Management of Anorectal Crohn's Fistulas

Abstract

The evaluation and management of anorectal fistulas in Crohn's disease remails a challenging delemma. An adequate evaluation delineates the extent of disease and guides therapy to alleviate symptoms while avoiding untoward side effects. Therapeutic options have evolved over the last few decades and vary from medical therapy to operative techniques. Medical therapy includes antibiotics and immunomodulators. Drainage setons or catheters offer long-term palliation without the risk of incontinence. Cautiously aggressive surgery, including fistulotomy and advancement flaps, allow significant symptomatic improvement. A protective temporary loop ileostomy may be a useful adjunct in some patients, especially in cases of redo flap surgery. If proctectomy is required, an intersphincteric dissection optimizes the chance for wound healing. An algorithm is presented to guide diagnosis and treatment.