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What Are theTreatment Options

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forPainful Anal Fissure inPatients withCrohn’s Disease?

MichaelA.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 difcult decisions in management.

Fissures are identied 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 signicant degree of caution must be applied when managing the refrac-

tory painful ssure in the setting of CD.

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.), Difcult Decisions in Colorectal Surgery, Difcult Decisions in Surgery: An Evidence-Based Approach,

https://doi.org/10.1007/978-3-031-42303-1_3

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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,” “inammatory bowel disease,” “lateral internal sphincterotomy,” Botulinum toxin,” and Botox.” Table3.1 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 conrmed 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 etal. 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 5years 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

Table 3.2 Literature reported outcomes and quality of evidence

Outcome

classication

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

denitive

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 signicant difference between the medical and surgical groups [6].

Several additional retrospective studies have been performed but very little outcome data exists. For example, Wolkomir etal. 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 etal. 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

Crohn’s disease

calcium channel

blocker cream

Not healed

No active anorectal

Nitroglycerin/

LIS

Active anorectal Crohn’s disease

Multidisciplinary

management of

Crohn’s disease

And

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 prole). 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 (50–100units) can be injected. Additionally, the injection of 40–80mg/ml of triamcinolone (Kenalog) into any anorectal inammatory strictures and /or inammation 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 inammation, 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, etal. 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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inPatients withUlcerative Colitis: How Many Stages?

RogerD.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).

R. D. Hurst (*) Department of Surgery, University of Chicago, Chicago, IL, USA e-mail: rhurst@surgery.bsd.uchicago.edu

https://doi.org/10.1007/978-3-031-42303-1_4

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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 denitive conclusive study exists as each of these studies is awed by either a lack of adequate numbers, poor study design, or signicant 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

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Table 4.3 Studies supporting the use of diverting stomas

Patients

Author Cohen, Z etal. [7] 1992 Retrospective,

Tjandra, J, etal. [8] 1993 Matched controls 50 50 Moderate Williamson, MER, etal. [9] 1997 Selected 50 50 Low Kienle P, etal. [10] 2003 Prospective

Weston-Petrus [11] 2008 Meta-analysis Moderate Mennigen, R, etal. [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

insufcient numbers. Add to this, the results of these studies have been conicting. 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 difcult. Thus by design such selective cannot conclusively demonstrate that there is no benet 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

Author Everett WG, etal.

[13] Matikainen M,

etal. [14] Galandiuk S, etal

[15] Grobler SP, etal.

[16] Sagar PM, etal

[17] Gorne SR, etal

[18] Gullberg K, etal.

[19] Hainsworth PJ,

etal. [20] Antos, F, etal.

[21] Dolgin SE, etal.

[22]

Mowschenson PM, etal. [23]

Heuschen UA, etal. [24]

Lepisto A, etal. [25]

Ikeuchi H, etal. [26]

Remzi FH, etal [27]

Joyce, MR [28] 2010 Retrospective 715 120 Low Gray BW, etal.

[29] Sahami, etal [30] 2016 Retrospective 305 316 Low Olecki, etal. [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 etal. [24] In this study 57 patients in the study group (no diversion) were compared to 114 matched controls. Heuschen et al. found no signicant 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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