Treatment Strategy for Perianal Fistulas in Crohn Disease Patients: The Surgeon’s Point of View

Abstract

Perianal fistula is a frequent complication and one of the subclassifications of Crohn disease (CD). It is the most commonly observed symptomatic condition by colorectal surgeons. Accurately classifying a perianal fistula is the initial step in its management in CD patients. Surgical management is selected based on the type of perianal fistula and the presence of rectal inflammation; it includes fistulotomy, fistulectomy, seton procedure, fistula plug insertion, video-assisted ablation of the fistulous tract, stem cell therapy, and proctectomy with stoma creation. Perianal fistulas are also managed medically, such as antibiotics, immunomodulators, and biologics including anti-tumor necrosis factor-alpha agents. The current standard treatment of choice for perianal fistula in CD patients is the multidisciplinary approach combining surgical and medical management; however, the rate of long-term remission is low and is reported to be 50% at most. Therefore, the optimum management strategy for perianal fistulas associated with CD remains controversial. Currently, the goal of management for CD-related perianal fistulas are controlling symptoms and maintaining long-term anal function without proctectomy, while monitoring progression to anorectal carcinoma. This review evaluates perianal fistula in CD patients and determines the optimal surgical management strategy based on recent evidence.

Cell-assisted lipotransfer in treating uncontrollable sepsis associated perianal fistula: a pilot study

“…Known surgical options for anal fistulas are fistulotomy, seton techniques, fistulectomy and repair (direct closure, advancement flap procedure, muscle filling technique, etc. ), ligation of intersphincteric fistula tract (LIFT) procedure, endoscopic ablation video-assisted anal fistula treatment (VAAFT), laser surgery, fibrin glue, bioprosthetic plug, and others [10,11,[18][19][20][21].…”

Risk of anorectal cancer in patients with Crohn's disease and perianal fistula: a nationwide Danish cohort study

“…Additionally, should the diagnosis with fistula be inaccurate, the associated potential risk calculated in this study would only be underestimated. Patients with refractory perianal disease may require proctectomy, but incidental cancer diagnosis in fistula is not well studied [19].…”

Crohn disease

“…38 Surgery is generally reserved for those unresponsive to drug therapy or in acute or life-threatening states (for example, bowel obstruction or fi stulas with abscesses). 39 Upon remission, maintenance therapy is used to support longevity. Factors impacting therapy choices include severity, extraintestinal manifestations, disease location, and patient characteristics (for example, age and concomitant diseases).…”

“…More than 50% of patients undergo at least one surgery after diagnosis 38. Surgery is generally reserved for those unresponsive to drug therapy or in acute or life-threatening states (for example, bowel obstruction or fistulas with abscesses) 39…”