physiologic state, as diverting stoma may be required to minimize the incidence and consequences of an

anastomotic leak. A minimally invasive approach, similar to other disease states, has been associated

with improved short-term outcomes in Crohn patients including decreased morbidity, shorter length of

stay, and reduced hospital charges for both primary and recurrent diseases.125 In addition, despite some

contradictory evidence, laparoscopy and open approaches appear to have similar long-term rates of

disease recurrence.126

Bypass is rarely performed for small bowel disease. The rare case of a septic, obstructed patient with

a large terminal ileum/ascending colon phlegmon involving the retroperitoneum that does not allow for

safe mobilization or identification of the ureter and vascular anatomy may be one indication where

bypass could still prove useful. These procedures have largely been abandoned as the underlying

inflammatory process remains and has not been adequately addressed. Therefore, resection and

strictureplasty continue to be the primary modalities to approach small bowel disease.

The mesentery in active Crohn disease always presents a particular challenge for surgeons. Due to its

thick, edematous nature with increased neovascularization, adequate hemostasis is always a point of

concern. Safe division in the era of open surgery involved techniques such as overlapping clamps with

both mass and individual vessel suture ligation, where appropriate. Laparoscopic approaches typically

rely on advanced vessel sealing devices for hemostasis, though they may be inadequate in the Crohn

patient. Surgeons must then rely on other means such as placing an ENDOLOOP (Ethicon, Cincinnati,

OH) on the major vessels or intracorporeal suturing. Crucial to whatever method is used is the notion to

avoid mesenteric hematomas, as these may result in continued bleeding as well compromise the blood

supply to the healthy remaining bowel.

Colorectal Conditions

Toxic Colitis

Toxic colitis may occur in Crohn patients similar to those with ulcerative colitis.127 Following

resuscitation and intravenous steroids or immunosuppressants, emergent surgical intervention is often

required for those with recalcitrant disease, perforation, or a deteriorating clinical state. The operative

procedure of choice is a subtotal colectomy with end-ileostomy. Debate exists as to the handling of the

rectal stump, though options include a distal mucus fistula with remnant sigmoid, implantation into the

subcutaneous space, or local reinforcement of the stump. Proctocolectomy should be avoided in this

situation due to the prolonged operative time and increased risk of morbidity and mortality.

Table 50-4 Perioperative Complications of Bowel Resection in Crohn Patientsa

Ileo-Anal Pouch

Ileo-anal pouch in the patient with Crohn disease most commonly occurs in the setting of an initial

“mis”diagnosis of ulcerative colitis. More often to the point, the pouch is performed, and the patient

will manifest Crohn disease at a later stage. While certain expert centers may advocate total

proctocolectomy and ileal pouch construction for highly select patients with Crohn disease128, in

general, this is to be discouraged. Retrospective studies have reported 35% to 93% of patients will have

Crohn’s-related complications such as pouchitis, abscesses, and pouch-anal fistulas, with another 10%

requiring pouch excision or permanent diversion. Furthermore, roughly half of patients will experience

urgency or continence issues. Of those patients with a functioning pouch, over half will continue to

require medication to treat active Crohn disease86,129,130 (Table 50-4).

Treatment of Anorectal Conditions

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6 A distinguishing characteristic of the surgical treatment for anorectal Crohn disease is to first consider

whether or not they are symptomatic (see Algorithm 50-1). As a follow-on principle, aggressive

intervention in the asymptomatic patient is unwarranted and potentially dangerous.

Algorithm 50-1. Crohn disease with anal complaints.

Algorithm 50-2. Anal skin tags in Crohn disease.

Specific Clinical Disease Processes

Anal Skin Tags and Hemorrhoids

7 Crohn patients often suffer from skin tags that appear as large, edematous, and blue colored (see

Algorithms 50-2 and 50-3). Similarly, they may also suffer from internal and external hemorrhoids that

may bleed, prolapsed, and cause difficulty with hygiene and irritation. It is important to keep in mind

that Crohn patients have the propensity for poor healing, especially in the face of diarrhea. Patients

should be counseled as to the risk of nonhealing wounds, continence problems, and mucus drainage.131

Therefore, at least an initial attempt at conservative treatment with warm sitz baths and control of

diarrhea is warranted. During this time, medical therapy toward Crohn should be also optimized, as

active inflammation/proctitis will lead to increased morbidity. Should a conservative route fail,

standard hemorrhoidectomy may be performed (in the absence of active proctitis). Topical

metronidazole has been shown to improve posthemorrhoidectomy pain as well as improve healing, with

very little downside.132 Finally, although internal hemorrhoids may occur as in any other patient, they

tend to be less symptomatic and often respond to conservative measures.

Anorectal Abscess/Fistula

Treatment of anorectal abscesses in the setting of Crohn is essentially no different than those of

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cryptoglandular origin – incision and drainage (see Algorithm 50-4). Crohn patients may have more

extensive disease, and adjunct radiology testing may be useful, especially when the examination does

not match the patient’s symptoms. From a technical standpoint, it is important to place the incision as

close to the anal verge as possible while still achieving adequate drainage, considering the possibility of

fistula development.133 Alternatively, a small pessar mushroom tipped catheter may be placed in the

cavity, thus evacuating the abscess and allowing the cavity to close around the catheter, while allowing

continued drainage.

Algorithm 50-3. Hemorrhoids in Crohn disease.

Algorithm 50-4. Anal abscess/fistula in Crohn disease.

Perianal fistulas are often deep, eroding through sphincter and occur in the setting of extensive

scarring around the sphincter. Moreover, they can have high blind tracts, originate at levels well above

the dentate line and are often found in conjunction with active proctitis. Determining the anatomy of

the tract is required, but attention should also be given to the presence or absence of proctitis, status of

the sphincter, prior anal operations, and potential for chronic diarrhea (i.e., medically controlled or

not). Aggressive fistulotomies must be avoided. Yet, low-lying fistulas in the absence of overt proctitis

can often be treated safely with fistulotomy.134 When the fistula is higher or more complex, endoanal

advancement flaps, fistula plugs, or the LIFT procedure (ligation of the intersphincteric fistula tract)

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may all be performed with varying rates of success. Many patients with fistulous disease require chronic

indwelling setons such as silastic vessel loops. Patients should be periodically reexamined both to ensure

that there is adequate drainage, as well as to look for a potential malignant growth, with case reports of

squamous cell and adenocarcinoma arising in a fistulous tract (Fig. 50-16). Unfortunately, fistulas and

fistula procedures all vary in their outcomes, with healing rates ranging from 15% to 97% and

morbidity rates 3% to 78%, making it difficult to accurately compare results. As such, consideration

should be given for a diverting stoma for recurrent or complex fistulas. Finally, a small percentage of

patients may require permanent diversion or even proctectomy.135

Rectovaginal/Anovaginal Fistula

Rectovaginal fistulas are particularly problematic in Crohn patients (Fig. 50-17). Because many of these

fistulas are associated with a deeply erosive process and intense inflammation, extensive tracts and

hidden associated abscesses may also be present. In addition, a rectovaginal fistula may originate from

small bowel, thus limiting potential diagnostic methods such as the methylene blue enema. Many

patients require diversion in this setting prior to any definitive repair to aid with control of proctitis and

to optimize the conditions needed for successful healing. First-line options include use of the fistula

plug, endorectal advancement flap, and LIFT procedure.136 Due to the complexity of the wounds and

need for healthy tissue interposition, muscle flaps (e.g., gracilis, bulbocavernosus) are especially useful,

and may require a multidisciplinary team.

Figure 50-16. Adenocarcinoma arising out of a chronic fistula tract in a Crohn patient. (Courtesy of Howard Ross, MD.)

Figure 50-17. Rectovaginal fistula in a Crohn patient.

Anal Fissure

Patients with Crohn disease and anal fissures present a particular challenge. Decreasing the continence

in any way may worsen an already difficult clinical situation, and limit the number of patients that may

successfully undergo surgery (see Algorithm 50-5). Despite an appearance that is hallmarked by deep,

burrowing, off the midline and sometimes multiple wounds (Fig. 50-18), many anal fissures are

fortunately painless and require no intervention. Excessive pain should raise the suspicion for an

underlying abscess and prompt an examination under anesthesia. Initial attempts at conservative

therapy with topical metronidazole, smooth muscle relaxants and local anesthetics may be attempted to

palliate symptoms and help with healing.137 For particularly symptomatic fissures, botulinum toxin has

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also been used. In contrast, other authors have advocated a more aggressive surgical approach in Crohn

patients, with one report citing 67% of patients who were treated surgically ultimately healed.138 Yet,

given the continence risks associated with surgery, medical management is the preferred initial therapy

in patients with Crohn-related fissures. Surgical intervention should be reserved for those patients with

minimal active anorectal inflammation who fail all reasonable conservative therapy, and still sphincter

muscle division should be kept to a minimum.

Figure 50-18. Crohn fissure – notice the deep burrowing nature off the midline with signs of old fistula tracts.

Algorithm 50-5. Anal fissure in Crohn disease.

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Algorithm 50-6. Anal stenosis/stricture and Crohn disease.

Anal Stenosis and Ulcer

Anal ulcers, stenosis, and strictures secondary to Crohn, while uncommon, can be extremely debilitating

(see Algorithm 50-6). Single institutional series have demonstrated success rates of biologic agents in

18% to 60%.139,140 Up to one-third of patients will have concomitant abscess or fistulas, and these

should be appropriately drained. Due to the association of chronic inflammation with the development

of malignancy, biopsy of any suspicious lesions should also be performed. For low-grade strictures, anal

dilation has proven successful, though repeated session is the norm. Other options include steroid

injection or biologics, balloon dilation, strictureplasty, flaps, and even proctectomy – depending on the

severity and response to therapy.141

Anorectal Malignancy

Anorectal cancer may occur in any setting, including Crohn disease. Risk factors in patients with Crohn

disease include the presence of chronic inflammation, long-standing open wounds, and use of

immunosuppressant medication. Both squamous cell carcinoma (Marjolin ulcer), adenocarcinoma, and

their variants may occur.142 Patients (especially those with long-term indwelling setons) should be

periodically examined to exclude the presence of malignancy. All suspicious lesions should undergo

biopsy and any malignancy identified should undergo proper staging and treatment.

SUMMARY

Crohn disease remains a complex disease process with many different manifestations in the GI tract.

Although advances in medical therapy continue to evolve and significantly alter the way patients are

managed, surgeons still play a large role in both the medical and surgical therapies of the disease. Due

to its recurring nature, surgeons must adhere to the principles of preventing and managing disease

complications versus aiming for cure. By focusing on the maximization of functional outcomes, surgeons

can optimize outcomes through a multimodality approach and minimize additional complications.

Financial Disclosure: No outside financial support or provision of supplies was solicited or received

in connection with this work.

Disclosure and Proprietary Statement: This is an original work by the above authors. The opinions

expressed are the authors’ alone. They do not necessarily reflect the opinion of the United States

Government, the US Department of Defense, or Madigan Army Medical Center.

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