Advertisement

Techniques in Coloproctology

, Volume 21, Issue 9, pp 683–691 | Cite as

Anoperineal lesions in Crohn’s disease: French recommendations for clinical practice

  • D. Bouchard
  • L. Abramowitz
  • G. Bouguen
  • C. Brochard
  • A. Dabadie
  • V. de Parades
  • M. Eléouet-Kaplan
  • N. Fathallah
  • J.-L. Faucheron
  • L. Maggiori
  • Y. Panis
  • F. Pigot
  • P. Rouméguère
  • A. Sénéjoux
  • L. Siproudhis
  • G. Staumont
  • J.-M. Suduca
  • B. Vinson-Bonnet
  • J.-D. Zeitoun
Review

Abstract

Background

Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn’s disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn’s disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn’s disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management.

Methodology

A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis.

Results

MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn’s disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn’s disease, and after obtaining luminal and perineal remission with anti-TNF ± immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn’s disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical–surgical cooperation.

Keywords

Crohn’s disease Anoperineal lesions Anal fistulas Abscess Anal stenosis Guidelines Recommendations 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This type of study does not need ethical approval.

Informed consent

This type of study does not need informed consent.

References

  1. 1.
    Lapidus A, Bernell O, Hellers G, Lofberg R (1998) Clinical course of colorectal Crohn’s disease: a 35-year follow-up study of 507 patients. Gastroenterology 114:1151–1160CrossRefPubMedGoogle Scholar
  2. 2.
    Beaugerie L, Seksik P, Nion-Larmurier I, Gendres JP, Cosnes J (2006) Predictors of Crohn’s disease. Gastroenterology 130:650–656CrossRefPubMedGoogle Scholar
  3. 3.
    Schwartz DA, Loftus EV, Tremaine WJ et al (2002) The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 122:875–880CrossRefPubMedGoogle Scholar
  4. 4.
    Hellers G, Bergstrand O, Ewerth S, Holmstrom B (1980) Occurrence and outcome after primary treatment of anal fistulae in Crohn’s disease. Gut 21:525–527CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Gionchetti P et al (2017) 3rd European evidence-based consensus on the diagnosis and management of Crohn’s disease 2016: part 2: surgical management and special situations. J Crohns Colitis 11:135–149CrossRefPubMedGoogle Scholar
  6. 6.
    Gecse KB et al (2014) A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn’s disease. Gut 63:1381–1392CrossRefPubMedGoogle Scholar
  7. 7.
    Pellino G et al (2015) A think tank of the Italian society of colorectal surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: Crohn’s disease. Tech Coloproctol 19:639–651CrossRefPubMedGoogle Scholar
  8. 8.
    Hughes LE (1992) Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 35:928–932CrossRefPubMedGoogle Scholar
  9. 9.
    Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB (2003) American Gastroenterological association clinical practice committee. AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508–1530CrossRefPubMedGoogle Scholar
  10. 10.
    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 20:27–32CrossRefPubMedGoogle Scholar
  11. 11.
    Beets-Tan RGH, Beets GL, van der Hoop AG et al (2001) Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology 218:75–84CrossRefPubMedGoogle Scholar
  12. 12.
    Schratter-Sehn AU, Lochs H, HandI-Zeller L, Tscholakoff D, Schratter M (1993) Endosonographic features of the lower pelvic region in Crohn’s disease. Am J Gastroenterol 88:1054–1057PubMedGoogle Scholar
  13. 13.
    Pescatori M, Interisano A, Basso L (1995) Management of perianal Crohn’s disease. Dis Colon Rectum 38:121–124CrossRefPubMedGoogle Scholar
  14. 14.
    McKee RF, Keenan RA (1996) Perianal Crohn’s disease: is it all bad news? Dis Colon Rectum 39:136–142CrossRefPubMedGoogle Scholar
  15. 15.
    Committee American Gastroenterological Association Clinical Practice (2003) American Gastroenterological Association medical position statement: perianal Crohn’s disease. Gastroenterology 125:1503–1507CrossRefGoogle Scholar
  16. 16.
    Tang LY, Rawsthorne P, Bernstein CN (2006) Are perineal and luminal fistulas associated in Crohn’s disease? A population-based study. Clin Gastroenterol Hepatol 4:1130–1134CrossRefPubMedGoogle Scholar
  17. 17.
    Maccioni F, Colaiacomo MC, Stasolla A, Manganaro L, Izzo L, Marini M (2002) Value of MRI performed with phased-array coil in the diagnosis and preoperative classification of perianal and anal fistulas. Radiol Med 104:58–67PubMedGoogle Scholar
  18. 18.
    Lunniss PJ, Barker PG, Sultan AH et al (1994) Magnetic resonance imaging of fistula-in-ano. Dis Colon Rectum 37:708–718CrossRefPubMedGoogle Scholar
  19. 19.
    de Souza NM, Hall AS, Puni R, Gilderdale DJ, Young IR, Kmiot WA (1996) High resolution magnetic resonance imaging of the anal sphincter using a dedicated endo-anal coil. Comparison of magnetic resonance imaging with surgical findings. Dis Colon Rectum 39:926–934CrossRefGoogle Scholar
  20. 20.
    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 121:1064–1072CrossRefPubMedGoogle Scholar
  21. 21.
    Chapple KS, Spencer JA, Windsor AC et al (2000) Prognostic value of magnetic resonance imaging in the management of fistula in ano. Dis Colon Rectum 43:511–516CrossRefPubMedGoogle Scholar
  22. 22.
    Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D (2004) Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 233:674–681CrossRefPubMedGoogle Scholar
  23. 23.
    Cuenod CA, de Parades V, Siauve N et al (2003) MR imaging of ano-perineal suppurations. J Radiol 84:516–528PubMedGoogle Scholar
  24. 24.
    Low RN, Sebrechts CP, Politoske DA et al (2002) Crohn disease with endoscopic correlation: single-shot fast spin-echo and gadolinium-enhanced fat-suppressed spoiled gradient-echo MR imaging. Radiology 222:652–660CrossRefPubMedGoogle Scholar
  25. 25.
    Florie J, Wasser MN, Arts-Cieslik K, Akkerman EM, Siersema PD, Stoker J (2006) Dynamic contrast-enhanced MRI of the bowel wall for assessment of disease activity in Crohn’s disease. AJR Am J Roentgenol 186:1384–1392CrossRefPubMedGoogle Scholar
  26. 26.
    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 98:332–339CrossRefPubMedGoogle Scholar
  27. 27.
    Mallouhi A, Bonatti H, Peer S, Lugger P, Conrad F, Bodner G (2004) Detection and characterization of perianal inflammatory disease: accuracy of transperineal combined gray scale and colour Doppler sonography. J Ultrasound Med 23:19–27CrossRefPubMedGoogle Scholar
  28. 28.
    Zbar AP, Oyetunji RO, Gill R (2006) Transperineal versus hydrogen peroxide-enhanced endo-anal ultrasonography in never operated and recurrent cryptogenic fistula in ano: a pilot study. Tech Coloproctol 10:297–302CrossRefPubMedGoogle Scholar
  29. 29.
    Domkundwar SV, Shinagare AB (2007) Role of transcutaneous perianal ultrasonography in evaluation of fistulas in ano. J Ultrasound Med 26:29–36CrossRefPubMedGoogle Scholar
  30. 30.
    Maconi G, Ardizzone S, Greco S, Radice E, Bezzio C, Bianchi Porro G (2007) Transperineal ultrasound in the detection of perianal and rectovaginal fistulae in Crohn’s disease. Am J Gastroenterol 102:2214–2219CrossRefPubMedGoogle Scholar
  31. 31.
    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 340:1398–1405CrossRefPubMedGoogle Scholar
  32. 32.
    Sands BE, Anderson FH, Bernstein CN et al (2004) Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 350:876–885CrossRefPubMedGoogle Scholar
  33. 33.
    Peyrin-Biroulet L, Loftus EV Jr, Tremaine WJ, Harmsen WS, Zinsmeister AR, Sandborn WJ (2012) Perianal Crohn’s disease findings other than fistulas in a population-based cohort. Inflamm Bowel Dis 18:43–48CrossRefPubMedGoogle Scholar
  34. 34.
    Eglinton TW, Roberts R, Pearson J et al (2012) Clinical and genetic risk factors for perianal Crohn’s disease in a population-based cohort. Am J Gastroenterol 107:589–596CrossRefPubMedGoogle Scholar
  35. 35.
    Siproudhis L, Mortaji A, Mary JY, Juguet F, Bretagne JF, Gosselin M (1997) Anal lesions: any significant prognosis in Crohn’s disease? Eur J Gastroenterol Hepatol 9:239–243CrossRefPubMedGoogle Scholar
  36. 36.
    Cosnes J, Bourrier A, Laharie D et al (2013) Early administration of azathioprine vs. conventional management of Crohn’s disease: a randomized controlled trial. Gastroenterology 145:758–765CrossRefPubMedGoogle Scholar
  37. 37.
    Ouraghi A, Nieuviarts S, Mougenel JL et al (2001) Infliximab therapy for Crohn’s disease ano-perineal lesions. Gastroenterol Clin Biol 25:949–956PubMedGoogle Scholar
  38. 38.
    Bouguen G, Trouilloud I, Siproudhis L et al (2009) Long-term outcome of non-fistulizing (ulcers, stricture) perianal Crohn’s disease in patients treated with infliximab. Aliment Pharmacol Ther 30:749–756CrossRefPubMedGoogle Scholar
  39. 39.
    Colombel JF, Sandborn WJ, Reinisch W et al (2010) Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 362:1383–1395CrossRefPubMedGoogle Scholar
  40. 40.
    Colombel J-F, Schwartz DA, Sandborn WJ et al (2009) Adalimumab for the treatment of fistulas in patients with Crohn’s disease. Gut 58:940–948CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    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 63:292–299CrossRefPubMedGoogle Scholar
  42. 42.
    Bell SJ, Williams AB, Wiesel P, Wilkinson K, Cohen RC, Kamm MA (2003) The clinical course of fistulating Crohn’s disease. Aliment Pharmacol Ther 17:1145–1151CrossRefPubMedGoogle Scholar
  43. 43.
    Tanaka S, Matsuo K, Sasaki T, Nakano M, Sakai K, Beppu R 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
  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 11:975–981CrossRefPubMedGoogle Scholar
  45. 45.
    Buchanan GN, Owen HA, Torkington J, Lunniss PJ, Nicholls RJ, Cohen CR (2004) Long-term outcome following loose-seton technique for external sphincter preservation in complex anal fistula. Br J Surg 91:476–480CrossRefPubMedGoogle Scholar
  46. 46.
    Haggett PJ, Moore NR, Shearman JD, Travis SP, Jewell DP, Mortensen NJ (1995) Pelvic and perineal complications of Crohn’s disease: assessment using magnetic resonance imaging. Gut 36:407–410CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Grimaud JC, Munoz-Bongrand N, Siproudhis L et al (2010) Fibrin glue is effective healing perianal fistulas in patients with Crohn’s disease. Gastroenterology 138:2275–2281CrossRefPubMedGoogle Scholar
  48. 48.
    Senéjoux A, Siproudhis L, Abramowitz L et al (2016) Fistula plug in fistulising ano-perineal Crohn’s disease: a randomised controlled trial. J Crohns Colitis 10(2):141–148CrossRefPubMedGoogle Scholar
  49. 49.
    Soltani A, Kaiser AM (2010) Endorectal flap for cryptoglandular or Crohn’s fistula in ano. Dis Colon Rectum 53:486–495CrossRefPubMedGoogle Scholar
  50. 50.
    Van Assche G, Dignass A, Reinisch W et al (2010) The second European evidence-based consensus on the diagnosis and management of Crohn’s disease: special situations. ECCO J Crohn’s Colitis 4:63–101CrossRefGoogle Scholar
  51. 51.
    Reenaers C, Louis E, Belaiche J et al (2012) Does co-treatment with immunosuppressors improve outcome in patients with Crohn’s disease treated with adalimumab? Aliment Pharmacol Ther 36:1040–1048CrossRefPubMedGoogle Scholar
  52. 52.
    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 disease. Ann Surg 260:1057–1061CrossRefPubMedGoogle Scholar
  53. 53.
    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 12:1183–1191CrossRefPubMedGoogle Scholar
  54. 54.
    Panés J, García-Olmo D, Van Assche G et al (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 388:1281–1290CrossRefPubMedGoogle Scholar
  55. 55.
    Lefevre JH, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y (2009) Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis Colon Rectum 52:1290–1295CrossRefPubMedGoogle Scholar
  56. 56.
    Furst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, Agha A (2008) Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease. Int J Colorectal Dis 23:349–353CrossRefPubMedGoogle Scholar
  57. 57.
    Pitel S, Lefevre JH, Parc Y, Chafai N, Shields C, Tiret E (2011) Martius advancement flap for low rectovaginal fistula: short- and long-term results. Colorectal Dis 13:e112–e115CrossRefPubMedGoogle Scholar
  58. 58.
    Songne K, Scotte M, Lubrano J, Huet E, Lefebure B, Surlemont Y et al (2007) Treatment of anovaginal or rectovaginal fistulas with modified Martius graft. Colorectal Dis 9:653CrossRefPubMedGoogle Scholar
  59. 59.
    Regimbeau JM, Panis Y, Marteau P, Benoist S, Valleur P (1999) Surgical treatment of ano-perineal Crohn’s disease: can abdominoperineal resection be predicted? J Am Coll Surg 189:171–176CrossRefPubMedGoogle Scholar
  60. 60.
    Regimbeau JM, Panis Y, Cazaban L et al (2001) Long-term results of faecal diversion for refractory perianal Crohn’s disease. Colorectal Dis 3:232–237CrossRefPubMedGoogle Scholar
  61. 61.
    Annese V et al (2015) European evidence-based consensus: inflammatory bowel disease and malignancies. J Crohns Colitis 9:945–965CrossRefPubMedGoogle Scholar
  62. 62.
    Rieder F et al (2016) European Crohn’s and colitis organisation topical review on prediction, diagnosis and management of fibrostenosing Crohn’s disease. J Crohns Colitis 10:873–885CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • D. Bouchard
    • 1
  • L. Abramowitz
    • 2
  • G. Bouguen
    • 3
  • C. Brochard
    • 3
  • A. Dabadie
    • 4
  • V. de Parades
    • 5
  • M. Eléouet-Kaplan
    • 1
  • N. Fathallah
    • 5
  • J.-L. Faucheron
    • 6
  • L. Maggiori
    • 7
  • Y. Panis
    • 7
  • F. Pigot
    • 1
  • P. Rouméguère
    • 8
  • A. Sénéjoux
    • 9
  • L. Siproudhis
    • 3
    • 10
  • G. Staumont
    • 11
  • J.-M. Suduca
    • 11
  • B. Vinson-Bonnet
    • 12
  • J.-D. Zeitoun
    • 13
  1. 1.Service de ProctologieHôpital Bagatelle, Maison de Santé Protestante BagatelleTalenceFrance
  2. 2.Proctologie médico-chirurgicalehôpital Bichat Claude-BernardParisFrance
  3. 3.Service des maladies de l’appareil digestifCHU PontchaillouRennesFrance
  4. 4.CHU Pontchaillou, CHU hôpital SudRennesFrance
  5. 5.Service de proctologie médico-chirurgicale, institut Léopold-Bellangroupe hospitalier Saint-JosephParisFrance
  6. 6.Unité de chirurgie colo-rectale, service de chirurgie digestive et de l’urgencehôpital Michallon, CHUGAGrenobleFrance
  7. 7.Service de chirurgie colo-rectale, pôle des maladies de l’appareil digestifhôpital Beaujon, université Paris 7ClichyFrance
  8. 8.Clinique Tivoli-DucosBordeauxFrance
  9. 9.CHP Saint-GrégoireSaint-GrégoireFrance
  10. 10.Inserm U991, service de gastro-entérologie, université de Rennes 1CHU PontchaillouRennesFrance
  11. 11.Clinique Saint-Jean-LanguedocToulouseFrance
  12. 12.Service de chirurgie viscérale et digestiveCHI, Poissy-St-Germain-en-LayeParisFrance
  13. 13.Service de proctologie médico-interventionnelleParisFrance

Personalised recommendations