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Updated Crohn’s fistula guidance broadens options, physicians retain ‘ultimate judgement’



Disclosures:
Gaertner reports financial relationships with Applied Medical, Becton Dickinson, Coloplast and Intuitive Surgical. Please see the study for all other authors’ relevant financial disclosures.

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The American Society of Colon and Rectal Surgeons has published clinical practice guidelines for the management of patients with cryptoglandular fistulas, rectovaginal fistulas and anorectal fistulas in the presence of Crohn’s disease.

“A generally accepted explanation for the cause of anorectal abscess and fistula-in-ano is that an abscess results from obstruction of an anal gland and that a fistula is caused by chronic infection and epithelialization of the abscess drainage tract,” Wolfgang B. Gaertner, MD, MSc, of the division of colon and rectal surgery at the University of Minnesota, and colleagues wrote in Diseases of the Colon & Rectum.

Key takeaways from The American Society of Colon and Rectal Surgeons clinical practice guideline: 1.	Initial evaluation of anorectal abscess and fistula should include the examination of a patient’s disease-specific history as well as a physical examination. 2.	Acute anorectal abscesses should be treated immediately by incision and drainage.  3.	Fecal diversion or proctectomy may be required among patients with uncontrolled symptoms from complex anorectal fistulizing CD.

“Distinct from cryptoglandular processes, anorectal abscess and fistula-in-ano can be manifestations of Crohn’s disease,” they added. “In Crohn’s disease, anorectal abscesses and fistulas seem to result from penetrating inflammation rather than from infection of an anorectal gland. Patients with fistulas related to Crohn’s disease are typically managed with a multidisciplinary approach.”

Among patients with CD, the incidence rate of fistula-in-ano is 10% to 20% in population-based studies and 50% in longitudinal studies; approximately 80% of patients with CD treated at tertiary referral centers may have a history of fistula-in-ano, the authors noted.

Building on the last clinical practice guideline for the management of anorectal abscesses and fistula-in-ano published in 2016, committee members conducted a literature review of 269 sources to formulate 25 updated treatment guidelines for patients with fistulas in the presence of CD.

Key takeaways on evaluation strategies and management of anorectal abscess, anal fistula, rectovaginal fistula and anorectal fistula-associated CD include:

  • Initial evaluation of anorectal abscess and fistula should include the examination of a patient’s disease-specific history as well as a physical examination of abscess and fistula location and presence of secondary cellulitis.
  • While not always necessary, diagnostic imaging may be considered among select patients with an occult anorectal abscess, recurrent or complex anal fistula, immunosuppression or anorectal-associated CD.
  • Acute anorectal abscesses should be treated immediately by incision and drainage; antibiotics may be reserved for patients with abscesses complicated by cellulitis, systemic signs of infection or immunosuppression.
  • Lay-open fistulotomy or endorectal advancement flap is recommended for the treatment of patients with simple fistula-in-ano and normal anal sphincter function.
  • While endorectal advancement flap with or without sphincteroplasty is the preferred procedure for most patients with rectovaginal fistula, a draining seton may facilitate the resolution of associated acute inflammation or infection in these patients.
  • Draining setons are typically useful in treatment of fistulizing anorectal CD and may also be used for long-term disease control.
  • For fistula-in-ano associated with CD, endorectal advancement flaps and ligation of intersphincteric fistula tract may be used.
  • Fecal diversion or proctectomy may be required among patients with uncontrolled symptoms from complex anorectal fistulizing CD.

“These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results,” Gaertner and colleagues wrote. “The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient.”



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