Anal Fistula pp 139-157 | Cite as

Crohn’s Disease

  • James Fleshman
  • Rachel Tay


Perianal and rectovaginal fistula are common and challenging problems for patients with Crohn’s disease. The initial steps in treating Crohn’s fistula patients revolve around obtaining control of the underlying intestinal disease. Optimum medical therapy must be implemented if surgical treatment is going to be successful. Several different surgical treatment options exist, and depend on the size, number, and location of the fistula, as well as the gender of the patient. These include fistulotomy/fistulectomy, plugs, glues, advancement flaps, tissue transposition, and the LIFT procedure. Though many of these options have shown promise, recurrence rates remain high, and further studies are needed to evaluate the long-term outcomes of these patients.


Fistula Tract External Anal Sphincter Anal Fistula Internal Opening Advancement Flap 
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.


  1. 1.
    Zawadzki A, Starck M, Bohe M, Thorlacius H. A unique 3D endoanal ultrasound feature of perianal Crohn’s fistula: the ‘Crohn ultrasound fistula sign’. Colorectal Dis. 2012;9:e608–11.CrossRefGoogle Scholar
  2. 2.
    Yousem DM, Fishman EK, Jones B. Crohn disease: perirectal and perianal findings at CT. Radiology. 1988;167:331–4.PubMedGoogle Scholar
  3. 3.
    Guillaumin E, Jeffrey Jr RB, Shea WJ, Asling CW, Goldberg HI. Perirectal inflammatory disease: CT findings. Radiology. 1986;161:153–7.PubMedGoogle Scholar
  4. 4.
    Leyendecker J, Bloomfield R, DiSantis D, Waters G, Mott R, Bechtold R. MR enterography in the management of patients with Crohn disease. Radiographics. 2009;6:1827–46.CrossRefGoogle Scholar
  5. 5.
    Buchanan G, Halligan S, Williams A, Cohen CR, Tarroni D, Phillips RK, et al. Effect of MRI on clinical outcome of recurrent fistula-in-ano. Lancet. 2002;360:1661–2.PubMedCrossRefGoogle Scholar
  6. 6.
    Law PJ, Talbot RW, Bartram CI, Northover JM. Anal endosonography in the evaluation of perianal sepsis and fistula in ano. Br J Surg. 1989;76(7):752–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Hildebrandt U, Feifel G, Schwarz HP, Scherr O. Endorectal ultrasound: instrumentation and clinical aspects. Int J Colorectal Dis. 1986;1(4):203–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Navarro-Luna A, García-Comingo MI, Rius-Macías J, Marco-Molina C. Ultrasound study of anal fistulas with hydrogen peroxide enhancement. Dis Colon Rectum. 2004;47(1):108–14.PubMedCrossRefGoogle Scholar
  9. 9.
    Lengyel AJ, Hurst NG, Williams JG. Pre-operative assessment of anal fistulas using endoanal ultrasound. Colorectal Dis. 2002;4(6):436–40.PubMedCrossRefGoogle Scholar
  10. 10.
    Halligan S, Stoker J. Imaging of fistula in ano. Radiology. 2006;239(1):18–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Schwartz DA, Wiersema MI, Dudiak KM, et al. A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology. 2001;121:1064–72.PubMedCrossRefGoogle Scholar
  12. 12.
    Sahni VA, Ahmad R, Burling D. Which method is best for imaging of perianal fistula? Abdom Imaging. 2008;33:26–30.PubMedCrossRefGoogle Scholar
  13. 13.
    West RL, van der Woude CJ, Hansen BE, Felt-Bersma RJ, van Tilburg AJ, Drapers JA, Kuipers EJ. Clinical and endosonographic effect of ciprofloxacin on the treatment of perianal fistulae in Crohn’s disease with infliximab: a double-blind placebo-controlled study. Aliment Pharmacol Ther. 2004;20(11–12):1329–36.PubMedCrossRefGoogle Scholar
  14. 14.
    Bernstein LH, Frank MS, Brandt LJ, Boley SJ. Healing of perineal Crohn’s disease with metronidazole. Gastroenterology. 1987;79:357–65.Google Scholar
  15. 15.
    Thia KT, Mahadevan U, Feagan BG, Wong C, Cockeram A, Bitton A, Bernstein CN, Sandborn WJ. 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. 2009;15(1):17–24.PubMedCrossRefGoogle Scholar
  16. 16.
    Lecomte T, Contou JF, Beaugerie L, Carbonnel F, Cattan S, Gendre JP, Cosnes J. Predictive factors of response of perianal Crohn’s disease to azathioprine or 6-mercaptopurine. Dis Colon Rectum. 2003;46(11):1469–75.PubMedCrossRefGoogle Scholar
  17. 17.
    Korelitz BI, Present DH. Favorable effect of 6-mercaptopurine on fistulae of Crohn’s disease. Dig Dis Sci. 1985;30(1):58–64.PubMedCrossRefGoogle Scholar
  18. 18.
    Present DH, Korelitz BI, Wisch N, Glass JL, Sachar DB, Pasternack BS. Treatment of Crohn’s disease with 6-mercaptopurine. A long-term, randomized, double-blind study. N Engl J Med. 1980;302(18):981–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Jeshion WC, Larsen KL, Jawad AF, Piccoli DA, Verma R, Maller ES, Baldassano RN. Azathioprine and 6-mercaptopurine for the treatment of perianal Crohn’s disease in children. J Clin Gastroenterol. 2000;30(3):294–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Ochsenkühn T, Göke B, Sackmann M. Combining infliximab with 6 mercaptopurine/azathioprine for fistula therapy in Crohn’s disease. Am J Gastroenterol. 2002;97(8):2022–5.PubMedGoogle Scholar
  21. 21.
    Kornbluth A. Infliximab approved for use in Crohn’s disease: a report on the FDA GI advisory committee conference. Inflamm Bowel Dis. 1998;4(4):328–9.PubMedGoogle Scholar
  22. 22.
    Present DH, Rutgeerts P, Targan S, Hanauer S, Mayer L, van Hogezand RA, Podolsky D, Sands B, Braakman T, DeWoody KL, Schaible TF, van Deventer SJH. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med. 1999;340:1398–405.PubMedCrossRefGoogle Scholar
  23. 23.
    Lichtiger S, Binion DG, Wolf DC, Present DH, Bensimon AG, Wu E, Yu AP, Cardoso AT, Chao J, Mulani PM, Lomax KG, Kent JD. The CHOICE trial: adalimumab demonstrates safety, fistula healing, improved quality of life and increased work productivity in patients with Crohn’s disease who failed prior infliximab therapy. Aliment Pharmacol Ther. 2010;32(10):1228–39.PubMedCrossRefGoogle Scholar
  24. 24.
    Schreiber S, Lawrance IC, Thomsen OØ, Hanauer SB, Bloomfield R, Sandborn WJ. Randomised clinical trial: certolizumab pegol for fistulas in Crohn’s disease—subgroup results from a placebo-controlled study. Aliment Pharmacol Ther. 2011;33(2):185–93.PubMedCrossRefGoogle Scholar
  25. 25.
    D’Haens GR, Panaccione R, Higgins PD, Vermeire S, Gassull M, Chowers Y, Hanauer SB, Herfarth H, Hommes DW, Kamm M, Löfberg R, Quary A, Sands B, Sood A, Watermeyer G, Lashner B, Lémann M, Plevy S, Reinisch W, Schreiber S, Siegel C, Targan S, Watanabe M, Feagan B, Sandborn WJ, Colombel JF, Travis S. The London position statement of the world congress of gastroenterology on biological therapy for IBD with the European Crohn’s and colitis organization: when to start, when to stop, which drug to choose, and how to predict response? Am J Gastroenterol. 2011;106(2):199–212.PubMedCrossRefGoogle Scholar
  26. 26.
    Takesue Y, Ohge H, Yokoyama T, Murakami Y, Imamura Y, Sueda T. Long-term results of seton drainage on complex anal fistulae in patients with Crohn’s disease. J Gastroenterol. 2002;37(11):912–5.PubMedCrossRefGoogle Scholar
  27. 27.
    Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn’s fistula-in-ano. Dis Colon Rectum. 2010;53(4):486–95.PubMedCrossRefGoogle Scholar
  28. 28.
    Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery. 1993;114(4):682–9.PubMedGoogle Scholar
  29. 29.
    Grimaud JC, Munoz-Bongrand N, Siproudhis L, Abramowitz L, Sénéjoux A, Vitton V, Gambiez L, Flourié B, Hébuterne X, Louis E, Coffin B, De Parades V, Savoye G, Soulé JC, Bouhnik Y, Colombel JF, Contou JF, François Y, Mary JY, Lémann M. Fibrin glue is effective healing perianal fistulas in patients with Crohn’s disease. Gastroenterology. 2010;138(7):2275–81.PubMedCrossRefGoogle Scholar
  30. 30.
    O’Riordan JM, Datta I, Johnston C, Baxter NN. A systematic review of the anal fistula plug for patients with Crohn’s and non-Crohn’s related fistula-in-ano. Dis Colon Rectum. 2012;55(3):351–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Taxonera C, Schwartz D, García-Olmo D. Emerging treatments for complex perianal fistula in Crohn’s disease. World J Gastroenterol. 2009;15(34):4263–72.PubMedCrossRefGoogle Scholar
  32. 32.
    Guadalajara H, Herreros D, De-La-Quintana P, Trebol J, Garcia-Arranz M, Garcia-Olmo D. Long-term follow-up of patients undergoing adipose-derived adult stem cell administration to treat complex perianal fistulas. Int J Colorectal Dis. 2012;27(5):595–600.PubMedCrossRefGoogle Scholar
  33. 33.
    Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai. 2007;90(3):581–6.PubMedGoogle Scholar
  34. 34.
    Sileri P, Franceschilli L, Angelucci GP, D’Ugo S, Milito G, Cadeddu F, Selvaggio I, Lazzaro S, Gaspari AL. Ligation of the intersphincteric fistula tract (LIFT) to treat anal fistula: early results from a prospective observational study. Tech Coloproctol. 2011;15(4):413–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Tan KK, Alsuwaigh R, Tan AM, Tan IJ, Liu X, Koh DC, Tsang CB. To LIFT or to flap? Which surgery to perform following seton insertion for high anal fistula? Dis Colon Rectum. 2012;55(12):1273–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Han JG, Yi BQ, Wang ZJ, Zheng Y, Cui JJ, Yu XQ, Zhao BC, Yang XQ. Ligation of the intersphincteric fistula tract plus bioprosthetic anal fistula plug (LIFT-Plug): a new technique for fistula-in-ano. Colorectal Dis. 2013;15(5):582–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Rehg KL, Sanchez JE, Krieger BR, Marcet JE. Fecal diversion in perirectal fistulizing Crohn’s disease is an underutilized and potentially temporary means of successful treatment. Am Surg. 2009;75(8):715–8.PubMedGoogle Scholar
  38. 38.
    Galandiuk S, Kimberling J, Al-Mishlab TG, Stromberg AJ. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg. 2005;241(5):796–801.PubMedCrossRefGoogle Scholar
  39. 39.
    Genua JC, Vivas DA. Management of nonhealing perineal wounds. Clin Colon Rectal Surg. 2007;20(4):322–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Ky A, Sohn N, Weinstein MA, Korelitz BI. Carcinoma arising in anorectal fistulas of Crohn’s disease. Dis Colon Rectum. 1998;41(8):992–6. Review.PubMedCrossRefGoogle Scholar
  41. 41.
    Korelitz BI. Carcinoma of the intestinal tract in Crohn’s disease: results of a survey conducted by the National Foundation for ileitis and colitis. Am J Gastroenterol. 1983;78(1):44–6.PubMedGoogle Scholar
  42. 42.
    Schwartz DA, Loftus Jr EV, Tremaine WJ, Panaccione R, Harmsen WS, Zinsmeister AR, Sandborn WJ. The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology. 2002;122(4):875–80.PubMedCrossRefGoogle Scholar
  43. 43.
    Sands BE, Blank MA, Patel K, van Deventer SJ. Longterm treatment of rectovaginal fistulas in Crohn’s disease: response to infliximab in the ACCENT II study. Clin Gastroenterol Hepatol. 2004;2(10):912–20.PubMedCrossRefGoogle Scholar
  44. 44.
    Shobeiri SA, Quiroz L, Nihira M. Rectovaginal fistulography: a technique for the identification of recurrent elusive fistulas. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(5):571–3.PubMedCrossRefGoogle Scholar
  45. 45.
    Stoker J, Rociu E, Schouten WR, Laméris JS. Anovaginal and rectovaginal fistulas: endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol. 2002;178(3):737–41.PubMedCrossRefGoogle Scholar
  46. 46.
    Maconi G, Ardizzone S, Greco S, Radice E, Bezzio C, Bianchi Porro G. Transperineal ultrasound in the detection of perianal and rectovaginal fistulae in Crohn’s disease. Am J Gastroenterol. 2007;102(10):2214–9. Epub 2006 Aug 4.PubMedCrossRefGoogle Scholar
  47. 47.
    Coller JA. Clinical application of anorectal manometry. Gastroenterol Clin North Am. 1987;16(1):17–33.PubMedGoogle Scholar
  48. 48.
    Tsang CB, Madoff RD, Wong WD, Rothenberger DA, Finne CO, Singer D, Lowry AC. Anal sphincter integrity and function influences outcome in rectovaginal fistula repair. Dis Colon Rectum. 1998;41(9):1141–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Buchanan GN, Bartram CI, Phillips RK, Gould SW, Halligan S, Rockall TA, Sibbons P, Cohen RG. Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Dis Colon Rectum. 2003;46(9):1167–74.PubMedCrossRefGoogle Scholar
  50. 50.
    Abel ME, Chiu YS, Russell TR, Volpe PA. Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum. 1993;36(5):447–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Gajsek U, McArthur DR, Sagar PM. Long-term efficacy of the button fistula plug in the treatment of ileal pouch-vaginal and Crohn’s-related rectovaginal fistulas. Dis Colon Rectum. 2011;54(8):999–1002.PubMedCrossRefGoogle Scholar
  52. 52.
    MacRae HM, McLeod RS, Cohen Z, Stern H, Reznick R. Treatment of rectovaginal fistulas that has failed previous repair attempts. Dis Colon Rectum. 1995;38(9):921–5.PubMedCrossRefGoogle Scholar
  53. 53.
    Khanduja KS, Padmanabhan A, Kerner BA, Wise WE, Aguilar PS. Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty. Dis Colon Rectum. 1999;42(11):1432–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Wise Jr WE, Aguilar PS, Padmanabhan A, Meesig DM, Arnold MW, Stewart WR. Surgical treatment of low rectovaginal fistulas. Dis Colon Rectum. 1991;34(3):271–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term results of anterior sphincteroplasty. Dis Colon Rectum. 2004;47(5):727–31.PubMedCrossRefGoogle Scholar
  56. 56.
    Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet. 2000;355(9200):260–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum. 2008;51(7):1084–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Haray PN, Stiff G, Foster ME. New option for recurrent rectovaginal fistulas. Dis Colon Rectum. 1996;39:463–4.PubMedCrossRefGoogle Scholar
  59. 59.
    Ruffolo C, Scarpa M, Bassi N, Angriman I. A systematic review on advancement flaps for rectovaginal fistula in Crohn’s disease: transrectal vs transvaginal approach. Colorectal Dis. 2010;12(12):1183–91.PubMedCrossRefGoogle Scholar
  60. 60.
    Marchesa P, Hull TL, Fazio VW. Advancement sleeve flaps for treatment of severe perianal Crohn’s disease. Br J Surg. 1998;85:1695–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn’s disease. Am J Surg. 1997;173(2):95–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Fürst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, Agha A. Gracilis transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn’s disease. Int J Colorectal Dis. 2008;23(4):349–53.PubMedCrossRefGoogle Scholar
  63. 63.
    McNevin MS, Lee PYH, Bax TW. Martius flap: an adjunct for repair of complex, low rectovaginal fistula. Am J Surg. 2007;193(5):597–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Songne K, Scotté M, Lubrano J, Huet E, Lefébure B, Surlemont Y, Leroy S, Michot F, Ténière P. Treatment of anovaginal or rectovaginal fistulas with modified Martius graft. Colorectal Dis. 2007;9(7):653–6.PubMedCrossRefGoogle Scholar
  65. 65.
    Schloericke E, Hoffman M, Zimmermann M, Kraus M, Bouchard R, Roblick UJ, Hildebrand P, Nolde J, Bruch HP, Limmer S. Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas. Colorectal Dis. 2012;14(5):604–10.PubMedCrossRefGoogle Scholar
  66. 66.
    El-Gazzaz G, Hull T, Mignanelli E, Hammel J, Gurland B, Zutshi M. Analysis of function and predictors of failure in women undergoing repair of Crohn’s related rectovaginal fistula. J Gastrointest Surg. 2010;14(5):824–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of SurgeryBaylor University Medical CenterDallasUSA

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