Transcript Perianal Fistulizing Crohn’s Disease

Perianal Fistulizing Crohn’s
Disease
Simple, Complex,
Incision and Drainage, Fistulotomy, Setons, Diversion or Proctectomy ?
OH MY!
Case Study
24 yr old male with a 1 ½ yr. h/o stricturing ileal disease s/p
ileocecetomy and rectosigmoid Crohn’s disease. He is
currently on Infliximab and Azathioprine but continues with
recurrent and now worsening perianal pain with severe
throbbing discomfort and swelling upon sitting especially for
extended periods. Past MRI had revealed incidentally a very
small fluid collection. He has had perianal discomfort on and
off in the past treated with short courses of antibiotics
resulting in drainage with resolution of swelling. He has
discomfort on walking and especially sitting for extended
periods. Now referred to colorectal clinic for surgical
evaluation of persistent perirectal abscess/fistula.
Perianal Fistulizing Crohn’s
What do we know?
• History
– h/o rectosigmoid disease and recurring abscess.
• Symptoms
– throbbing pain, periodically drains purulence, smells
• Testing
– MRI showing fluid collection
• Treatments
– Azathioprine and Infliximab
– Cipro/flagyl
• QoL – constant annoyance
– Difficulty sitting, sometimes walking, recurring abscess,
difficult when job requires sitting in multiple meetings a day
Perianal Abscess
abscess
What testing might be considered to
evaluate abscess?
• Digital exam
– feel fistula, induration, swelling - may be too painful
• MRI
– helps delineate tracts and fluid collection, helps evaluate
healing – may over report in some cases
• Anal Endosongraphy
– good to evaluate tracts close to the anal canal but loss of
resolution further away
• Exam under anesthesia
– Very good to evaluate the area as usually painful and note
presence of fluid collections
Kamm, M, NG.S 2008 Clin Gastroenterol and Hepatol 6:7-10
Recent testing - MRI abd/pelvis
Thickening rectal- sigmoid area with left lateral rectal
area with small fluid collection
Exam Under Anesthesia
• Complex fistula opening was found in the
rectum on the left lateral aspect.
• Wire probe placed through the opening and
followed tract to an abscess cavity within the
sphincter muscles to the outside of the
perineum. The abscess was opened and
purulent material drained through to the
outside opening.
Abscess
fistula
What surgical procedure would you
recommend for this perianal abscess?
•
•
•
•
Incision and drainage
Fistulotomy
Seton placement
Diverting stoma
Abscess is superficial outside the sphincter muscles!
Schwartz, D.A., J.H. Pemberton, and W.J. Sandborn, Diagnosis and treatment of perianal fistulas in Crohn disease. Ann Intern Med, 2001. 135(10): p. 906-18.
Seton keeps the
fistula track
open so abscess
drains
Abscess is within the
sphincter muscles
Preoperative discussions?
• What major risk should be discussed related to perianal
procedures?
– Incontinence - damage to sphincters
– Perineal tissue destruction - scarring
• What postoperative recommendations and patient education
should you discuss for this case?
– Hot sitz baths several times per day
– Use of butterfly or anal incontinence pads to wick away
moisture
– For a seton left in with a circle tie:
• Move seton from side to side
• Sutured connection needs to be outside tract
• Recommend leaving a tail on the seton so cannot rotate inside the tract
In Perineal Crohn’s
Evolution
toward upfront aggressive COMBINED
medical AND surgical therapy
Surgery for Perianal Crohn’s Disease
Combination Therapy
Initial
Response
(%)
Recurrence
Time to
(%)
Recurrence
(Months)
Infliximab
82
79
3.6
EUA +
Seton+
Infliximab
100
44
13
Regueiro M & Mardine H. Inflammatory Bowel Diseases, March 2003, 9(2):98-103
ACCENT 2 trial extended trial
Treatment of Perianal Fistulae
• Antibiotics often help to decrease inflammation in the
short term
– Metronidazole and/or Ciprofloxacin
• Patients generally start infliximab therapy after sepsis
has been drained
• Often a seton is left in to control drainage, prevent
recurrent sepsis and allow inflammation to resolve.
• Removal of a seton within a few weeks of starting
therapy is necessary to facilitate track healing! In
extensive complex fistulae may be longer
Causey, Marlin et al Gastroenterol April 5 ( 2013) 58-63
Surgery for Crohn’s Disease
Infliximab & Perineal Fistula
For perianal fistulizing CD, repeat doses of
Infliximab improves clinical and radiological
outcomes, although complete radiologic
healing occurs in a minority of patients!
Rasul I et al. Am J Gastro2004:99:82-88
Surgery for Perineal Crohn’s
Disease Summary
• Setons prevent sphincter damage by preventing recurrent
abscess formation
• Presence of active proctitis reduces chance of the fistula
healing, thus proctitis needs to be aggressively treated!
• Setons can be removed after a couple doses of a biologic
when the tract is healing or left in long term if healing
does not occur. If the tract appears healed or dry the
seton can be removed.
• The perineum is re-examined regularly – MRI
• If fecal incontinence develops, proctectomy is discussed
Kamm, M, NG.S 2008 Clin Gastroenterol and Hepatol 6:7-10
Cutting Seton – elastic band
Chuang-Wei,Surgeon,1 June 2008 185-88
Tightening can occur every 2-3 weeks as tolerated.
With each tightening, the seton
cuts slowly through the sphincter tissue
and heals the tissue behind.
Eventually the seton falls out and has done it’s job!
COMBINATION
TREATMENT
EUA, seton,
Infliximab ,AZA
Healed Fistula tracts
Case Study #2
• 25 y/o gentleman who was referred for evaluation of uncontrolled
perianal Crohn's disease originally noted symptoms in high school of
increased stools and progressed to LLQ abdominal pain and diarrhea
• Colonoscopy in August 2011 which was notable for perianal CD with
multiple fissures, deep ulcerations in the distal rectum as well as
severe inflammation with ulceration extending up to the splenic
flexure. TI was normal.
• Initiated on prednisone, mesalamine, and metronidazole. He was then
started on adalimumab in late 2011, but no loading doses.
• SHx: Works in a factory building doors. States that normally he 'just
comes home and goes to his room' after work, does not socialize
much.
• FHx: Denies family history of IBD or CRC
• ROS: No F/C, No N/V. No SOB/CP. No HA. Denies dysphoria. No
abdominal pain, + perianal discomfort + diarrhea + perianal skin
wetness and lots of milky drainage. Patient smells of sickness and
clothes wet.
• He is notably despondent in the office
and is not forthcoming about how he is
feeling, wearing a hat pulled over eyes,
poor eye contact and soft voice with
paucity of words. He appears to be very
uncomfortable sitting but states he is
definitely sitting fine! Father does most
of the talking.
Perineal Fistulizing Disease
• Perianal fistulizing disease can lead to substantial
physical and emotional disease:
–
–
–
–
–
Pain
Discharge
Incontinence
Perineal and genital disfigurement
Slow resolution even with treatment
Patients often reluctant to seek medical care
Providers unfamiliar with nuances to manage
the disease
Causey, Marlin et al Gastroenterol April 5 ( 2013) 58-63
Complex fistular network
24
• Evaluation/Testing/Surgical Procedure?
– MRI or US?
– EUA, I&D, setons, fistulotomy?
– Stoma? Diverting/permanent?
MRI
• MRI : Changes in the descending colon and
sigmoid colon compatible with CD. Extensive
perianal and rectal fistulas and abscess
collection extending into the gluteal soft
tissues, perineum and scrotal sac.
Exam under anesthesia and setons
Returns now for follow up visit:
• Since his EUA he has remained on adalimumab,
Ciprofloxacin, and metronidazole
• States he is feeling 'better' with setons but has had
persistent daily perianal drainage,
leakage/accidents of stool and has 5 BMs during
day and 1-2 BMs at night.
• Still despondent, not sitting comfortably, not eating
as fear of bowel movements
Clearly patient is not doing well
Perianal area will not heal with continued stool flow!
Patient Discussion and Education
• Chance of fistulae and rectum
healing given his severe proctitis
• Diversion – Stoma
• Need for removal of colon/rectum
• Quality of life
• Depression
• Patient support network/education
Risk factors for Proctectomy
5 yr.
• Extensive fistula/abscess vs simple
– 26% vs. 6%
• Severe Proctitis vs none or mild
– 37% vs. 10%
• Severe proctitis and extensive fistula/abscess
– 46% proctectomy rate
Often Proctectomy performed only after a patient has
“had enough” of their disease!
Causey, Marlin et al Gastroenterol April 5 ( 2013) 58-63
Fecal Diversion
Diversion does not alter the course of the disease!
• Patients undergoing diversion for perineal CD
have <20% chance of successful restoration of
intestinal continuity which is NOT improved with
biologic therapy
Hong MK et al Colorectal Dis 2011 13 (2); 171-6
However…..Fecal diversion is useful to quiet the
perineum and promote healing:
• Prior to repairing an RV fistula
• Gives patients time to often realize a better
quality of life with a stoma
• Staging prior to a completion proctectomy
Causey, Marlin et al Gastroenterol April 5 ( 2013) 58-63
Option:
Proctectomy?
Patient:
No way!!!!
Provider:
Pelvis too septic!
Option:
Diverting stoma?
Patient:Yes as a temporary step!
Leaves door open for reconnection!
Have him return in 6-12 months
Now What?
Takedown stoma and reconnect bowel?
Keep stoma?
Proctectomy? –risk of malignancy
Often patients do not want to risk
return of severe perianal disease and
recognize life with the ileostomy is
better!!
Kamm, M, NG.S 2008 Clin Gastroenterol and Hepatol 6:7-10
It is all about QUALITY OF LIFE!
Staging procedures to get patient
acceptance!
Patient/family engagement
at every step with shared
decision-making!!