CONTROVERSIES IN THE SURGICAL MANAGEMENT OF IBO

Management of perianal Crohn's disease

MRB KEll,J ILFY, MS, FRCS

MRB KEIGHLEY, MS, FRCS. Management of perianal Crohn's disease. Can J Gastroenterol 1993;7(2):266-271. Most perianal Crohn's disease is asymp­tomatic and may well resolve given adequate medical treatment for more proximal lesions. This will consist, in the main, of sulphasalazine and prcd­nisolone, both of which are known to be effective m the treatment of Crohn's disease. Should the local perianal disease become more severe, a trial of oral metronidazole may be worthwhile. The development of an ischiorectal or perianal abscess is indicalion for the simplest surgical drainage procedure, and rectal strictures resulting from the healing of perianal fissures may be gently dilated. Further progression of <liscase may be treated by diversion of the fecal stream, but this will stan<l a greater chance of success in patients without florid rectal Crohn's disease. Diversion is also indicated as a preliminary co the repair of rectovaginal fistulae. Patients with florid perianal Crohn's disease and severe anorectal disease will prohably come to proctocolectomy, but initial defunction­ing of the colon will make the operative procedure easier, may facilitate perinea! healing, and in some patients, subsequent procrecrnmy with the risk of a persist­ent perinea! sinus may be avoided.

Key Words: Fecal diversion, Perianal Crohn's disease, Proctocolecwmy

T raitement de la maladie de Crohn perianale

RESUME: Dans la plupart des cas, la maladie de Crolm perianale est asymp­tomatique et pcut rentrer darn; l'ordre avcc un traitcmcnt mcdicamenteux adequat pour Jes lesions plu~ proximales. II consistera principalement de salazopyrinc et de preunisolone, cous deux connus pour leur efficacite clans le craitement de la maladie de Crohn. Si la maladie perianale locale s'aggrave, ii peut etre appropric <l'cssayer le metronidazolc par voie orate. Le developpemcnt d'un abces ischiorecral ou perianal est une indication pour Le drainage chirurgical Le plus simple et le retrecissement rectal qm resulte de la cicatrisation d'w1e fissure perianale peut etre dilate en douceur. La progression de la maladie peut etre traitee par deviation de l'ccoulement fecal, mais cette intervention aura de meillcures chances de succcs chez !es patients sans maladie de Crohn rectale

Department of Surgery. Q ueen Elizabech T-lospical, Binnmglwm, llniced Kmp;dom Corres/)()ndence: Profcmn· MRB Keip;liley. D<!/mrnnent of Surgery, Queen Eli,ahec/1

Hospiwl, Brnninp;ham, R / "i 2TH, Un1ceJ Kingdom

PERI ANAL PROBLEMS ARE COMMON

among patients with Crohn's dis­ease. Such lesions may preceed the oc­currence of proximal gastromtestinal Crohn's <lisease hy as much as 22 years ( l ). They occur more commonly m as­sociation wi th colonic rather than small bowel disease (2,3 ) but the exact incidence of perianal Crohn's disease 1s

difficult to assess because estimates vary widely between ~c ries. An mcidencc of belween 20 and 80% is reported for perianal <liscase in Crohn's patienrs {3-5 ), the problem be ing m decide what constitutes perianal Crohn's disease 1

Some series consider only symptomatic disease (6), some include cases with skin tags (7) while others do nol (8). Such differences probably account for the observed variations m frequency, rather than a truly altered incidence of perianal disease between series. The perianal lesions of Crohn's disea~e arc often asymptomatic but they can be­come both painful and disabling. In this case they will require energetic treat­ment.

T he trcalment of any pathological condition dcpcn<ls upon the cause ni that condition, but the cause of Crohn's <l1seasc remains unknown. It 1s proposed by Hughes (9) that penanal Crohn's disease takes its origm in cer· tain primary lesions which occur in

266 CAN J GA~TROENTEROL VOL 7 No 2 FEBRUARY 1993

Controversies In the surgical management of IBD

manifes te. La deviation est egalement indiquee comme mcsure pre liminaire avant la reparation d'une fistule rectovaginale. Les patients portcurs d'une maladie de Crohn perianale manifeste et d 'une maladie anorectale grave devront probablement subir une proctocolectomie, mais une ileostomie initia le rendra !'intervention chirurgicale plus fac ile, aidera probablement la circulation perianale et chez certains patients, la proctectomie subsequente avec risque de sinus perianal persistant, sera ainsi evitee.

rclat1on to the anorecral mucosa. These primary lesions include mucosc1l fis­sures, ulcerated edematous piles anJ cav1rat1ng ulcers. F1ssunng of the anc1l margm heals by fibrosis and may sub­sequently cause the anal stenos1s which 1s commonly seen in these pauenrs ( 10). Some edematous piles resolve to

form skm tags, hut it is the cavitatmg ulcers which progress to form the majority of the t issue destructmn. These ulcers penetrate through the full thickness of the rectal mucosa, spread­ing sepsis into the pcrirecral t issues. Their propensity to spread through the rectal musculature might partly be due ro obstruction of forward flnw of rccrnl contents by the anal sph111cters. This may encourage fecal material under pressure to dischnrgc down the penrcc­ral tracts. Once outside the wall of the anorectum, sepsis may spread for quite long d istances before emerging on rhe perianal skin to form a fistu la. If such a fistula tract becomes obstruued, exten­sive anorccral sepsis may resu lt.

Such a pathological sequence of events seems dire, and certainly periam1l Crohn's disease can look alarming. However, the temptation to treat alarming appearances with aggres­sive surgery must he resisted if the situa­tion is not to he made worse hy iatrogenic morhid1ty. Careful studies nf the natural history of penanal Crohn's disease reveal that 1t is surprisingly in­dolent. Of parucular mterest arc the l09 patients reported by Fielding ro have perianal Crohn's dbease in 1968 (6). Patients with skin tags alone were excluded from this study and only those patients with either a defin ite fistu la or fissure were included. This cohort of patients was re-examined m L 978 ro determine the outcome of the perianal Crohn's disease. During follow-up, I 0 of the ongmal patients 111 the study

came to pmctectomy, although 111 only five was thb dnne d irectly because llf pcrianal disease. Fourteen patients d ied from comc1dental causes or from com­plications of Crohn's disease. Twenty­four were completely asymptomatic hut refused to he reassessed pmcwlogically m 1978. T he remaining 61 patients had their penanal Crohn\ disease thoroughly evaluated both 111 1968 and in 1978 ( 11 ). Of 54 patients with an anal fissure m 1968, l 7 h ,1J healed sp1mtancnusly hy 1978. Twenty-seven further panenb had also healed their anal fissures but with some mmm de­gree of narrowing of the anal canal. Two patients with no fissure at the hcg111n111g of the srudy developed one over the follow-up decade.

In 1968, 21 patients had an anal fistula. Eight patients who had no surg1 c.al treatment healed their fistulac spontaneously. Seven were treated sur­gically by lay111g open a low fistula, hut one of these recurred. The remainder with fistulac were unhealed hut as they were asymptomatic no operation inter­vention was necessary. These findings umlerlme the generally benign nature of perianal Crnhn's disease. When planning rrearmcnr for such les1om 1t must be against the background of a strong tendency for spontancnus re,nlution of the les1nn and the nsk of mcontmence by surgical 111rcrvent1on ( 23 ).

MEDICAL TREATMENT OF PERIANAL CROHN'S DISEASE

Before any form nf treatment 1s srnrteJ, 11 1s 11nportant to estahbh the Jiagnosi~ of the lesmn as accurately as possible. Any anal lesion 111 a patient who is known ro he suffering from Crohn's disease 1~ likely to he perianal Cmhn\ disease. However, 1f the pcnanal J1sease 1s the first lesion to

CAN J l~1\STROENTFRl)L V1 it 7 Nt1 l rERRLJARY I 99l

manifest 1rscl( as 1s the ca,e in 30'\i of the author's panenrs drngnos1s may he mnre difficult. In th is s1tuauon the clm1c1an ma) cnns1dcr the penanal dis­ease to he a nonspec 1fic le~itm. How­ever, the relative lack of pam, mult1rlic1ty of the lesions, or rhc unJcr­m111ed nature of thL· fissures on the lateral margin of the anus, nrny alert the nhsL·rver that rh1s 1s 111 fact pcnanal Crohn's disease. Further cmena for d1f fcrenrnnion may he a visually ,1cuw procttt1s at sigmrndmcopy. Biopsy of the rectal mucosa for h1stolog1cal ex­am111ai ion together with similar h1op­s1cs of any skin tag or fistula track may allo~ a firm h1srologicnl diagnorn to he made. Other pathologies which may be confused with penanal Crohn's disease mcluJe tuherculos1s, venereal proct1t1s, bilharzia and hidraden1m suppurauva. In seriously ill patients wtth sudden un­cxpla111ed tlonJ pcrianal disease, leukemia 11r mycloma should be con­sidered.

There 1, i:, ,Jenee rhar perianal I cs inns may heal 1f acuvc Crohn \ dis­ease elsewhere m th<: gut b successful!) treated ( 12, I 3 ). Such treatment may include resccuon nf a proxima l lesion. For examplL· I leuman and colleagues ( 3) founJ that m c1 scm·s nf 15 patients with perianal lesiom before a re~cction for more pmx1mal Crnhn\ d isease, 80% of the pcnanal lesion healed fol­lowing rescLt1on (2). Similar results are reported by Helle rs er al (I 4) who found that 4 70,,, of their patiem:. with anal fistulc1 healed spomaneously after 1ntesunal re~ection. There are no prospective. cnntrnlled trials u( drug therapy in pcriannl Crohn's d1$ease alone, but bed-rest, correction nf fluid Jeplec1on, ,is well ns ,ulphasalazmc ( 4. 15-17) and methylpredntsolone ( 4, 15, 16) arc knnwn to be effective treatment for Crohn's rnl1ti,. The 1mmunosup­prcss1ve drug azathioprme and its mera­holite 6-mL·rcaptopurinc arc abn effective m the treatment of colonic Crohn's disease. There is some evi­dence that they may h(; u~efu l in heal­ing perirectal fistulae ( 18, 19). Against this, the N,monal Cooperauvc Crohn's Di~ease Study (NCCDS) in the United Srntes did nor find a:athioprinc of value m hL·almg Crohn's disease (15).

267

Krn,111 fl

This difference may m pare he due to

the shorter follow-up pcnod in the NCCDS compared w11h the studies of Brooke ct al ( 18) and Prcsant et al ( 19).

There is mounting evidence that an­tihiotics are effective in controlling pcnanal Crlihn's disease. In 1977 Allan and Cooke (20) rcporrcd striking im­provement m rwo patients with penanal Cmhn's disease treated by metronidamlc. This report was fd­l,1wed hy further studies (2 l,22); in the study of Rrandt and rnlleagues ( 22) 26 rat 1ents with pemmal Crohn'~ disease were treated with 20 mg/kg/day mctron1dazole nrally. Ten p;nients progressed tn complete healing of pcrianal disease while on the drug. The remaining 16 patients underwent pHr­tial healing. Unfortunately the clrug was required (or nrnny m,1nths and 111 unc c;:ise fnr three years. Such pm­longed treatment was assnci,1tcd with parcsthes1a in 50'X, of patients, which developed a mean of six months after onset of treatment. Mnst paresthes1a was bilateral and pedal. However, Ambrose and others found the resrxmse to

metronidazole to be dL~appomting (24). Further evidence that Crohn 's

culius nught respond lO metronidazolc therapy is prnvidcJ hy the trial earned out by Ursing ct al ( l 7) who Jemon­srrated th,it oral mccronidazole thcrnry was as effective ;is sulphasalazinc in controlling Crohn's colitb. A prosrec­tive, randomized, cross-over trial of metnmidaznle therapy in Crnhn's dis­ease showed clinirnl imprnvcmcnr in six patients with Cn,hn\ colitis but not in a furl her 16 ratients with small howel Jiscase (25). H,1w merrnnidazolc hrings aht,ut this improvement is un­certain. It seems likely that it exerts its action through its antimicrobial effect nn the bowel micrnflora and as a sys­temic antibiotic. Ursing and colleagues ( 17) found thac metronidaznle reduces the Bactcrrndcs content of the colon after only one week and this nften lastl'd until the drug was stopped. Be­sides its antimicrobial effect rnetronida­zolc 1s known ro 111nucnce lcucocyte chemntaxis (26) as well as bemg an 11nmunnsuprressive agent (27). Roth or either of these actions could Clmtrihute to its efficacy.

268

SURGICAL TREATMENT FOR PERIANAL CROHN'S DISEASE

The potential benefits of surgical treatment for perianal Crohn's disease must be carefully weighed against the possibility that spontaneous resolution will occur in the penanal disease. A recent sLUdy from Birmingham (23) rc\'icwcd 202 Crohn 's disease pauencs. Their note~ \Wrc examined to ,1ssess evidence of pcnanal Crohn\ d1sea,e at sometime during their rrcvious illness. The most common ma111fcsrarion of pl'rianal disease was skin tags 111 75 patients. Most skin tags were asympwmatic ,mJ had disappeared hy the time of review in 1984. There were 38 pat icnts with documented evidence tif a hssure-in-ano hut 29 of these had als1i disappeared spontaneou~ly by the tune of review. Low lying fistula-111-ano had been present in 40 patients but 14 had spontaneously resolved on review. Thirteen were still present hut caused lntle rrouble, while LO patients with a low fistula required procrecmmy. Twelve patients with a high fistula-111-ann were idenufied, nf whom seven had come to proctecttimy and the remain­ing had rrouhlesome symptoms. A similar pattern was observed in six patients with a reccovaginal fistula, four of whom had come to proctectomy by the ume of review. Thus, this study showed a strong tendency for perianal lesions 111 Crohn's disease to remtt spontaneously, similar to results reported by Buchmann et al ( l ).

Of the patients in the Birmingham series (26), only a small numher received operative treatment for perianal disease. In those who did come w surgery, there was a high incidence of complicauons together with little clinical benefit. Gentle anal dilation achieved healing in only four of ~even patients with a fissure and one patient was rendered temporarily inconrmcnt of feces afterwards. Laying open of a low fistula-m-ano achieved healing in only one of 12 fistulas but six developed impairment of continence afterwards. This finding is in contrast with a report from St Mark's Hosp1rnl, which relates to 49 low fistulae treated along conven­nonal I mes; 2 5 healed ~ucces~ful I y (28). No patient with a high fistula was

treated by local surgery; the majont~ were advised to unJcrgn a pmctectomy. lt is l1f great mtcrc~t that the rrescnce of perianal disease has a marked effect on the healing o( proctcctomy wounds after rectal excision. 0( 27 pancnt~ with perianal disease who came tn prnctectomy, 19 were associated with a persi,tcnt penanal sinus, Lomparl'J with wmplete perianal healing in all patients undcrgomg a rectal exc1s1nn in rhe ahscncc ,,( perianal disease ( 2 3).

The most prcssmg 111Jicat1nn for local surgery for perianal ( 'rohn 's d1,­casc is the dramage of a perianal or ischiorecral ahsces,. This is :1 surgical emergenLy a, for other forms of pyogcrnc abscess. It an absce,;s is

Jra111cd and a fisrula results, then unless this is very low and symptomatic thcrL is no further 111d1cauon for surgery.

On the current ,l\'ndahle evidence, anal fissures, which arc nften rainb,s, usually hc,1l spontaneously. They dP not, therefore, require ,urg1cal treat ­ment. Dur111g the hcalmg pmccss rhey may produce some degree of fibrosis with consequent anal narrowmg. Such narrowing 1s nf short length ,mJ usually responds well to gentle dilation with hougics. These short superftcrnl stm tures are in contrast to the long, craggy, fibrous anorecral srnctures rhat some­times Dccur as a consequence ol cavicaung ulceratiun of the annn'ct um 111 Crnhn\ proctit1s. Such stricture, may respond to bnlloon ddar1on (29) but more commonly require a proctec­tomy if they hccomc symptonrnt1c. (30).

Low anal fistulnc 111 perian,11 Crohn's disease arc often asymptomatll and many heal spontaneously. Thcrl' arc few 111d1cat10ns t ,, lay chem ,,pen, hut 1f a subcutaneous fistula 1s as­sociated wnh an ahsccss 111 the absence of act ivc proximal disease, It 1s rclauve­ly safe 1,i h1y 1t open while drninmg the abscess. S,1me surgeom recommend thl' use of pan ial internal sphmctcrot,,111, (3 l, H) for low intcrsrhmctcnc fbtula . The present author h,1s not found rlw, to he a useful ,,peration in penanal Crohn's disease. Patients with a high fistula and remmal Crohn\ disease ,ltcn come t() proctectmny (23,28). Thts 1s hecaw,c suc.h fbtulae often amc 111 rhL· rec.tum as a result of cav1tatmg

Ci\N J G'\STRl)l.NTFR\11 v,11 7 N l) 2 FrnRL •\RY [ l)t)1

ulceration. Entcrovaginal fistulac may occur m as~t,ci..1tion w1cl1 penan,11 Crohn\ disease. C1vcl and colleaguL's (3 3) report their experience of l 3 such fistulas. Seven came to proctccwmy w1cl1 penneal hcalmg 111 fiv<:, anJ a per­s1sten t \'agmocutaneous fisru la 111 one. ln a further two patients, attempts at local repair of the fistula without a covermg colostomy were unsucccsstul. ln a further patient, a local repair of the rectnvagmal fistub was successful fol­lowing creation of ,\ pniximal loop ileustomy. The ilenstomy was suh sequenrly clnseJ wnh no ill effects. One further patient JevclopeJ ,111 aJcnncar­cin< ima of the fistula track after l O yc,irs of medical treatment Provided the patient docs not require a procrcctomy for comc1dental seven: rect,11 d1Sl'aM~. a local repair of the rectnvagmal fistula should he attempted following creatitm of a proximal loop ilcostomy. Very Im, anovagmal fistulac may he safely laid Opl'll.

Cm:x1sting hcmorrhrnds arc nnt common m patients with perianal Cmhn's disease ( 10) and their treat­ment 111 patients with active disease 1s not to be n:commcnded. In one study, six of 20 patients with hemorrhoids and act 1vc Crohn's disea~c whn underwent treatment for their hemorrht,iJs catnL' to proctectomy for complications ap­parently dating from the treatment of their hemmrhoids ( 34 ).

In summary, the mdicauons for local surgery m perianal Crohn's J1s­casc arc limited to rlw Jramage of pw,, gentle di lat1Lm of short lt1w strictures, and a very occasional laymg open of ,1

,ympromatic low nnnl fistula. Some cntenwagmal fistulac should also he repaired bur if so a preluninary loop ileostomy should be raised; however, a large prnportion of these patient~ have few symptoms and, if so, the fistula should 1->c left alnm•.

FECAL DIVERSION Whether fetal d1vers1on has n pl.Kc

m the managcml.'nt of mtrnctahlc pcriannl Crohn 's disease remams dehatahle. Ir is possihle tn divert thl.' fecal stream 111 one ot two ways. Recently t hl.'re has hcl.'n much interest m the use of an elemental diet to trc,ll

Controversies in the surgical management of IBD

acute exacerhat1ons nf Crohn's disease hy reducmg the fecal stream. MLlst reports do not spcc1fo;ally mention the effect of such diets on penanal manifes­tations ofCrohn's disease, hur use of an elemental diet was shown to he as effec­tive as predn1solonc tn the treatment of large and small howcl Crohn's disease ( 35) and rem1ss1on of disease can be achieved m,>rc rapidly when ,m eleml'ntal diet b combined with a non­ahsorbahk· ant1biot1c ( 36). The ekmcntal diet b of thcorencal value for thL· treatment of penanal disease hut as yet not much information b available concerning m therapeutic efficacy.

An altcrnanvc approach uses a l(Hlp (37) or split ilcostomy (38) w defunL­t1nn the culnn. This method has bl·cn cxrem1vcly tested with rl·gard to its ct­feLt 111 treating Crnhn's colitts, and some 111format1on 1s avail,1blc c,mccrn­ing perianal Crohn's disease The twn largest series of patients with Crohn's coliris treated hy thb technique arc those from Oxford ( 39) and the Cleveland Cima: (40). The OxforJ group hn, shown that when patients w1rh Cn,hn's colitis arc treated hy a ,plit ilcoswrny, 25% relapse while the C(>lon 1s JetunLt 1oned and a further 2 5% once the ilcnstomy b closed ( 41 ). The Oxford group reviewed l 02 patients who had undergone ;1 split ileostorny for Crohn \ disease, 29 of whom h,1J symptomatic pcn,mal Crohn 's dise,1se at the tune of focal d1versmn. Eleven \,f l 9 patients with fotulae-m-ant, impmved with d1vcr­s1on, six healed partially and live healed complecely. ln addition. 12 women had rectovaginal fisrulae; these five fistulae persisted hut remameJ asymptomanc, two healed spon­taneow,ly follmvmg dcfuncuon, ,md of these nne relapsed when the deosromy was dosed. A further five healed after local ,urgcry while the colon remained JefuncrnmcJ ,lnd tlf these, two rclapscJ when the 1lcostom) was dosed. Over­all, the penanal dbease unproved nr healed after 72% of the split ilcos­cnm1es. The hest response to d1vers1un appeared t<) he in patients without rev cal involvement and whose intestinal disease was quiescent. Harper (39) also noted that the reduct 1011 m mflamma-

tion and 1mpro\'cment 111 the perineum greatly facilitated the pcnneal d1ssCL r1on 111 patients requiring pmctectom). FurthermL,rl.', It ha, hcen ,hmvn thm healing of the perinea! wound w,b less cert,11n following pr,K.tcctnm\ m p,ments with Crohn's pn>Ltltls, wuh a high f1stula-m-.1no, or with a rec mvaginal fistul,1 (42).

lela, and Jagelman ( 40) rL'\'lL'wcd the result nf a loop ilctlstt,my m 79 patient, with sl'\'erc Cn1hn's uiln1s or dcocol1t 1,. Twenty-rhrel' 11f the patients had ,everL' pcnanal Crohn\ disease ,It the ume of Jdunct1on, and 22 improved following diversion of thL· kcal strc,1m ,is assL·,,ed hy d1111cal an,I ,erolng1Lal paraml·ters. Of these, six rcm,11ncd well with an ileosrnmy ,1lone. N inc required dcfin1rn·c surgcr) a mean ul nme months folluwing ilcnstomy for­mation and six had a relapse of symptums requiring Jcfmttt\'C surgery l l month, .1ftcr ileostom) formation. Six remained well with an ilcostom) akme when followed for between three and five years. Ocher smaller series of pauenrs treated hy dcfurKtl(llling ilcos­wmy for pt·rnmal Crohn's disease tes­tify to the value of this method of management ( 4 3.44 ). Not all surgeons agree, however ( 2), anJ sevcra I reports \if the appl1carion nf Jcfrn1Lt1onmg ileosromy (primarily t\l treat Crohn':, 1..ol1t1s hut includmg ,omL' paucnts with pen,mal Cmhn \ disease) revealed di:,­apprnntmg results. For example thL series of Berman et al (45) includes 10 patients wnh pcrwnal Cmhn's disease. Among the 10 patient, hcfnrl' diver­sion, two had a hssurc-m-ano, seven had a fistula-111-ano and one had both. After d1vcrs1on over a mean follow-up pcnod of 2 5 months, all the fissures healed as J1d om· fistula, hut m six patients the hstula-m-ano persisted. Three patients developed a rectal smc­ture while dcfunc tioncd (also mm·d h) ocher surgetms [411) and m one case rh1s was the m,1111 md1cat1on for a suh­scqucnt prnctcctomy. Four further patients developed penanal Cmhn's disease followmg defunction. Mcilrath (46) reports ,11rnlar Jisapprnncmg results with only four nf l O patient, showmg any 1mpro\'emcnt of penanal Crohn's disease following fecal Jivcr-

CAN J CiA-;rnoENTlROL VL)I 7 NL) 2 FERRl AR) 199~ 269

KEK11 ILEY

sion, and in a further four cases worsen­ing of the anorectal dise::isc led to proc­tcctomy.

MANAGEMENT OF COMPLICATIONS OF

PERIANAL CROHN'S DISEASE The most se rious complications of

pcrianal C rohn's disease are incon­tinence of feces or the development of carcinoma. Alexander-Williams (47)

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9. Hughes LE, J(mes IRO. Penanal lesions in Crohn 's disease. ln: Allan RN, Keighley MRB, Hawkins C, Alexander-Williams J. eds. lnflammacory Bowel Diseases. Churchill Livmgswne 1982.

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l 2. Lockhart-Mummery HE, Morson BC. Crohn's dbea,e nf the large bowel. Gut I 964;5:493-509.

13. Garlock JI I. Surgery of the Alimentary

270

reported 16 patients wllh mcontmencc of feces subsequent to perianal C rohn's disease. S ix of these pauents were Cl)m­plercl y incontinem of tcccs anJ l 0 were i11Clll1tinent only when they haJ diarrhea. Four of the less severe group had undergone no previous surgical treatment bur the other six all had some form of anal surgery. Results such as these have led to the view that m­conrinence subsequent en anorecral

Tract. London: Butterworth,, 196 7 14. Heller, G. Berg~trnnd 0, Ewcrth S.

Occurrence and ,,utcorne llf rhe primary treatment (,r anal fistulac m Crohn's discnse. Gut 1980;2 I :525-7.

15. Summers RW, Swm DM, Sessions JT. N,1tiunal coopcra11ve Crnhn\ disease study: Results of drug treatment. G,1,troentcrnl 1979; 77 :84 7 -96.

16. Melchow 1-1 , Ewe K, Brander,JW, ct al. European cooperative Crohn 's disease study (ECCDS). Results ol drug treatment. Gastroenrcrolngy I 984;86:249-66.

17. Ursmg R, Alm T, Bmamy F. A c,>rnparativc study nf metronida:olc .ind sulfasahmne for acrivc Crohn\ di ease. The couperativc Crohn\ disease study in Sweden. II: Results. Gastr,1enccrology 1984;8 >:550-62.

18. Rrookc BN, Cave DR, Kmg DW. The place of azath1oprme for Crohn's disease. Lancet 1976; 1: 1041 -2.

19. Present OM, Korclit: Bl, Wbch N. et al. T reatrnent of Crohn \ disease with 6-mccapwpurme. N Engl J Med 1980; 302:981-7.

20. Allan RN, Cooke TW Evaluation of mctrnnidazole m the management of Crohn's d1sea,e. Gut 1977; 18:A422.

2 l. & mstcin LH. Frank MS, Brandt LJ. Healing of penanal Crohn's disease with metronidazole. Gastroenrerology 1982;79: 157-65.

22. Brandt LJ, Berstein LH, Bolyc JS, Frank MS. Metronidazole thl!rapy for pemmal Crohn', disease: A follow-up study. Gastmentemlogy I 982;83:383-7.

23. Keighley MRB, Allan RN. Current status and influence of l>peratton on pcnanal Crohn'sJ1scase. Int J Colorectal Dis 1986; I: I 04- 7.

24. Ambrose NS, Allan RN, Keighley MRB, er .ii. Dis Colon Rectum 1984;28:81-5.

25. Bltchfeldt P, Blnmhoff JP, Myhre E, G1 ne E. Metro111dazole tn Crohn';, disease: ,1 double blind cross-over dmkal m al. Scand J Ga,trocntcrol 1978;13:12>-7.

26. Unmpe H, Persson$, Belsheim J. lnflucnce of mecronilhizole and rm1damlc 1m leucncytc chernotaxts in

Crohn 's disease is Jue tl> aggressive sur­geons and not co progressive d isease. Adenocarcinoma may develop in the track of a ch ronic fistula and one such 1s reported 111 relation w a longstanding rectovaginal fistula m Crohn 's disease ( 48) which had been present for 20 years. This is such a rare occurrence that it shliuld noc influence the treat­ment policy 111 pcnanal Crohn\ d is­ease.

Crohn\ di~e~ise. lnfccc1nn i 978;6(Suppl): I 07-9.

27. Grove DI, Mahrnuud AAF. Warren KS. Suppressinn nf cell nwJ1ated immunity hy merrnnidazolc lnr Arch Allergy Appl lmmu1wl I 977;54:422-7

28. Marks CG, Ritch ie JK, Lockhart-Mummery HE. Anal fistuhi tn Crohn\ dbcase. Br J Surg 1981;68:525-7.

29. Alexander-Willi;irns J, Allan A, Morel P, ct al. Thcrapcui 1c coax1,1l ball non dilatation of Cmhn \ stricture Ann R Coll Surg Eng I 986;68:95-7.

30. Lrn.khan-Murnmery LE. Perianal Crohn's d1se,1se: Invited commentary . World Journal Surgery 1980;4:208.

31. Parb AG. Pathogenesis ,md treatmem of fistula- m-am>. Br Med J 1961; I :463-9.

32. Sohn N, Korelic: R. Wcmstcm MA. Anorectal Cmhn 's d1se:,i,e: Dcfininve surgery for fistulas ::ind recurrent abscess. Am J Surg 1980; 139: 394-7.

33. Give! JC, Hawker P, Allan RN, Alexan,ler-Willtams J. Enterovagmal fotulas associated with Cmhn\ dise.ise. Surg Gynecol Ohstei 1982; 155:494-6.

34. Jeffrey PJ, R1tch1e JK, Parb AG. Treatment nf haemorrhoids 111 p<1tients with inflammatory howel disease. Lnncct 1977;i:1084-5.

35. O'Mornin C, Segal AW, Levi AJ. Elemental dll't .is a primary creatrneni of acute Cmhn 's disease: a controlled mal.RrMcdJ 1984;288: 1859-61.

~6. Saveryrnuw S, Hodgson HJF, Chadwick VS. Controlled mal comparing preJnisolonc with an elemental diei plw, rnm-absorhable anrih1otics m acttvc Crohn ·s d1sc.ise. Gue 1985;26:994-8.

>7. AlcxanJcr-Willwm, J. Loop 1lt::osromy and colo,t,1my fllr faec<1l J1vcrmm. Ann R Coll Surg Eng 1974:54:141-8.

18. Lee E. Split tlcnsrorny m chc cre.itrnen1 of Crohn', dbe,1,e of the colon. Ann R Coll Surg Engl 1975;56:94-102.

39. Harper Pl I, Kettlewell MGW, Lee E. The effect nf spite ileostnmy on perianal C rnhn's disease. Br J Surg i 982;69:608-10.

40. Zelas P, Jagelman DO. Loop ileo,rorny

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... Controversies In the surgical management of IBD

m the managemem of Crohn's coliti, m the debilttated pattenc. Ann Surg 1980; 19 1: 164-8.

41. Harper PH, T ruclove SC, Lee ECG, Kettlewell MOW, Jewell DP Spltt ileostomy anJ ileoc\1leLtomy for Cmhn's disease of the colon anJ ulcerauve colitis: a 20 year survey. Gm 1983;24:106-13.

42. Scammell BE, Keighley MRB. Delayed penneal wound healing after procrectomy for Cmhn', colitis. Br J Surg 1986;73:150.2.

4 3. Waterman IT, Pena AS. The place

,if , p ill dellsWmy in the managcmL·nt of Crohn\ Jiscasl. In: ThL· Man,1gcmcnt ,if Crllhn \ l )1,c.1,L·. Amstcrdam-Oxf,,rd: ExLcrpt ,1 Mt•d, 1976:224.

44. O~rhelman HA. ThL' cll<'Ll ,,t mtc,1 mal J,,·cr'lon 1-,y de,,,t,imv lln Crohn's d1'easl' nf thL· n,lon. In: The !'vfon,1gement llf Crnhn \ l )1,t',1,c. Amsterdam-Oxford: ExLcrpta MeJ, 1976:216

45. Rcnnan JI I, Th,,mp,nn 11, ConKL' WT. Alexander-Willi.umJ Thecflect11f d1vcr,1on ,if mtestinal <.:llntenc, on the

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progress of Crohn \ disease 111 the large howel.liur 1971;12:I I 15.

46 l\1dlrarh [)(._' D1n·rt1n 1lcmtomy ,)r c,110,11 ,my 111 thL· m<1nagcm1•111 11! ( ·r,,hn's d1ScasL' of the u1l,1n. ArchSurg 1971,IOU08 16.

4 7 Alcxander.Willia1m J. Pen.ma[ Crohn's d1,ca-.c. Am,tcrdam-OxfrnJ: faLcrpta !'vkd, 1975:4 3.

4H Rudm1ann P, Allan RB, Th\lmp,un H, Alcx,mdcr Willi.1111'.f C.1runoma m ;i recto·\',1gmal hstul.1111 :1 p.ir1cn1 with Cmhn's J1sease. Am J ~urg 1980; 140:462

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