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75
was well tolerated and without complication” but do not comment on healing or
other problems that might have developed after the excision. This could indicate
that there were no long-term complications, or that the procedure itself was com-
pleted without difculty. Given the nature of the study, the former seems more
likely but without careful reading this could be misinterpreted.
No study includes information about overall disease severity at the time of inter-
vention. This information would be useful as most colorectal surgeons would not
perform surgery for skin tags in a patient suffering with active inammation.
Several studies report on outcomes of hemorrhoidectomy in Crohn’s disease
patients. Unfortunately, the time to complications is not well described across stud-
ies. This makes it difcult to infer causation and whether the complications that
developed were driven by the disease itself or were truly procedure-related. It is
quite likely in some series that the high rate of proctectomy reects severe perianal
disease such as when proctectomy was performed 15years after the hemorrhoidec-
tomy [8]. When surgery is restricted to hemorrhoids arising in patients with stable
intestinal disease without the need for corticosteroids and a Crohn’s disease activity
index (CDAI) <150, signicant complications were infrequent [9].
When studies include patients who were not diagnosed with IBD until after their
surgery, patients tend to have higher reported rates of complications [9, 10]. This
demonstrates the importance of excluding Crohn’s disease prior to proceeding with
anorectal surgery. It may also reect the reluctance and more stringent criteria of
surgeons operating on patients with known Crohn’s disease. While the heterogene-
ity in the data limits the ability of practitioners to apply the ndings to their patients,
it does suggest that patients with well controlled disease will experience better
outcomes (Tables 8.2 and 8.3).
Table 8.2 Studies evaluating surgery for perianal skin tags in Crohn’s disease patients
First author
(year)
Patients
studied Intervention
Study
design N Complications
Quality
of evidence
Buchman
(1980) [11]
Patients with
skin tags
and CD
Observation RO 37 Resolved in 32% Very low
Keighley
(1986) [6]
Patients with
skin tags
and CD
Observation
Excision
RO 75
2
excisions
Observation:
Resolved in 39% of
patients with no
treatment; 10 had
proctectomy due to
intestinal disease
Excision: 1 (50%)
healed; 1 did not and
developed stenosis
Very low
Taylor
(1989) [7]
Patients
with skin
tags and
CD
Excision PO 26 0 Very low
R retrospective, PO prospective observational, RO retrospective observational
8 Management ofPerianal Skin Tags
76
Table 8.3 Studies evaluating surgery for hemorrhoids in Crohn’s disease patients
First author
(year)
Patients studied Intervention
Study
design N
Complication rate with surgery
Complications
Quality
of evidence
Jeffery
(1977)[10]
Patients with hemorrhoids
and CD; included those
diagnosed after treatment
Observation; excisional
hemorrhoidectomy if observation
failed
RO 21
patients;
12 required
surgery
66%
1 anal pain
10 stula/abscess→6 went on
to require proctectomy for
stulas
Very low
Hughes
(1978) [5]
Patients with hemorrhoids
and CD
Surgery PO 2 0 Very low
Keighley
[6]
(1986)
Patients with hemorrhoids
and CD
RBL PO 2 50%
1 stenosis
Very low
Wolkomir
(1993) [8]
Patients with hemorrhoids
and CD
Surgery RO 17 29.4%
2 stenosis
2 nonhealing wounds
1 ssure→proctectomy (15y
later)
Very low
D’Ugo
(2013) [9]
Patients with hemorrhoids
and CD; included those
diagnosed after surgery
Excisional hemorrhoidectomy or
RBL if failed conservative
management
PO 17 (2
RBL)
41.2%
3 bleeding
2 ssure
2 abscess/ssure
Very low
RBL rubber band ligation, R retrospective, PO prospective observational, RO retrospective observational
E. Steinhagen
77
Recommendations Based ontheData
Perianal skin tags in patients with Crohn’s disease should generally not be excised.
(Weak recommendation based on very low quality evidence).
Personal View oftheData
While there is essentially no high-quality data evaluating the outcomes of perianal
skin tag excision in Crohn’s disease patients, there is certainly common sense that
can and should dictate management.
Patients with symptomatic skin tags and active inammation, particularly in the
rectum, should have treatment directed at controlling the inammation. This will
intrinsically help with the inammation of the tags but will also decrease the num-
ber of bowel movements and improve stool consistency; this, in turn, should pro-
vide some symptomatic relief. Sitz baths, moistened wipes for hygiene, and careful
cleaning also play a role in reducing the symptoms of irritated skin tags. Anorectal
surgery in the face of uncontrolled inammation is a setup for poor healing.
For Crohn’s disease patients in remission complaining of hygiene issues and
impaired quality of life secondary to large or multiple skin tags, it may be reason-
able to consider excision especially if the tags are narrow-based and the resulting
defects will be small. However, it is difcult to truly quantify the risk in this situa-
tion and a good understanding of the potential complications is critical. The associa-
tion between skin tag excision and proctectomy is more likely a reection of natural
disease progression than the procedure itself based on the very limited descriptions
in the available studies.
Much of the data on this topic is a subset of a smaller series on overall perianal
disease, and essentially (or virtually) all of it includes patients treated prior to mod-
ern Crohn’s disease therapies such as biologic agents. To truly understand the risk
of operating for perianal skin tags, anecdotal common wisdom requires quantica-
tion. Large databases and registries may enable appropriate data analysis to guide
future practice.
References
1. Bonheur JL, Braunstein J, Korelitz BI, Panagopoulos G.Anal skin tags in inammatory bowel
disease: new observations and a clinical review. Inamm Bowel Dis. 2008;14(9):1236–9.
https://doi.org/10.1002/ibd.20458.
2. 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. http://www.ncbi.nlm.nih.
gov/pubmed/8620803. Accessed July 2, 2018.
3. Alexander-Williams J, Buchmann P.Perianal Crohn’s disease. World J Surg. 1980;4(2):203–8.
http://www.ncbi.nlm.nih.gov/pubmed/7405258. Accessed July 2, 2018.
4. Cracco N, Zinicola R.Is haemorrhoidectomy in inammatory bowel disease harmful? An old
dogma re-examined. Color Dis. 2014;16(7):516–9. https://doi.org/10.1111/codi.12555.
8 Management ofPerianal Skin Tags
78
5. Hughes LE.Surgical pathology and management of anorectal Crohn’s disease. J R Soc Med.
1978;71(9):644–51. http://www.ncbi.nlm.nih.gov/pubmed/712742
6. Keighley MRB, Allan RN.Current status and inuence of operation on perianal Crohn’s dis-
ease. Int J Color Dis. 1986;1(2):104–7. https://doi.org/10.1007/BF01648416.
7. Taylor BA, Williams GT, Hughes LE, Rhodes J.The histology of anal skin tags in Crohn’s
disease: an aid to conrmation of the diagnosis. Int J Color Dis. 1989;4(3):197–9. http://www.
ncbi.nlm.nih.gov/pubmed/2769004. Accessed July 2, 2018.
8. Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal ssures
in Crohn’s disease. Dis Colon Rectum. 1993;36(6):545–7. http://www.ncbi.nlm.nih.gov/
pubmed/8500370. Accessed July 2, 2018.
9. 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):47.
https://doi.org/10.1186/1471-230X-13-47.
10. Jeffery PJ, Ritchie J, Parks AG.Treatment of hæmorrhoids in patients with inammatory bowel
disease. Lancet. 1977;309(8021):1084–5. https://doi.org/10.1016/S0140-6736(77)92337-6.
11. Buchmann P, Keighley MR, Allan RN, Thompson H, Alexander-Williams J. Natural his-
tory of perianal Crohn’s disease. Ten year follow-up: a plea for conservatism. Am J Surg.
1980;140(5):642–4.
E. Steinhagen
79
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_9
S. Whitney · R. Steinhagen (*)
Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
e-mail: randolph.steinhagen@mountsinai.org
9
Management ofChronic Anal Fissures
inPatients withCrohn’s Disease
StewartWhitney andRandolphSteinhagen
Introduction
Anal ssures begin with a tear in the anoderm that often presents with bleeding and
pain, and can progress to a chronic ssure in up to 40% of patients [1]. In the gen-
eral population, the etiology is believed to be related to local trauma and/or isch-
emia. Most acute ssures heal with stool-bulking, topical medications, and local
care. If acute ssures do not heal and become chronic, the treatment algorithm
expands. Non-surgical options, including botulinum toxin injection or topical medi-
cations such as nitric oxide donors and calcium channel blockers are efcacious, but
have been shown to be inferior to lateral internal sphincterotomy (LIS) in promoting
healing and preventing recurrence. However, LIS carries a small risk of both tran-
sient and permanent incontinence [2].
Management of ssures becomes much more complicated in patients with peri-
anal Crohn’s disease, who can develop perianal pathology secondary to chronic
inammation linked to the disease. As a result, the treatment algorithm is much
different because the pathophysiology is dissimilar and surgical intervention carries
a higher risk of complications related to poor wound healing and incontinence. We
will review the literature concerning management of chronic ssures in patients
with Crohn’s disease with regards to LIS and other surgical procedures, and provide
recommendations based on this appraisal.
80
Search Strategy
A comprehensive literature search of the Cochrane Review Database, Medline and
PubMed was performed to identify all publications involving chronic anal ssures
and Crohn’s disease between 1960 and 2018. Keywords for search included: “anal
ssure,” “chronic anal ssure,” “Crohn’s disease.” References of these studies were
then reviewed to incorporate any other pertinent studies. Outcomes measured and
compared were: short-term morbidity, mortality, intra-operative complications, res-
olution of ssure, recurrence, long-term complications (incontinence).
Results
The management of chronic anal ssures has been well-studied, and multiple
Cochrane reviews have examined this topic. The rst was comprised of 75 random-
ized clinical trials that included over 5000 patients who were managed with either
medical therapy or surgery [3, 4]. The review showed that topical nitroglycerine
was superior to placebo in promoting healing (48.9% vs. 35.5%, p<0.0009) and
similar results were found with topical calcium channel blockers (e.g., nifedipine)
and botulinum toxin injection making these agents safe and effective as rst-line
treatment for chronic ssures. However, recurrence was noted in approximately
50% of cases. LIS has been shown to have more enduring cure rates as compared
to medical management in the general population. One prospective randomized
controlled trial consisting of 142 patients showed healing at 8weeks in 88.2% of
patients in the LIS group and 68.9% of patients in the nifedipine group (p=0.007)
[5]. This study also found decreased pain at 3 and 7days with LIS compared to
topical nifedipine. A different randomized controlled trial comparing LIS to botu-
linum toxin injection plus topical diltiazem showed a signicantly higher rate of
healing in the LIS group for ssures that had been present for longer than 12months
(86% vs. 23%, p<0.001) [6].
Chronic anal ssures in patients with Crohn’s disease have a different etiology
when compared to the general population. It is believed that chronic ssures in this
group develop as the result of chronic inammation secondary to the underlying
disease rather than local trauma [7]. Another characteristic of anal ssures or ulcer-
ations in Crohn’s disease is the variability of their location. In the general popula-
tion, the posterior and anterior midlines are the most commonly involved sites
whereas ssures are often multiple and frequently situated off the midline in patients
with Crohn’s disease [7]. As a result, a different treatment algorithm should be
applied to these patients. One retrospective study looked at a cohort of patients with
Patients
Intervention Comparator
Outcome
Patients with Crohn’s
disease with chronic anal
ssure
LIS Non-operative
management
Fissure healing,
incontinence, symptomatic
relief
Table 9.1
S. Whitney and R. Steinhagen
81
Crohn’s disease at a single institution [8]. They compared 29 male and 27 female
patients who had anal ssures; 41 patients underwent initial medical management
and 15 underwent immediate LIS with ssurectomy. They reported short-term heal-
ing rates of 50% in the medical group and 67% in the surgical group. In patients
who also had severe bowel involvement, only 43% experienced proper healing.
After long-term follow-up, 17 of 35 patients in the medical group had healed s-
sures (49%), while 9 of 15 patients in the surgical group healed (60%). Of the
patients with non-healed ssures, 26% developed a stula leading the authors to
propose a more aggressive use of LIS in this population to prevent stula or abscess
formation. Moreover, a statistically higher rate of healing was observed in the surgi-
cal patients who did not have concomitant resection of involved proximal bowel
compared to those who also underwent intraabdominal surgery (88% vs. 29%,
p=0.03) [8].
Another study looked at outcomes for patients previously diagnosed with Crohn’s
disease presenting with symptomatic hemorrhoids and ssures; 41 patients were
diagnosed with ssures and 53.7% of these also manifested intestinal involvement
[9]. All patients were initially treated nonoperatively and those with stable intestinal
disease who failed conservative management were eligible for surgical intervention.
Ultimately, 14 of the 41 patients underwent surgery for their anal ssure (i.e., botu-
linum toxin injection, botulinum toxin injection plus ssurectomy, LIS), and 8 of 14
patients (57%) suffered one or more complications including poor wound healing,
recurrence, and stula formation (Table9.1).
As a result of the distinctive etiology of chronic ssures in patients with Crohn’s
disease, different non-surgical options exist. Topical metronidazole was used in one
study and did show some relief in symptoms at 4weeks [12]. Use of other topical
agents, such as tacrolimus, has also been reported. One study showed improvement
with topical tacrolimus in 3 out of 4 patients (while also on systemic therapy for
Crohn’s disease) compared with 0 out of 3in the placebo group [13]. Systemic agents
Table 9.1 Studies involving anal ssures and Crohn’s disease and surgical interventions
First author
(year)
Study population Intervention N Healing rate
Quality
of evidence
Fleshner
(1995) [8]
Patients with
ssures and CD
LIS or Fissurectomy
vs. Medical
management, bowel
surgery
56 Medical—19/38
Anal surgery −7/8
Bowel surgery-3/7
Low
Sweeney
(1988) [10]
Patients with
ssures and CD
Medical
management vs.
anal surgery
61 Medical—19/24
Surgery—0/6
Low
D’Ugo
(2013) [9]
Patients with
ssures or
hemorrhoids and
CD
Medical
management vs.
anal surgery
41 Medical Low
Wolkomir
(1993) [11]
Patients with
ssures and CD
Fissurectomy/
ulcerectomy, LIS,
partial LIS, multiple
LIS
25 Short term
outcomes not
reported
Low
9 Management ofChronic Anal Fissures inPatients withCrohn’s Disease
82
have been used in management of ssures or ulcerations in Crohn’s disease, but the
results are inconsistently reported with none of the studies having primary end-points
related to ssures. Cyclosporine, thalidomide, and hyperbaric oxygen have been
reported to provide possible benet, but only in small uncontrolled studies [14–16].
Anti-TNF agents have become increasingly utilized for the management of peri-
anal Crohn’s disease. Although many reports have focused on stulizing disease,
some also looked at the efcacy of anti-TNF agents with regards to healing of s-
sures and ulcerations. One study had patients on systemic iniximab therapy while
also performing local injections of iniximab for chronic ssures [17]. Only a triv-
ial potential benet was reported in this small uncontrolled study. Bouguen exam-
ined healing rates of chronic ssures and ulcerations using systemic iniximab [18].
Of 94 patients identied with anal canal ulcers, 40 patients (42.5%) had a complete
response following induction of therapy. After a median follow-up of 175weeks
(range 13–459), complete response was seen in 68 of 94 patients (72.3%).
Control of proximal bowel disease has long been known to inuence perianal
Crohn’s disease. The role of fecal diversion has been well described regarding ano-
rectal stulas in Crohn’s disease; however often the diversion becomes permanent
[19]. Sweeney reported that most patients with ssures improved with medical
therapy alone; 42 of 61 patients who demonstrated disease in the proximal bowel
had ssure healing, however 16% developed other perianal lesions [10]. McKee
found that outcomes of patients with perianal Crohn’s disease were related to the
extent and severity of proximal bowel involvement, with patients who had more
severe proctitis exhibiting lower rates of perianal disease healing [20]. Fleshner
reported that only 3 of 7 patients with ssures who had severe small bowel or
colonic disease and underwent an intraabdominal operation healed their ssure [8].
Surgery has long been discussed in the management of ssures in Crohn’s dis-
ease and its role remains debated. Due to the association of ssures with sphincter
hypertonicity, LIS has been a common procedure performed in the general popula-
tion. In patients with Crohn’s disease, ssures are more likely to result from the
underlying disease. Accordingly, they are at signicant risk for developing chronic
non-healing wounds or stulas after surgical intervention. Additionally, patients
with Crohn’s disease have higher rates of chronic diarrhea, thus potentially increas-
ing the risk of fecal incontinence after LIS.It is because of these factors that we
recommend taking a more conservative approach to anal ssures in the Crohn’s
disease population with management focused on control of proximal bowel disease
and symptoms related to the ssure. LIS can be considered in highly selected cases
with quiescent rectal disease and evidence of sphincter hypertonicity.
Recommendation Based ontheData
Surgical management of ssures in patients with Crohn’s disease should be
approached with great caution due to the high risk of poor wound healing and the
possibility of continence issues in these patients with chronic diarrhea. LIS should
S. Whitney and R. Steinhagen
83
be considered only in highly selected patients who demonstrate internal sphincter
hypertonicity and ssures that resemble a typical anal ssure without proctitis.
(moderate recommendation, low quality evidence)
A personal View oftheData
Despite the lack of high-quality evidence, lateral internal sphincterotomy should be
approached with a great deal of caution in patients with Crohn’s disease. Fissures
complicating Crohn’s disease are not commonly associated with hypertonicity of the
internal sphincter and LIS in this setting is illogical and potentially harmful because
perianal wounds heal very poorly in patients with Crohn’s disease, especially when
signicant proctitis or more proximal intestinal disease is present. If faced with a
ssure secondary to hypertonicity of the internal sphincter in a patient with Crohn’s
disease and signicant proctitis, the proctitis should be successfully managed before
considering a LIS.Finally, the issue of impaired continence becomes much more
important in a patient with Crohn’s disease compared to the general population.
The typical patient without Crohn’s disease who has an anal ssure and a hyper-
tonic internal sphincter, is more likely to complain of associated constipation.
Therefore, the small reduction in sphincter pressure associated with a LIS is more
likely to improve their bowel function than cause incontinence. Conversely,
Crohn’s disease patients often suffer from diarrhea that is either chronic or epi-
sodic, and the reduction in sphincter pressure resulting from a LIS is more likely to
produce long- term disturbances in continence. Therefore, the only patients with
Crohn’s disease for whom LIS is considered are those with an internal sphincter
that is clearly hypertonic and hypertrophied and a ssure that is single, located in
the midline, and uncomplicated by overhanging edges, proctitis, or more proximal
disease. The practical result of these rather stringent criteria is that only a very
small number of patients with ssure complicating their Crohn’s disease are suit-
able candidates for LIS.
References
1. Madalinski MH. Identifying the best therapy for chronic anal ssure. World J Gastrointest
Pharmacol Ther. 2011;2(2):9.
2. Garg P, Garg M, Menon GR.Long-term continence disturbance after lateral internal sphinc-
terotomy for chronic anal ssure: a systematic review and meta-analysis. Colorectal Dis.
2013;15(3):e104–17.
3. Nelson RL, Thomas K, Morgan J, Jones A.Non surgical therapy for anal ssure. Cochrane
Database Syst Rev. 2012;2:CD003431.
4. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S.Operative procedures for
ssure in ano. Cochrane Database Syst Rev. 2011;11:CD002199.
5. Derosa M, Cestaro G, Vitiello C, Massa S, Gentile M.Conservative versus surgical treat-
ment for chronic anal idiopathic ssure: a prospective randomized trial. Updates Surg.
2013;65(3):197–200.
9 Management ofChronic Anal Fissures inPatients withCrohn’s Disease
84
6. Gandomkar H, Zeinoddini A, Heidari R, Amoli HA.Partial lateral internal sphincterotomy
versus combined botulinum toxin A injection and topical diltiazem in the treatment of chronic
anal ssure: a randomized clinical trial. Dis Colon Rectum. 2015;58(2):228–34.
7. Gorne S. Anorectal Crohn’s Disease. The ASCRS Textbook of Colon and Rectal Surgery.
2015;48(3):819–41.
8. 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.
9. 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;13:47.
10. Sweeney JL, Ritchie JK, Nicholls RJ. Anal ssure in Crohn’s disease. Br J Surg.
1988;75(1):56–7.
11. Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal ssures in
Crohn’s disease. Dis Colon Rectum. 1993;36:545–7.
12. Stringer EE, Nicholson TJ, Armstrong D.Efcacy of topical metronidazole (10%) in the treat-
ment of anorectal Crohn’s disease. Dis Colon Rectum. 2005;48(5):970–4.
13. Hart AL, Plamondon S, Kamm MA.Topical tacrolimus in the treatment of perianal Crohn’s
disease: exploratory randomized controlled trial. Inamm Bowel Dis. 2007;13(3):245–53.
14. Plamondon S, Ng SC, Kamm MA. Thalidomide in luminal and stulizing Crohn’s disease
resistant to standard therapies. Aliment Pharmacol Ther. 2007;25(5):557–67.
15. Cat H, Sophani I, Lemann M, Modiglani R, Solue JC. Cyclosporine treatment of anal and
perianal lesions associated with Crohn’s disease. Turk J Gastroenterol. 2003;14(2):121–7.
16. Colombel JF, Mathieu D, Bouault JM, etal. Hyperbaric oxygenation in severe perineal Crohn’s
disease. Dis Colon Rectum. 1995;38(6):609–14.
17. Poggioli G, Laureti S, Pierangeli F, etal. Local injection of Iniximab for the treatment of
perianal Crohn’s disease. Dis Colon Rectum. 2005;48(4):768–74.
18. Bouguen G, Trouilloud I, Siproudhis L, etal. Long-term outcome of non-stulizing (ulcers,
stricture) perianal Crohn’s disease in patients treated with iniximab. Aliment Pharmacol Ther.
2009;30(7):749–56.
19. Singh B, McC Mortensen NJ, Jewell DP, George B. Perianal Crohn’s disease. Br J Surg.
2004;91(7):801–14.
20. McKee RF, Keenan RA. Perianal Crohn’s disease is it all bad news? Dis Colon Rectum.
1996;39(2):136–42.
S. Whitney and R. Steinhagen