Techniques in Coloproctology

, Volume 22, Issue 12, pp 905–917 | Cite as

Management of anoperineal lesions in Crohn’s disease: a French National Society of Coloproctology national consensus

  • D. BouchardEmail author
  • F. Pigot
  • G. Staumont
  • L. Siproudhis
  • L. Abramowitz
  • P. Benfredj
  • C. Brochard
  • N. Fathallah
  • J.-L. Faucheron
  • T. Higuero
  • Y. Panis
  • V. de Parades
  • B. Vinson-Bonnet
  • D. Laharie
Review Article


The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn’s disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.


Crohn’s disease Anal fistula Treatment 



Anoperineal lesion


Crohn’s disease


Professional agreement


Expert agreement


Nuclear magnetic resonance imaging





This work was supported by the French National Society of Coloproctology (SNFCP) and the Groupe d’Etudes Thérapeutique des Affections Inflammatoires du Tube digestif (GETAID).

Compliance with ethical standards

Conflict of interest

Dominique Bouchard is the recipient of fees for education and consulting from Abbvie, François Pigot is the recipient of fees for lectures from Abbvie, Laurent Siproudhis is the recipient of fees for consulting, teaching and research from Abbvie, Ferring, MSD and Takeda, Laurent Abramowitz is the recipient of fees for research from Abbvie and Takeda, Jean-Luc Faucheron is the recipient of fees for consulting and research from AMI and Medtronic, David Laharie is the recipient of fees for consulting and research from Abbvie, Janssen, MSD and Takeda, Ghislain Staumont, Paul Benfredj, Charlène Brochard, Nadia Fathallah, Thierry Higuero, Yves Panis, Vincent de Parades, and Béatrice Vinson-Bonnet have no conflict of interest or financial ties to disclose.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Bouchard D, Abramowitz L, Bouguen G, Brochard C, Dabadie A, de Parades V, Eleuet-Kaplan M, Fathallah N, Faucheron J-L, Maggiori L, Panis Y, Pigot F, Roume P, Roumeguere P, Sénéjoux A, Siproudhis L, Staumont G, Suduca J-M, Vinson-Bonnet B, Zeitoun J-D (2017) Anoperineal lesions in Crohn’s disease: French recommendations for clinical practice. Tech Coloproctol 21:683–691. CrossRefPubMedGoogle Scholar
  2. 2.
    Hughes LE (1992) Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 35:928–932CrossRefGoogle Scholar
  3. 3.
    Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12CrossRefGoogle Scholar
  4. 4.
    Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB (2003) American Gastroenterological Association Clinical Practice Committee. AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508–1530CrossRefGoogle Scholar
  5. 5.
    Allan A, Linares L, Spooner HA, Alexander-Williams J (1992) Clinical index to quantitate symptoms of perianal Crohn’s disease. Dis Colon Rectum 35:656–661CrossRefGoogle Scholar
  6. 6.
    Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 20:27–32CrossRefGoogle Scholar
  7. 7.
    Beets-Tan RG, Beets GL, van der Hoop AG et al (2001) Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology 218:75–84CrossRefGoogle Scholar
  8. 8.
    Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR (2004) Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 233:674–681CrossRefGoogle Scholar
  9. 9.
    Orsoni P, Barthet M, Portier F, Panuel M, Desjeux A, Grimaud JC (1999) Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn’s disease. Br J Surg 86:360–364CrossRefGoogle Scholar
  10. 10.
    Schwartz DA, Wiersema MJ, Dudiak KM et al (2001) A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology 121:1064–1072CrossRefGoogle Scholar
  11. 11.
    Sordo-Mejia R, Gaertner WB (2014) Multidisciplinary and evidence-based management of fistulizing perianal Crohn’s disease. World J Gastrointest Pathophysiol 5:239–251CrossRefGoogle Scholar
  12. 12.
    Thia KT, Mahadevan U, Feagan BG et al (2009) Ciprofloxacin or metronidazole for the treatment of perianal fistulas in patients with Crohn’s disease: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis 15:17–24CrossRefGoogle Scholar
  13. 13.
    Maeda Y, Ng SC, Durdey P et al (2010) Topical metronidazole in perianal Crohn’s Study Group. Randomized clinical trial of metronidazole ointment versus placebo in perianal Crohn’s disease. Br J Surg 97:1340–1347CrossRefGoogle Scholar
  14. 14.
    Dewint P, Hansen BE, Verhey E et al (2014) Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn’s disease: a randomised, double-blind, placebo controlled trial (ADAFI). Gut 63:292–299CrossRefGoogle Scholar
  15. 15.
    West RL, van der Woude CJ, Hansen BE et al (2004) Clinical and endosonographic effect of ciprofloxacin on the treatment of perianal fistulas in Crohn’s disease with infliximab: a double-blind placebo-controlled study. Aliment Pharmacol Ther 20:1329–1336CrossRefGoogle Scholar
  16. 16.
    Ruemmele FM, Veres G, Kolho KL et al (2014) European Crohn’s and Colitis Organisation; European Society of Pediatric Gastroenterology, Hepatology and Nutrition. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn’s disease. J Crohns Colitis 8:1179–1207CrossRefGoogle Scholar
  17. 17.
    Malik AI, Nelson RL, Tou S (2010) Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev 7:CD006827Google Scholar
  18. 18.
    El-Gazzaz G, Hull T, Church JM (2012) Biological immunomodulators improve the healing rate in surgically treated perianal Crohn’s fistulas. Colorectal Dis 14:1217–1223CrossRefGoogle Scholar
  19. 19.
    Hyder SA, Travis SP, Jewell DP, Mortensen NJM, George BD (2006) Fistulating anal Crohn’s disease: results of combined surgical and infliximab treatment. Dis Colon Rectum 49:1837–1841CrossRefGoogle Scholar
  20. 20.
    Yassin NA, Askari A, Warusavitarne J et al (2014) Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn’s disease. Aliment Pharmacol Ther 40:741–749CrossRefGoogle Scholar
  21. 21.
    Regueiro M, Mardini H (2003) Treatment of perianal fistulizing Crohn’s disease with infliximab alone or as an adjunct to exam under anesthesia with seton placement. Inflamm Bowel Dis 9:98–103CrossRefGoogle Scholar
  22. 22.
    Crandall W, Hyams J, Kugathasan S et al (2009) Infliximab therapy in children with concurrent perianal Crohn disease: observations from REACH. J Pediatr Gastroenterol Nutr 49:183–190CrossRefGoogle Scholar
  23. 23.
    Dupont-Lucas C, Dabadie A, Alberti C, Ruemmele FM (2014) GETAID (Group d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif) Pédiatrique. Predictors of response to infliximab in paediatric perianal Crohn’s disease. Aliment Pharmacol Ther 40:917–929CrossRefGoogle Scholar
  24. 24.
    Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS, ACPGBI Perianal Crohn’s Disease Group (2017) Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn’s disease. Colorectal Dis 19:418–429CrossRefGoogle Scholar
  25. 25.
    Vial M, Parés D, Pera M, Grande L (2010) Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review. Colorectal Dis 12:172–178CrossRefGoogle Scholar
  26. 26.
    Zhang H, Zhou ZY, Hu B et al (2016) Clinical significance of 2 deep posterior perianal spaces to complex cryptoglandular fistulas. Dis Colon Rectum 59:766–774CrossRefGoogle Scholar
  27. 27.
    Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG (2017) MR imaging of perianal crohn disease. Radiology 282:628–645CrossRefGoogle Scholar
  28. 28.
    Tanaka S, Matsuo K, Sasaki T et al (2010) Clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing Crohn’s disease: when and how were the seton drains removed? Hepatogastroenterology 57:3–7PubMedGoogle Scholar
  29. 29.
    Present DH, Rutgeerts P, Targan S et al (1999) Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398–1405CrossRefGoogle Scholar
  30. 30.
    Sands BE, Anderson FH, Bernstein CN et al (2000) Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 350:876–885CrossRefGoogle Scholar
  31. 31.
    Colombel JF, Sandborn WJ, Rutgeerts P et al (2007) Adalimumab for maintenance of clinical response and remission in patients with Crohn’s disease: the CHARM trial. Gastroenterology 132:52–65CrossRefGoogle Scholar
  32. 32.
    Echarri A, Castro J, Barreiro M, Carpio D, Pereira S, Lorenzo A (2010) Evaluation of adalimumab therapy in multidisciplinary strategy for perianal Crohn’s disease patients with infliximab failure. J Crohns Colitis 4:654–660CrossRefGoogle Scholar
  33. 33.
    Ford AC, Sandborn WJ, Khan KJ et al (2011) Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 106:644–659CrossRefGoogle Scholar
  34. 34.
    Moon W, Pestana L, Becker B, Loftus EV Jr, Hanson KA, Bruining DH, Tremaine WJ, Kane SV (2015) Efficacy and safety of certolizumab pegol for Crohn’s disease in clinical practice. Aliment Pharmacol Ther 42:428–440CrossRefGoogle Scholar
  35. 35.
    Sandborn WJ, Feagan BG, Rutgeerts P et al (2013) GEMINI 2 Study Group. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 369:711–721CrossRefGoogle Scholar
  36. 36.
    Pearson DC, May GR, Fick GH, Sutherland LR (1995) Azathioprine and 6-mercaptopurine in Crohn disease. A meta-analysis. Ann Intern Med 123:132–142CrossRefGoogle Scholar
  37. 37.
    Prefontaine E, Macdonald JK, Sutherland LR (2010) Azathioprine or 6-mercaptopurine for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 6:CD000545Google Scholar
  38. 38.
    Cosnes J, Bourrier A, Laharie D et al (2013) Groupe d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif (GETAID). Early administration of azathioprine vs conventional management of Crohn’s disease: a randomized controlled trial. Gastroenterology 145:758–765CrossRefGoogle Scholar
  39. 39.
    Panés J, López-Sanromán A, Bermejo F et al, AZTEC Study Group (2013) Early azathioprine therapy is no more effective than placebo for newly diagnosed Crohn’s disease. Gastroenterology 145:766–774CrossRefGoogle Scholar
  40. 40.
    Chande N, Patton PH, Tsoulis DJ, Thomas BS, MacDonald JK (2015) Azathioprine or 6-mercaptopurine for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev 10:CD000067Google Scholar
  41. 41.
    Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R (2009) Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas. Dis Colon Rectum 52:1877–1881CrossRefGoogle Scholar
  42. 42.
    Hart AL, Plamondon S, Kamm MA (2007) Topical tacrolimus in the treatment of perianal Crohn’s disease: exploratory randomized controlled trial. Inflamm Bowel Dis 13:245–253CrossRefGoogle Scholar
  43. 43.
    Colombel JF, Sandborn WJ, Reinisch W et al (2010) SONIC Study Group. Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 362:1383–1395CrossRefGoogle Scholar
  44. 44.
    Bouguen G, Siproudhis L, Gizard E et al (2013) Long-term outcome of perianal fistulizing Crohn’s disease treated with infliximab. Clin Gastroenterol Hepatol 11:975–981.e1–4CrossRefGoogle Scholar
  45. 45.
    Molendijk I, Bonsing BA, Roelofs H et al (2015) Allogeneic bone marrow-derived mesenchymal stromal cells promote healing of refractory perianal fistulas in patients with Crohn’s disease. Gastroenterology 149:918–927.e6CrossRefGoogle Scholar
  46. 46.
    Panés J, García-Olmo D, Van Assche G et al, ADMIRE CD Study Group Collaborators (2016) Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn’s disease: a phase 3 randomised, double-blind controlled trial. Lancet 388:1281–1290CrossRefGoogle Scholar
  47. 47.
    Van Assche G, Vanbeckevoort D, Bielen D et al (2003) Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn’s disease. Am J Gastroenterol 98:332–339CrossRefGoogle Scholar
  48. 48.
    Tougeron D, Savoye G, Savoye-Collet C, Koning E, Michot F, Lerebours E (2009) Predicting factors of fistula healing and clinical remission after infliximab-based combined therapy for perianal fistulizing Crohn’s disease. Dig Dis Sci 54:1746–1752CrossRefGoogle Scholar
  49. 49.
    Braithwaite GC, Lee MJ, Hind D, Brown SR (2017) Prognostic factors affecting outcomes in fistulating perianal Crohn’s disease: a systematic review. Tech Coloproctol 21:501–519. CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Karmiris K, Bielen D, Vanbeckevoort D et al (2011) Long-term monitoring of infliximab therapy for perianal fistulizing Crohn’s disease by using magnetic resonance imaging. Clin Gastroenterol Hepatol 9:130–136CrossRefGoogle Scholar
  51. 51.
    Savoye-Collet C, Savoye G, Koning E, Dacher JN, Lerebours E (2011) Fistulizing perianal Crohn’s disease: contrast-enhanced magnetic resonance imaging assessment at 1 year on maintenance anti-TNF-alpha therapy. Inflamm Bowel Dis 17:1751–1758CrossRefGoogle Scholar
  52. 52.
    Colombel JF, Schwartz DA, Sandborn WJ et al (2009) Adalimumab for the treatment of fistulas in patients with Crohn’s disease. Gut 58:9 40–48CrossRefGoogle Scholar
  53. 53.
    Gaertner WB, Decanini A, Mellgren A et al (2007) Does infliximab infusion impact results of operative treatment for Crohn’s perianal fistulas? Dis Colon Rectum 50:1754–1760CrossRefGoogle Scholar
  54. 54.
    Haenning A, Staumont G, Lepage B et al (2015) The results of seton drainage combined with anti-TNF therapy for anal fistula in Crohn’s disease. Colorectal Dis 17:311–319CrossRefGoogle Scholar
  55. 55.
    Lichtenstein GR, Yan S, Bala M, Blank M, Sands BE (2005) Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulising Crohn’s disease. Gastroenterology 128:862–869CrossRefGoogle Scholar
  56. 56.
    Feagan BG, Panaccione R, Sandborn WJ et al (2008) Effects of adalimumab therapy on incidence of hospitalization and surgery in Crohn’s disease: results from the CHARM study. Gastroenterology 135:1493–1499CrossRefGoogle Scholar
  57. 57.
    Sands BE, Blank MA, Diamond RH, Barrett JP, Van Deventer SJ (2006) Maintenance infliximab does not result in increased abscess development in fistulising Crohn’s disease: results from the ACCENT II study. Aliment Pharmacol Ther 23:1127–1136CrossRefGoogle Scholar
  58. 58.
    Roumeguère P, Bouchard D, Pigot F et al (2011) Combined approach with infliximab, surgery, and methotrexate in severe fistulizing anoperineal Crohn’s disease: results from a prospective study. Inflamm Bowel Dis 17:69–76CrossRefGoogle Scholar
  59. 59.
    Grimaud JC, Munoz-Bongrand N, Siproudhis L et al (2010) Groupe d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif. Fibrin glue is effective healing perianal fistulas in patients with Crohn’s disease. Gastroenterology 138:2275–2281, 2281.e1CrossRefGoogle Scholar
  60. 60.
    Senéjoux A, Siproudhis L, Abramowitz L et al (2016) Groupe d’Etude Thérapeutique des Affections Inflammatoires du tube Digestif [GETAID]. Fistula plug in fistulising ano-perineal Crohn’s disease: a randomised controlled trial. J Crohns Colitis 10:141–148CrossRefGoogle Scholar
  61. 61.
    Gingold DS, Murrell ZA, Fleshner PR (2014) A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn’s disease. Ann Surg 260:1057–1061CrossRefGoogle Scholar
  62. 62.
    Joo JS, Weiss EG, Nogueras JJ, Wexner SD (1998) Endorectal advancement flap in perianal Crohn’s disease. Am Surg 64:147–150PubMedGoogle Scholar
  63. 63.
    Makowiec F, Jehle EC, Becker HD, Starlinger M (1995) Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn’s disease. Br J Surg 82:603–606CrossRefGoogle Scholar
  64. 64.
    Jones IT, Fazio VW, Jagelman DG (1987) The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum. Dis Colon Rectum 30:919–923CrossRefGoogle Scholar
  65. 65.
    van Onkelen RS, Gosselink MP, Schouten WR (2012) Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract? Dis Colon Rectum 55:163–166CrossRefGoogle Scholar
  66. 66.
    Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y (2015) Rectovaginal fistula. Ann Surg 262:855–861CrossRefGoogle Scholar
  67. 67.
    Gajsek U, CDArthur DR, Sagar PM (2011) Long-term efficacy of the button fistula plug in the treatment of Ileal pouch-vaginal and Crohn’s-related rectovaginal fistulas. Dis Colon Rectum 54:999–1002CrossRefGoogle Scholar
  68. 68.
    Ruffolo C, Scarpa M, Bassi N, Angriman I (2010) A systematic review on advancement flaps for rectovaginal fistula in Crohn’s disease: transrectal vs transvaginal approach. Colorectal Dis 12:1183–1191CrossRefGoogle Scholar
  69. 69.
    Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD (2010) Are there predictors of outcome following rectovaginal fistula repair? Dis Colon Rectum 53:1240–1247CrossRefGoogle Scholar
  70. 70.
    Mege D, Frasson M, Maggiori L, Panis Y (2016) Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula? Colorectal Dis 18:O61–O65CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • D. Bouchard
    • 1
    Email author
  • F. Pigot
    • 1
  • G. Staumont
    • 2
  • L. Siproudhis
    • 3
  • L. Abramowitz
    • 4
  • P. Benfredj
    • 5
  • C. Brochard
    • 3
  • N. Fathallah
    • 5
  • J.-L. Faucheron
    • 6
  • T. Higuero
    • 7
  • Y. Panis
    • 8
  • V. de Parades
    • 5
  • B. Vinson-Bonnet
    • 9
  • D. Laharie
    • 10
  1. 1.Hôpital BagatelleTalence CedexFrance
  2. 2.Clinique Saint Jean du LanguedocToulouseFrance
  3. 3.Centre Hospitalier UniversitaireRennes Cedex 9France
  4. 4.Centre Hospitalier Universitaire BichatParisFrance
  5. 5.Hôpital Saint JosephParisFrance
  6. 6.Centre Hospitalier Universitaire Grenoble-AlpesLa TroncheFrance
  7. 7.BeausoleilFrance
  8. 8.Hôpital BeaujonClichyFrance
  9. 9.Hôpital de Poissy-Saint Germain en LayePoissyFrance
  10. 10.Centre Hospitalier Universitaire Haut LévêquePessac CedexFrance

Personalised recommendations