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306
P. Rooney and N. Eardley
be weighed up against the potential side effects of the drugs, and it is often benefi -
cial to have this treatment guided by the gastroenterologist. In our practice, we are
currently moving away from treating with metronidazole and mesalamine postop-
eratively and aim to enter patients into the TOPPIC (Trial Of Prevention of Post-
operative Crohn’s disease) trial, a randomized controlled trial of 6-mercaptopurine
vs. placebo to prevent recurrence of Crohn’s disease after surgical resection.
21.4.13 What Are the Considerations for Surgery for Recurrent
Crohn’s Disease?
Approximately 80% of patients with small bowel Crohn’s disease will need surgical
treatment within their lifetime, and 30–50% of these will need further surgery within
the subsequent 10 years [ 54– 56 ] . Recurrent Crohn’s disease is frequently at the site
of the anastomosis and may require further resection or in some situations or may
be treatable by strictureplasty. Surgery for recurrent Crohn’s disease should aim to
make a full assessment of the bowel and conserve bowel length if possible remem-
bering that surgery for Crohn’s disease is not curative but should be about best
managing the complications of the disease using the principles described here,
especially “SNAP.”
References
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Key Points
Surgery can’t cure Crohn’s.•
Surgery is good for stricturing disease.•
Use SNAP when approaching complex disease, drain sepsis at every •
opportunity and pay attention to nutrition.
Do not be afraid to make a stoma. •
307
21 Surgery for Small Bowel Crohn’s Disease
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treated with azathioprine or 6-mercaptopurine. Lancet. 1996;347:215–9.
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of Crohn’s disease. Cochrane Database Syst Rev. 2009;4:CD006873.
18. Kandiel A, Fraser AG, Korelitz BI, et al. Increased risk of lymphoma among infl ammatory
bowel disease patients treated with azathioprine and 6-mercaptopurine. Gut.
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19. Feagan BG, Rochon J, Fedorak RN, et al. Methotrexate for the treatment of Crohn’s disease.
The North American Crohn’s Study Group Investigators. N Engl J Med. 1995;332:292–7.
20. Feagan BG, Fedorak RN, Irvine EJ, et al. A comparison of methotrexate with placebo for the
maintenance of remission in Crohn’s disease. North American Crohn’s Study Group
Investigators. N Engl J Med. 2000;342:1664–6.
21. Connell W, Miller A. Treating infl ammatory bowel disease during pregnancy: risks and safety
of drug therapy. Drug Saf. 1999;21:311–23.
22. Rutgeerts P, Hiele M, Geboes K, et al. Controlled trial of metronidazole treatment for preven-
tion of Crohn’s recurrence after ileal resection. Gastroenterology. 1995;108:1617–21.
23. Rutgeerts P, Van Assche G, Vermeire S, et al. Ornidazole for prophylaxis of post operative
Crohn’s disease recurrence: a randomized, double blind, placebo controlled trial.
Gastroenterology. 2005;128(4):856–61.
24. Hanauer SB, Feagan BG, Lichtenstein GR, et al. Maintenance infl iximab for Crohn’s disease:
the ACCENT I randomized trial. Lancet. 2002;359:1541–9.
25. Rutgeerts P, Feagan BG, Lichtenstein GR, et al. Comparison of scheduled and episodic treat-
ment strategies of infl iximab in Crohn’s disease. Gastroenterology. 2004;126:402–13.
26. Sands BE, Anderson FH, Bernstein CN, et al. Infl iximab maintenance therapy for fi stulizing
Crohn’s disease. N Engl J Med. 2004;350:876–85.
27. Hanauer SB, Sandborn WJ, Rutgeerts P, et al. Human anti-tumor necrosis factor monoclonal
antibody (adalimumab) in Crohn’s disease: the CLASSIC I trial. Gastroenterology.
2006;130:323–33.
28. Sandborn WJ, Hanauer SB, Rutgeerts P, et al. Adalimumab for maintenance treatment of
Crohn’s disease: results of the CLASSIC II trial. Gut. 2007;56:1232–9.
29. Hommes D, Baert F, Van Assche G, et al. A randomized controlled trial evaluating the ideal
medical management for Crohn’s disease: top-down verses step-up strategies. Gastroenterology.
2005;128 Suppl 2:A577.
308
P. Rooney and N. Eardley
30. Calkins BM. A meta-analysis of the role of smoking in infl ammatory bowel disease. Dig Dis
Sci. 1989;34:1841–54.
31. Timmer A, Sutherland LR, Martin F. Oral contraceptive use and smoking are risk factors for
relapse in Crohn’s disease. Canadian Mesalamine for Remission of Crohn’s Disease Study
Group. Gastroenterology. 1998;114:1143–50.
32. Cottone M, Rosselli M, Orlando A, et al. Smoking habits and recurrence in Crohn’s disease.
Gastroenterology. 1994;106:643–8.
33. Cosnes J, Beaugerie L, Carbonnel F, et al. Smoking cessation and the course of Crohn’s dis-
ease: an intervention study. Gastroenterology. 2001;120:1093–9.
34. Michelassi F, Stella M, Balestracci T, et al. Incidence, diagnosis and treatment of enteric and
colorectal fi stulae in patients with Crohn’s disease. Ann Surg. 1993;218(5):660–6.
35. Poritz LS, Rowe WA, Koltun WA. Remicade does not abolish the need for surgery in fi stuliz-
ing Crohn’s disease. Dis Colon Rectum. 2002;45(46):771–5.
36. Kaushal M, Carlson GL. Management of enterocutaneous fi stulas. Clin Colon Rectal Surg.
2004;17(2):79–88.
37. D’Haens G, van Deventer S, van Hogzand R, et al. Endoscopic and histological healing with
infl iximab anti-tumour necrosis factor antibodies in Crohn’s disease: European multi-centre
trial. Gastroenterology. 1999;166:1029–34.
38. Targan SR, Hanauer SB, van Deventer SJ, et al. 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(15):1029–35.
39. Appau KA, Fazio VW, Shen B, et al. Use of infl iximab within 3 months of ileocolonic resec-
tion is associated with adverse postoperative outcomes in Crohn’s patients. J Gastrointest Surg.
2008;12(10):1738–44.
40. Kunitake H, Hodin R, Shellito PC, et al. Perioperative treatment with infl iximab in patients
with Crohn’s disease and ulcerative colitis is not associated with an increased rate of postop-
erative complications. J Gastrointest Surg. 2008;12(10):1730–6.
41. Sewell JL, Mahadevan U. Infl iximab and surgical complications: truth or perception?
Gastroenterology. 2009;136(1):354–5.
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1988;12:180–5.
43. Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn’s disease-the
patient’s view. Gut. 1994;35:656–7.
44. Burnstein CN, Balnchard JF, Houston DS, et al. The incidence of deep venous thrombosis and
pulmonary embolism among patients with infl ammatory bowel disease: a population-based
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45. Nicholson G, Burrin JM, Hall GM. Peri-operative steroid supplementation. Anaesthesia.
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46. Rosenthal RJ, Bashankaev B, Wexner SD. Laparoscopic management of infl ammatory bowel
disease. Dig Dis. 2009;27(4):560–4.
47. Fazio VW, Marchetti F, Church M, et al. Effect of resection margins on the recurrence of
Crohn’s disease in the small bowel: a randomized controlled trial. Ann Surg.
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48. Greenstein AJ, Sachar D, Pucillo A, et al. Cancer in Crohn’s disease after diversionary surgery.
A report of seven carcinomas occurring in excluded bowel. Am J Surg. 1978;135(1):86–90.
49. Yamamoto T, Fazio VW, Tekkis PP. Safety and effi cacy of strictureplasty for Crohn’s disease:
a systematic review and meta-analysis. Dis Colon Rectum. 2007;50(11):1968–86.
50. Choy PY, Bissett IP, Docherty JG, et al. Stapled versus handsewn methods for ileocolic anas-
tomoses. Cochrane Database Syst Rev. 2007;3:CD004320.
51. Resegotti A, Astegiano M, Farina EC, et al. Side-to-side stapled anastomosis strongly reduces
anastamotic leak rates in Crohn’s disease surgery. Dis Colon Rectum. 2005;48(3):464–8.
52. McLeod RS, Wolff BG, Ross S, et al. Recurrence of Crohn’s disease after ileocolic resection
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309
21 Surgery for Small Bowel Crohn’s Disease
53. Weston LA, Roberts PL, Schoetz DJ, et al. Ileocolic resection for acute presentation of Crohn’s
disease of the ileum. Dis Colon Rectum. 1996;39:841–6.
54. Olaison G, Smedh K, Sjodahl R. Natural course of Crohn’s disease after ileocolic resection:
endoscopically visualised ileal ulcers preceding symptoms. Gut. 1992;33:331–5.
55. Bemelman WA, Ivenski M, van Hogezand RA, et al. How effective is extensive nonsurgical
treatment of patients with clinically active Crohn’s disease of the terminal ileum in preventing
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rence following surgery for Crohn’s disease. Colorectal Dis. 2001;3:100–6.
311
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_22, © Springer-Verlag London Limited 2012
22.1 Crohn’s Disease and the Anus
Crohn’s disease has been associated with perianal fi stulation since the condition
was fi rst recognized. The pathophysiology of anal involvement is initiated by a
penetrating ulcer which can progress to form a fi stula to the perineum, vagina, or
scrotum. Perianal Crohn’s disease (PCD) can also produce an anal stricture, typi-
cally in the upper anal canal [ 1 ] . Thus the characteristic lesions of perianal Crohn’s
disease are ulceration, fi stula/abscess, and stricture (Table 22.1 ).
Typically, perianal disease is more likely to be associated with colorectal Crohn’s
disease than small bowel involvement [ 2 ] . A signifi cant proportion of Crohn’s
patients (10%) present with perianal disease. The cumulative risk of perianal fi stula
formation is 26% at 20 years [ 3 ] .
Perianal Crohn’s disease can present with trivial symptoms or very severe and
disabling symptomatology. Assessment requires a detailed history, MRI imaging,
and EUA. The protean manifestations of the disease, the stoicism of individual
patients and the evolution of new therapeutic agents, now present the colorectal
surgeon with a complex range of management problems (Box 22.1 ) .
22.2 Minimal Disease or Trivial Symptoms
The mere presence of skin tags and or fi stulation, including minimally symptomatic
anovaginal fi stulation, does not mandate a therapeutic intervention. If the patient is
untroubled by symptoms, then irrespective of the clinical fi ndings, it seems diffi cult
N. Scott , M.D., FRCS
Department of Colorectal Surgery , Royal Preston Hospital ,
Sharoe Green Lane , Fulwood, Preston, Lancashire , PR2 9HT , UK
e-mail: nigel.scott11@btinternet.com
Chapter 22
Perianal Crohn’s Disease
Nigel Scott
312
N. Scott
to recommend any therapy that might be associated with morbidity. Long-term anti-
biotics may be useful in reducing discharge and perianal discomfort. The commonly
used antibiotics to suppress perianal sepsis in PCD are metronidazole and cipro-
fl oxacin. Both antibiotics are associated with 60–80% symptomatic improvement in
unselected patients with PCD sepsis. Relapse of symptoms is common after cessa-
tion of antibiotics, and this therapy if helpful is often maintained indefi nitely.
Patients on metronidazole must be told to discontinue metronidazole if they develop
paresthesia in fi ngers or toes [
4 ] as this indicates the development of peripheral
neuropathy (Box 22.2 ) .
Table 22.1 Chief site of intestinal disease related to occurrence of perianal disease
Site n
Perianal disease (%)
Small bowel 19
8 (42)
Ileocolonic 122 64 (52)
Colon 56 33 (59)
Anorectum 5 5 (100)
Total 202 110 (54)
From Keighley and Allan [
2 ]
Box 22.1: Perianal Crohn’s – Problem Scenarios
1. Minimal disease or trivial symptoms from perianal or anovaginal fi stulae
2. Severe symptoms – but no abscess collection
Painful anal ulcer •
Severe perianal infl ammation, with no collection (usually children) •
3. Symptomatic septic collection due to perianal fi stula/abscess
4. Decision making after a successful draining seton
5. The failing/failed bottom
Case Scenario
A 32-year-old man with no previous medical history presents with an acutely
painful bottom. An urgent MRI scan is negative, but EUA demonstrates a
cavitating ulcer. Which of the following is appropriate?
(a) Open up both ischiorectal fossae to drain occult sepsis.
(b) Biopsy the ulcer and consider Depo-Medrone injection.
(c) Recommend long-term nicorandil.
(d) Commence infl iximab and then azathioprine.
(e) Counsel the patient for a defunctioning loop ileostomy.
313
22 Perianal Crohn’s Disease
22.3 Severe Painful Disease Without Abscess Collection
22.3.1 Painful Anal Canal Ulcer
An unusual but dramatic presentation: the patient may have no background of
Crohn’s disease but presents with severe and disabling anal pain. MRI does not
show a collection, but EUA demonstrates an anal canal ulcer which responds well
to Depo-Medrone injection [ 5 ] .
Box 22.2: Antibiotics for Perianal Crohn’s Disease
Ursing B, Kamme C.
Metronidazole for
Crohn’s disease. Lancet.
1975;1:775–77.
Metronidazole 4/5 Improved
Bernstein LH, et al. Healing
of perineal Crohn’s
disease with metronida-
zole. Gastroenterology.
1980;79(3):599.
Metronidazole 21 Patients
20 mg/kg/day
56% Complete
healing
Brandt LJ, Bernstein LH,
Boley SJ, Frank MS.
Metronidazole therapy
for perineal Crohn’s
disease: a follow-up
study. Gastroenterology.
1982;83:383–87.
Metronidazole 26 Patients
Successfully discon-
tinued in only
28%
Jakobovits J and Schuster
MM. Metronidazole
therapy for Crohn’s disease
and associated fi stulae. Am
J Gastroenterol.
1984;79:533–40.
Metronidazole 1,000–
1,500 mg/day
8 Patients
Draining fi stulae
reduced 20-fold
number of
detectable fi stulous
openings by 50%
Solomon MJ, McLeod RS,
O’Connor BI, Steinhart
AH, Greenberg GR,
Cohen Z. Combination
ciprofl oxacin and
metronidazole in severe
perianal Crohn’s disease.
Can J Gastroenterol.
1993;7:571–73.
Ciprofl oxacin and
metronidazole
14 Patients
3 Healed
9 Improved
1 Unchanged
1 Stoma
85% Benefi t
314
N. Scott
22.4 Severe Ulcerating Perineal Disease Without Sepsis
This is an unusual surgical presentation and is most often seen in children with
severe Crohn’s disease [
6, 7 ] – “Highly Destructive Perianal Crohn’s Disease.”
Surgical drainage, once MRI scanning has excluded a deep collection, has no
role. The management is using immunomodulators such as azathioprine or tac-
rolimus followed by infl iximab infusion. If this fails to control anal symptoms
then the only useful surgical intervention is a defunctioning stoma. This will help
control symptoms, but it is very rarely associated with reestablishing continuity
and, more usually, is the stepping stone to proctectomy (see the Failing/Failed
Bottom).
22.5 Symptomatic Septic Collection Due
to Perianal Fistula/Abscess
A symptomatic septic collection requires surgical drainage with or without prior
MRI imaging. If the track of a fi stula is identifi ed, then surgeon can consider fi stu-
lotomy if the track is superfi cial – or the insertion of a draining seton.
22.5.1 Fistulotomy or Seton
Laying open a perianal Crohn’s fi stula is not associated with problems of healing in
the large majority of patients [ 8 ] . However, as the majority of Crohn’s fi stulae involve
signifi cant sphincter thickness [ 9, 10 ] , fi stulotomy is contraindicated in most patients.
Preservation of function with relief of sepsis is the prime aim in dealing with perianal
Crohn’s disease; for this reason, the large majority of patients with an identifi ed fi s-
tula tract are managed by seton insertion and not fi stulotomy [ 9, 10 ] .
22.5.2 The Successful Seton: Whither Next?
In the large majority of patients, seton drainage controls their perianal sepsis and
makes life much more tolerable. After the initial relief of symptom improvement,
most patients are keen to know when the seton will be removed. From the patient’s
perspective, the seton is associated with continuing perineal drainage; it can be uncom-
fortable, and for young patients seeking sexual partners, it is the one body piercing
that takes a bit of explaining. It can also be diffi cult for the patient to understand that
the seton is not curing the fi stula, but by allowing skin drainage, it is a palliative mea-
sure preventing abscess formation while preserving sphincter function (Box
22.3 ).
315
22 Perianal Crohn’s Disease
1. Just Take It (the Seton) Out!!!
This is the course of action requested by some patients. In one series of 18
patients in whom the seton was simply removed, 15 (83%) had a further abscess
after 60 months follow-up. Not a good option [ 11 ] .
2. Leave the Seton Indefi nitely – (i.e., Forever)
This is the default position (Fig. 22.1 ) when counseling a patient who has had
repeated abscess formation brought to an end by a successful seton (Box 22.4 ).
F1b
F1a
F2b
F2a
Fig. 22.1 Hughes Classifi cation of Perianal Crohn’s Disease Low fi stulas F1a,b – perianal and
anovulval; F2a - translevator extension of fi stula; F2b – direct anorectal fi stula
Box 22.3: Perianal Crohn’s – Successful Seton Options
Take the fl ipping thing out
Leave the seton in – indefi nitely
Try glue/ plug/fl ap
Remove seton – long-term biologicals (e.g., infl iximab, Humira)
Box 22.4: The Well Seton – The Default Position
28 patients – 43 complex Crohn’s fi stulas •
Seton inserted – 13 (2–81) months follow-up •
• 89% No further surgery
• No deterioration in faecal continence
Thornton and Solomon [ 12 ] .
316
N. Scott
This approach is associated with no deterioration in faecal continence, and at
12 months, 89% of patients with a PCD fi stula managed by a seton have required no
further surgery [ 12 ] . The downside is that the fi stula is simply palliated with resid-
ual discharge, seton discomfort, and the risk of sexual embarrassment
3. Remove Seton – Close the Hole (Glue/Plug/Flap)
The role of glue and plugs in PCD fi stula is simply not well enough established
to recommend this course of action [
13, 14 ] . Advancement fl aps have a longer pedi-
gree [ 15 ] – but they also have some signifi cant disadvantages (Box 22.5 ).
4. Remove Seton – Go on Long-Term Infl iximab/Humira Therapy
So what happens if the patient insists on having the seton removed and going on a
biologic therapy? (Box 22.6 ). Well, for a start, the results of perianal fi stula closure seem
to be better if a seton is used fi rst and then followed by infl iximab therapy (21% closure
on infl iximab therapy alone versus 56% on infl iximab after seton removal) [ 22 ] .
In addition, access to indefi nite infl iximab infusions seems to offer a better out-
come than a fi xed regimen of three infusions after seton removal [ 23 , 24 ] . Thus, in
the Oxford study of fi xed infusions, 13/21 patients required further surgery com-
pared with Leeds experience of no surgical intervention in 21 patients given indefi -
nite access to infl iximab infusions (median infusions 5 range 3–19) [ 25 ] .
Box 22.6: Biologic Therapy – Perianal Crohn’s
I n fl iximab – a chimeric antibody (25% mouse derived, 75% human •
protein)
Infl iximab – binds and neutralizes both soluble and membrane-bound •
TNF a – and inhibits further activity
Infl iximab – closes the external opening in 50–60% of cases [ • 17 ]
Infl iximab maintenance therapy – keeps the external opening closed in •
50–60% responders (ACCENT II trial 17)
Infl ixmab – does not heal the fi stula track on radiological follow-up – pal-•
liative [ 18– 20 ]
Infl iximab therapy – prevents the need for surgical therapy by about 10% •
after 12 months therapy [ 21 ]
Infl iximab downside – expense £2,000 per infusion; infusion reactions •
(very rare cases – TB, lymphoma, demyelinating disease, lupus)
Box 22.5: Advancement Flaps in Perianal Crohn’s Fistulae
Can only be used in selected patients when the lower rectum and upper •
anal canal is normal
Access can be diffi cult; retraction may compromise the sphincter •
Overall 57% fail even in selected patients [ • 16 ]
Mizrahi et al. [ • 15 ] .
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