Medical and surgical treatment of haemorrhoids and anal fissure in Crohn’s disease: a critical appraisal

Abstract

BackgroundThe principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn’s disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years.MethodsClinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment.ResultsEighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications.ConclusionsConservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can’t be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.

Fistulizing Crohn’s Disease Presenting After Surgery on a Perianal Lesion

“…In addition, surgical intervention on perianal lesions may increase the risk of fistula development. 15,21 Other than abscesses, most perianal lesions of Crohn's disease respond to medical therapy without surgery. 22 This finding suggests that surgery for Crohn's disease-related perianal lesions other than abscesses may not be beneficial and could result in worse outcomes than medical therapy.…”

“…Such cases are rarely reported. [15][16][17] The present case series describes patients who underwent surgery for perianal lesions not previously recognized to be Crohn's disease related but subsequently were found to be associated with perianal fistulizing Crohn's disease.…”

Is haemorrhoidectomy in inflammatory bowel disease harmful? An old dogma re‐examined

“…In a series of 12 patients half required proctectomy following complications of haemorrhoidectomy [15]. Vignal et al and Keighley and Allan showed similar rate of severe complications in CD [16,17], but other authors have reported haemorrhoidectomy to be safe in CD with a low risk of complications [4,7,[18][19][20][21]. In patients with UC there is less information.…”

“…Three studies were identified with a low complication rate [1,15,22]. Few authors have reported the duration of the interval from haemorrhoidectomy to complications leading to major surgery [4,16,19]. It is unclear if the complication should be attributed to the disease or to the surgery.…”

Sphincterotomy for anal fissure in Crohn’s disease: is it dangerous?

“…Three patients complained of a not healed wound at the site of LIS. LIS was performed in unknown CD only in six out of 48 patients (12 %) [1]. The interval between surgery and occurrence of a complication was reported only in three studies and ranged from 4 months to 9 years (mean 16 months) [2][3][4].…”