Surgical Treatment of Perineal Crohn’s Disease

  • Bruno Roche
  • Joan Robert-Yap


Anorectal disorders affect many patients with Crohn’s disease. Clinical manifestations range from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management must be conservative and must focus on draining septic foci if present, preserving sphincter function and palliating symptoms. Medical management has shown some success in improving symptoms but has not yet been able to ameliorate most perineal complaints quickly with long lasting effects. Many new and exciting treatment modalities are being investigated, and it is hoped that more effective approaches to these complex and difficult problems will be found.


Anal Fissure Anal Fistula Advancement Flap Fistulous Tract Perianal Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Schraut WH, Medich DS (1997) Crohn’s disease. In: Greenfield LJ, Mulholland M, Oldham KT et al (eds) Surgery scientific principles and practice, 2nd edn. Lippincott, PhiladelphiaGoogle Scholar
  2. 2.
    Kodner IJ (1997) Perianal Crohn’s disease. In: Allan RN, Rhodes JM, Hanauer SB et al (eds) Inflammatory bowel diseases, 3rd edn. Churchill Livingstone, New York, p 863Google Scholar
  3. 3.
    Platell C, Mackay J, Collopy B et al (1996) Anal pathology in patients with Crohn’s disease. Aust N Z J Surg 66:5–7PubMedGoogle Scholar
  4. 4.
    Solomon MJ (1996) Fistulae and abscesses in symptomatic perianal Crohn’s. Int J Colorectal Dis 11:222–224PubMedCrossRefGoogle Scholar
  5. 5.
    Williamson PR, Hellinger MD, Larach SW et al (1995) Twenty-year review of the surgical management of perianal Crohn’s disease. Dis Colon Rectum 38:389–391PubMedCrossRefGoogle Scholar
  6. 6.
    Williams DR, Collier JA, Corman ML et al (1981) Anal complications in Crohn’s disease. Dis CoIon Rectum 24:22–24Google Scholar
  7. 7.
    Allan A, Keighley MR (1988) Management of perianal Crohn’s disease. World J Surg 12:198–201PubMedCrossRefGoogle Scholar
  8. 8.
    Lunniss PJ, Barker PG, Sultan AH et al (1994) Magnetic resonance imaging of fistula-in-ano (comments). Dis Colon Rectum 37:708–711PubMedCrossRefGoogle Scholar
  9. 9.
    Borley NR, Mortensen NJ, Jewell DP (1999) MRI scanning in perianal Crohn’s disease: an important diagnostic adjunct. Inflamm Bowel Dis 5:231–233PubMedCrossRefGoogle Scholar
  10. 10.
    Hellers G, Bergstrand O, Ewerth S et al (1980) Occurrence and outcome after primary treatment of anal fistulae in Crohn’s disease. Gut 21:525–527PubMedGoogle Scholar
  11. 11.
    Heuman R, Bolin T, Sjodahl R et al (1981) The incidence and course of perianal complications and arthralgia after intestinal resection with restoration of continuity for Crohn’s disease. Br J Surg 68:528–530PubMedCrossRefGoogle Scholar
  12. 12.
    Buchmann P, Keighley MRB, Allan RN et al (1980) Natural history of perianal Crohn’s disease. Ten year follow-up: a plea for conservatism. Am J Surg 140:642–644PubMedCrossRefGoogle Scholar
  13. 13.
    Fry RD, Shemesh EI, Kodner IJ et al (1989) Techniques and results in the management of anal and perianal Crohn’s disease. Surg Gynecol Obstet 168:42–48PubMedGoogle Scholar
  14. 14.
    Wolff BG, Culp CE, Beart RW et al (1985) Anorectal Crohn’s disease: a long-term perspective. Dis Colon Rectum 28:709–711PubMedCrossRefGoogle Scholar
  15. 15.
    Kosinski L, Welton ML (1998) Surgical options in the management of perianal Crohn’s disease. Semin Gastrointest Dis 9:15–20PubMedGoogle Scholar
  16. 16.
    Williams JG, Rothenberger DA, Nemer FD et al (1991) Fistula-in-ano in Crohn’s disease Results of aggressive surgical treatment. Dis Colon Rectum 34:378–384PubMedCrossRefGoogle Scholar
  17. 17.
    Pescatori M, Interisano A, Basso L et al (1995) Management of perianal Crohn’s disease: results of a multicenter study in Italy. Dis Colon Rectum 38:121–124PubMedCrossRefGoogle Scholar
  18. 18.
    Buchmann P, Alexander-Williams J (1980) Classification of perianal Crohn’s disease. Clin Gastroenterol 9:323–330PubMedGoogle Scholar
  19. 19.
    Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. J Clin Gastroenterol 20:27–32PubMedCrossRefGoogle Scholar
  20. 20.
    Hamilton CH (1975) Anorectal problems: the deep postanal space: surgical significance in horseshoe fistula and abscess. Dis Colon Rectum 18:642–645PubMedGoogle Scholar
  21. 21.
    Ramanujam P, Prasad ML, Abcarian H (1983) The role of seton in fistulotomy of the anus. Surg Gynecol Obstet 57:419–422Google Scholar
  22. 22.
    Keighley MR, Allan RN (1986) Current status and influence of operation on perianal Crohn’s disease. Int J Colorectal Dis 1:104–107PubMedCrossRefGoogle Scholar
  23. 23.
    Makowiec F, Jehl EC, Becker H et al (1997) Perianal abscess in Crohn’s disease. Dis Colon Rectum 40:443–450PubMedCrossRefGoogle Scholar
  24. 24.
    Fuhrman GM, Larach SW (1989) Experience with perirectal fistulas in patients with Crohn’s disease. Dis Colon Rectum 32:847–848PubMedCrossRefGoogle Scholar
  25. 25.
    Sohn N, Korelitz BI, Weinstein MA (1980) Anorectal Crohn’s disease: definitive surgery for fistulas and recurrent abscesses. Am J Surg 139:394–397PubMedCrossRefGoogle Scholar
  26. 26.
    Levien DH, Gross EL, Auriemma WS (1995) Anal Crohn’s disease. In: Mazier WP, Levien DH et al (eds) Surgery of the colon, rectum, and anus. Saunders, Philadelphia, p 971Google Scholar
  27. 27.
    Fleshner P, Schoetz D, Roberts P et al (1995) Anal fissure in Crohn’s disease: a plea for aggressive management. Dis Colon Rectum 38:1137–1143PubMedCrossRefGoogle Scholar
  28. 28.
    Wolkomir AF, Luchtefeld MA (1993) Surgery for symptomatic hemorrhoids and anal fissures in Crohn’s disease. Dis Colon Rectum 36:545–547PubMedCrossRefGoogle Scholar
  29. 29.
    Linares L, Moreira LF, Andrews H et al (1988) Natural history and treatment of anorectal strictures complicating Crohn’s disease. Br J Surg 75:653–655PubMedCrossRefGoogle Scholar
  30. 30.
    Homan WP, Tang C, Thorbjarnarson B (1976) Anal lesions complicating Crohn’s disease. Arch Surg 111:1333–1335PubMedGoogle Scholar
  31. 31.
    Jeffery PJ, Ritchie JK, Parks AG (1977) Treatment of haemorrhoids in patients with inflammatory bowel disease. Lancet 1:1084–1085PubMedCrossRefGoogle Scholar
  32. 32.
    Felt-Bersma R, Poen AC, Cuesta MA et al (1999) Anal lesions and anorectal function in perianal Crohn’s disease (abstract). Gastroenterology 116:714Google Scholar
  33. 33.
    Scott A, Hawley PR, Phillips RKS (1989) Results of external sphincter repair in Crohn’s disease. Br J Surg 76:959–960PubMedCrossRefGoogle Scholar
  34. 34.
    Keighley MR, Williams NS (1999) Surgical treatment of perianal Crohn’s disease. In: Keighley MR, Williams NS (eds) Surgery of the Anus, Rectum, and Colon. 2nd edn. Saunders, Philadelphia, p 2135Google Scholar
  35. 35.
    Buchman AL, Ament ME, Doty J (1991) Development of squamous cell carcinoma in chronic perineal sinus and wounds in Crohn’s disease. Am J Gastroenterol 86:1829–1832PubMedGoogle Scholar
  36. 36.
    Bernstein D, Rogers A (1996) Malignancy in Crohn’s disease. Am J Gastroenterol 91:434–440PubMedGoogle Scholar
  37. 37.
    Gyde SN, Prior P, Macartney JC et al (1980) Malignancy in Crohn’s disease. Gut 21:1024–1029PubMedGoogle Scholar
  38. 38.
    Nikias G, Eisner T, Katz S et al (1995) Crohn’s disease and colorectal carcinoma: rectal cancer complicating longstanding active perianal disease. Am J Gastroenterol 90:216–219PubMedGoogle Scholar
  39. 39.
    Richards ME, Rickert RR, Nance FC (1989) Crohn’s disease associated carcinoma: a poorly recognized complication of inflammatory bowel disease. Ann Surg 209:764–773PubMedCrossRefGoogle Scholar
  40. 40.
    Hawker PC, Gyde SN, Thompson H et al (1980) Adenocarcinoma of the small intestine complicating Crohn’s disease. Gut 23:188–193Google Scholar
  41. 41.
    Lavery IC, Jagelman DG (1982) Cancer in the excluded rectum following surgery for inflammatory bowel disease. Dis Colon Rectum 25:522–524PubMedCrossRefGoogle Scholar
  42. 42.
    Galandiuk S, Kimberling J, Al-Mishalb TG, Stromberg AJ (2005) Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg 241:796–801PubMedCrossRefGoogle Scholar
  43. 43.
    Lockhart-Mummery HE (1975) Crohn’s disease: anal lesions. Dis Colon Rectum 18:200–202PubMedGoogle Scholar
  44. 44.
    Shivananda S, Hordijk ML, Pena AS, Mayberry JF (1989) Crohn’s disease: risk of recurrence and reoperation in a defined population. Gut 30:990PubMedGoogle Scholar
  45. 45.
    Harper PH, Fazio VW et al (1987) Long-term outcome in Crohn’s disease. Dis Col Rectum 30:174–177CrossRefGoogle Scholar
  46. 46.
    Allan A, Keighley MRB (1988) Management of perianal Crohn’s disease. World J Surg 12:198–201PubMedCrossRefGoogle Scholar
  47. 47.
    Corman ML (1989) Colon and rectal surgery, 2nd edn. Lippincott, PhiladelphiaGoogle Scholar
  48. 48.
    Bell SJ, Williams AB, Wiesel Pilkinson K et al (2003) The clinical course of fistulating Crohn’s disease. Aliment Pharmacol Ther 17:1145–1151PubMedCrossRefGoogle Scholar
  49. 49.
    Lapidus A, Bernell O, Hellers G, Löfberg R (1998) Clinical course of colorectal Crohn’s disease: a 35-year follow-up study of 507 patients. Gastroenterology 114:1151–1160PubMedCrossRefGoogle Scholar
  50. 50.
    Targan SR, Hanauer SB, van Deventer SJ et al (1997) A short-term study of chimeric monoclonal antibody cA2 to tumor necrosis factor alpha for Crohn’s disease: Crohn’s Disease cA2 Study Group. N Engl J Med 337:1029–1035PubMedCrossRefGoogle Scholar
  51. 51.
    Sands BE, Anderson FH, Bernstein CN et al (2004) Infliximab maintenance therapy for fistulising Crohn’s disease. N Engl J Med 350:876–885PubMedCrossRefGoogle Scholar
  52. 52.
    Sandborn WJ, Hanauer SB (1999) Antitumor necrosis factor therapy for inflammatory bowel disease: a review of agents, pharmacology, clinical results, and safety. Inflamm Bowel Dis 5:119–133PubMedCrossRefGoogle Scholar
  53. 53.
    Lichtiger S (2001) Healing of perianal fistulae by local injection of antibody to TNF. Gastroenterology 120(Suppl l):A3154Google Scholar
  54. 54.
    Poggioli G, Laureti S, Pierangeli F et al (2005) Local injection of Infliximab for the treatment of perianal Crohn’s disease. Dis Colon Rectum 48:768–774PubMedCrossRefGoogle Scholar
  55. 55.
    Fiocchi C (2004) Closing fistulas in Crohn’s disease: should the accent be on maintenance or safety? N Engl J Med 350:934–936PubMedCrossRefGoogle Scholar
  56. 56.
    Vitton V et al (2005) Long term healing of Crohn’s anal fistulas with fibrin glue injection. Aliment Pharmacol Ther 21:1453–1457PubMedCrossRefGoogle Scholar
  57. 57.
    Hjortrup A, Moesgaard F, Kjaergard J (1991) Fibrin adhesive in the treatment of perineal fistulas. Dis Colon Rectum 34:752–754PubMedCrossRefGoogle Scholar
  58. 58.
    Abel ME, Chiu YS, Russell TR, Volpe PA (1993) Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum 36:447–449PubMedCrossRefGoogle Scholar
  59. 59.
    Cintron JR, Park JJ, Orsay CP et al (2000) Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum 43:944–949PubMedCrossRefGoogle Scholar
  60. 60.
    Venkatesh KS, Ramanujam P (1999) Fibrin glue application in the treatment of recurrent anorectal fistulas. Dis Colon Rectum 42:1136–1139PubMedCrossRefGoogle Scholar
  61. 61.
    Patrlj L, Kocman B, Martinac M et al (2000) Fibrin glue-antibiotic mixture in the treatment of anal fistulae: experience with 69 cases. Dig Surg 17:77–80PubMedCrossRefGoogle Scholar
  62. 62.
    Park JJ, Cintron JR, Orsay CP et al (2000) Repair of chronic anorectal fistulae using commercial fibrin sealant. Arch Surg 135:166–169PubMedCrossRefGoogle Scholar
  63. 63.
    Sentovich SM (2003) Fibrin glue for anal fistulas: long-term results. Dis Colon Rectum 46:498–502PubMedCrossRefGoogle Scholar
  64. 64.
    Sainio P, Husa A (1985) Fistula-in-ano: clinical features and long-term results of surgery in 199 adults. Acta Chir Scand 151:169–176PubMedGoogle Scholar
  65. 65.
    Van Tets W F, Kuijpers HC (1994) Continence disorders after anal fistulotomy. Dis Colon Rectum 37:1194–1197PubMedCrossRefGoogle Scholar
  66. 66.
    Makowiec F, Jahle EC, Starlinger M (1995) Clinical course of perianal fistulas in Crohn’s disease. Gut 37:696–701PubMedGoogle Scholar
  67. 67.
    Athanasiadis S, Lux N, Fischbach N et al (1991) Onestage surgery of high trans-and supra-sphincter anal fistula using primary fistulectomy and occlusion of the internal fistula ostium: a prospective study of 169 patients. Chirurg 62:608–613PubMedGoogle Scholar
  68. 68.
    Athanasiadis S, Köhler A, Nafe M (1994) Treatment of high anal fistulae by primary occlusion of the internal ostium, drainage of the intersphincteric space and mucosal advancement flap. Int J Colorect Dis 9:153–157CrossRefGoogle Scholar
  69. 69.
    Girona J, Denkers D (1996) Fistula, fissure, abscess [in German]. Chirurg 67:222–228PubMedGoogle Scholar
  70. 70.
    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 30:919–923PubMedCrossRefGoogle Scholar
  71. 71.
    Makowiec F, Jehle EC, Becker HD et al (1995) Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn’s disease. Br J Surg 82:603–606PubMedCrossRefGoogle Scholar
  72. 72.
    Ozuner G, Hull TL, Cartmill J et al (1996) Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 39:10–14PubMedCrossRefGoogle Scholar
  73. 73.
    Finan PJ (1996) Management by advancement flap technique. In: Phillips RKS, Luniss PJ (eds) Anal fistula. Chapman, London pp 107–115Google Scholar
  74. 74.
    Goodsall DH, Miles WE (1900) Diseases of the anus and rectum. Longmans, London, pp 92–173Google Scholar
  75. 75.
    Oh C (1983) Management of high recurrent anal fistula. Surgery 93:330–332PubMedGoogle Scholar
  76. 76.
    Dukes CE, Galvin C (1956) Colloid carcinoma arising within fistulae in the anorectal region. Ann R Coll Surg Engl 18:246–261PubMedGoogle Scholar
  77. 77.
    Parks AG, Thomson JPS (1973) Intersphincteric abscess. Br Med J 2:537–539PubMedCrossRefGoogle Scholar
  78. 78.
    Hull TL (1996) rectovaginal fistula in Crohn’s disease. In: Phillips RKS, Luniss PJ (eds) Anal fistula. Chapman, London, pp 143–1162Google Scholar
  79. 79.
    Contou JF (1993) Imagerie et suppurations anopérinéales. Gastroenterol Clin Biol 17:159–161PubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2006

Authors and Affiliations

  • Bruno Roche
    • 1
  • Joan Robert-Yap
    • 1
  1. 1.Unit of Proctology, Department of SurgeryUniversity Hospital of GenevaGenevaSwitzerland

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