perianal crohn’s disease from a - university of oxford · oxford inflammatory bowel disease...
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Oxford Inflammatory Bowel Disease MasterClass
Perianal Crohn’s Disease from a
Surgeon’s Perspective
Richard Guy MD FRCS Consultant Colorectal Surgeon
Oxford University Hospitals
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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)
Keighley & Allen, Int J Colorect Dis. 1986
•202 consecutive patients •110 (54%) had some perianal involvement
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Crohn’s Fistulae
Perianal 55%
Entero-enteric 24%
Recto-vaginal 9%
Other 12%
Schwartz DA Gastroenterology 2002
Cumulative risk for any fistula in CD: 33% after 10 years, 50% after 20 years
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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
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Range of severity of perianal Crohn’s disease
Good prognosis Poor prognosis
Skin tags
Fissures
Fistulae
Strictures
Deep cavitating ulcers
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Spectrum of Crohn’s Anal Fistulae
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Crohn’s ileoanal pouch
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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
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Perianal Sepsis & Fistulae: First Aid Surgery
•adequate drainage •skin-sparing where possible •liberal use of catheters & setons
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Bridging treatment
often involves loose seton(s)
short course antibiotics metronidazole
ciprofloxacin
allows patient to be established on immunomodulator
assessment of fistula anatomy
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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
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Fistula “Rules”
Too often broken in Crohn’s!
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Simple vs Complex
Bell SJ et al. Aliment Pharmacol Ther 2003;17:1145-51
•Simple •Superficial •intersphincteric
•Complex •Trans-sphincteric •Trans-levator •Supralevator •Extra-sphincteric
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Crohn’s fistulae: procedure choice
Fistula size
Length
Anatomical location
Complexity
Disease activity
Concomitant intestinal disease
Undrained sepsis
Bayer & Gordon; DCR 1994
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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
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Find & treat active luminal disease!
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Glues & Plugs
Generally disappointing
Not adequately evaluated
Systematic review of plugs in Crohn’s 42 pts only
55% closure
O’Riordan DCR 2012
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Insufficient data
Proctitis must be treated
Overall “success” 64%
Incontinence 9.4%
Combination therapy may improve outcome
Endorectal Advancement Flaps
Soltani & Kaiser DCR 2010
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Endorectal Advancement Flaps
Soltani & Kaiser DCR 2010
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Complex Crohn’s
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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
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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
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Teamwork!
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Colorectal Dis 2011;14:331-335
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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
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0
10
20
30
40
50
60
% of patients
with complete
closure of
fistulae
placebo
5mg/kg
10mg/kg
infliximab
*
* *
Infliximab-induced closure of fistulae
Present et al. N Eng J Med 1999;340:1399-1405
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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
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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
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Irvine EJ. J Clin Gastroenterol 1995;20:27-32
PCDAI
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There are known, knowns. There are known unknowns. There are unknown unknowns
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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
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Luminal Disease
Perianal Disease
Perianal Crohn’s: relapse post-Infliximab
Domenech et al. Aliment Pharmacol Ther 2005
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Combined seton, infliximab and
maintenance immunosuppression
Topstad et al. Dis Colon Rectum 2003;46:577-583
•Setons removed after second infusion •67% complete healing at follow-up (mean 9 mths)
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Multistep Strategy: IFX induction & surgery
Van der Hagen DCR 2005
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Combination Therapy: Oxford
Hyder et al. DCR 2006
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MDT discussion!
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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
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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
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Combination Therapy: Cleveland Clinic 1999-2009
El-Gazzazz et al; Colorectal Dis 2012
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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
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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
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Rectovaginal Fistula:Cleveland Clinic 1997-2007
El-Gazzazz et al. J Gastrointest Surg 2010
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Rectovaginal Fistula: Cleveland Clinic 1997-2007
El-Gazzazz et al. J Gastrointest Surg 2010
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What if bridging treatment is going badly?
Check that sepsis adequately drained
Consider defunctioning stoma
Consider proctectomy
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Defunctioning ileostomy for perianal Crohn’s
• 18 patients defunctioned for severe perianal Crohn’s
• 15 acute remission
• 2 reversed with satisfactory function
Edwards et al. Br J Surg 2000
We’re still not really sure who to defunction!
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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
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Operate when conditions as favourable as possible preliminary ileostomy
nutrition
setons/anti-TNF
Primary myocutaneous flap
Proctectomy
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VRAM flap
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Perineal Wound Failure
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Perineal Wound Failure
Early failure
VAC dressing
Late failure
re-investigate for active small bowel Crohn’s
re-do flaps
hyperbaric oxygen
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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)
Hyperbaric Oxygen
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Complex Fistulating Crohn’s: Conclusions
Surgery must achieve adequate drainage
Surgery & biologics combination improves fistula healing
Diversion can assist disease stabilisation
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Benefits of Team Working