Download PDF
Clin Colon Rectal Surg 2013; 26(02): 090-099
DOI: 10.1055/s-0033-1348047
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Surgical Treatment of Anorectal Crohn Disease

Robert T. Lewis
1   Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
,
Joshua I. S. Bleier
2   Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
› Author Affiliations
Further Information

Publication History

Publication Date:
27 June 2013 (online)

    Permissions and Reprints

Abstract

Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.

Keywords

anorectal - Crohn disease - fistula - abscess - flap - plug - ligation of intersphincteric fistula tract (LIFT) - immunomodulators - fistulotomy
 

  • References

  • 1 Crohn BB, Ginzberg L, Oppenheimer GD. Regional ileitis: a pathologic and clinical entity. JAMA 1932; 99: 1323
    CrossrefPubMedGoogle Scholar
  • 2 Kirsner JB. Historical origins of current IBD concepts. World J Gastroenterol 2001; 7 (2) 175-184
    PubMedGoogle Scholar
  • 3 Colles A. Practical observations upon certain diseases of intestines, colon and rectum. Dublin Hospital Reports 1830; 5: 131
    PubMedGoogle Scholar
  • 4 Bissell AD. Localized chronic ulcerative ileitis. Ann Surg 1934; 99 (6) 957-966
    CrossrefPubMedGoogle Scholar
  • 5 Penner A, Crohn BB. Perianal fistulae as a complication of regional ileitis. Ann Surg 1938; 108 (5) 867-873
    CrossrefPubMedGoogle Scholar
  • 6 Hellers G, Bergstrand O, Ewerth S, Holmström B. Occurrence and outcome after primary treatment of anal fistulae in Crohn's disease. Gut 1980; 21 (6) 525-527
    CrossrefPubMedGoogle Scholar
  • 7 Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB. American Gastroenterological Association Clinical Practice Committee. AGA technical review on perianal Crohn's disease. Gastroenterology 2003; 125 (5) 1508-1530
    CrossrefPubMedGoogle Scholar
  • 8 Schwartz DA, Loftus Jr EV, Tremaine WJ , et al. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002; 122 (4) 875-880
    CrossrefPubMedGoogle Scholar
  • 9 Safar B, Sands D. Perianal Crohn's disease. Clin Colon Rectal Surg 2007; 20 (4) 282-293
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Williams DR, Coller JA, Corman ML, Nugent FW, Veidenheimer MC. Anal complications in Crohn's disease. Dis Colon Rectum 1981; 24 (1) 22-24
    CrossrefPubMedGoogle Scholar
  • 11 Cosnes J, Cattan S, Blain A , et al. Long-term evolution of disease behavior of Crohn's disease. Inflamm Bowel Dis 2002; 8 (4) 244-250
    CrossrefPubMedGoogle Scholar
  • 12 Roberts PL, Schoetz Jr DJ, Pricolo R, Veidenheimer MC. Clinical course of Crohn's disease in older patients. A retrospective study. Dis Colon Rectum 1990; 33 (6) 458-462
    CrossrefPubMedGoogle Scholar
  • 13 Beaugerie L, Seksik P, Nion-Larmurier I, Gendre JP, Cosnes J. Predictors of Crohn's disease. Gastroenterology 2006; 130 (3) 650-656
    CrossrefPubMedGoogle Scholar
  • 14 Rankin GB, Watts HD, Melnyk CS, Kelley Jr ML. National Cooperative Crohn's Disease Study: extraintestinal manifestations and perianal complications. Gastroenterology 1979; 77 (4 Pt 2) 914-920
    PubMedGoogle Scholar
  • 15 Gelbmann CM, Rogler G, Gross V , et al. Prior bowel resections, perianal disease, and a high initial Crohn's disease activity index are associated with corticosteroid resistance in active Crohn's disease. Am J Gastroenterol 2002; 97 (6) 1438-1445
    CrossrefPubMedGoogle Scholar
  • 16 Keighley MR, Allan RN. Current status and influence of operation on perianal Crohn's disease. Int J Colorectal Dis 1986; 1 (2) 104-107
    CrossrefPubMedGoogle Scholar
  • 17 el Mouaaouy A, Tolksdorf A, Starlinger M, Becker HD. [Endoscopic sonography of the anorectum in inflammatory rectal diseases]. Z Gastroenterol 1992; 30 (7) 486-494
    PubMedGoogle Scholar
  • 18 Giovannini M, Bories E, Moutardier V , et al. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 2003; 35 (6) 511-514
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Rieger N, Tjandra J, Solomon M. Endoanal and endorectal ultrasound: applications in colorectal surgery. ANZ J Surg 2004; 74 (8) 671-675
    CrossrefPubMedGoogle Scholar
  • 20 Caliste X, Nazir S, Goode T , et al. Sensitivity of computed tomography in detection of perirectal abscess. Am Surg 2011; 77 (2) 166-168
    PubMedGoogle Scholar
  • 21 Pritchard TJ, Schoetz Jr DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Perirectal abscess in Crohn's disease. Drainage and outcome. Dis Colon Rectum 1990; 33 (11) 933-937
    CrossrefPubMedGoogle Scholar
  • 22 Sohn N, Korelitz BI, Weinstein MA. Anorectal Crohn's disease: definitive surgery for fistulas and recurrent abscesses. Am J Surg 1980; 139 (3) 394-397
    CrossrefPubMedGoogle Scholar
  • 23 Schwartz DA, Wiersema MJ, 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 (5) 1064-1072
    CrossrefPubMedGoogle Scholar
  • 24 Schaefer O, Lohrmann C, Langer M. Assessment of anal fistulas with high-resolution subtraction MR-fistulography: comparison with surgical findings. J Magn Reson Imaging 2004; 19 (1) 91-98
    CrossrefPubMedGoogle Scholar
  • 25 Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004; 233 (3) 674-681
    CrossrefPubMedGoogle Scholar
  • 26 Beets-Tan RG, Beets GL, van der Hoop AG , et al. Preoperative MR imaging of anal fistulas: Does it really help the surgeon?. Radiology 2001; 218 (1) 75-84
    CrossrefPubMedGoogle Scholar
  • 27 Buchanan GN, Halligan S, Williams AB , et al. Magnetic resonance imaging for primary fistula in ano. Br J Surg 2003; 90 (7) 877-881
    CrossrefPubMedGoogle Scholar
  • 28 Dejaco C, Harrer M, Waldhoer T, Miehsler W, Vogelsang H, Reinisch W. Antibiotics and azathioprine for the treatment of perianal fistulas in Crohn's disease. Aliment Pharmacol Ther 2003; 18 (11-12) 1113-1120
    CrossrefPubMedGoogle Scholar
  • 29 Bernstein LH, Frank MS, Brandt LJ, Boley SJ. Healing of perineal Crohn's disease with metronidazole. Gastroenterology 1980; 79 (3) 599
    PubMedGoogle Scholar
  • 30 Turunen UM, Färkkilä MA, Hakala K , et al. Long-term treatment of ulcerative colitis with ciprofloxacin: a prospective, double-blind, placebo-controlled study. Gastroenterology 1998; 115 (5) 1072-1078
    CrossrefPubMedGoogle Scholar
  • 31 Brandt LJ, Bernstein LH, Boley SJ, Frank MS. Metronidazole therapy for perineal Crohn's disease: a follow-up study. Gastroenterology 1982; 83 (2) 383-387
    PubMedGoogle Scholar
  • 32 Jakobovits J, Schuster MM. Metronidazole therapy for Crohn's disease and associated fistulae. Am J Gastroenterol 1984; 79 (7) 533-540
    PubMedGoogle Scholar
  • 33 Pearson DC, May GR, Fick GH, Sutherland LR. Azathioprine and 6-mercaptopurine in Crohn disease. A meta-analysis. Ann Intern Med 1995; 123 (2) 132-142
    CrossrefPubMedGoogle Scholar
  • 34 Hinterleitner TA, Petritsch W, Aichbichler B, Fickert P, Ranner G, Krejs GJ. Combination of cyclosporine, azathioprine and prednisolone for perianal fistulas in Crohn's disease. Z Gastroenterol 1997; 35 (8) 603-608
    PubMedGoogle Scholar
  • 35 Egan LJ, Sandborn WJ, Tremaine WJ. Clinical outcome following treatment of refractory inflammatory and fistulizing Crohn's disease with intravenous cyclosporine. Am J Gastroenterol 1998; 93 (3) 442-448
    CrossrefPubMedGoogle Scholar
  • 36 Gurudu SR, Griffel LH, Gialanella RJ, Das KM. Cyclosporine therapy in inflammatory bowel disease: short-term and long-term results. J Clin Gastroenterol 1999; 29 (2) 151-154
    CrossrefPubMedGoogle Scholar
  • 37 Sandborn WJ, Present DH, Isaacs KL , et al. Tacrolimus for the treatment of fistulas in patients with Crohn's disease: a randomized, placebo-controlled trial. Gastroenterology 2003; 125 (2) 380-388
    CrossrefPubMedGoogle Scholar
  • 38 Present DH, Rutgeerts P, Targan S , et al. Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med 1999; 340 (18) 1398-1405
    CrossrefPubMedGoogle Scholar
  • 39 Sands BE, Anderson FH, Bernstein CN , et al. Infliximab maintenance therapy for fistulizing Crohn's disease. N Engl J Med 2004; 350 (9) 876-885
    CrossrefPubMedGoogle Scholar
  • 40 Parsi MA, Lashner BA, Achkar JP, Connor JT, Brzezinski A. Type of fistula determines response to infliximab in patients with fistulous Crohn's disease. Am J Gastroenterol 2004; 99 (3) 445-449
    CrossrefPubMedGoogle Scholar
  • 41 Ricart E, Panaccione R, Loftus EV, Tremaine WJ, Sandborn WJ. Infliximab for Crohn's disease in clinical practice at the Mayo Clinic: the first 100 patients. Am J Gastroenterol 2001; 96 (3) 722-729
    CrossrefPubMedGoogle Scholar
  • 42 Alzafiri R, Holcroft CA, Malolepszy P, Cohen A, Szilagyi A. Infliximab therapy for moderately severe Crohn's disease and ulcerative colitis: a retrospective comparison over 6 years. Clin Exp Gastroenterol 2011; 4: 9-17
    PubMedGoogle Scholar
  • 43 Schiff MH, Burmester GR, Kent JD , et al. Safety analyses of adalimumab (HUMIRA) in global clinical trials and US postmarketing surveillance of patients with rheumatoid arthritis. Ann Rheum Dis 2006; 65 (7) 889-894
    PubMedGoogle Scholar
  • 44 Colombel JF, Schwartz DA, Sandborn WJ , et al. Adalimumab for the treatment of fistulas in patients with Crohn's disease. Gut 2009; 58 (7) 940-948
    CrossrefPubMedGoogle Scholar
  • 45 Lichtiger S, Binion DG, Wolf DC , et al. 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) 1228-1239
    CrossrefPubMedGoogle Scholar
  • 46 Schreiber S. Certolizumab pegol for the treatment of Crohn's disease. Therap Adv Gastroenterol 2011; 4 (6) 375-389
    CrossrefPubMedGoogle Scholar
  • 47 Sandborn WJ, Feagan BG, Stoinov S , et al; PRECISE 1 Study Investigators. Certolizumab pegol for the treatment of Crohn's disease. N Engl J Med 2007; 357 (3) 228-238
    CrossrefPubMedGoogle Scholar
  • 48 Schreiber S, Khaliq-Kareemi M, Lawrance IC , et al; PRECISE 2 Study Investigators. Maintenance therapy with certolizumab pegol for Crohn's disease. N Engl J Med 2007; 357 (3) 239-250
    CrossrefPubMedGoogle Scholar
  • 49 Schreiber S, Lawrance IC, Thomsen OO, 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) 185-193
    CrossrefPubMedGoogle Scholar
  • 50 Colombel JF, Sandborn WJ, Reinisch W , et al; SONIC Study Group. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med 2010; 362 (15) 1383-1395
    CrossrefPubMedGoogle Scholar
  • 51 Guidi L, Pugliese D, Armuzzi A. Update on the management of inflammatory bowel disease: specific role of adalimumab. Clin Exp Gastroenterol 2011; 4: 163-172
    PubMedGoogle Scholar
  • 52 Hämäläinen KP, Sainio AP. Cutting seton for anal fistulas: high risk of minor control defects. Dis Colon Rectum 1997; 40 (12) 1443-1446 , discussion 1447
    CrossrefPubMedGoogle Scholar
  • 53 Ritchie RD, Sackier JM, Hodde JP. Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis 2009; 11 (6) 564-571
    CrossrefPubMedGoogle Scholar
  • 54 Nordgren S, Fasth S, Hultén L. Anal fistulas in Crohn's disease: incidence and outcome of surgical treatment. Int J Colorectal Dis 1992; 7 (4) 214-218
    CrossrefPubMedGoogle Scholar
  • 55 Matos D, Lunniss PJ, Phillips RK. Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg 1993; 80 (6) 802-804
    CrossrefPubMedGoogle Scholar
  • 56 Singh B, George BD, Mortensen NJ. Surgical therapy of perianal Crohn's disease. Dig Liver Dis 2007; 39 (10) 988-992
    CrossrefPubMedGoogle Scholar
  • 57 Williams JG, Rothenberger DA, Nemer FD, Goldberg SM. Fistula-in-ano in Crohn's disease. Results of aggressive surgical treatment. Dis Colon Rectum 1991; 34 (5) 378-384
    CrossrefPubMedGoogle Scholar
  • 58 Halme L, Sainio AP. Factors related to frequency, type, and outcome of anal fistulas in Crohn's disease. Dis Colon Rectum 1995; 38 (1) 55-59
    CrossrefPubMedGoogle Scholar
  • 59 Sangwan YP, Schoetz Jr DJ, Murray JJ, Roberts PL, Coller JA. Perianal Crohn's disease. Results of local surgical treatment. Dis Colon Rectum 1996; 39 (5) 529-535
    CrossrefPubMedGoogle Scholar
  • 60 Faucheron JL, Saint-Marc O, Guibert L, Parc R. Long-term seton drainage for high anal fistulas in Crohn's disease—a sphincter-saving operation?. Dis Colon Rectum 1996; 39 (2) 208-211
    CrossrefPubMedGoogle Scholar
  • 61 Pearl RK, Andrews JR, Orsay CP , et al. Role of the seton in the management of anorectal fistulas. Dis Colon Rectum 1993; 36 (6) 573-577 , discussion 577–579
    CrossrefPubMedGoogle Scholar
  • 62 Thornton M, Solomon MJ. Long-term indwelling seton for complex anal fistulas in Crohn's disease. Dis Colon Rectum 2005; 48 (3) 459-463
    CrossrefPubMedGoogle Scholar
  • 63 Buchanan GN, Owen HA, Torkington J, Lunniss PJ, Nicholls RJ, Cohen CR. Long-term outcome following loose-seton technique for external sphincter preservation in complex anal fistula. Br J Surg 2004; 91 (4) 476-480
    CrossrefPubMedGoogle Scholar
  • 64 Eitan A, Koliada M, Bickel A. The use of the loose seton technique as a definitive treatment for recurrent and persistent high trans-sphincteric anal fistulas: a long-term outcome. J Gastrointest Surg 2009; 13 (6) 1116-1119
    CrossrefPubMedGoogle Scholar
  • 65 Hobbiss JH, Schofield PF. Management of perianal Crohn's disease. J R Soc Med 1982; 75 (6) 414-417
    PubMedGoogle Scholar
  • 66 Morrison JG, Gathright Jr JB, Ray JE, Ferrari BT, Hicks TC, Timmcke AE. Surgical management of anorectal fistulas in Crohn's disease. Dis Colon Rectum 1989; 32 (6) 492-496
    CrossrefPubMedGoogle Scholar
  • 67 Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg 1991; 78 (10) 1159-1161
    CrossrefPubMedGoogle Scholar
  • 68 El-Gazzaz G, Hull T, Church JM. Biological immunomodulators improve the healing rate in surgically treated perianal Crohn's fistulas. Colorectal Dis 2012; 14 (10) 1217-1223
    CrossrefPubMedGoogle Scholar
  • 69 Cintron JR, Park JJ, Orsay CP, Pearl RK, Nelson RL, Abcarian H. Repair of fistulas-in-ano using autologous fibrin tissue adhesive. Dis Colon Rectum 1999; 42 (5) 607-613
    CrossrefPubMedGoogle Scholar
  • 70 Cintron JR, Park JJ, Orsay CP , et al. Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum 2000; 43 (7) 944-949 , discussion 949–950
    CrossrefPubMedGoogle Scholar
  • 71 Park JJ, Cintron JR, Orsay CP , et al. Repair of chronic anorectal fistulae using commercial fibrin sealant. Arch Surg 2000; 135 (2) 166-169
    CrossrefPubMedGoogle Scholar
  • 72 Swinscoe MT, Ventakasubramaniam AK, Jayne DG. Fibrin glue for fistula-in-ano: the evidence reviewed. Tech Coloproctol 2005; 9 (2) 89-94
    CrossrefPubMedGoogle Scholar
  • 73 Zmora O, Neufeld D, Ziv Y , et al. Prospective, multicenter evaluation of highly concentrated fibrin glue in the treatment of complex cryptogenic perianal fistulas. Dis Colon Rectum 2005; 48 (12) 2167-2172
    CrossrefPubMedGoogle Scholar
  • 74 Sehgal R, Koltun WA. Fibrin glue for the treatment of perineal fistulous Crohn's disease. Gastroenterology 2010; 138 (7) 2216-2219
    CrossrefPubMedGoogle Scholar
  • 75 Lindsey I, Smilgin-Humphreys MM, Cunningham C, Mortensen NJ, George BD. A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum 2002; 45 (12) 1608-1615
    CrossrefPubMedGoogle Scholar
  • 76 Vitton V, Gasmi M, Barthet M, Desjeux A, Orsoni P, Grimaud JC. Long-term healing of Crohn's anal fistulas with fibrin glue injection. Aliment Pharmacol Ther 2005; 21 (12) 1453-1457
    CrossrefPubMedGoogle Scholar
  • 77 Grimaud JC, Munoz-Bongrand N, Siproudhis L , et al; Groupe d'Etude Thérapeutique des Affections Inflammatoires du Tube Digestif. Fibrin glue is effective healing perianal fistulas in patients with Crohn's disease. Gastroenterology 2010; 138 (7) 2275-2281 , e1
    CrossrefPubMedGoogle Scholar
  • 78 Loungnarath R, Dietz DW, Mutch MG, Birnbaum EH, Kodner IJ, Fleshman JW. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum 2004; 47 (4) 432-436
    CrossrefPubMedGoogle Scholar
  • 79 Champagne BJ, O'Connor LM, Ferguson M, Orangio GR, Schertzer ME, Armstrong DN. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum 2006; 49 (12) 1817-1821
    CrossrefPubMedGoogle Scholar
  • 80 Badylak SF. The extracellular matrix as a scaffold for tissue reconstruction. Semin Cell Dev Biol 2002; 13 (5) 377-383
    PubMedGoogle Scholar
  • 81 Garg P, Song J, Bhatia A, Kalia H, Menon GR. The efficacy of anal fistula plug in fistula-in-ano: a systematic review. Colorectal Dis 2010; 12 (10) 965-970
    CrossrefPubMedGoogle Scholar
  • 82 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) 351-358
    CrossrefPubMedGoogle Scholar
  • 83 Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R. Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas. Dis Colon Rectum 2009; 52 (11) 1877-1881
    CrossrefPubMedGoogle Scholar
  • 84 Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. Dis Colon Rectum 2008; 51 (7) 1084-1088
    CrossrefPubMedGoogle Scholar
  • 85 van Koperen PJ, Bemelman WA, Gerhards MF , et al. The anal fistula plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial. Dis Colon Rectum 2011; 54 (4) 387-393
    CrossrefPubMedGoogle Scholar
  • 86 Ortiz H, Marzo J, Ciga MA, Oteiza F, Armendáriz P, de Miguel M. Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. Br J Surg 2009; 96 (6) 608-612
    CrossrefPubMedGoogle Scholar
  • 87 Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 2009; 13 (3) 237-240
    CrossrefPubMedGoogle Scholar
  • 88 Bleier JI, Moloo H, Goldberg SM. Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas. Dis Colon Rectum 2010; 53 (1) 43-46
    CrossrefPubMedGoogle Scholar
  • 89 Ooi K, Skinner I, Croxford M, Faragher I, McLaughlin S. Managing fistula-in-ano with ligation of the intersphincteric fistula tract procedure: the Western Hospital experience. Colorectal Dis 2012; 14 (5) 599-603
    CrossrefPubMedGoogle Scholar
  • 90 Shanwani A, Nor AM, Amri N. Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano. Dis Colon Rectum 2010; 53 (1) 39-42
    CrossrefPubMedGoogle Scholar
  • 91 Abcarian AM, Estrada JJ, Park J , et al. Ligation of intersphincteric fistula tract: early results of a pilot study. Dis Colon Rectum 2012; 55 (7) 778-782
    CrossrefPubMedGoogle Scholar
  • 92 Tan KK, Tan IJ, Lim FS, Koh DC, Tsang CB. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum 2011; 54 (11) 1368-1372
    CrossrefPubMedGoogle Scholar
  • 93 Joo JS, Weiss EG, Nogueras JJ, Wexner SD. Endorectal advancement flap in perianal Crohn's disease. Am Surg 1998; 64 (2) 147-150
    PubMedGoogle Scholar
  • 94 Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano. Dis Colon Rectum 2010; 53 (4) 486-495
    CrossrefPubMedGoogle Scholar
  • 95 Hull TL, Fazio VW. Surgical approaches to low anovaginal fistula in Crohn's disease. Am J Surg 1997; 173 (2) 95-98
    CrossrefPubMedGoogle Scholar
  • 96 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) 682-689 , discussion 689–690
    PubMedGoogle Scholar
  • 97 Sher ME, Bauer JJ, Gelernt I. Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach. Dis Colon Rectum 1991; 34 (8) 641-648
    CrossrefPubMedGoogle Scholar
  • 98 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 , discussion 801–802
    CrossrefPubMedGoogle Scholar
  • 99 Mueller MH, Geis M, Glatzle J , et al. Risk of fecal diversion in complicated perianal Crohn's disease. J Gastrointest Surg 2007; 11 (4) 529-537
    CrossrefPubMedGoogle Scholar
  • 100 Kasparek MS, Glatzle J, Temeltcheva T, Mueller MH, Koenigsrainer A, Kreis ME. Long-term quality of life in patients with Crohn's disease and perianal fistulas: influence of fecal diversion. Dis Colon Rectum 2007; 50 (12) 2067-2074
    CrossrefPubMedGoogle Scholar
  • 101 Yamamoto T, Allan RN, Keighley MR. Effect of fecal diversion alone on perianal Crohn's disease. World J Surg 2000; 24 (10) 1258-1262 , discussion 1262–1263
    CrossrefPubMedGoogle Scholar
  • 102 Cohen JL, Stricker JW, Schoetz Jr DJ, Coller JA, Veidenheimer MC. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 1989; 32 (10) 825-828
    CrossrefPubMedGoogle Scholar
  • 103 Yamamoto T, Bain IM, Allan RN, Keighley MR. Persistent perineal sinus after proctocolectomy for Crohn's disease. Dis Colon Rectum 1999; 42 (1) 96-101
    CrossrefPubMedGoogle Scholar
  • 104 Rius J, Nessim A, Nogueras JJ, Wexner SD. Gracilis transposition in complicated perianal fistula and unhealed perineal wounds in Crohn's disease. Eur J Surg 2000; 166 (3) 218-222
    CrossrefPubMedGoogle Scholar
  • 105 Buchmann P, Keighley MR, Allan RN, Thompson H, Alexander-Williams J. Natural history of perianal Crohn's disease. Ten year follow-up: a plea for conservatism. Am J Surg 1980; 140 (5) 642-644
    CrossrefPubMedGoogle Scholar
  • 106 Sweeney JL, Ritchie JK, Nicholls RJ. Anal fissure in Crohn's disease. Br J Surg 1988; 75 (1) 56-57
    CrossrefPubMedGoogle Scholar
  • 107 Fleshner PR, Schoetz Jr DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Anal fissure in Crohn's disease: a plea for aggressive management. Dis Colon Rectum 1995; 38 (11) 1137-1143
    CrossrefPubMedGoogle Scholar
  • 108 Steele SR. Operative management of Crohn's disease of the colon including anorectal disease. Surg Clin North Am 2007; 87 (3) 611-631
    CrossrefPubMedGoogle Scholar
  • 109 Linares L, Moreira LF, Andrews H, Allan RN, Alexander-Williams J, Keighley MR. Natural history and treatment of anorectal strictures complicating Crohn's disease. Br J Surg 1988; 75 (7) 653-655
    CrossrefPubMedGoogle Scholar
  • 110 Alexander-Williams J, Allan A, Morel P, Hawker PC, Dykes PW, O'Connor H. The therapeutic dilatation of enteric strictures due to Crohn's disease. Ann R Coll Surg Engl 1986; 68 (2) 95-97
    PubMedGoogle Scholar
  • 111 Williamson ME, Hughes LE. Bowel diversion should be used with caution in stenosing anal Crohn's disease. Gut 1994; 35 (8) 1139-1140
    CrossrefPubMedGoogle Scholar
  • 112 Nelson RL, Abcarian H, Davis FG, Persky V. Prevalence of benign anorectal disease in a randomly selected population. Dis Colon Rectum 1995; 38 (4) 341-344
    CrossrefPubMedGoogle Scholar
  • 113 Jeffery PJ, Parks AG, Ritchie JK. Treatment of haemorrhoids in patients with inflammatory bowel disease. Lancet 1977; 1 (8021) 1084-1085
    PubMedGoogle Scholar
  • 114 Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal fissures in Crohn's disease. Dis Colon Rectum 1993; 36 (6) 545-547
    CrossrefPubMedGoogle Scholar
  • 115 Karin E, Avital S, Dotan I, Skornick Y, Greenberg R. Doppler-guided haemorrhoidal artery ligation in patients with Crohn's disease. Colorectal Dis 2012; 14 (1) 111-114
    CrossrefPubMedGoogle Scholar
  • 116 Ingle SB, Loftus Jr EV. The natural history of perianal Crohn's disease. Dig Liver Dis 2007; 39 (10) 963-969
    CrossrefPubMedGoogle Scholar
  • 117 Singh B, McC Mortensen NJ, Jewell DP, George B. Perianal Crohn's disease. Br J Surg 2004; 91 (7) 801-814
    CrossrefPubMedGoogle Scholar
  • 118 Mahmoud N, Rombeau JL, Ross HM, Fry RD. Colon and rectum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, , eds. Sabiston Textbook of Surgery. 17th ed. Philadelphia, PA: Saunders; 2004
    Google Scholar
  • 119 Sjödahl RI, Myrelid P, Söderholm JD. Anal and rectal cancer in Crohn's disease. Colorectal Dis 2003; 5 (5) 490-495
    CrossrefPubMedGoogle Scholar
  • 120 Ky A, Sohn N, Weinstein MA, Korelitz BI. Carcinoma arising in anorectal fistulas of Crohn's disease. Dis Colon Rectum 1998; 41 (8) 992-996
    CrossrefPubMedGoogle Scholar
  • 121 Connell WR, Sheffield JP, Kamm MA, Ritchie JK, Hawley PR, Lennard-Jones JE. Lower gastrointestinal malignancy in Crohn's disease. Gut 1994; 35 (3) 347-352
    CrossrefPubMedGoogle Scholar
  • 122 Weedon DD, Shorter RG, Ilstrup DM, Huizenga KA, Taylor WF. Crohn's disease and cancer. N Engl J Med 1973; 289 (21) 1099-1103
    CrossrefPubMedGoogle Scholar
  • 123 Vermeire S, Van Assche G, Rutgeerts P. Perianal Crohn's disease: classification and clinical evaluation. Dig Liver Dis 2007; 39 (10) 959-962
    CrossrefPubMedGoogle Scholar