. It is more an ulcer than a fissure and needs to be treated with biologic agents. Sphincterotomy is contraindicated. Consideration should be given for other causes if nonhealing, even consider culture or biopsy.

Anal Fistula

Anal fistulas present commonly in patients with Crohn disease. Sometimes, they are related to perineal Crohn disease and are initially drained with setons before being treated with biologics. Once the perineal Crohn is controlled and relatively asymptomatic, the internal opening can be repaired. If the fistula is a “usual” cryptoglandular anal fistula that just happens to

be present in a patient with Crohn disease, biologics are not needed and the fistula can be repaired immediately. The technique of repair is at the discretion of the surgeon, but we favor advancement flap. In our practice, it has a high success rate (87% healing), no impact on continence, and if it fails, it can be repeated. Sometimes, fistulas cannot be repaired due to ulceration or acute inflammation in and around the anal canal. Long-term seton drainage is a good way of controlling symptoms. In select cases, a “watering-can” perineum is present is Crohn, and dilute hydrogen peroxide is useful to identify all tracks (Fig. 16-7). Sepsis should be drained and setons placed.

FIGURE 16-7 Watering-can perineum in a patient with Crohn disease. Hydrogen

peroxide is injected into one opening with multiple external connections identified.

Perianal Abscess

Needs to be drained. Look in the anus at the time of drainage to see if there is pus coming from a crypt. Drainage of the abscess will often lead to a fistula, which will then need to be repaired. Often, these patients can have a purplish hue perineum (Fig. 16-8) that may mask the overt abscess. EUA is critical to palpate for fluctuance and drain the sepsis.

FIGURE 16-8 Perineum of a patient with Crohn disease. Note the purple hue of and

large tags. There is evidence of fistula tracks, and palpation will demonstrate the fluctuance of sepsis.

Hemorrhoidal Disease

Hemorrhoidal symptoms in a patient with Crohn disease may be due to abnormal bowel habit from proximal disease, from a low residue diet, or because the patient is prone to hemorrhoids anyway. If there is no perineal Crohn disease, they can be treated based on the severity of the symptoms and the degree of prolapse. If there is perineal Crohn disease, this must be treated first by biologics. Then if the hemorrhoids are still significantly symptomatic, very conservative measures can be taken (try elastic band ligation first).