Perianal Crohn's disease

PURPOSE: This study relates our experience with local surgical management of perianal Crohn's disease. METHOD: Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention. RESULTS: All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus. CONCLUSION: Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.Poster presentation at the meeting of the American Gastroenterological Association, Digestive Disease Week, San Diego, California, May 14 to 17, 1995.     

Factors related to frequency,type, and outcome of anal fistulas in Crohn's disease

PURPOSE: Relation of clinical factors to frequency, type, and, in particular, outcome of anal fistulas in Crohn's disease was studied. METHODS: One hundred twelve patients seen in this hospital between January 1972 and June 1993 who suffered from Crohn's disease were included in the study. Those 35 (31 percent) with anal fistulas were reexamined or interviewed and asked about their perianal symptoms and anal control. RESULTS: Rectal involvement of Crohn's disease was associated with an increased incidence of anal fistula (49 vs. 17 percent;P <0.01), especially high ones (82 vs. 17 percent;P <0.01). Ten of 18 patients with low fistulas underwent fistulotomy; all 10 fistulas healed, but slowly (mean healing time, 7.5 months), and 4 of them recurred. Of eight low fistulas managed by drainage alone, four healed. Finally, 11 of 18 patients with low fistulas had their fistulas healed. Fourteen of 17 patients with high fistulas were primarily treated by drainage and 3 by local surgery. Finally, only three patients had healed fistulas—two after simple drainage and one after local surgery, and seven patients had to undergo proctectomy. Only two patients with low fistulas required proctectomy. Eight patients (33 percent) of those 24 with fistulas in whom anal continence could be assessed, 5 with local surgery and 3 with drainage alone, reported minor defects in anal control. CONCLUSIONS: Fistulotomy is a justifiable option with satisfactory results for low symptomatic anal fistulas associated with Crohn's disease, although healing may be delayed and some fistulas will recur. Outcome of high fistulas is less satisfactory, and proctectomy is ultimately required in a number of patients; therefore, for high fistulas a conservative approach is primarily recommended.     

Selected operative management of fistula-in-ano in Crohn's disease

PURPOSE: The operative management of patients with fistula-in-ano in the presence of Crohn's disease has been controversial. Our aim was to review the results of operative treatment in this clinical setting. METHODS: Twenty-eight such patients treated between 1976 and 1990 were reviewed. The duration of local symptoms, location of the Crohn's disease, medications, and previous operations were noted. An effort was made to classify the fistula-in-ano according to Parks' classification, but many fistulas were complicated and did not neatly fit into one of the described categories (intersphincteric 9, transsphincteric 10, complex 9). Patients underwent fistulotomy (three with a seton). RESULTS: Complete healing was achieved in 71.4 percent of cases with an average healing time of 3.5 months (range, 3 weeks-26 months). With an average follow-up of 71 months (range, 12 months-14 years), postoperative function was good in 20 (71.5 percent) patients. Of the remaining eight patients, five ultimately underwent total proctocolectomy because of the severity of their colorectal disease, one patient developed alteration of continence, and two patients developed stenosis. There were two recurrences, (one at nine months and one at six years). CONCLUSION: Operative treatment should be offered to selected patients with fistula-in-ano in the presence of Crohn's disease.Supported by the Sir Mortimer B. Davis-Jewish General Hospital Research Foundation.Read at the Tripartite Colorectal Meeting, Sydney, Australia, October 17 to 20, 1993.     

Role of the seton in the management of anorectal fistulas

PURPOSE: To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton. METHODS: A five-year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow-up ranged from 2 to 61 months (mean, 23 months). RESULTS: Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long-term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent). CONCLUSIONS: Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.     

Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano

PURPOSE: The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a risk of fecal incontinence. We have assessed the functional impact of treating patients with a complex fistula-in-ano by a cutting seton fistulotomy technique that preserves the internal sphincter. METHODS: The operative steps consisted of initial eradication of sepsis, identification of the internal and external openings of the fistula tract, excision of the fistula tract with anal canal mucosa, and insertion of a cutting silk seton around both the internal and external sphincters. In this way open drainage of the intersphincteric space was avoided, and integrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradication and effect on fecal continence was assessed in 27 patients (15 males) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery. RESULTS: The fistula was cured in 26 patients (96 percent) with no reports of altered continence at the time of discharge from outpatient review. Recurrence developed in one patient (4 percent) in whom hidradenitis suppurativa was subsequently diagnosed. All four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently undergone proctectomy for severe perianal and rectal Crohn's involvement. Long-term follow-up revealed three patients (19 percent, all rectovaginal fistulas) who experienced a deterioration in continence after discharge. CONCLUSIONS: Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are effective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.Published in abstract form inGut 1992;33:156A and Int J Colorectal Dis 1992;7:232.     

Perianal abscess in Crohn's disease

PURPOSE: Perianal disease is frequent in patients with Crohn's disease, and many of these patients will eventually have abscess formation. In a prospective follow-up study, we evaluated factors influencing the occurrence and recurrence of perianal abscesses. METHODS: Of 126 consecutive patients with perianal Crohn's disease seen regularly in an outpatient clinic, 61 (48.4 percent) had at least one perianal abscess (mean follow-up, 32±17 months). In all, 110 episodes of an abscess with 145 anatomically distinct abscesses were documented. RESULTS: The occurrence of first abscesses was dependent on the type of anal fistula (ischiorectal, 73 percent; transsphincteric, 50 percent; superficial, 25 percent;P < 0.02). Surgical therapy consisted of seton drainage (34 percent), mushroom catheter drainage (49 percent), or incision and drainage (29 percent) and led to inactivation in all patients. Cumulative two-year recurrence rates after the first and second abscess were 54 and 62 percent, respectively. Abscess recurrence was less frequent in patients with a stoma (13 vs. 60 percent in patients without stoma after two years) and in patients with superficial anal fistulas (0 vs. 55 percent/56 percent in patients with transsphincteric/ischiorectal fistulas). Only two abscesses recurred within one year after removal of seton drainage, whereas 13 abscesses recurred with the seton still in place. Neither intestinal nor rectal activity of Crohn's disease significantly influenced the occurrence of an abscess. During the study period, only two patients developed partial stool incontinence. CONCLUSION: Development of perianal abscesses in Crohn's disease depends on the fecal stream and the anatomic type of anal fistula. Seton and catheter drainage are safe and highly effective in treatment. Long-term use of setons to prevent recurrent abscesses is not supported by our data.     

Cutting seton for anal fistulas

PURPOSE: Long-term results of cutting seton in the treatment of anal fistulas were studied. METHODS: Of the 44 patients with anal fistulas, mainly of the high variety, managed with this method, 35 (25 men) attended a clinical and manometric follow-up examination on average 70 (range, 28–184) months after operation. Fistula distribution was high transsphincteric (25), low transsphincteric (5), extrasphincteric (3), and suprasphincteric (2). The seton was tightened at one-week to two-week intervals to achieve gradual sphincter division. RESULTS: Time required to achieve complete fistula healing ranged from 37 to 557 (mean, 151) days. Two (6 percent) of the 35 patients reexamined had recurrence of fistula and 22 (63 percent) reported symptoms of minor impairment in anal control, which in four patients had existed already before operation. Anal resting pressures were similar for defective and normal control, but other manometric variables were inferior in incontinence, although total squeeze pressure only showed statistically significant difference from normal continence ( P =0.0345). Incontinence was likely associated with hard and gutter-shaped operation scars in the anal canal, but the difference from normal continence was not statistically significant. CONCLUSION: Cutting seton yields fairly good results in regard to cure of fistula, but the risk of anal incontinence, despite its minor degree, seems to be too high to recommend its routine use for all high fistulas. The suprasphincteric fistulas and some extrasphincteric fistulas are difficult to treat otherwise, but especially for high transsphincteric fistulas, other methods of treatment (preferably those in which sphincter division can be avoided and the risk of anal canal deformity and incontinence are minimized) are advocated.No reprints are available.     

Successful Sphincter-Sparing Surgery for All Anal Fistulas

Purpose This study was designed to evaluate the success of a sphincter-sparing treatment algorithm for patients with anal fistulas. Methods All patients with anal fistulas presenting to a single surgeon from 1999 to 2004 were retrospectively reviewed. Patients were treated according to a sphincter-sparing algorithm that utilized three operative approaches: subcutaneous fistulotomy, seton placement followed by fibrin glue, and/or seton placement followed by rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, treatment success, and functional results. Results A total of 137 patients with anal fistulas were evaluated (age range, 23–74 years). Fistula etiology was cryptoglandular in 116 (85 percent), inflammatory bowel disease in 9 (7 percent), HIV in 3 (2 percent), and miscellaneous in 9 (7 percent). A subcutaneous fistulotomy was possible in 38 patients (28 percent), and all of these patients healed. The remaining 99 patients (72 percent) with transsphincteric fistulas underwent staged procedures: 89 patients (65 percent) underwent seton placement followed by fibrin glue closure (55 healed, 62 percent success rate), 9 patients had seton placement followed by flap (9 healed, 100 percent success rate), and 1 patient had seton placement alone. Of the 34 patients with fibrin glue failure, retreatment with glue was successful in 8 of 14 (57 percent success rate). The remaining 20 patients who declined glue retreatment and the 6 patients who failed glue retreatment underwent flap (26 healed, 100 percent success rate). All fistulas healed with an average of two operations per patient, and fecal continence was maintained in all patients. Conclusions By using staged operative procedures without any division of anal sphincter muscle, all fistulas healed with excellent functional results. A sphincter-sparing approach can successfully treat all anal fistulas. Presented at the Tripartite Colorectal Meeting, Dublin, Ireland, July 5 to 7, 2005. Reprints are not available.     

Prospective randomized trial of drainage alonevs. drainage and fistulotomy for acute perianal abscesses with proven internal opening

PURPOSE: Incision and drainage (I & D) with concurrent or delayed fistulotomy is the usual treatment for abscess-fistula with a demonstrated internal opening. We compared incision and drainage alonevs. with concurrent fistulotomy for perianal abscesses with a demonstrated internal opening. METHODS: Consecutive patients with acute perianal abscesses and a demonstrated internal opening were prospectively randomized into either the I & D group or drainage with concurrent fistulotomy group. They were followed up at one month, three months, and one year. RESULTS: The I & D group had 21 patients, and the fistulotomy group had 24 patients. Thirteen patients had low intersphincteric abscess-fistula, and seven had low transsphincteric fistulas in the I & D group. The fistulotomy group had 9 intersphincteric abscess-fistula compared with 14 low transsphincteric ones. Median duration of surgery, hospital stay, and continence at final follow-up were the same in the two groups. Three had recurrent abscess-fistula in the I & D group compared with none in the fistulotomy group (P=0.09). CONCLUSION: I & D alone for acute anal abscess-fistula with demonstrated internal opening showed a tendency to recurrence that did not reach a statistically significant difference compared with concurrent fistulotomy. I & D, therefore, puts only a few patients at risk for recurrence.     

Long-term results of seton drainage on complex anal fistulae in patients with Crohn's disease

Background: The aim of this study was to assess the long-term (greater than 2 years) results of seton drainage on anal fistulae in patients with Crohn's disease. Methods: Between September 1990 and September 1999, 32 patients with Crohn's disease underwent seton drainage for complex anal fistulae. The median follow-up time in these patients was 62 months (range, 25–133 months). In 10 patients (31.3%), recurrent perineal abscesses occurred with inlying seton drainage, and these were drained by re-insertion of the seton. A Malecot catheter was also inserted in 8 patients with recurrence. Results: The overall success rate of long-term seton usage was 87.5%. The subsequent associated procedure was simple seton removal (n = 9), secondary core-out fistulectomy (n = 7), or lay-open fistulotomy (n = 4). Eleven patients still had the seton in place. Recurrence developed in 3 patients (33%) who underwent simple seton removal and in 2 patients (18.2%) who underwent the secondary core-out procedure or fistulotomy. At the last follow-up examination, continence had not changed in 28 (87.5%) of the 32 patients. No change in continence was experienced by 10 of the 11 patients who underwent secondary fistulotomy or the secondary core-out procedure. Conclusions: Long-term seton drainage for complex anal fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function. A relatively good result was achieved by the secondary core-out procedure or fistulotomy at the time of seton removal. Received: January 15, 2002 / Accepted: April 12, 2002 Reprint requests to: Y. Takesue     

Long-term seton drainage for high anal fistulas in Crohn's disease—A sphincter-saving operation?

METHODS: Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place. RESULTS: Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two. CONCLUSION: Long-term seton drainage for high anal fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.     

Evaluation of surgery for perianal Crohn's fistulas

PURPOSE: This study was designed to evaluate the operative treatments performed on patients with perianal Crohn's disease at a tertiary referral colorectal university hospital and to determine the efficacy of management by assessing patient satisfaction. METHODS: A retrospective survey included 59 patients with perianal Crohn's disease who had undergone surgery during the period of 1991 to 1993, inclusive. RESULTS: Twenty-seven patients were treated by laying the fistula open (81 percent successful), and another 27 cases were treated with a loose seton (85 percent successful). Five cases were complicated fistulas and underwent diversionary stomas as part of a primary procedure. Overall success rate, as judged by patient satisfaction, was 83 percent. CONCLUSION: Conservative surgery has a role in management of perianal Crohn's disease. Patient satisfaction can be achieved without complete healing. Better preoperative assessment may improve results further.     

Horseshoe abscess fistula

A study was undertaken to analyze seton fistulotomy with counter drainage as a treatment modality for horseshoe abscess fistula. In a previous report of 27 patients with partial or complete horseshoe abscess fistula, 24 patients underwent primary fistulotomy and counter drainage with a recurrence rate of 28.6 percent. Two patients were treated by seton fistulotomy and counter drainage with no recurrence. Therefore, nine additional patients underwent this procedure. Recurrent horseshoe abscess fistula occurred in 2 of 11 patients (18.1 percent). Seton fistulotomy with counter drainage has become the authors' operative procedure of choice for horseshoe abscess fistula. This method may prove more effective if the true primary abscess cavity is identified, the seton is removed appropriately, and postoperative care of the cavity is adequate. Method of management is discussed.     

Surgical management of anorectal fistulas in Crohn's disease

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated. Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988. Read at the XIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Glasgow, Scotland, July 10 to 14, 1988.     

Seton management of complex anorectal fistulas in patients with Crohn's disease

Anorectal fistulas associated with Crohn's disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohn's disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohn's disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohn's disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patients have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohn's disease.     

Autologous fibrin glue in the treatment of rectovaginal and complex fistulas

This nonrandomized series reports the use of autologous fibrin glue to treat complex rectovaginal and anorectal fistulas. The use of an autologous source to prepare fibrin glue eliminates the risk of disease transmission. Ten patients, six women and four men, with complex fistulas were treated with autologous fibrin glue application. Five patients had rectovaginal fistulas; one of them had Crohn's disease. Five patients had complex anal fistulas; two of them had Crohn's disease, and one had a large postanal ulcer associated with HIV disease. All patients had outpatient preoperative mechanical bowel preparation and prophylactic parenteral antibiotics. Six of the ten patients (60 percent) reported complete healing of the fistulas. Follow-up ranged from three months to one year. Four of five rectovaginal fistulas healed. The two patients with Crohn's disease and complex anal fistulas and the patient with HIV disease did not heal, but all three reported significantly less drainage. Autologous fibrin glue is a viable alternative for the treatment of recurrent rectovaginal and complex abscess/fistulas.     

Vaginal fistula following restorative proctocolectomy

Vaginal fistula (VF) is a devastating complication following restorative proctocolectomy. PURPOSE: This study was designed to examine the perioperative factors influencing the outcome and management of vaginal fistula. METHOD: Between October 1983 and September 1994, 526 women underwent restorative proctocolectomy. Nineteen develop VF (3.6 percent), and six were referred from other institutions with this complication. These 25 women were followed for a minimum of nine months. RESULTS: Preoperative diagnosis of ulcerative colitis was made in 23 of the patients with VF (92 percent), and indeterminate colitis and familial adenomatous polyposis was determined in the rest of the patients. Postoperatively, 12 of the 23 women (52 percent) with a preoperative diagnosis of ulcerative colitis had clinical/pathologic findings of Crohn's disease, and 1 woman was reclassified as having indeterminate colitis. Postoperative pelvic sepsis was significantly higher in women with VF than in those without VF (26.3 vs.6.3 percent;P =0.003). Median time until occurrence of VF following loop ileostomy closure was later for women with delayed findings of Crohn's disease at 16.5 (range, <1–72) months, compared with women without Crohn's disease at 0.5 (range, <1–67) months (P}<0.05). Of the 163 women with handsewn anastomosis performed at our institution, 12 developed VF (7.4 percent), In contrast, 7 of the 363 patients with stapled anastomosis had VF (1.9 percent;P=0.003). Site of VF was found at the anastomosis in 12 patients, below in 12 patients, and above in 1 patient. Presence of Crohn's disease and anastomotic technique did not influence the site of VF. Initial management of VF consisted of transanal repair in 20 patients (advancement flap, 12; direct repair, 6; and neoileoanal anastomosis, 2), seton in 1 patient, transabdominal approach in 1 patient, transvaginal in 1 patient, observation in 1 patient, and pouch excision in 1 patient. Of the 13 women without Crohn's disease, 12 had transanal repair (10 healed, 1 had recurrence, and 1 had pouch excision), and 1 had successfully repair with transabdominal technique, for an overall success rate of 84.6 percent. Of the 12 women with VF and delayed findings of Crohn's disease, transanal repair was performed on 9, 1 had pouch excision without repair, 1 had seton placement and pouch excision, and 1 underwent observation. Transanal technique of repair in women with Crohn's disease successfully healed three women (33.3 percent). Overall, of the 12 women with delayed findings of Crohn's disease, 6 had pouch excision, 3 had recurrences, and 3 healed. CONCLUSION: VF is an uncommon complication following restorative proctocolectomy and is associated with a high incidence of pelvic sepsis and handsewn anastomosis. Late presentation of VF is more common with Crohn's disease and is associated with a poor prognosis and pouch salvage rate. Transanal techniques are an effective means of VF repair.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Conservative treatment of low rectovaginal fistula in Crohn's disease

A conservative operative treatment of anovaginal fistula in Crohn's disease is described. This consists of simply laying open the fistula with section of the rectovaginal septum and the portion of external sphincter superficial to the fistula. The operation may be performed in the presence of rectal involvement even during an acute exacerbation of the disease; a temporary defunctioning stoma is not required. The fistula was of the high transsphincteric type in three patients and low transsphincteric in six. All wounds healed in less than 3 months without any further surgery. At a mean follow-up of 29 months, 6 had perfect continence and 3 could control solid but not liquid stools nor flatus.     

Low Hartmann's procedure for severe anorectal Crohn's disease

Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and perineal fistulas, necessitating excisional surgery, underwent a low Hartmann's procedure in lieu of a standard proctectomy. Fifteen of the 25 (60 percent) patients had a completely healed perineum and required no further surgical therapy. Although perineal disease persisted in the other 10 patients, their perinea were much improved compared with the initial presentation. Following a low Hartmann's procedure, the rectal stump becomes atrophic and anoperineal disease regresses, thereby permitting subsequent perineal proctectomy in less inflamed tissues. Since only a 3-cm to 5-cm cuff of rectum was retained from the initial surgery, a perineal intersphincteric approach could be employed and no abdominal dissection was necessary. Of the 10 patients who subsequently underwent perineal proctectomies, three patients still have an unhealed perineum. Twenty-two of the 25 (88 percent) patients have a completely healed perineum (mean follow-up period, 69.1 months). No attempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the problem of the unhealed perineal wound can be averted with this approach, thereby reducing the long-term morbidity to the patient.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

V-Y Advancement Flap for Treatment of Fistula-In-Ano

PURPOSE: The management of high fistula-in-ano presents a difficult surgical challenge. Laying open of high transsphincteric, intersphincteric, and suprasphincteric fistulas is associated with incontinence. Mucosal advancement flap can be technically difficult and is associated with ectropion and incontinence. We report a new technique for the treatment of fistulas, which may eliminate these problems. PATIENTS AND METHODS: Between 1997 and 2002, 18 patients (13 males), median age 46 (range, 25–64) years with high fistula-in-ano were treated. There were ten transsphincteric, four intersphincteric, and four suprasphincteric fistulas. In all patients, perianal sepsis was allowed to resolve completely with a drainage seton before definitive surgery. The surgical technique used involved core fistulectomy, curettage of any cavity, closure of the defect in the internal anal sphincter, and a V-Y advancement buttock flap to cover the internal opening, leaving the site of the external opening for drainage while preserving both internal and external sphincters. Outcome was assessed in terms of healing and continence. RESULTS: Most patients were discharged from the hospital within 48 hours. Median follow-up was 19 (range, 3–60) months. There were three patients who failed to heal. Of these, two underwent repeat surgery and healed. Two further patients had recurrent fistulas, both of whom continued with conservative treatment. Overall, 15 of 18 (83 percent) patients experienced healing of their fistula. Continence was preserved in all patients. CONCLUSION: This procedure is easy to perform, healing is rapid, and it appears to be effective in curing fistula-in-ano while preserving both external and internal anal sphincters.