Current Management of Anal Fistulas in Crohn’s Disease

1. Current Management of Anal Fistulas in Crohn’s Disease Rita YK Chang Joint Hospital Surgical Grand Round 23th April 2016

2. Background • 20-50% Crohn’s disease (CD) have perianal fistula • More distal luminal CD are at higher risk • 90% proctitis have fistula • Low remission and high recurrence • More complications • Stricture, stenosis, abscess

3. Classification • Park’s classification • High vs. low • Simple vs. complex • Complex: • Secondary branches • Involving >= 1/3 of the sphincter circuit • Anterior fistulas in women • Faecal incontinence, strictures

5. Investigations • Colonoscopy • Concomitant active proctocolitis • Malignancy • Examination under anaesthesia (EUA): • Accuracy of 90% • Allow concomitant surgery

6. Investigations • Pelvic MRI: • Non-invasive • Identifying deep abscesses and classifying fistulas, sphincter anatomy • Endoanal ultrasound • 3-dimensional • Enhanced with hydrogen peroxide • Requires expertise • Rectal stenosis has to be excluded • Ultrasound or MRI used together with EUA are 100% accurate (Schwartz et al. 2001)

7. Contrast-enhanced fat suppressed T1-weight MRI

9. Management principle • Medications traditionally control intestinal CD are ineffective for perineal CD • Not all surgical treatment for crytograndular perianal fistula are beneficial to Crohn’s perianal fistula • Treat active luminal Crohn’s disease • Drain perianal abscess as urgency • Combined approach: medical + surgical

10. Management outline • Medical • 1st line: antibiotics (metronidazole + ciprofloxacin) • Symptoms typically recur immediately after discontinuation • 2nd line:  immunomodulators (azathioprine/6-mercaptopurineas) • Slow response (at least 8 weeks) • Leukopenia and drug-induced hepatitis • 3rd line: Biological agents: (infliximab/ adalimumab) • Surgical: Drainage of abscess

11. Adalimumab for the treatment of fistulas in patients with Crohn's disease (Colombel et al. 2009)

12. Infliximab maintenance therapy for fistulizingCrohn’s disease (Sands etal. 2004)

13. Medical therapy- anti-TNF • Infliximab (IV) • 5–10 mg/kg body weight • Induction: 0, 2, and 6 weeks • Maintenance: every 8 weeks (for 1 year) • Adalimumab (SC) • Induction: 160 mg in 0 week, 80 mg in week 2, 40 mg every other week until week 12 • Maintenance: 40 mg every other week (for 1 year) • Efficacy in closing fistula ~50% in 10 weeks

14. Is anti-TNF the ultimate solution? • Adverse reaction • severe septic infections, drug-induced lupus, haemic malignancies • Relapses after discontinuation of therapy • 17% at 1 year • 40% at 5 years • Cost

15. Surgery principle: more alleviative then radical • Radical treatment not advocated • High rate of recurrence, impaired wound healing, damage to the anal sphincter • I&D, non-cutting seton • timing of seton removal: no consensus

16. Cristina B. Geltzeiler, Nicole Wieghard, Vassiliki L. Tsikitis. Recent developments in the surgical management of perianal fistula for Crohn’s disease. Annals of Gastroenterology (2014) 27, 320-330

17. Anorectal advancement flap Rakinic J, Poola VP.  Curr Probl Surg. 2014. 51 (3):98-137

18. Anorectal advancement flap • Healing rate: 25-64% • Incontinence rate: 9.4% • Temporary stoma • Mild proctitis • Significant sphincter involvement • History of failed repairs • 47% restore intestinal continuity

19. Proctectomy • Proctectomy rate 12-38%; higher if proctitis • Often difficult healing of the perineal wound • Myocutaneous flap (rectus abdominus flap/ gracilis flap) may be required

20. New treatment • Local anti-TNF injection • Stem cell in fibrin glue • Video-assisted fistula treatment

21. Sepsis control: I&D, seton, antibiotics Complex case: Stoma Look out for malignancy Treat active luminal Crohn’s disease Maintenance medical therapy Yes Healing of fistula No Yes Fistulotomy Sphincter-preserving procedures Simple fistula No Chronic seton (proctitis) Mucosal advancement flap (no proctitis) Medical therapy Refractory, aggressive Cristina B. Geltzeiler, Nicole Wieghard, Vassiliki L. Tsikitis. Recent developments in the surgical management of perianal fistula for Crohn’s disease. Annals of Gastroenterology (2014) 27, 320-330 Proctectomy

22. References: • Cristina B. Geltzeiler, Nicole Wieghard, Vassiliki L. Tsikitis. Recent developments in the surgical management of perianal fistula for Crohn’s disease. Annals of Gastroenterology (2014) 27, 320-330 • Elsa Limura, Pasquale Giordano. Modern management of anal fistula. World J Gastroenterol 2015 January 7; 21(1): 12-20 • Meniero P. Tech Coloproctol 2009 13:347 • Rojanasakul A . LIFT procedure: a simplified technique for fistula-in-ano. TechColoproctol. 2009 Sep;13(3):237-40. • Yamaguchi T, Kagawa R, Takahashi H, Takeda R, Sakata S, Nishizaki D. Diagnostic implications of MR imaging for mucinous adenocarcinoma arising from fistula in ano. Tech Coloproctol. 2009 Sep;13(3):251-3. doi: 10.1007/s10151-009-0509-z. Epub 2009 Jul 17. • Rakinic J, Poola VP. Hemorrhoids and fistulas: new solutions to old problems. Curr Probl Surg. 2014. 51 (3):98-137 • G.A. Santoro, C. Ratto. Accuracy and Reliability of Endoanal Ultrasonography in the Evaluation of Perianal Abscesses and Fistula-in-ano. P. 141-182 • Z Abdool, A H Sultan,  R Thakar. Ultrasound imaging of the anal sphincter complex: a review. Br J Radiol. 2012 Jul; 85(1015): 865–875 • Michael R. Torkzad and Urban Karlbom. MRI for assessment of anal fistula. Insights Imaging. 2010 May; 1(2): 62–71