Perianal Crohn`s Disease from a Surgeon`s Perspective

Oxford Inflammatory Bowel Disease MasterClass
Perianal Crohn’s Disease from a
Surgeon’s Perspective
Richard Guy MD FRCS
Consultant Colorectal Surgeon
Oxford University Hospitals
Crohn’s Disease: perianal lesions
Type of Lesion
No of patients (%)
Skin tag
75 (37)
Anal fissure
38 (19)
Anal fistula
52 (26)
Recto-vaginal fistula
6 (3)
Perianal abscess
32 (16)
Complex abscess
21 (10)
Anorectal stricture
19 (9)
Haemorrhoids
15 (7)
Anal ulcer
12 (6)
•202 consecutive patients
•110 (54%) had some perianal involvement
Keighley & Allen, Int J Colorect Dis. 1986
Crohn’s Fistulae
Other
12%
Recto-vaginal
9%
Perianal
55%
Entero-enteric
24%
Cumulative risk for any fistula in CD:
33% after 10 years, 50% after 20 years
Schwartz DA Gastroenterology 2002
Prevalence of anal disease in intestinal Crohn’s
Isolated ileal disease
12%
Ileocolonic disease
15%
Colonic disease (rectal sparing)
41%
Colonic & rectal disease
92%
In 20-36% perianal disease precedes
intestinal disease
Hellers et al. Gut 1980;21:525-527
Range of severity of perianal Crohn’s disease
Poor prognosis
Good prognosis
Skin tags
Fistulae
Fissures
Strictures
Deep cavitating ulcers
Spectrum of Crohn’s Anal Fistulae
Crohn’s ileoanal pouch
Surgical treatment of Crohn’s fistulae




First aid

incision & drainage of sepsis
Bridging treatment


convert acute ‘uncontrolled’ situation into potentially ‘curative’ one
seton & immunomodulator
Quality of life based treatment


attempt to heal fistula if symptomatic & realistic
consider other options
Proctectomy & permanent stoma
Perianal Sepsis & Fistulae: First Aid Surgery
•adequate drainage
•skin-sparing where possible
•liberal use of catheters & setons
Bridging treatment
 often involves loose
seton(s)
 short course antibiotics
 metronidazole
 ciprofloxacin
 allows patient to be
established on
immunomodulator
 assessment of fistula
anatomy
Crohn’s Fistulae: Assessment & Imaging
 EUA
 90% accuracy
 Ultrasound
 56-100% accuracy
 MRI
 76-100% accuracy
Haggett 1995, Orsoni 1999, Sloots 2001, Schwartz 2002
rectal
Fistula “Rules”
Too often broken in Crohn’s!
Simple vs Complex
•Simple
•Superficial
•intersphincteric
•Complex
Bell SJ et al. Aliment Pharmacol Ther 2003;17:1145-51
•Trans-sphincteric
•Trans-levator
•Supralevator
•Extra-sphincteric
Crohn’s fistulae: procedure choice
 Fistula size
 Length
 Anatomical location
 Complexity
 Disease activity
 Concomitant intestinal disease
 Undrained sepsis
Bayer & Gordon; DCR 1994
Fistulotomy for low fistulae
 60-80% healing
 20-40% slow wound healing
 10%-20% risk of recurrence
 small risk of incontinence
 better results if no proctitis
Levien et al. 1989, Williams et al. 1991, Scott & Northover 1996
Find & treat active luminal disease!
Glues & Plugs
 Generally disappointing
 Not adequately evaluated
 Systematic review of plugs in
Crohn’s
 42 pts only
 55% closure
O’Riordan DCR 2012
Endorectal Advancement Flaps
 Insufficient data
 Proctitis must be treated
 Overall “success” 64%
 Incontinence 9.4%
 Combination therapy may
improve outcome
Soltani & Kaiser DCR 2010
Endorectal Advancement Flaps
Soltani & Kaiser DCR 2010
Complex Crohn’s
Complex fistulae: treatment options
 Do nothing: long-term setons
 Remove setons only
 Remove setons and attempt to heal medically
 Attempt to heal surgically
 Combination medical and surgical treatment
 varying patient expectations
 varying end-points in studies
 uncertain natural history
Crohn’s Fistulae: long-term loose seton
 Williams et al. 1991
 11 of 23 “good” result
 seton usually removed
 6 minor incontinence
 5 proctectomy
 Scott & Northover 1996
 23 of 27 “good” result
 18 left in situ
 3 proctectomy, 1 chronic sepsis/pain
Teamwork!
Colorectal Dis 2011;14:331-335
Medical therapy in combination with surgery
Consensus
 Antibiotics
 metronidazole &/or ciprofloxacin
 short-term use only
 lack of clinical trials
 Azathioprine/mercaptopurine
 appear to be effective in closure & maintenance
 lack of clinical trials
 In combination with surgical therapy
Van Assche et al. (ECCO); J Crohn’s Colitis 2010;4:63-101
Infliximab-induced closure of fistulae
60
50
% of patients 40
with complete
30
closure of
20
fistulae
10
0
Present et al. N Eng J Med 1999;340:1399-1405
*
*
*
placebo
5mg/kg
10mg/kg
infliximab
ACCENT II
•At 14 weeks
•69% response
•RCT 5mg/kg IFX every 8 weeks vs
placebo
•At 54 weeks
•36% closure IFX vs 19%
placebo
•14.9% new abscess formation
Sands et al. N Engl J Med 2004;350:1398-1405, Sands et al. Clin Gastroenterol Hepatol 2004;2:912-920
Biologicals:Monitoring Therapeutic Response
 Problem of “end-points”
 Clinical assessment (decreased
drainage)
 MRI
 Perianal Crohn’s Disease Activity
Index (PCDAI)
Irvine et al. J Clin Gastro 1995, Present et al. N Engl J Med 1999
PCDAI
Irvine EJ. J Clin Gastroenterol 1995;20:27-32
There are known,
knowns. There are
known unknowns.
There are unknown
unknowns
Immunomodulation & Surgery
 Immunomodulation may not be enough
 Combined approach generally more effective
 Some controversy & confusion
 No consensus on ideal combination
 Definitive surgery possible
 Worries about second malignancies
Topstad 2003, Van der Hagen 2005, Van der Hagen 2006, Hyder 2006, Gaertner 2007, Tozer 2012
Perianal Crohn’s: relapse post-Infliximab
Luminal Disease
Perianal Disease
Domenech et al. Aliment Pharmacol Ther 2005
Combined seton, infliximab and
maintenance immunosuppression
•Setons removed after second infusion
•67% complete healing at follow-up (mean 9 mths)
Topstad et al. Dis Colon Rectum 2003;46:577-583
Multistep Strategy: IFX induction & surgery
Van der Hagen DCR 2005
Combination Therapy: Oxford
Hyder et al. DCR 2006
MDT discussion!
Combination Therapy: IFX vs IFX/Surgery
 32 patients
 IFX vs IFX + EUA/seton
IFX
IFX+Surg
P
Initial response (%)
82.6
100
0.014
Recurrence rate (%)
79
44
0.001
Time to recurrence (m)
3.62
13.5
0.0001
Regueiro & Mardini; Inflamm Bowel Dis 2003
Combination Therapy: Minnnesota 1991-2005
•Overall healing rates similar
•For IFX + Surgery patients
•shorter healing time (12.1 vs 6.5 mths)
•better healing of TS fistulae
Gaertner et al. DCR 2007
Combination Therapy: Cleveland Clinic 1999-2009
El-Gazzazz et al; Colorectal Dis 2012
Combination therapy: Leeds, UK
•52 patients, median follow-up 66 mths
•73% EUA +/- seton
•22 (42.3%) complete response
•13 (59%) no recurrence at 40 mths
Duff et al. Colorectal Dis 2012
Rectovaginal Fistula
 Affects up to 10% of women with CD
 Reported healing rates 40-60%
 ACCENT II trial
 72.2% healing at 14 weeks
 44.4% healing at 54 weeks
 Higher healing rates with combination therapy?
Hull & Fazio 1997, Morrison et al. 1989, O’Leary et al. 1998, Pennincx et al. 2001, Sands et al. 2004
Rectovaginal Fistula:Cleveland Clinic 1997-2007
El-Gazzazz et al. J Gastrointest Surg 2010
Rectovaginal Fistula: Cleveland Clinic 1997-2007
El-Gazzazz et al. J Gastrointest Surg 2010
What if bridging treatment is going badly?
Check that sepsis
adequately drained
Consider defunctioning
stoma
Consider proctectomy
Defunctioning ileostomy for perianal Crohn’s
• 18 patients defunctioned for severe
•
•
perianal Crohn’s
15 acute remission
2 reversed with satisfactory function
We’re still not really sure who to defunction!
Edwards et al. Br J Surg 2000
Predictors of permanent diversion
•356 consecutive CD patients
•86 (24%) perianal CD
•20 RVF
•344 operations
•53 (62%) pts diverted
•42 (49%) permanent stoma
Galandiuk et al. Ann Surg 2005
Proctectomy
 Operate when conditions as
favourable as possible
 preliminary ileostomy
 nutrition
 setons/anti-TNF
 Primary myocutaneous flap
VRAM flap
Perineal Wound Failure
Perineal Wound Failure
 Early failure
 VAC dressing
 Late failure
 re-investigate for active
small bowel Crohn’s
 re-do flaps
 hyperbaric oxygen
Hyperbaric Oxygen
 13 papers for CD, 9 for perianal disease
 Improvements for 31/40 (78%) patients
 Promising for chronic sinus/unhealed perineum in
combination with flap surgery (Oxford)
Complex Fistulating Crohn’s: Conclusions
 Surgery must achieve adequate drainage
 Surgery & biologics combination improves fistula healing
 Diversion can assist disease stabilisation
 Proctectomy is not usually a happy day out!
Benefits of Team Working