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128
A. T. Schlussel and K. Alavi
a
b
Fig. 15.5 (a, b) Exam under anesthesia of complex ano-
rectal stulae in Crohn’s disease
technique was combined with a thorough
exam under anesthesia, the accuracy of
dening stula anatomy was 100%.
C. The standard in management of an anorectal
stula in the setting of CD is seton placement. Drains are typically in place prior to
the initiation of medical management, and
are often placed even before the diagnosis of
CD is made. The utilization of a silastic loop
or suture through the tract allows for adequate drainage of the stula, which prevents
further septic complications, promotes epithelialization, and provides the necessary
means to treat this process in a staged fashion. There is no limit to the duration of time
a seton drain can remain in place. However,
despite the benets, stula closure is not possible while the drain is in place. In certain
cases, this could function as a denitive treatment strategy, or provide time for medical
therapy to take effect. Seton removal alone is
associated with a 33–70% risk of a recurrent
or persistent disease. In addition, leaving a
seton in place indenitely, or not treating the
stula tract has a low but potential risk of
malignant degeneration. In a recent systematic review by Thomas et al., a total of 61
cases, from 34 separate studies, identied a
carcinoma arising from in an anorectal stula
tract. These stulas most commonly originated from the rectum (59%), with 41%
developing from the perineum or anus.
Histologically, adenocarcinoma was identied in 59% of cases, followed by squamous
cell carcinoma in in 31%. Therefore, a strong
consideration for an additional procedure to
address the stula tract is advised.
D. Prior to initiating treatment, a full endoscopic
exam should be performed to further delineate any proximal luminal disease. Surgical
intervention, short of drainage procedures,
should be approached with caution if active
proctitis is present.
E. Management strategies require a multidisci-
plinary approach and are divided into medical (antibiotic, immunologic, and biologic
therapy) and surgical. Antibiotics are typically considered rst line therapy when treating the initial infectious process.
Ciprooxacin and metronidazole have been
considered as drugs of choice.
F. In the era of biologic therapy, particularly
anti-tumor necrosis factor (TNF) agents,
seton removal following effective medical
management may be considered. Present and
colleagues in 1999 described the administration of iniximab, an anti-TNFα antibody,
for the treatment stulas in CD, and results
demonstrated complete closure in 46% of
15 Anal Conditions: Anorectal Crohn’s Disease—Fistula
129
patients. Authors evaluated both perianal and
abdominal stulas, however, 90% of the
study population consisted of those with anorectal disease. Kotze and colleagues demonstrated a remission rate of 53% seton
placement was combined with iniximab.
Further studies have supported seton removal
alone as a denitive treatment strategy following multimodal therapy. If this approach
is considered, the patient should be treated
with a minimum of three iniximab infusions, and there should be no evidence of
persistent of active proximal inammation.
G. Operative interventions depend on disease
complexity, and may be as simple as a stulotomy, or aggressive as a proctectomy. Due to
the high risk of recurrence of anorectal CD,
performing a standard lay open stulotomy
should be reserved in cases of a low- lying
simple stula, with no evidence of active proctitis. Delayed wound healing is not uncommon, for up to six months following surgery.
In the appropriately selected patient the risk of
fecal incontinence is minimal. If there is additional concern for the degree of sphincter
muscle involvement, a partial stulotomy,
opening the perianal skin to the level of the
external sphincter, and simultaneous seton
placement is a suitable option. Furthermore, if
the patient is asymptomatic, with a low stula,
observation may be the best strategy.
H. Surgical options that have minimal to no
effect on sphincter function include the injection of brin glue or the placement of a stula plug. Although the recurrence rate may
be as high as 41% and 12% for glue and stula plug respectively, these procedures have
no risk of incontinence and should be considered in CD patients with complex stula
tracts. The key steps in insertion of the stula
plug are to rst ensure all perianal sepsis is
resolved, and no active abscess remains. The
stula plug is suitable for a long external
tract to allow the plug to be seated appropriately in position. Furthermore, the internal
opening must be identied to either suture
the proximal portion of the stula plug to the
mucosa, or the mucosa must be closed over
the prosthesis, promoting incorporation of
the biosynthetic material and ultimate closure of the stula.
I. The ligation of the intersphincteric tract
(LIFT) procedure has been recently introduced as a successful treatment option for a
complex transsphincteric stula. This operation is performed within the intersphincteric
space, and involves division of the stula
tract in efforts to preserve continence without
injury to the sphincter muscles. Success of
this operation requires a well-epithelized
tract, and is often performed as a second
stage operation following placement of a
draining seton. Adequate effacement of the
anus is necessary, providing a means the
clearly identify the internal and external
sphincter complex. A transverse incision is
made over the intersphincteric groove, and
careful dissection is carried proximally into
the intersphincteric space, localizing the stula tract. Placing a probe through the tract
may aid in the dissection. Once identied,
the stula tract is encircled, clamped proximally and distally, sharply divided, partially
resected, if feasible, and suture ligated
(Fig.15.6). The tract should be probed from
the internal and external openings to ensure it
is securely closed, as this will minimize the
risk of recurrence. The internal opening is
then closed, and the external segment of the
tract is debrided. The incision is closed
loosely in a transverse fashion. This operation is associated with complete stula closer
in >60% of cases following twelve months,
however, there is a paucity of data regarding
the long term results of the LIFT procedure
in CD.Gingold and colleagues more specically reported that the LIFT was successful
in 60% of patients with CD at two months
with no evidence of fecal incontinence;
12 months after surgery, 33% of patients
were stula free. Recurrence typically presents with drainage at the incision over the
intersphincteric space. Generally, the recurrent or persistent stula has been converted
from a transsphincteric to an intersphincteric
stula, and this may be managed with a
Exter
130
nal
opening
Fig. 15.6 Ligation of intersphincteric stula tract
simple stulotomy if the tract is low.
However, seton drainage always remains an
option regardless of the stula’s anatomy.
J. Endorectal advancement ap is one option to
treat complex stulizing disease in patients
without evidence of proctitis. This technique
involves mobilizing a proximal healthy full
or partial thickness rhomboid or U-shaped
ap of rectal wall to cover and close the
internal stula opening (Fig.15.7). The base
of the ap should be twice as wide as the
apex to ensure adequate blood supply, and
ap length is determined by the size of the
defect requiring coverage. The tract should
be thoroughly debrided and then closed prior
coverage by the ap. The external opening
should be widely debrided and opened up to
A. T. Schlussel and K. Alavi
the edge of the sphincter complex to prevent
abscess recurrence. The editor’s (SDW) preference is to utilize an elliptical ap without
corners. Physiologically, by covering the
internal opening, this disrupts the ow of
feces and bacterial contents into the stula
tract allowing the external segment to obliterate and close. This technique is better suited
for cases of anal stulae located in the upper
two-thirds of the sphincter complex. In a systematic review by Soltani, the reported rate
of success was 64%, with a risk of incontinence of 9.4% in cases of CD. A proximal
diverting stoma may also be considered
depending on the extent of repair and the
number and type(s) of prior repair(s). When
possible any proximal disease should be
treated prior to attempted ap construction.
Unfortunately, only 47% of patients requiring temporary fecal diversion are able to
achieve successful stula closure, and subsequent restoration of intestinal continuity.
These patients should be strongly counseled
on the aggressive nature of their disease, and
sphincter function should be evaluated objectively prior to the consideration of stoma
reversal.
K. Due to the aggressive nature of Crohn’s
related stulas, high rate of recurrence, subsequent risk of fecal incontinence, and effect
on quality of life, innovative approaches in
the treatment of this disease process have
been popularized. In efforts to promote tissue
regeneration and repair, expanded adiposederived stem cells (ASCs) have been introduced. This substance is thought to suppress
inammation while having the potential to
differentiate into native cells to allow for the
stula tract to seal. The ASCs are harvested
from lipoaspirated fat cells that are resuspended in human albumin. The cellular
matrix is injected through a long needed
directly into the stula tract and then sealed
with brin glue. Phase III trials evaluating
this therapy identied a higher rate of stula
closure at twelve weeks when ASCs were
combined with brin glue compared to brin
glue alone; however, no signicant difference
b
15 Anal Conditions: Anorectal Crohn’s Disease—Fistula
a
c
131
Fig. 15.7 (a) Healthy full or partial thickness rhomboid
or U-shaped ap of rectal wall to cover and close the
internal stula opening. (b) Excise the tip of the ap con-
was found at 24–26 weeks postoperatively.
The authors concluded that additional investigations are required to further elucidate the
optimal use for ASC therapy.
L. To focus on managing persistent stula
tracts due to remaining stula epithelium
and granulation tissue Wilhelm in 2011
developed a novel technique using a radially
emitting diode laser probe to seal the stula
tract. The safety of this technique has been
validated in Crohn’s related stulas, and has
been studied in cases of mid or high transsphincteric stulas and anterior intersphincteric or low transsphincteric stulas in
woman with some degree of fecal incontinence. This approach was initially described
as a technique to be performed in conjunction with an endorectal advancement ap to
close the internal opening; however, a more
recent study has demonstrated a success rate
of over 70% when the laser was used alone.
taining the stula tract. (c) After debriding and closing the
tract, suture the ap to cover the internal opening
Fistula tract ablation with the diode laser has
recently been approved for use in the US but
must be used with caution in the setting of
Crohn’s perianal disease.
M. Applying similar fundamental principle to
laser therapy, Meinero and colleagues introduced the video-assisted anal stula treatment (VAAFT) in 2014. This technique
involves inserting a stuloscope into the
external opening, identifying the internal
opening and applying therapeutic interventions. Direct visualizing allows the identication of secondary tracts and undrained
abscess cavities. Once the tract is fully characterized a unipolar electrode is placed
within the stuloscope, it is slowly retracted
cauterizing the stula walls under direct
visualization. The authors reported that following six months the rate of stula closure
was 70% based on a Kaplan-Meier analysis.
This technique has been demonstrated to be a
132
A. T. Schlussel and K. Alavi
safe and feasible option in the treatment of
complex perianal CD.
N. Despite the advancements in medical therapy
and surgical techniques patients with moderate to severe CD may still require a colostomy or an ileostomy. Patients with fulminant
disease may ultimately require a proctectomy. Temporary or permanent diversion has
been reported at rates of 20%, and a strong
multidisciplinary approach to the treatment
of anorectal CD can aid in avoiding this operation. Typically, fecal diversion is reserved
for cases of chronic perianal CD refractive to
medical therapy, where systemic medications
may be used in addition to minimize the incidence of recurrent disease. In addition, fecal
diversion should be considered in cases of
fecal incontinence secondary to disease progression or as the result of multiple stula
operations. Kasperek etal. even reported an
improved quality of life in regards to bowel
function when diverted patients were compared to those with active severe perianal
Crohn’s.
O. Proctectomy, or proctocolectomy based on
the degree of luminal involvement, should be
reserved for cases of anal CD where localized sepsis cannot be controlled with either
medical or surgical interventions, anal disease so extensive a local surgery is precluded,
poor quality of life due to persistent incontinence despite diversion, and inability to continue chronic wound care. Despite removal
of all disease with an abdominoperineal
resection, these patients will have difculty
healing a perineal wound, and the surgeon
should consider myocutaneous ap coverage
in the appropriate setting.
Conclusion
Perianal CD is a complex and challenging
entity to treat. The principles in management
includes correctly identifying and closing the
internal opening, while fully characterizing the
anatomy in efforts to obliterate and close all s-
tula tracts and remaining abscess cavities. With
a variable number of presentations, the medical
and surgical treatment must be individualized
to minimize morbidity while preventing recurrence and incontinence. Given these challenges
long-term non-cutting seton drainage combined
with medical therapy may be the most realistic
option.
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Anorectal Crohn’s Disease: Anal
Stenosis andAnal Fissure
JeanetteZhang andHowardM.Ross
16
Refer toAlgorithm inFig. 16.1
A. Anal strictures with brotic induration have
been shown to develop in up to 50% of
patients with Crohn’s disease (CD) with anal
ulceration. These become clinically signicant in about 5% of those with perianal
CD.Strictures often are asymptomatic or produce minimal symptoms due to reduced stool
consistency in CD. When symptoms do
occur, they can include overow diarrhea,
perineal pain, constipation and/or fecal incontinence. Dilation can be achieved in many
ways: digital, with dilators, or balloon dilation; each option will be discussed in this
chapter. The latter method has become the
choice for many, entailing a considerable
long-term cost. A perianal Crohn’s disease
scoring system can be useful to help decide
upon therapeutic alternatives and to monitor
disease status.
B. The extent of perianal, intestinal and colonic
disease are chief considerations prior to pursuing dilation. We generally start with a thor-
J. Zhang
Department ofSurgery, Temple University Hospital,
Philadelphia, PA, USA
H. M. Ross (*)
Division ofColon andRectal Surgery, Lewis Katz
School ofMedicine at Temple University, Temple
University Health System, Philadelphia, PA, USA
e-mail: Howard.Ross@Tuhs.Temple.Edu
ough examination under anesthesia to
evaluate the extent of perianal disease and
characteristics of the stricture. Computerized
tomographic enterography and magnetic resonance imaging are important modalities to
evaluate the extent of intestinal and colonic
disease. In addition, appropriate endoscopic
surveillance/evaluation should be performed
in all patients with Crohn’s, as the risk of
malignancy both at the site of stricture and
more proximal are higher than in the general
population.
C. Fecal continence must always be considered.
Baseline fecal incontinence and extensive
perianal disease might be more satisfactorily
addressed with combinations of resection and
diversion. Biopsy of strictures, ulcers and
chronic stulae is recommended to exclude
malignancy, though this is rare.
D. Interestingly, there are no published guidelines
or standards regarding Crohn’s anal stricture
dilation. In a retrospective study by Linares
etal., patients with anorectal strictures underwent anal dilatation, which was performed by
gentle digital examination in the majority of
patients or by coaxial balloon technique in a
few patients. In ~70% of cases, one or two
dilatations were sufcient to improve symptoms related to anal stricture. Dilatation should
be cautiously performed owing to the risk of
sepsis. The authors reported subsequent
abscess and stulas in 18% (6/33) of patients,
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_16
135
136
J. Zhang and H. M. Ross
Fig. 16.1 Algorithm for anal stricture
with this risk being increased in the event of
severe proctitis or associated sepsis during the
surgery. Thus, an anorectal stricture cannot be
dilated in the presence of severe anal disease or
proctitis. Medical treatment is recommended
in such patients.
E. A recent study from a single university teach-
ing hospital demonstrated the technical feasibility, safety, long-term efcacy and
cost-effectiveness of bougie dilation of CD
anal strictures. Ten patients with symptomatic
strictures underwent serial dilation with silicone bougies, undergoing as few as 14 to as
many as 106 procedures. All patients in their
sample reported immediate symptom improvement and noted increased treatment interval
over the course of follow up, though 6 were still
undergoing periodic dilations at time of publication. The authors determined bougie dilation
to be a cost-effective manner of improving
symptoms and, perhaps more importantly, of
avoiding the need for surgical division of strictures and its associated complications.
F. Surgical division of short brotic strictures
that are recalcitrant to dilation can be
employed. Both open and endoscopic techniques are appropriate to divide the stricture
from proximal to distal in a direction parallel
to the length of the bowel. Lee and colleagues
described an intriguing Heineke–Mikulicz
technique in a small number of patients (6).
In their recently published work, 7 patients
with anorectal Crohn’s disease underwent
transanal rectal stricturoplasty using a
16 Anorectal Crohn’s Disease: Anal Stenosis andAnal Fissure
137
Fig. 16.2 Transanal rectal stricturoplasty. (With permission from Lee SW, Niec R, Melnitchouk, Samdani
T.Transanal anorectal stricturoplasty using the Heineke–
Heineke–Mikulicz type stricturoplasty (Fig.
16.2) and found it a simple and effective
treatment of with low morbidity.
G. In the presence of extensive perianal disease,
treatment should focus on control of infection
and medical optimization rather than dilation
or surgical intervention. Similarly, addressing
anal disease in the context of extensive intestinal or colonic disease may not be the most
appropriate manner to help the patient.
H. Patients with extensive stricture should be
periodically re-examined both to ensure that
there is adequate patency, as well as to look
for a potential malignant growth, with case
reports of squamous cell and adenocarcinoma arising in perianal Crohn’s disease.
Despite all medical therapy and non-operative treatment, a small percentage of patients
Mikulicz principle: a novel technique. Colorectal Disease
2016;18:101–5 © John Wiley and Sons)
may require permanent diversion or even
proctectomy.
Refer toAlgorithm inFig. 16.3
A. Anal fissures most commonly present with
pain, though patients may also experience
discharge, pruritus and bleeding. Similar
to the general population, they are most
commonly located in the posterior midline. However, fissures in CD are more
likely than in the general population to be
eccentrically located, with 9–20% located
away from the midline. Fissures are also
more likely to have atypical appearance
and can cause deep ulcerations. The edges
of such lesions are edematous and irregu-