Management of Anal Fistulae in Crohn’s disease

1. Management of Anal Fistulae in Crohn’s disease Bruce D George John Radcliffe Hospital Oxford

2. Penner and Crohn 1938 Perianal involvement in 33% (range 4-80%) Increased risk with increasingly distal inflammation 92% Crohn’s proctitis have perianal disease Perianal Crohn’s disease

3. Spectrum of Crohn’s anal pathology Poor prognosis Good prognosis Fistulae Deep cavitating ulcers Skin tags Fissures Strictures

4. Spectrum of Crohn’s Anal Fistulae

5. “Natural history of perianal Crohn’s disease. Ten year follow-up; a plea for conservatism.” Buchmann et al 1980 109 patients 38% spontaneous fistula healing

6. Metronidazole/ciprofloxacin Azathioprine/6MP Infliximab Abscess drainage Seton drain Fistulotomy Advancement flap Defunctioning ileostomy Proctectomy Treatment Options

7. No random controlled trials Extreme opinions Different starting points Different end points Variable natural history Changing medical therapy Problems in Surgical Management

8. J. Alexander-Williams 1976 “faecal incontinence is the result of aggressive surgeons and not progressive disease” J. Graham Williams et al 1991 Fistula-in-ano in Crohn’s disease. Results of aggressive surgical treatment Extreme views

9. Partial/complete healing of fistula Duration of healing Continence scores Patient satisfaction Radiological/clinical healing Problem of “end-points”

10. MRI studies of fistula healing Bell et al 2003 7 perianal fistula assessed pre and post infliximab (0,2,6) 4 healed, 2 no response, 1 partial response 1 healed clinically, but persisting on MRI

11. Principles of Management • Thorough disease assessment • Clinical history and examination • Small bowel enema and colonoscopy • Ultrasound and MRI • EUA +/- biopsy • Tailoring of treatment to individual patient

12. Detection of intestinal disease Proctitis Type of fistula(e) Low/high Undrained sepsis Patients symptoms and expectations Aims of assessment

13. First aid Incision and drainage of abscess Bridging treatment Aims to convert acute uncontrolled situation into potentially curative situation Quality of life based treatment Attempt to heal fistula if symptomatic and realistic 4. Proctectomy and permanent stoma Principles of Surgical Treatment of of Crohn’s Anal Fistulae

14. First Aid Surgery

15. Bridging treatment • Often involves loose seton drain • Allows patient to be established on immunomodulator

16. If bridging treatment going badly • Check that sepsis drained adequately • MRI • Consider defunctioning stoma • Consider proctectomy

17. Defunctioning ileostomy for perianal Crohn’s disease • to assist stabilisation • as “bridge” to proctocolectomy 18 patients defunctioned for severe perianal Crohn’s 1970-1997 15 acute remission 2 reversed with satisfactory function Edwards et al 2000

18. Controlled situation No sepsis Well patient Seton in situ Established on immunomodulator Quality of Life Based Treatment What are the treatment options?

19. Do nothing: long-term seton Remove seton only Remove seton and attempt to heal medically Attempt to heal surgically Combination medical and surgical treatment Treatment Options

20. Metronidazole 34-50% fistula healing in uncontrolled trials High recurrence rates Risk of peripheral neuropathy Ciprofloxacin No controlled studies Medical therapy to encourage fistula healing

21. Azathioprine/ 6-mercaptopurine 22 of 41 fistulae healed with AZA/6MP 6 of 29 fistulae healed with placebo odds ratio: 4.44 Pearson et al 1995

22. Present et al 1999 94 patients of whom 85 (90%) had perianal fistulae Reduction of 50% or more of number of draining fistulae 62% infliximab treated reached end point 26% placebo group reached end point 11% perianal abscess Anti-tumour necrosis factor-alphainfliximab

23. Surgery for low fistula Simple fistulotomy

24. Levien et al 1989 46 patients 29 healed, but 10 recurred 17 unhealed wounds Williams et al 1991 41 fistulae in 33 patients 73% healed at 3 months 26 of 33 had no deterioration in continence Scott and Northover 1996 81% “successful” Results of fistulotomy

25. 60-80% healing of fistula 20-40% slow wound healing 10%-20% risk of recurrence Small risk of incontinence Most studies report better results if no proctitis Fistulotomy for low fistulae

26. Williams et al 1991 11 of 23 good result (seton usually removed) 6 minor incontinence 5 ultimately requiring proctectomy Scott and Northover 1996 23 of 27 good result (18 left in situ) 3 proctectomy, 1 chronic sepsis/pain Long-term loose seton for high fistula

27. Advancement flap for high fistulae • Must be no proctitis • Joo et al 1998 19 0f 26 healed

28. Topstad et al 2003 Combined seton, infliximab and immunosuppression 67% complete healing + 19% partial healing Regueiro and Mardini 2003 EUA/seton and infliximab versus infliximab alone Improved results if infliximab therapy preceded by EUA and seton placement Combination therapy

29. EUA +/- seton drainage. Ensure no sepsis Infliximab 0 and 2 weeks Remove seton if necessary Infliximab at 6 weeks Current protocol in Oxford

30. To improve patients quality of life if “first aid, bridging and attempted healing treatments” inadequate Proctectomy

31. First aid Incision and drainage of abscess uncontroversial Bridging treatment Aims to convert acute uncontrolled situation into potentially curative situation Seton and immunomodulator Quality of life based treatment Attempt to heal fistula if symptomatic and realistic (low and no proctitis) Consider other options 4. Proctectomy and permanent stoma Summary of Principles of Surgical Treatment of of Crohn’s Anal Fistulae