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

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

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

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

Investigations Pelvic MRI: Endoanal ultrasound 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)

Contrast-enhanced fat suppressed T1-weight MRI

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

Management outline Medical Surgical: Drainage of abscess 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

Adalimumab for the treatment of fistulas in patients with Crohn's disease (Colombel et al. 2009) CHARM = Crohn’s Trial of the Fully Human Antibody Adalimumab for Remission Maintenance Fistula efficacy defined as no draining fistulas at the last two consecutive period before and on that visit

Infliximab maintenance therapy for fistulizing Crohn’s disease (Sands etal. 2004)

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

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

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

Fistula classification Concomitant proctitis Management Simple, low No Fistulotomy Sphintcer-preserving procedures (fibrin glue, fistula plug and LIFT) Yes Non-cutting seton Complex, high Mucosal advancement flap or Rectal sleeve advancement if anal canal disease +/- Temporary stoma Temporary fecal diversion Proctectomy 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

Anorectal advancement flap Complicated by anal canal ulceration or stricturing rectal sleeve advancement with temporary fecal diversion extensive version of the rectal mucosal advancement flap full thickness of the rectum is circumferentially mobilized after excision of the ulcerated or strictured area Formal proctoanal anastomosis is performed in combination with diverting loop ileostomy. Although Occ required trans-abdominal mobilization Rakinic J, Poola VP.  Curr Probl Surg. 2014. 51 (3):98-137

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

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

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

Maintenance medical therapy Fistulotomy Sphincter-preserving procedures Healing of fistula Simple fistula Look out for malignancy Treat active luminal Crohn’s disease Sepsis control: I&D, seton, antibiotics Complex case: Stoma Chronic seton (proctitis) Mucosal advancement flap (no proctitis) Proctectomy Yes No Refractory, aggressive Medical therapy 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

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