The surgical treatment of perianal fistulas in CD is based on the fistula type (low or high) and, more importantly, the presence of active proctitis. For those with low fistula in ano, fistulotomy still has a role. The data to date support the conclusion that, for low fistulas with no active disease, surgery for CD patients is as effective as in non-IBD patients (Figure 82-4). Interestingly, a University of Minnesota series of41 fistulas in 33 patients without active proctocolitis showed a 93% healing rate at 6 months with standard fistulotomy (Williams et al, 1981). As expected, Nordgren and colleagues (1992) found a healing rate of only 27% in those treated with fistulotomy who had active proctocolitis and 83% in those without active disease. More recently, Scott and Northover (1996) documented in patients with CD that in simple fistula, low fistulas without active disease, fistulotomy is acceptable treatment. For those with active disease, the fistula should be treated with a noncutting Seton (Radcliffe et al, 1988) and concomitant medical therapy.
Those fistulas which involve a significant portion of the anal sphincter, such as high transsphincteric, supra-sphincteric, or extrasphincteric, including rectovaginal and anal vaginal fistula, as well as those with primary openings in the rectum, require a more thoughtful approach. The type of surgical treatment is again dependent on the type of fistula and the presence and severity of rectal disease. Patients with complex fistulas often required proctectomy because of the failure of both medical and surgical therapy. More recently, techniques such as Seton placement, fibrin glue, advancement flaps, and, of course, anti-tumour necrosis factor-a infusion therapies, have all been used successfully.
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