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 John Beynon
Dean Anthony Harris
Mark Davies
Martyn Evans Editors

Coloproctology

A Practical Guide

123
Coloproctology
John Beynon • Dean Anthony Harris
Mark Davies • Martyn Evans
Editors

Coloproctology
A Practical Guide
Senior Editor
John Beynon
Department of Colorectal Surgery
Singleton Hospital
Swansea
United Kingdom

Editors
Dean Anthony Harris Martyn Evans
Department of Colorectal Surgery Department of Colorectal Surgery
Singleton Hospital Singleton Hospital
Swansea Swansea
United Kingdom United Kingdom

Mark Davies
Department of Colorectal Surgery
Singleton Hospital
Swansea
United Kingdom

ISBN 978-3-319-55955-1    ISBN 978-3-319-55957-5 (eBook)

DOI 10.1007/978-3-319-55957-5

Library of Congress Control Number: 2017941722

© Springer International Publishing AG 2017

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Contents

1 Management of Perianal Crohn’s Disease in the Biologic Era��������������   1

Samuel O. Adegbola, Kapil Sahnan, Philip J. Tozer, Omar Faiz,
and Ailsa Hart
1.1 Introduction������������������������������������������������������������������������������������������ 1
1.2 Classification���������������������������������������������������������������������������������������� 2
1.3 Anal Skin Tags�������������������������������������������������������������������������������������� 4
1.4 Anal Fissure������������������������������������������������������������������������������������������ 4
1.5 Anal Ulcers ������������������������������������������������������������������������������������������ 6
1.6 Anal Stenosis���������������������������������������������������������������������������������������� 6
1.7 Abscess ������������������������������������������������������������������������������������������������ 8
1.8 Fistula���������������������������������������������������������������������������������������������������� 8
1.9 Rectovaginal Fistulae���������������������������������������������������������������������������� 13
1.10 Pregnancy���������������������������������������������������������������������������������������������� 14
1.11 Anal Cancer������������������������������������������������������������������������������������������ 15
1.12 Scoring Tools���������������������������������������������������������������������������������������� 16
1.13 Prognosis of pCD���������������������������������������������������������������������������������� 17
References���������������������������������������������������������������������������������������������������� 19
2 The Catastrophic Abdominal Wall—Management
and Reconstruction����������������������������������������������������������������������������������   29
Iain David Anderson and Jonathan Epstein
2.1 Introduction���������������������������������������������������������������������������������������� 29
2.2 The Open Abdomen���������������������������������������������������������������������������� 31
2.3 Managing the Open Abdomen������������������������������������������������������������ 33
2.4 Management of the Open Abdomen �������������������������������������������������� 35
2.5 Management Steps in Maturing
Enterocutaneous Fistula���������������������������������������������������������������������� 36
2.6 Procedure (Surgery)������������������������������������������������������������������������������ 40
2.7 Principles of Gastrointestinal Component
of Procedure������������������������������������������������������������������������������������������ 41
2.8 Cases with Infected Mesh �������������������������������������������������������������������� 43
2.9 Principles of Abdominal Closure���������������������������������������������������������� 43
2.10 Summary ���������������������������������������������������������������������������������������������� 46
References���������������������������������������������������������������������������������������������������� 47

v
vi Contents

3 Colorectal Complications of Radiotherapy ������������������������������������������   51

Malcolm S. Wilson and Omer Aziz
3.1 Introduction���������������������������������������������������������������������������������������� 52
3.2 Risk Factors���������������������������������������������������������������������������������������� 52
3.3 Acute Complications�������������������������������������������������������������������������� 53
3.4 Chronic Complications ���������������������������������������������������������������������� 55
3.5 Life Threatening Problems����������������������������������������������������������������� 58
3.6 Risk of Further Pathology—Second Malignancy ������������������������������ 60
3.7 Risk of Further Pathology—Skeletal Problems������������������������������������ 61
3.8 Treatment Strategies����������������������������������������������������������������������������� 61
References���������������������������������������������������������������������������������������������������� 67
4 Robotics in Colorectal Surgery��������������������������������������������������������������   71
David Jayne
4.1 Introduction���������������������������������������������������������������������������������������� 71
4.2 Robotic Rectal Cancer Surgery���������������������������������������������������������� 72
4.3 Robotic Right Hemicolectomy ���������������������������������������������������������� 77
4.4 Robotic Surgery for Benign Disease�������������������������������������������������� 79
4.5 Training in Robotic Colorectal Surgery������������������������������������������������ 80
4.6 Future Robotic Developments�������������������������������������������������������������� 82
4.7 Summary ���������������������������������������������������������������������������������������������� 84
References���������������������������������������������������������������������������������������������������� 84
5 The Dysfunctional Pouch������������������������������������������������������������������������   87
Laura Hancock and Peter Sagar
5.1 Introduction���������������������������������������������������������������������������������������� 87
5.2 Aetiology of Pouch Dysfunction�������������������������������������������������������� 88
5.3 Assessment of Ileoanal Pouch Dysfunction������������������������������������������ 99
5.4 Salvage Procedures ���������������������������������������������������������������������������� 101
5.5 Pouch Failure�������������������������������������������������������������������������������������� 102
References�������������������������������������������������������������������������������������������������� 102
6 The Iatrogenic Complications of Pelvic Cancer Surgery ������������������   107
Alexander G. Heriot and J. Alastair D. Simpson
6.1 Introduction�������������������������������������������������������������������������������������� 107
6.2 Anatomy�������������������������������������������������������������������������������������������� 108
6.3 Haemorrhage������������������������������������������������������������������������������������ 110
6.4 Sepsis������������������������������������������������������������������������������������������������ 111
6.5 Neurological Damage ������������������������������������������������������������������������ 118
6.6 Urological ������������������������������������������������������������������������������������������ 120
6.7 Perineal Hernia������������������������������������������������������������������������������������ 123
6.8 Small Bowel Obstruction�������������������������������������������������������������������� 124
6.9 Early Postoperative Bowel Obstruction���������������������������������������������� 125
6.10 Reoperative Pelvic Surgery���������������������������������������������������������������� 126
6.11 Minimising Complications in Reoperative Pelvic Surgery���������������� 126
References�������������������������������������������������������������������������������������������������� 129
Contents vii

7 Assessment of Bowel Vascularity and Adjuncts

to Anastomotic Healing ������������������������������������������������������������������������   133
Matthew Cassar, Ghazi Yahya Ismael, and Ronan A. Cahill
7.1 Introduction�������������������������������������������������������������������������������������� 134
7.2 Central Vascular Ligation (CVL) for Complete
Mesocolic Excision (CME)�������������������������������������������������������������� 134
7.3 Vascular Anatomy Versus Vascular Physiology�������������������������������� 137
7.4 Preoperative Vascularity Assessment Methods �������������������������������� 137
7.5 Near Future Applications and Next Step Advances�������������������������� 139
7.6 Intraoperative Vascularity Assessment Methods������������������������������ 140
7.7 Postoperative Vascularity Assessment Methods �������������������������������� 153
7.8 Intramucosal pH Measurement ���������������������������������������������������������� 154
7.9 Microdialysis�������������������������������������������������������������������������������������� 154
7.10 Concluding Remarks�������������������������������������������������������������������������� 155
References�������������������������������������������������������������������������������������������������� 155
8 Transanal Total Mesorectal Excision ��������������������������������������������������   161
F. Borja DeLacy, Marta Jiménez-Toscano, and Antonio M. Lacy
8.1 Introduction�������������������������������������������������������������������������������������� 161
8.2 Indications���������������������������������������������������������������������������������������� 162
8.3 Technical Aspects������������������������������������������������������������������������������ 163
8.4 Operative Morbidity���������������������������������������������������������������������������� 173
8.5 Short Term and Functional Results���������������������������������������������������� 174
References�������������������������������������������������������������������������������������������������� 175
9 Anal Cancer and Sentinel Node Biopsy ����������������������������������������������   179
Jonathan Morton and Justin Davies
9.1 Introduction�������������������������������������������������������������������������������������� 179
9.2 Anatomy of the Anal Canal�������������������������������������������������������������� 180
9.3 Aetiology������������������������������������������������������������������������������������������ 180
9.4 Pre-cancerous Lesions���������������������������������������������������������������������� 183
9.5 Anal Intraepithelial Neoplasia���������������������������������������������������������� 183
9.6 Buschke-Lowenstein Tumours/Giant Condyloma Acuminatum������ 184
9.7 Squamous Cell Carcinoma���������������������������������������������������������������� 186
9.8 Treatment������������������������������������������������������������������������������������������ 187
9.9 Sentinel Lymph Node Biopsy and Anal Cancer �������������������������������� 190
9.10 Basal Cell Carcinoma ������������������������������������������������������������������������ 192
9.11 Anal Adenocarcinoma������������������������������������������������������������������������ 192
9.12 Anal Melanoma���������������������������������������������������������������������������������� 194
9.13 Anal Neuroendocrine Tumours���������������������������������������������������������� 195
9.14 Sarcomas �������������������������������������������������������������������������������������������� 196
References�������������������������������������������������������������������������������������������������� 198
10 Rectal Cancer That Responds to Radiotherapy����������������������������������   209
Ben Creavin and Desmond Winter
10.1 Introduction������������������������������������������������������������������������������������ 209
viii Contents

10.2 Assessing Complete Response�������������������������������������������������������� 212

10.3 Clinical and Endoscopic Assessment���������������������������������������������� 212
10.4 Short Course Radiotherapy ������������������������������������������������������������ 216
10.5 Radiation Dose Escalation�������������������������������������������������������������� 217
10.6 Delaying the Interval to Surgery ���������������������������������������������������� 217
10.7 Induction Chemotherapy as an Alternative
to Adjuvant Chemotherapy?�������������������������������������������������������������� 219
10.8 Can Neoadjuvant Radiotherapy Be Omitted?���������������������������������� 221
10.9 Biological Agents������������������������������������������������������������������������������ 221
10.10 Local Excision for Rectal Cancer ���������������������������������������������������� 222
10.11 Quality of Life and Function������������������������������������������������������������ 224
10.12 Predictive Markers: The Future of Rectal Cancer?�������������������������� 226
References�������������������������������������������������������������������������������������������������� 226
11 The Advanced Primary or Recurrent
Rectal Cancer: Pushing the Boundaries����������������������������������������������   241
Andrew J. Herd and Michael J. Solomon
11.1 Introduction������������������������������������������������������������������������������������ 241
11.2 Preoperative Assessment���������������������������������������������������������������� 242
11.3 Anatomical Compartments ������������������������������������������������������������ 243
11.4 Surgical Techniques for Compartment Resections ������������������������ 245
11.5 Postoperative Care���������������������������������������������������������������������������� 257
References�������������������������������������������������������������������������������������������������� 257
12 Personalised Genomics and Molecular Profiles
in Colorectal Cancer: Towards Precision Cancer Care���������������������   261
Kjetil Søreide and Dordi Lea
12.1 Introduction������������������������������������������������������������������������������������ 261
12.2 A Personalised Approach to Treatment
and Prognostication in CRC?���������������������������������������������������������� 263
12.3 Evolving Understanding of Cancer Biology Points
to Heterogeneity������������������������������������������������������������������������������ 263
12.4 Evolving Multidisciplinary Care���������������������������������������������������� 264
12.5 Limitations in Current TNM Staging���������������������������������������������� 265
12.6 Current Understanding of Colorectal Carcinogenesis�������������������� 266
12.7 Chromosomal Instability (CIN) Pathway �������������������������������������� 269
12.8 Microsatellite Instability (MSI)������������������������������������������������������ 269
12.9 Epigenetics (CIMP)������������������������������������������������������������������������ 269
12.10 EMAST—The New Kid on the Block�������������������������������������������� 269
12.11 The Cancer Genomic Landscape������������������������������������������������������ 270
12.12 Genome Wide Association Studies in Populations �������������������������� 271
12.13 Colorectal Cancer Models and Classifications �������������������������������� 272
12.14 New Suggested Classification: Consensus
Molecular Subtypes (CMSs)������������������������������������������������������������ 272
12.15 Mutation Pathways with Treatment Implications:
The EGFR Pathway�������������������������������������������������������������������������� 273
Contents ix

12.16 Extended RAS Testing for Targeted Therapy ���������������������������������� 274

12.17 Role of the Immune System in Future Precision Therapy���������������� 275
12.18 Role of Infiltrating T-Cells���������������������������������������������������������������� 276
12.19 Role of Foxp3 and Tregs������������������������������������������������������������������ 276
12.20 Development of an ‘Immunoscore’�������������������������������������������������� 276
12.21 Novel (Non-Invasive) Biomarkers (Blood, Faeces,
Urine, Volatile Markers)�������������������������������������������������������������������� 277
12.22 Improved and Innovative Trial Design���������������������������������������������� 279
References�������������������������������������������������������������������������������������������������� 280
13 Assessing Outcomes in Colorectal Cancer Surgery����������������������������   287
Abigail Vallance and James Hill
13.1 Introduction������������������������������������������������������������������������������������ 287
13.2 Why Should We Assess and Report Outcomes? ���������������������������� 288
13.3 Outcome Measures Used in Assessment���������������������������������������� 288
13.4 Post-Operative Mortality���������������������������������������������������������������� 289
13.5 Long-Term Disease Free Survival and Overall Survival���������������� 290
13.6 Quality Indicators and Surrogate Outcome Measures�������������������� 290
13.7 Outcome Reporting Through Large Clinical Databases ���������������� 294
13.8 Individual Consultant and Unit Outcome Reporting������������������������ 297
13.9 Patient Reported Outcomes�������������������������������������������������������������� 300
References�������������������������������������������������������������������������������������������������� 304
Index������������������������������������������������������������������������������������������������������������������ 311
List of Contributors

Samuel Adegbola, BSc (Hons), MBBS, MRCS Department of Colorectal

Surgery, St. Mark’s Hospital, London, UK
Iain David Anderson, MD, FRCS, BSc Hope Hospital, Manchester, UK
Department of General Surgery and Colorectal Surgery, Spire Manchester Hospital,
University of Manchester, Manchester, UK
Omer Aziz, BSc, MBBS, PhD, FRCS Colorectal and Peritoneal Oncology Centre,
The Christie NHS Foundation Trust, Manchester, UK
Ronan A. Cahill, MB, BAO, BCh, MD, FRCS Section of Surgery and Surgical
Specialties, Department of Surgery, School of Medicine, Mater Misericordiae
Universtiy Hospital, University College Dublin, Dublin, Ireland
Matthew Cassar, MD MRCS (Edin) ChM (Edin) FRCSEd Section of Surgery
and Surgical Specialities, Department of Surgery, Mater Misericordiae University
Hospital, University College Dublin,, Dublin, Ireland
Ben Creavin, MD, BAO, BCH Department of Colorectal, St. Vincent’s University
Hospital, Dublin, Ireland
Justin Davies, MChir LRCP FRCS (Gen) EBSQ Cambridge Colorectal Unit,
Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,
Cambridge, UK
Jonathan Epstein, MBChB, MD, FRCS Department of General and Colorectal
Surgery, Spire Medical Hospital, Salford Royal Foundation Trust, Manchester, UK
Omar Faiz, MBBS, FRCS, MS Department of Colorectal Surgery, St. Mark’s
Hospital, London, UK
Laura Hancock, BSc, MD, FRCS Department of Colorectal Surgery,
Leeds Teaching Hospital NHS Trust, Leeds, UK
Ailsa Hart, BM Bch, FRCP, PhD IBD Unit, St Mark’s Hospital, London, UK
Andrew J. Herd, BSc, MB, ChB, FRACS Department of Colorectal Surgery,
Royal Prince Albert Hospital, Sydney, NSW, Australia

xi
xii List of Contributors

Alexander G. Heriot, MB BChir MD FRCSEd FRACS Peter MacCallum

Cancer Centre, Melbourne, Australia
James Hill, MB, ChB, FRCS, ChM Department of Surgery, Manchester Academic
Health Sciences Center, Manchester Royal Infirmary, Manchester, UK
Ghazi Yahya Ismael, MBBS, MRCS Department of Colorectal Surgery, Mater
Misericordiae, Dublin, Ireland
David Jayne, BSc, MBBCh, FRCS, MD Academic Surgery, St. James University
Hospital, Leeds, UK
Marta Jiménez-Toscano, MD, PhD Department of Gastrointestinal Surgery,
Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clinic, Barcelona,
Spain
IDIBAPS, Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas
y Digestivas (CIBERchd), Centro Esther Koplowitz, University of Barcelona,
Barcelona, Spain
Gastrointestinal Department, Clinic Hospital, Barcelona, Barcelona, Spain
Antonio M. Lacy, MD, PhD, FASCRS (Hon) Gastrointestinal Department, Clinic
Hospital, Barcelona, Barcelona, Spain
Dordi Lea, MD Department of Pathology and Gastrointestinal Translational
Research Unit, Stavanger University Hospital, Stavanger, Norway
Jonathan Morton, FRCS, MS Cambridge Colorectal Unit, Department of
Colorectal Surgery, Addenbrooke’s Hospital, Cambridge University NHS
Foundation Trust, Cambridge, UK
Peter Sagar, BSc MD FRCS The John Goligher Department of Colorectal
Surgery, St. James University Hospital, Leeds, UK
Kapil Sahnan, BSc (Hons), MBBS, MRCS Department of Colorectal Surgery,
St. Mark’s Hospital, London, UK
J. Alastair D. Simpson, BMedSci BMBS PhD FRCS Peter MacCallum Cancer
Centre, Melbourne, Australia
Michael J. Solomon, MBBCh BAO MSc FRACS Department of Colorectal
Surgery, Royal Prince Albert Hospital, Newtown, NSW, Australia
Kjetil Søreide, MD, PhD Department of Clinical Medicine, University of Bergen,
Bergen, Norway
Gastrointestinal Translational Research Unit, Laboratory of Molecular Biology,
Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger,
Norway
Philip J. Tozer, MBBS MRCS Eng MCEM Colorectal Surgery, St. Mark’s
Hospital, London, UK
List of Contributors xiii

Abigail Vallance, MRes, MBBS, MRCS Clinical Research, University of Leeds,

Leeds, UK
Malcolm S. Wilson, BSc, MBBS, MD, FRCS Colorectal and Peritoneal Oncology
Center, The Christie NHS Foundation Trust, Manchester, UK
Desmond Winter, MD, FRCSI Department of Colorectal, St. Vincent’s University
Hospital, Dublin, Ireland
Management of Perianal Crohn’s Disease
in the Biologic Era 1
Samuel O. Adegbola, Kapil Sahnan, Philip J. Tozer,
Omar Faiz, and Ailsa Hart

Key Points

• Perianal Crohn’s disease (pCD) encompasses a range of manifestations from

simple anal skin tags, to ulceration and complex networks of fistulae and abscess.
• It affects a third of patients with Crohn’s disease and in 10%, perianal disease is
the initial manifestation of Crohn’s. It denotes a poor prognostic phenotype and
has a negative impact on patients’ quality of life.
• Each manifestation of pCD is nuanced in its own way with options of manage-
ment which depend on the nature of pCD and on the patient, their symptoms and
burden of disease elsewhere (particularly the rectum).
• The increasing use of immunosuppressants and particularly biologics has improved
outcomes of complex fistulising pCD, with induction of response seen in >50%, but
this number decreases to about a third of patients maintaining remission after a year.
• Issues remain regarding the loss of response and side effects of prolonged immu-
nosuppression. Surgical procedures aim to heal fistulae but these too have only
modest results with significant failures and recurrences. Combined surgical and
medical therapies offer improved outcomes but rarely a healing.

1.1 Introduction

Crohn’s disease (CD) is a chronic inflammatory condition of the bowel with between
3000 and 6000 new cases diagnosed each year in the UK and around 115,000 peo-
ple in the UK are living with CD. The diagnosis of CD represents a wide range of

S.O. Adegbola, BSc (Hons), MBBS, MRCS • K. Sahnan, BSc (Hons), MBBS, MRCS
P.J. Tozer, MBBS, FRCS (Eng), MD (res) • O. Faiz, MBBS, FRCS, MS
A. Hart, BM, BCh, FRCP, PhD (*)
St Mark’s Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
e-mail: alisa.hart@nhs.net

© Springer International Publishing AG 2017 1

J. Beynon et al. (eds.), Coloproctology, DOI 10.1007/978-3-319-55957-5_1
2 S.O. Adegbola et al.

disease phenotypes, classification of which allows correlation between serotype,

genotype, and phenotypes (particularly in the field of research). The classification
also plays an important role in determining treatment, as well as assessing the likely
clinical course of disease [1]. There are substantial data suggesting that perianal
disease within the context of CD (pCD) represents a distinct, more aggressive phe-
notype, with associated higher rates of recurrence following treatment and a shorter
median time to recurrence [2, 3]. This is reflected in the Montreal classification of
2005, in which perianal CD obtained a separate sub-classification [4]. Armuzzi
et al. [5, 6] reported the IBD5 risk haplotype (encompassing a number of immuno-
regulatory genes) being associated specifically with Crohn’s disease and genotype-
phenotype analysis revealed that the strongest association is observed in patients
with perianal Crohn’s disease. Furthermore, there is evidence that the presence of
pCD, predicts those who are more likely to develop more extensive (ileo-­colonic)
and complicated (stricturing and penetrating) disease behaviour and do so more
rapidly [1, 7]. Beaugerie and co-workers [7] reported that pCD at presentation was
a predictive factor of subsequent 5-year disabling disease course with an increased
likelihood of repeated courses of corticosteroids (and risk of dependence), increased
admissions to hospital, increased surgical resections and a predisposition to chronic
disabling symptoms.
The epidemiology of pCD is not fully understood and there is a wide range in
prevalence reported in the literature (10–80%) [8–10]. This is in part due to inconsis-
tent use of the term ‘perianal Crohn’s disease’, such that it doesn’t always encompass
the full spectrum of perianal disease. In particular, most reports focus on septic peri-
anal complications of Crohn’s disease (fistula and abscess) and don’t always consider
the non-fistulising manifestations. Other factors include the duration of follow-up, the
source of the patient’s care (primary, secondary or tertiary care), and discrepancies in
the classification and inclusion of perianal lesions in different studies [8].
The incidence of perianal disease increases the more distal the luminal disease
[10]. Hellers et al. [11] reported that more than 90% of patients with colitis and
rectal involvement had perianal fistulas compared to 41% with colitis and rectal
sparing. In contrast, only 12% of patients with small bowel disease had perianal
complications. Other studies have supported this finding [12, 13]. The timing of the
development of pCD is widely variable, but some studies have reported a significant
proportion (up to 20%) of patients developing perianal symptoms at least 6 months
prior to their intestinal disease [8, 11]. Sangwan et al. reported a shorter time inter-
val to perianal involvement in colonic than ileal disease [14].

1.2 Classification

Perianal Crohn’s disease can manifest in a variety of ways ranging from simple anal
skin tags to complex networks of fistulae and abscesses (see Fig. 1.1). There has
been no generally accepted method of documenting these, with resultant discrepan-
cies in the classification and inclusion of perianal lesions in different studies. The
first classification based on surgical pathology was published from Cardiff in 1978
1 Management of Perianal Crohn’s Disease in the Biologic Era 3

Fig. 1.1 Patient

demonstrating features of
PCD including fistula, skin
tags, scarring from
previous abscess drainage
procedure

[15, 16]. Anal lesions in pCD were sub-divided into primary and secondary lesions
where primary lesions were considered to be part of Crohn’s disease and secondary
lesions arose from mechanical or infective complications of the primary lesions.
However, further experience by the author led to the Hughes classification of 1992
[16] with the inclusion of incidental perianal lesions of unrelated conditions coex-
isting with CD (e.g. haemorrhoids). Rarer entities, such as perianal fistulas originat-
ing from ileal (i.e. enterocutaneous) rather than anal disease and the complication of
malignancy in long-standing cases, are also covered. Uptake of these classifications
has been modest though, due to limited clinical applicability and relevance, particu-
larly when considering the effect on patient management [17]. This issue was high-
lighted by the American Gastroenterological Association (AGA) clinical practice
committee in 2003, when they published a technical review of pCD [18]. They
proposed a more empirical approach based on physical examination to identify the
spectrum of perianal disorders associated with CD as well as endoscopic examina-
tion to determine inflammatory status of the rectum.
In our review, we adopt a similarly empirical approach and describe lesions
according to anatomical location, i.e. skin lesions (e.g. anal skin tags) anal canal
disease (e.g. fissure, ulcers, stenosis/stricture), perianal abscess and fistula.
4 S.O. Adegbola et al.

1.3 Anal Skin Tags

Anal skin tags are a common finding in the context of pCD. Reported prevalence
varies between 24% and 75% [19–21] although these data are largely from tertiary
centres and therefore may represent a selection bias. Whether the skin tags are
symptomatic is also generally poorly reported in epidemiological studies. The pae-
diatric inflammatory bowel disease (IBD) collaborative group registry reported a
4% incidence of non-fistulising anal CD (including skin tags and fissure) at the time
of diagnosis [22]. The cumulative probability of perianal skin tags in the only popu-
lation study of its kind was 18.7% (95% CI, 13.9–23.3) at 10 years [9]. The same
study also indicated that 14–50% of skin tags may be symptomatic and that baseline
factors associated with time to first perianal skin tags in univariate analysis were
female gender, former cigarette smoker status relative to non-smokers and the pres-
ence of extra-intestinal manifestations [9].
Anal skin tags (ASTs) were initially classified (according to the Hughes/Cardiff
classification) along with anal ulcers with which they were thought to be associated.
However, the American Gastroenterology Association (AGA) more recently classi-
fied ASTs into two types [18]:

–– a large oedematous type which is often hard and cyanotic and typically arising
from a healed anal fissure, ulcer or haemorrhoid, (lymphoedema secondary to
lymphatic obstruction has also been postulated as a potential cause) and
–– “Elephant Ears” type, which is flat, soft/compressible, of varying size (but usu-
ally smaller than the above).

As a general rule the large oedematous type, tend to be symptomatic (perhaps

because they are usually associated with other pCD features), whereas the ‘ele-
phant ears’ type tend to be asymptomatic [15]. The AGA advices avoidance of
excision of skin tags, particularly for the large oedematous type, owing to prob-
lems with wound healing [18]. One small study reported stenosis in one of two
patients undergoing surgical excision [21]. Delayed wound healing and a failure to
resolve symptoms must be seriously considered prior to undertaking excision.
ASTs are generally persistent but can resolve spontaneously [19, 23]. They often
follow a benign course and may increase in size and thickness and may become
firmer during an active CD flare. There has been one case of malignancy reported
in the literature [24].

1.4 Anal Fissure

Anal fissures are common in Crohn’s disease with a prevalence of 10–29% [21,
25–31] reported. Cumulative probability in a population study of 310 incident cases
of Crohn’s disease was reported as 10.5% at 10 years [9].
Superficial fissures in non-IBD cases are usually found in the posterior midline
or less commonly the anterior midline, whereas CD fissures have been thought to
occur in more lateral positions [31, 32]. However, there have been several more
1 Management of Perianal Crohn’s Disease in the Biologic Era 5

Fig. 1.2 Patient with PCD

demonstrating fissues/
ulcers

recent studies which challenge this view and suggest that the majority of fissures in
Crohn’s disease are found in the anterior or posterior midline [31, 33, 34]. They are
often described as painless when associated with pCD [18], however, it is important
to note that painful fissures can and do occur in CD [31, 33] where they are also
often multiple in contrast to non-IBD fissures. Furthermore, they are closely related
to anal ulcerations, see Fig. 1.2 (with which they are sub-classified in the ­Hughes/
Cardiff classification) as well as other perianal Crohn’s conditions, e.g. skin tags
[16, 33].
Non-IBD anal fissures are thought to occur due to anal trauma in the form of the
passage of hard, bulky stool and persist due relative ischaemia influenced by high
anal tone. The aetiology of anal fissure in Crohn’s disease is thought to be related to
inflammation, and the treatment is also therefore different. In a retrospective study
[33], medical treatment including steroids, antibiotics or amino-salicylate healed
fissures in 46% of 52 patients after a median follow-up of 92 months. The exact
route (i.e. topical/systemic) or regimen was not specified. Factors predictive of suc-
cessful medical treatment included male gender, painless fissure, and acute fissure.
Infliximab has also been reported to be successful in both inducing healing and
long-term maintenance [35, 36]. In this retrospective study by Bouguen et al. com-
plete healing was observed in 53% (18/34) in the short term (i.e. follow up: 4–12
week). Long-term follow-up data revealed a healing rate of 70.6% (24/34) at median
follow-up duration of 175 weeks (range, 13–459) [36].
There are few published data on the efficacy of surgery for fissures in
pCD. Furthermore, little is known about the impact of proctitis on outcomes of fis-
sure surgery in pCD [31, 33]. The concern is that surgery will not improve the
patient’s symptoms and could actually make the situation worse. The septic compli-
cations as a consequence of surgery have necessitated later proctectomy [31, 37].
6 S.O. Adegbola et al.

1.5 Anal Ulcers

Anal ulceration is less common than other pCD lesions. Siproudhis et al., reported
an incidence of 5% in a series of 101 CD patients with perianal sepsis referred to a
tertiary institution [38]. The most common symptom is pain, especially on defaeca-
tion [38]. Patients can also experience pruritus, discharge, and bleeding [23]. Ulcers
tend to extend deep to the dermis and can be large, oedematous and have irregular
edges [23]. They can be found in the anal canal, the lower rectum and in some cases
may extend to the surrounding peri-anal skin in aggressive disease [16].
Anal ulcers are often associated with distal rectal inflammation and can predis-
pose to other forms of pCD such as fistulae, abscess and anal stenosis. Cavitating
ulcers are often more symptomatic and more likely to evolve into fistulae [23].
In the case of deep cavitating ulcers the long term outcome is poor and nearly 50%
of patients progress to anal stenosis [39]. Studies on symptomatic pCD, including
patients with ulcers, have shown some benefit of topical treatments such as metronida-
zole (10%) ointment to improve symptoms [40]. Topical tacrolimus has been shown to
improve the depth of the ulcer but the studies are small and further, randomized evalua-
tion is needed [41, 42]. The evidence for systemic treatment is mostly from retrospective
series. A benefit was demonstrated in 63% of patients after three intravenous infusions
of infliximab at 2 months following the first infusion, assessed using a combination of
functional scores and proctological examination [43]. Bouguen et al., demonstrated
complete response in 40 out of 94 patients (43%) at induction and complete response in
72% after maintenance treatment for ulcers after a median follow up of 3 years [36].

1.6 Anal Stenosis

Anal stenosis is an abnormal narrowing of the anal canal that can cause proximal
obstruction but can also lead to symptoms of discomfort and pain. Up to half of
Crohn’s anorectal stenoses are in the rectum, a third are in the anal canal and the
remainder are anorectal [44]. Patients often have other forms of pCD such as ulcers,
fissures and fistula. It is the inflammatory process which leads to fibrosis and even-
tually to circumferential stenosis. The prevalence of stenosis is between 9% and
22% and is more commonly found in patients with colonic than ileocolonic disease
[45], approximately 96% of cases have associated proctitis [23]. Fields and col-
leagues, found more manifestations of pCD in a cohort of 70 CD patients with ste-
nosis compared to controls: perirectal fistulae (61% vs. 34%), peri-rectal abscess
(50% vs. 17%) and anal skin tags (23% vs. 16%) [45].
One theory of anal stenosis is that it is the end result of a severe inflammatory
process and is a predictor of poorer outcomes, including proctectomy [44]. One
study demonstrated that patients with anal stenosis had a higher rate of temporary
diversion (OR 3.90, 95% CI 1.18–15.8, p = 0.03) and permanent stoma (OR 3.69,
95% CI 1.39–10.7, p = 0.01) on multivariate analysis [46].
1 Management of Perianal Crohn’s Disease in the Biologic Era 7

Stenosis in patients with Crohn’s disease tend to present later than in those
patients without Crohn’s disease in which constipation tends to be a feature. In
Crohn’s patients, stenosis tends to be associated with proctitis and looser stools,
therefore constipation tends to be less of a presenting feature. Instead the patients
typically present with other manifestations of perianal sepsis, such as fistulae which
lead to detection of the stricture [44, 47]. A digital rectal examination may be impos-
sible due to the degree of stenosis, but where possible the level and length of the
stenosis should be noted in reference to the dentate line [48].
Ideally patients should be assessed using a multi-disciplinary approach. Focused
histories on current and past medical treatments and perianal disease, as well as the
nature of the patient’s bowel motion (consistency and frequency) should be under-
taken. Following this an examination under anaesthesia with biopsies to exclude
malignancy should be performed. Imaging (usually MRI) is used to ascertain the
morphology (the anatomical location, the length and extent of stricture and any
associated perianal disease) of the stenosed segment.
Treatment can be determined in accordance with the severity of the presentation
and the anatomical nature of the stenosis. However, anatomical correlation with
symptomatology can be poor.
Stool softeners can be helpful in the short term, especially if the stool is firm.
In mild stenosis, if the patient is motivated and amenable, manual digitation
(with a single digit) or appropriately sized dilators can prevent deterioration of
the stenosis. Galandiuk and colleagues, found patients with anal stricture who
performed self-­dilatation with Hegar dilators were less likely to require diversion
[46]. This is more useful in shorter strictures where it is easier for the patient to
undertake. Topical treatments with steroids or five ASAs or metronidazole have
been described [48].
An examination under anaesthesia (EUA) and dilatation with Hagar dilators is
usually warranted in mild-moderate stenosis even in cases of the severely scarred
Crohn’s anus [49]. Ideally gentle progressive dilatation up to 22–26 mm in diameter
can be used in adults [50]. A coaxial balloon technique can also be applied for dila-
tation [44]. Trauma as a consequence of over vigorous dilatation may lead to further
stenosis. Patients who self-dilate must be counselled appropriately and supported
by specialist nurses and regular clinic appointments as bleeding and sphincter dam-
age have been reported with dilatation [51].
Interposition flap procedures have been described in the absence of significant
rectal mucosal disease though some studies have shown CD has a negative impact
on healing in flap repairs [15, 52–54]. Anal stricture in association with perianal
sepsis is a poor prognostic feature and is likely to require faecal diversion [44].
Galandiuk et al. found in a study of 356 patients with CD, the presence of both an
anal stricture and colonic disease had a 30-fold increase in the likelihood of a per-
manent stoma compared to those patients with colonic disease without anal stricture
[46]. Proctectomy should be considered when medical and surgical therapies have
been exhausted.
8 S.O. Adegbola et al.

1.7 Abscess

Perianal abscesses are a common complication in Crohn’s disease and one study
found up to 62% of Crohn’s patients will develop at least one during the course of
the disease [30]. Two suggested aetiologies have been described including the cryp-
toglandular hypothesis [54] and Hughes’ theory that rectal inflammation leads to
ulcers which in turn evolve into fistulae [15]. More recent studies have also pro-
posed the role of genetics [5, 55–58] and an alteration in or unregulated response to
the normal GI microbiota [59–62] in perianal Crohn’s abscess/fistula.
An abscess may present acutely with pain in the perianal region as a local-
ized, erythematous swelling. Signs include a swollen tender lump with sur-
rounding erythema. Abscesses are classified anatomically in relation to the anal
sphincter (e.g. intersphincteric, superficial, suprasphincteric etc). In a prospec-
tive series of 126 patients with pCD, just under half (48%) had at least one
perianal abscess [63].
Clinical examination often reveals the location of the abscess, but in more com-
plex presentations EUA is a useful diagnostic adjunct with a specificity of 91% [13,
64] Certain anatomical locations, such as intersphincteric [65], are more difficult to
assess clinically and imaging such as MRI or endoanal ultrasound [66] if tolerated,
in combination with an EUA may be needed to identify the abscess. Abscesses
appear as areas of high signal intensity in T2 weighted MRI scans and may be asso-
ciated with a rim of inflammatory tissue [67].
Antibiotic therapy is required if there are signs of systemic sepsis and can be
used in combination with the patient’s normal immunomodulators [68–70]. A com-
mon cause of recurrence of the abscess is undrained sepsis, so patients will usually
undergo incision and drainage.
An abscess is part of the natural history of the untreated anal fistula and
although they may occur separately, both are more common in Crohn’s disease
than in the general population—an underlying fistula should be sought when an
abscess is found. Makowiec et al., found that 73% of abscesses were associated
with an ischiorectal fistula and 50% with a trans-sphincteric fistula [63]. In the
acute setting, the abscess should be drained and if a fistula is identified, seton
suture placement is advised. However, caution should be exercised in the acute
setting, as probing the acutely inflamed ano-rectum in search of a fistula, may
cause iatrogenic injury.

1.8 Fistula

Anal fistulae occur in a third of all Crohn’s disease patients [71]. They denote a
distinct and aggressive phenotype [12], with a higher risk of a severe and disabling
disease course, relapse and the need for repeated operations. They cause pain and
discharge and result in a reduced quality of life [72]. In a population study, Schwartz
et al. found the cumulative risk of at least one perianal fistula after 1 year was 12%,
after 10 years was 21%, and after 20 years was 26% [13].
1 Management of Perianal Crohn’s Disease in the Biologic Era 9

Crohn’s anal fistulae were first described in 1934 [73] and it is known that they
can precede luminal disease [7]. Anal fistulae are the initial manifestation and the
presenting complaint in 10% of patients with Crohn’s disease [74]. Patients diag-
nosed before the age of 40 are at an increased risk of a penetrating phenotype,
including anal fistula [75]. Anal fistulae are more common in men, non-Caucasians
and Sephardic (as opposed to Ashkenazi) Jews [ 11, 12, 75, 76]. Patients with
colonic disease but specifically those who have active rectal disease are at greatest
risk of developing fistulae [77].
A number of classification systems exist for anal fistulae including Hanley’s
[78], Parks’ [79] and the American Gastroenterological Association (AGA) [18]
classification which describes fistulae as either simple or complex. Simple fistu-
lae have one external opening and are low (below the dentate line; superficial,
inter- or trans-sphincteric). Complex fistulae may have more than one external
opening, be high (above the dentate line; inter-, trans-, supra-, or extra-sphinc-
teric) or have extensions (a term denoting abscess/secondary tracts). Patients
with Crohn’s disease can present with either, but complex fistulae are more com-
mon in Crohn’s than non-Crohn’s patients. They have a tendency to recur and
often patients require multiple operations (see Fig. 1.1) [80]. With repeated sur-
gery and episodes of sepsis the fistulae become harder to assess both clinically
and radiologically due to an increase in scar tissue and distortion of the surround-
ing anatomy [81]. Assessment includes a focused history, examination including
procto-sigmoidoscopy. MRI is the gold standard for imaging anal fistula and has
been shown to be superior to examination under anesthesia [82] and endoanal
ultrasound [83]. A technical review by the American Gastrointestinal Association
[18] found a diagnostic accuracy of 76–100% in complex Crohn’s fistula [64,
84–90]. However, the location of the internal opening can be difficult to ascertain
on MRI [90]. Schwartz et al., demonstrated in 32 patients with perianal Crohn’s
fistula that diagnostic accuracy could be improved if two modalities (MRI, endo-
anal ultrasound, EUA) were used in combination [87]. Establishing the presence
or absence of proctitis is fundamental and influences both treatment and progno-
sis. Procto-sigmoidoscopy or formal endoscopy should be performed to deter-
mine this [67].
Established treatment principles involve draining the sepsis and aggressively
managing proctitis whilst treating the fistula medically, usually with a combination
of antibiotics, thiopurines and anti-TNF therapies. Clinical response to treatment is
defined as a 50% decrease in the number of external openings and/or a lack of dis-
charge from these openings over two consecutive clinic visits [91]. Clinical remis-
sion or ‘healing’ is the complete cessation of drainage despite gentle finger pressure
or the healing of all external openings. This subjective, clinical drainage assessment
has been criticised for failing to appreciate the natural history of anal fistulae and
failing to assess residual tracts which have been radiologically shown to heal a
median of a year after clinical ‘healing’ by Tozer et al. [82].
Previous attempts to standardize radiological response, such as the [92] van
Assche system have been criticised due to insensitivity to change in the long term
[93] and weak correlation with PDAI (r = 0.371, p = 0.036) [92]. Currently, there is
10 S.O. Adegbola et al.

no universally accepted or reliable method of monitoring long-term radiological

response to treatment. Clinical scoring systems such as the Perianal Disease Activity
Index (PDAI) have been used, though they are not specific to fistulous disease and
currently no widely accepted scoring system exists [93, 94].
Tozer et al., summarized the principles of treatment being to drain the underlying
sepsis, aggressively manage proctitis and medically treat the fistulae with a combi-
nation of antibiotics, immunosuppressants and anti-TNF therapy [82]. Simple fistu-
lae, in the absence of proctitis, are sometimes managed by experienced surgeons in
a similar fashion to those of cryptoglandular aetiology. However, the risks of impair-
ment of continence, recurrence and poor wound healing, heightened in the Crohn’s
patient, lead to a preference for sphincter preserving techniques. Complex fistulae
are notoriously difficult to manage with high rates of recurrence and wound failure
and necessitate a combined surgical and medical approach with anti-TNF therapies
as standard. Bell et al., working in the pre-anti TNF era, found complex fistulae
required a median of six procedures to heal and 50% ultimately went on to proctec-
tomy [95]. Patients need to be assessed in an individualized fashion but a multi-
disciplinary team and clear communication with the patient and management of
expectations are fundamental [95].
Antibiotics alone have failed to demonstrate long-term benefit [18]. Adjunctive
antibiotic therapies in the form of ciprofloxacin or metronidazole are used in pCD
with some success. West et al., compared combined treatment of infliximab + cip-
rofloxacin with infliximab-alone, in a double blind randomized control trial (RCT)
and found 73% vs. 39% (p = 0.12) fistula response respectively [69]. The ADAFI
trial, a multicentre, double-blinded RCT, demonstrated that clinical response was
observed in 71% of patients treated with adalimumab plus ciprofloxacin compared
with 47% treated with adalimumab plus placebo (p = 0.047) [96]. Although both
metronidazole and ciprofloxacin have demonstrated a benefit [97, 98], the side
effect profile of ciprofloxacin is preferred.
Despite widespread use, the evidence for immunomodulators (such as azathio-
prine and 6-mercaptopurine) inducing fistula healing is limited. A recent Cochrane
review assessed immunomodulators vs. placebo for fistula healing and found a non-­
significant benefit (RR 2.0; 95% CI 0.67–5.93). However, the review only had a
small number of patients and the studies included were over 40 years old. A recent
meta-analysis by Jones et al., found anti-TNF monotherapy was equivalent to con-
comitant use of immunomodulators and anti-TNF therapy [99]. As such the role of
these agents does need addressing in prospective trials.
Anti-TNF therapies have enhanced our management of pCD and a number of
different agents exist [100]. The ACCENT II trial, a double blind RCT, demon-
strated the benefit of infliximab maintenance treatments in perianal fistulising
Crohn’s disease [101]. A partial response was shown in 64% at 54 weeks and a
complete response was shown in 36% vs. 19% in the placebo group. In addition,
there was a 50% reduction in the rate of hospital admissions and there is increasing
evidence that infliximab improves health related quality of life [102, 103]. In gen-
eral, the better the initial response to infliximab the lower the fistula recurrence rate
[104] and monitoring drug levels and proactive dosing are advocated.
1 Management of Perianal Crohn’s Disease in the Biologic Era 11

The combination of anti-TNF therapy and seton insertion has been assessed
recently in a multicentre observational study [105]. Both utilization of infliximab
prior to surgery [106, 107] and seton insertion prior to infliximab have demonstrated
benefit [108].
The search for clinical factors which can predict response to therapy and relapse
rate is a focus for current research [109]. The role of antibodies and trough levels of
the anti-TNF agents have also been explored and indeed both may guide therapy
[110, 111].
Continuing with the first anti-TNF agent is usually recommended unless there is
a loss in response. Several studies have shown some benefit of changing biological
agents after a loss of response to anti-TNF therapy. The CHARM study showed
benefits in both the anti-TNF naïve patients and those who had switched to adalim-
umab. In this study, patients who had received infliximab or any TNF antagonist
other than adalimumab, greater than 12 weeks before screening, could be enrolled.
This was provided they did not exhibit initial nonresponse to the agent (i.e. no clini-
cal response to first injection as judged by the investigator). Fistula response was
found in 41% of patients at 56 weeks [112]. Of all those patients who had fistula
response (including those in the placebo group), 90% had maintained response fol-
lowing 1 year of open-label adalimumab therapy, for at least an additional year
[113, 114]. Similarly, the CHOICE trial found complete fistula closure in 34/88
(39%) treated with adalimumab after loss of response to infliximab [115].
The role of adalimumab following lack of response to infliximab has been con-
sidered in several studies. Notably, the GAIN study found no difference between
adalimumab and placebo as a second line agent [114].
An other anti-TNF therapy used thus far in pCD is Certolizumab Pegol. This was
compared against placebo and assessed at 26 weeks in the PRECISE 1 and 2 trials.
Of the 55 patients with perianal fistula the closure rate was superior with
Certolizumab compared to placebo (36% vs. 17%, p = 0.038). However, the differ-
ence was not statistically significant (54% vs. 43%, p = 0.069) for the protocol defi-
nition of fistula closure (≥50% closure at two consecutive post-baseline visits
≥3 weeks apart) [116, 117]. Trials are ongoing with newer monoclonal agents such
as Vedolizumab which may prove to be a viable alternative.
The role of surgery is predominantly to assess and drain the fistula complex prior
to medical management. Due to the risks of impairment of continence, recurrence
and poor wound healing, fistulotomy is rarely (if ever) appropriate in Crohn’s dis-
ease. Sphincter preserving treatments may be considered and data on drainage
­procedures (long term loose seton), disconnection procedures (advancement flaps,
the LIFT procedure), infill procedures (glues, plugs) and ablative procedures
(VAAFT, FiLaC™), whilst mostly limited to case series, have shown feasibility in
Crohn’s disease.
In the context of rectal inflammation and a complex fistula, a long term loose
seton in combination with medical therapies can be effective [118, 119]. Cutting
setons are less widely used and it is argued that they cause pain and sphincter
injury [50]. A long-term loose seton is an acceptable management strategy in
some patients and may only need to be changed in the case of persistent
12 S.O. Adegbola et al.

inflammation (which suggests they are not fulfilling the function of a conduit for
suppuration and that further drainage may be needed), snapping or calcification.
More commonly the loose seton is placed to ensure full drainage of all perianal
sepsis prior to anti-TNF therapy. Traditionally and empirically seton removal has
been after the second infliximab infusion however more recent evidence suggests
decreased fistula recurrence rates when setons are left in place longer [120, 121].
There is no consensus as to the optimum time to remove the seton and the ongoing
PISA trial attempts to address this issue [122]. Setons may be used as a bridge
between draining the initial sepsis and optimizing the patient medically before
definitive surgical treatment.
‘Infill strategies’ such as glues and plugs have been employed with varying suc-
cess. The closure rate was 57% at 23.4 months in one study of 14 patients [123]. A
systematic review found a 55% fistula closure rate in a pooled analysis of 42 patients
[124]. The initial success for infill strategies has not been replicable in other centres
and limited long-term data are available in pCD [124]. There are however potential
uses for these materials as scaffolds for newer therapies such as stem cells and local
pharmaceuticals. Indeed, a phase II multicentre study of complex fistula (14 patients
out of 49 had pCD), compared glue vs. glue and expanded adipose-derived stem
cells (ASCs) and reported healing in 16% vs. 71% respectively, with a one-year
recurrence rate of 17.6% in the ASCs group [125].
Endorectal advancement flaps (ERAF) for anorectal and rectovaginal fistula
(RVF) have been used in Crohn’s disease with variable success. The surrounding
mucosa in the rectum must be healthy and creating a tension free anastomosis is key
[48]. Patients with perineal descent and/or internal intussusception are often better
suited to advancement flaps and surgeons may choose between mucosal, partial or
full thickness flaps. In a series of 36 Crohn’s fistulae, there was an 11% primary
failure rate and recurrence rate of 31% [126]. Solanti et al., performed a review of
the literature in which ten studies featured pCD with a 64% success rate and a 9.4%
incontinence rate [127] but multiple attempts at advancement flap were permitted.
A retrospective review from the Cleveland clinic identified 28 patients with pCD
and a higher recurrence rate was found compared to idiopathics (57.1% vs. 33.3%,
p < 0.04).
‘Ligation of the intersphincteric tract’ (LIFT) is a procedure used to treat trans-
sphincteric fistula. Many of the earlier studies excluded pCD however Gingold
et al., found 8 of 12 patients (67%) had LIFT site healing at 12 months [128]. In
patients without perineal descent it is an alternative to an advancement flap.
Complexity in the intersphincteric space and high fistula (difficult the surgical
access) are relative contraindications.
Novel treatments such as ‘Fistula tract laser closure’ (FiLaC™) and ‘Video
assisted anal fistula treatment’ (VAAFT) have shown some promising results in
cryptoglandular fistula but prospective trials in pCD are needed.
Intra-fistula injection of stem cells has been shown to be safe and a promising
area of research and has shown benefit in previously refractory complex fistula. De
la Portilla et al. performed an open-label, single-arm clinical trial in six Spanish
hospitals of 24 patients with pCD. At 24 weeks, 56.3% of patients achieved
1 Management of Perianal Crohn’s Disease in the Biologic Era 13

complete closure of the tract, with 30% achieving closure of all existing tracts;
defined clinically and radiologically as the absence of collections [129]. A Phase II
trial in Korea reported complete fistula healing (defined clinically) in 27/33 patients
(82%) at 8 weeks [130] and the same group have recently reported their 2 year out-
comes in which in modified per protocol analysis 75% had complete healing at
2 years defining clinically [131]. A longer follow up was found by Ciccocioppo
et al., who found a fistula free survival of 88% at 1 year, 50% at 2 years, and 37% at
4 years [132].
Faecal diversion can be a useful adjunct to complex pCD operations either in the
form of de-functioning colostomy or an ileostomy. A recent meta-analysis of 16
cohort studies (556 patients) found that 63.8% (95% CI: 54.1–72.5) of patients had
early clinical response after faecal diversion for refractory pCD. Whilst most often
the decision to de-function is regarded as temporary, the same study reported that
restoration of bowel continuity was only attempted in 34.5% (95% CI: 27.0–42.8)
of patients, and was successful (without relapse of symptoms or need for additional
surgery) in only 17% of patients [133]. The authors concluded that 42% of patients
undergoing restoration of bowel continuity go on to require proctectomy due to
relapse of symptoms.
In severe and refractory pCD, proctectomy can be considered. A combination of
immunosuppressive medications and chronic disease often mean the rates of poor
perineal wound healing are high. Yamamoto and colleagues found a persistent peri-
neal sinus in 33 out of 145 patients (28%) after proctocolectomy for Crohn’s disease
[134]. Other post-operative complications include recurrent sepsis, fluid collections
in the pelvic ‘dead space’ created and iatrogenic damage to pelvic nerves.
Proctectomy is often seen as a failure of management but in a few patients with very
severe perianal disease and/or proctitis, it may be a life changing intervention.
Careful discussion and counselling are crucial.
The overall aim of surgery in Crohn’s fistula is to provide high rates of closure
without significant impairment of continence whether by definitive surgical inter-
vention or, more commonly, by preparing a fistula tract for medical treatment [135].
However, despite advances in diagnosis, medications and surgical techniques, sur-
gery for complex pCD remains challenging [106, 136–139]. Recurrence and reop-
eration rates are high and proctectomy may ultimately be required in 10–18% of
cases [30, 118, 119, 140]. Complex fistulous disease may never be cured and for
some patients a palliative approach is currently the only option.

1.9 Rectovaginal Fistulae

Rectovaginal or anovaginal fistulae (RVF) can occur in 10% of women with Crohn’s
disease and are classed as complex anal fistulae [141]. The majority occur in the
middle of the rectovaginal septum and are secondary to an anterior rectal ulcer
which erodes into the vagina [48]. RVF which are higher, associated with active
rectal disease or originating from a Bartholin’s abscess are associated with worse
symptoms and prognosis [77, 141–143].
14 S.O. Adegbola et al.

Symptoms include intermittent vaginal flatus, discharge [144] and, rarely, faecal
incontinence [48]. Examination under anaesthesia, proctoscopy and vaginoscopy
can be used in conjunction with contrast enemas or methylene blue infusion per
vaginal tampon to identify the tract. MRI may miss the fistula but provides informa-
tion about inflammatory changes, ongoing sepsis and may delineate fistula
morphology.
Management of RVF is dependent on anatomical location, complexity and
whether there is active inflammation in the rectum. A multidisciplinary team should
determine management options and reference must be made to severity of luminal
as well as perianal disease, the presence of localized sepsis, sphincter function
(through anorectal physiology studies) and treatment goals of the patient. Patients
should be appropriately counselled that there is often no ‘panacea’ treatment and the
risks of sphincter injury and recurrence should be explained.
The aim of the immediate treatment is to control proctitis and drain any underly-
ing sepsis. Surgical management is the mainstay but medical adjuncts are often used
to alleviate active inflammatory processes and control pre/post-operative bowel habit
[145]. The ACCENT II trial, included 25 patients with Crohn’s RVF who had inflix-
imab infusions. Following infusions at induction, 2 and 6 weeks 44% of fistulas were
closed at 14 weeks [146]. Infliximab has been shown to reduce hospitalisation and
the number of operations in fistulizing disease including a subgroup of RVF patients,
but it is less likely to be curative in RVF than perianal fistulae [18, 102].
Surgical options are indicated when there is endoscopic evidence of healed rec-
tosigmoid mucosa [18]. There is a lack of high quality data on the subject and the
options are varied including fistulotomy (rarely) if very superficial, trans-anal/vagi-
nal advancement flaps, Martius flaps [147], gracilis interposition and direct repair
with sphincter repair [148].
Mucosal advancement flaps have been found to have highly variable rates of suc-
cess ranging from 28% to 92% [126, 149, 150]. Makoweic et al., found that the recur-
rence rates at 2-year follow up were higher following advancement flaps for Crohn’s
RVF compared to anal fistulae (70%; 25%) [126]. In cases where proctitis cannot be
managed medically, options for treatment include anocutaneous flaps [151, 152] or
protectomy [141]. Full sleeve/Soave-type advancements have been described in the
presence of anal stenosis or in cases where the fistula has occurred at the site of an
anastomosis [153, 154]. As the failure rate of all surgical options is high, diverting
stoma should be considered. However, with long-term closure rates of 50%, patients
should be counselled appropriately, particularly where their symptoms are minimal.

1.10 Pregnancy

A recent retrospective review of all deliveries from 1998–2009 found patients with
pCD were more likely to have a caesarean section compared to those patients with
non-CD perianal disease (83.1% vs. 38.9%, p < 0.001). Multivariate analysis was
performed to identify independent risk factors of fourth degree lacerations. Crohn’s
disease alone was not a risk factor (OR 1.18; 95% CI, 0.8–1.8, p 0.4), perianal
1 Management of Perianal Crohn’s Disease in the Biologic Era 15

disease was (OR, 10.9; 95% CI, 8.3–4.1; p < 0.001) but a distinction between pCD
and non-CD perianal disease was not made [155]. The European Crohn’s and Colitis
Organisation (ECCO) guidelines recommend normal vaginal delivery as safe for all
patients except those with active perianal disease, but to avoid episiotomy where
possible [155, 156].

1.11 Anal Cancer

Epidemiologic data about anal cancer in patients with CD are scarce because the
majority of available articles are case reports or small case series [25]. It has previ-
ously been reported that the incidence of anal cancer is higher in patients with
Crohn’s disease [24]. Frisch and colleagues [26] sought to address this question
using a population-based estimate of the incidence of anal SCC in patients with
inflammatory bowel disease (IBD). Anal cancer was studied in 9602 patients with
Crohn’s disease or ulcerative colitis. They were followed for up to 18 years with
99,229 person years of observation. Two cases occurred vs. 1.3 expected
(Standardized Incidence Ratio—SIR 1.6 (95% CI 0.2–5.7)). The conclusion was
that although this may be a type 2 error and an association is present but not detected,
anal squamous cell carcinoma remains rare in patients with IBD.
Nevertheless, the association between complicated perianal Crohn’s disease and
cancer in the rectum and anus has also been reported by others [25, 27, 28]. Anal
cancer has been described in patients with longstanding anorectal fistulae in the
absence of Crohn’s disease and it is possible that chronic inflammation is more
important in the carcinogenesis than the presence of Crohn’s disease itself. The rar-
ity of anal SCC in Crohn’s disease makes accurate assessment of incidence and
prediction of risk difficult.
The diagnosis of anal cancer has often been delayed because of the non-specific
symptoms (similar to those in the patient with pre-existing pCD), unawareness of
the cancer risk or confusion between cancer and a benign stricture. Connell et al.
[28] reported their experience regarding the presence of lower gastrointestinal
malignancy in 15 of 1240 patients with CD seen at St Mark’s Hospital, UK, between
1940 and 1992. A total of five patients had anal cancer (all squamous cell carcino-
mas) and all five had chronic disease affecting the anorectal region (mean duration
18 years). Two patients had fistulae affecting the anus and rectum, one had a chronic
anorectal stricture, one a persistent perianal abscess, and one had a ‘grossly enlarged
skin tag’. Known risk factors associated with anal SCC such as HIV and infection
with HPV subtypes were not described in this retrospective study [28].
Many patients with anal lesions have few symptoms despite grossly distorted
perianal anatomy. Thus the diagnosis is clinched on the basis of heightened suspi-
cion and the possibility of malignancy should always be considered when examin-
ing chronic pCD of any type but in particular non-healing fistulae or ulcers.
Curettage or biopsy of the fistulous tract and histology of the biopsy material should
be performed when suspicion is raised either by chronicity, examination findings or
a change in symptoms.
16 S.O. Adegbola et al.

Anal SCC in Crohn’s disease should be managed in the same was as that in non-­
IBD patients with the corresponding stage disease [27] and the expert consensus of
the AGA recommends that standard oncologic surgical principles and procedures
should be followed. The prognosis, however, tends to be poor due to the advanced
stage of the cancer and were excisional surgery required, the risk of poor perineal
wound healing remains high.

1.12 Scoring Tools

There are a number of questionnaires that are used in Crohn’s disease to determine
a patient’s quality of life. However, these can under-estimate the degree of morbid-
ity or impairment in quality of life specific to perianal disease. Such scoring tools
are therefore of limited use in assessing clinical progress/response to treatment in
pCD [18]. The Cardiff classification described in 1978 by Hughes [15] assigned a
score of 0–2 for each manifestation of perianal Crohn disease: ulceration, fistula,
and stricture, and also classified fistula location with respect to the dentate line. A
later modification added a score for proximal intestinal Crohn disease [16].
In 1995, Irvine proposed the Perianal Disease Activity Index (PDAI) [94]. This
sought to address the deficiencies of existing activity indices in recognising the peri-
anal complications of CD [18, 157]. The score was designed to improve the estima-
tion of pCD severity, both in clinical practice and in the context of clinical trials. The
PDAI focuses on five areas which assess quality of life (restriction of sexual activity,
pain/restriction of activities) as well as disease severity (type of perianal disease,
fistula discharge and degree of induration). In the study validation, there was good
correlation between the score and patient global assessment [94, 158].
A more recent scoring system proposed by Pikarsky et al. [157] is useful in
attempting to predict the outcome following surgical intervention in patients with
perianal Crohn’s disease. The index consists of six items that are ascertained during
history taking and physical examination, i.e. abscess, fistula, fissure and/or ulcer,
stenosis, incontinence. Each feature was rated on a point scale according to severity
and complexity. A score of zero indicates the absence of that feature. Uniformly, a
score of 1 represented de novo acute disease; 2, chronic disease; and 3, recurrent
disease [157]. An incontinence score of 1–6 was graded as 1 point, 7–14 as 3 points,
and more than 14 as 5 points using an incontinence score described by Jorge and
Wexner [159]. The scoring system has correlated well with short-term outcomes of
surgical intervention [158]. However, despite their ability to document the severity
of symptoms objectively, none of the above classification systems has gained wide-
spread acceptance owing to their lack of impact on clinical decision-making.
However, despite their ability to document the severity of symptoms objectively,
none of the above classification systems has gained widespread acceptance owing
to their lack of impact on clinical decision-making [91, 160].
The most widely used instrument for assessing treatment outcomes in clinical
trials is the Fistula Drainage Assessment [161], described above. It was introduced
as the primary end point in the trial of Infliximab for the ACCENT II trial. In this
1 Management of Perianal Crohn’s Disease in the Biologic Era 17

assessment tool, fistulas are classified as open (i.e. purulent material is expelled
with gentle pressure) or closed. A fistula has to remain closed for two consecutive
visits (at least 4 weeks apart) to be considered closed. If half of all external openings
are closed the patient has responded. If they are all closed they are in remission, at
least for that 4-week period. There are limitations of the Fistula Drainage Assessment
tool, as it does not consider changes in anal pain, which is an important marker of
treatment response.

1.13 Prognosis of pCD

The clinical course and overall prognosis of pCD largely depends on the clinical
picture (as discussed under the various headings), the location of disease and the
presence of proctitis. The natural history is however, difficult to predict, due to het-
erogeneous terminology in the literature. In general, skin tags and fissures are asso-
ciated with a more benign course, whereas complex anal fistulas, deep cavitating
ulcers and dense anorectal strictures tend to carry a poor prognosis. In general,
perianal disease in the absence of rectal inflammation has a better outlook than dis-
ease associated with rectal inflammation.
The lower threshold for the use of immunosuppressants and particularly anti-­
TNF agents has improved outcomes of complex fistulising pCD. Short-term
improvements are seen in over 50% of patients and this maintenance can be seen
in up to a third of patients at 1 year. These medical treatments often have to be
used in conjunction with prompt drainage of sepsis and preservation of anatomy
to offer the best outcomes [162]. As well as drainage, surgery includes bridging
treatments (seton insertion, temporary faecal diversion) and definitive fistula
surgery.
A proportion of patients go on to have multiple attempts at controlling symptom-
atic disease. Despite these multiple therapeutic interventions, some patients remain
refractory to treatment and will require ‘temporary’ faecal diversion or eventual
proctectomy [133]. Diversion is usually in the form of a loop ileostomy or colos-
tomy and is intended to control the inflammatory process and optimise the patient’s
nutritional and general status prior to attempting definitive surgical treatment. A
quarter of patients require re-diversion after restoration of bowel continuity and just
under half of all patients requiring temporary diversion go on to eventual proctec-
tomy [133]. Interestingly, the use of anti-TNF therapy has not had a significant
impact on these rates. The absence of proctitis is the only significant factor associ-
ated with restoration of bowel continuity [163–165].

Conclusion
Each aspect of perianal Crohn’s disease is nuanced in its own way, with options
for management (see Fig. 1.3) which depend on the nature of the pCD and on the
patient, their symptoms and their burden of disease elsewhere, particularly in the
rectum. A multidisciplinary approach involving gastroenterologists, surgeons,
radiologists, IBD nurses and dieticians and an awareness of pCD, its forms and
Another random document with
no related content on Scribd:
 “Study your spelling, Charlie.”
“Charlie, come up here and stand by my desk.”
And so throughout the year, Miss Marlowe ignored the facts that
ought to have led to a reformation of this little boy’s habits.

CONSTRUCTIVE TREATMENT

When a child shows he has not been given careful teaching relative
to sex hygiene, go to his mother and advise her to take the child to a
physician. Explain the physical as well as the moral and mental help
it may be to the child to have one of two very slight operations
performed, after which, with proper diet and bathing, the boy may
easily forget his wrong habits.

COMMENTS

Children can best be taught at home on matters of sex hygiene.

This is especially true of children in the lower grades. Mothers, as a
rule, gladly respond to a teacher’s or physician’s suggestions for
improving the health of their children.

ILLUSTRATION (FOURTH GRADE)

Miss Morris, a fourth grade teacher, School Nurse

called together the mothers of her pupils Instructs
and asked a trained nurse who lived in the village to address them on
sex hygiene. After the talk, Miss Morris said: “The subject just
discussed is a most important one. I shall be very glad, indeed, to
make reports to any mothers whose children, in my judgment, need
attention relative to this subject, if it is the wish of the mothers here
present for me to do so.”
A vote was taken and the mothers thus expressed their desire to
have such help as the teacher could render. Thereafter she felt
perfectly free to go to them whenever it seemed necessary to discuss
this great subject, so pertinent to a child’s welfare.
CASE 153 (FOURTH GRADE)

Miss Vane saw a note fall upon Mary Pratt’s desk. She said,
“Mary, bring that note to me.”
The child, she knew had not yet read the note. Greatly
embarrassed, Mary looked questioningly at Clyde Mitchel before
starting toward Miss Vane.
Contrary to the courtesy which teachers Improper Notes
admonish pupils to show, Miss Vane stood
up, opened the note and perused it in the presence of the school.
While she was looking at the note, Clyde Mitchel buried his scarlet
face in his book.
“You wrote this note, didn’t you, Clyde?” asked Miss Vane.
Clyde only nodded “Yes,” and burrowed even deeper into his book.
“This is a shameful note,” said Miss Vane. “It contains words that
no child should ever write or speak. You may stay after school,
Clyde.”
The boys waited at the second corner from the school house for
Clyde after school.
In about ten minutes Clyde came running toward them.
“What did she do, Clyde?” they asked.
“Aw, nothing; she just preached a little and gave me a few licks
that wouldn’t hurt a baby.”
“What was in the note, anyway?”
He told them exactly what was in the note, and a loud “Hurray!”
went up from the group of listeners. The subject of conversation
among these boys as they went on down the street was as full of
unclean words and suggestions as the worst boys in the group could
think up.

CONSTRUCTIVE TREATMENT

If you can not deal with sex subjects privately, with pupils in the
lower grades, do not deal with them at all. Miss Vane made a mistake
in reading or referring to the note in the presence of others. In her
efforts to suppress such foul communications she occasioned a talk
upon the unnamable topics by all of her own room and many in other
rooms as well.

COMMENTS

Public punishment of culprits who offend by talking or writing on

sex subjects only occasions more such talk. It is like trying to quench
fire by brandishing a fire-brand which emits live sparks in every
direction, each one of which starts a conflagration.

ILLUSTRATION (THIRD GRADE)

When Sadie Moore picked up a note from Avoid Spreading

the floor and handed it to Miss Dietz, who Harm
taught the third grade, the teacher allowed no one to see her when
she read the note. She said privately to Sadie: “I desire that you say
nothing to any one about that note. That is the best way to help me in
this matter.” She studied the handwriting and note paper and fixed
the blame to a certainty upon Conrad James. She resolved at once to
keep sharp eyes on that boy, unknown to him, and to see that he had
no chance to have unrestricted conservation with other pupils for a
while. She supervised all play periods and thereby assured herself
that no harm should come to any one of her pupils through
association with him.

CASE 154 (SEVENTH GRADE)

Pearl Goodwin’s mother was a widow of Morbid Sex-

ill-repute in the village. The eighth grade consciousness
girls slighted Pearl hourly. They avoided sitting with her whenever
possible; they gave her too wide a space at the blackboard while the
rest of them stood so close together as to crowd their work; she went
sadly to and from school, walking alone, for none of the others would
walk with her.
 The teacher, Miss Terman, herself a native of the village,
understood, and made no effort to change the situation.
One day Pearl brought a shameful note to Miss Terman, saying
that she found it on her desk. Miss Terman was shocked and made
public inquiry as to where the note came from. Some of the girls felt
sorry for Pearl and showed it by their attitude toward her. The writer
was not discovered. Every day, thereafter, for a week, Pearl showed a
similar note to Miss Terman, and the mystery grew and with it
sympathy for Pearl. Daily Miss Terman made a speech about the
notes and asked help in finding out the writer.
Finally, in despair, she consulted the superintendent of the school.
When he heard the history of the case he said:
“I believe that Pearl herself is the writer of those notes. Her mind
has been poisoned on the sex subject by taunts. I believe she is the
only one in your room who would write such notes.”
With this thought in mind, Miss Terman sought evidence of Pearl’s
guilt. She was not long in finding the half leaves in Pearl’s tablet from
which the paper for the notes had been torn. She even found Pearl
writing a note, and got her pitiful confession of taking this way to call
attention and sympathy to herself.
Miss Terman sentenced Pearl to isolation for the remainder of the
school year (about two months). She was compelled to take her seat
as soon as she arrived at school in the morning and at noon, to have
a separate recess from the others, and remain in her seat after school
closed until the other children had time to reach their homes.

CONSTRUCTIVE TREATMENT

Miss Terman should have drawn Pearl into the games of the other
girls early in the year. She should have said to the leader among the
girls, in private. “You have it in your hands to make a classmate
happy or miserable. You, yourself, will enjoy school better if no girl is
made sad and lonely. I know that the other girls will follow your lead
and, therefore, I desire that you invite Pearl Goodwin into your
school games and give her an opportunity to know and like good
company.”
COMMENTS

Miss Terman, by allowing the note-writing to be publicly known,

caused an epidemic of undesirable talk in her school. She kept this in
mind daily by her isolation program for Pearl. It is only when all are
concerned in a question of this kind that a public talk should be
made on questions of sex.

ILLUSTRATION (EIGHTH GRADE)

Enoch Fites found the disgraceful Hygienic Toilet

condition of the toilet rooms belonging to Rooms
his school to be a source of great temptation and danger to his
pupils. He first solved the general problem of winning his pupils’
confidence. He was a master in quietly introducing improvements in
the school. For example, he secured funds for a splendid clock, which
was connected with the Western Union Telegraph wires and was
corrected every hour. He established a manual training department
and set every boy in high school and in the eighth grade at a bench.
He opened up a domestic science department. He organized tennis
teams and put through a large number of important measures.
When the appropriate time came, he found no difficulty in putting
the toilet rooms for boys in a sanitary condition and keeping them
so. He remarked to a visitor,
“I have not inspected those rooms for two months, but I know just
how they are kept.”
“How in the world do you manage it?”
“I put it up to my boys. I made the toilet rooms entirely adequate
for their needs and then put it up to my boys to keep them clean.
They have never disappointed me.”
3. Meeting the Boy and Girl Question

CASE 155 (HIGH SCHOOL)

 When Mr. Harley went to take up his work as superintendent of
the Jamesville High School, he said to a teacher who had served
there the year before: “I believe in preparedness—what was your
greatest disciplinary problem last year?”
“Parties, without a doubt,” she replied. High School
“The last party or the coming party Parties
occupied the minds of the students to the exclusion of their studies.
They were out late at night and consequently did mediocre work,
even the brightest of them.”
“Was nothing done to stop party going?”
“Well, you see, many of the parents upheld the pupils in what they
called their social education, so Mr. Turner (the former
superintendent) didn’t try to prohibit parties.”
“I’m glad to have this information,” replied Mr. Harley.
Later, when the pupils were known to be planning a hallowe’en
party, Mr. Harley announced that he would suspend every pupil who
attended any party at any time during the school year, without first
securing his permission, and that such permission would be given
only very rarely.
A storm of protest from the pupils was seconded by several
mothers, who called upon Mr. Harley to discuss the social aspect of
education.
When, after a nerve-racking day, he told Mrs. Hines, the leading
society woman of the village, that he must carry out his own plans
unaided by the parents, he unwisely aroused the opposition of so
many of his patrons that his work in Jamesville was very seriously
handicapped and he resigned at the end of his first year there.

CONSTRUCTIVE TREATMENT

A Parent-Teachers’ Club should be organized in every school. Early

in the year a meeting of the club should be devoted to the discussion
of out-of-school-hour entertainments. The superintendent should
have the pros and cons presented before the club by both parents
and teachers. The teacher who upholds parties should advise
mothers to talk often with their children upon the subject of
desirable companions; to forego all teasing of the sons and daughters
about “girls” and “beaux”; and to see to it that the young people have
wise chaperons.

COMMENTS

Much of the mischief that arises from parties is due to parents.

Realizing this to be the case, teachers should find a way to talk to
mothers about how to win and hold the confidence of their children
during the trying high school period. The girls should also be
admonished by their teachers to talk to their mothers freely about
their social affairs.

ILLUSTRATION 1 (HIGH SCHOOL)

Miss Fanson was a high school teacher who was justly admired by
the girls under her care. She had talked to the girls about the
deference and homage which they should show to their parents in
social matters. Alice Grant believed that Miss Fanson was exactly
right, hence was willing to act upon her teacher’s advice.
Since she had entered high school, boys had suddenly become very
interesting to Alice. She blushed one afternoon as she plucked up her
courage to reveal certain developments to her mother.
“Mother, the Freshmen are going to give a party, and a boy in my
German class has asked me to go. May I?” Her voice affected
indifference.
But Mrs. Grant knew her young daughter Retaining
and saw through that coolness. Her Alice Control
was excited and flushed and happy over a boy! And she stared
blankly for a moment as the realization forced its way. Then a
tempestuous refusal from a heart that resented her little girl’s
growing up sprang swiftly to her lips, but she kept back the words. It
did, indeed, hurt to have Alice begin to be a young lady, but could
even she, the most adoring of mothers, restrain time and the youth
that was blossoming in her child?
“I’ll have to think it over, Alice. I’ll tell you in the morning.”
 And Alice went to her studying, confident that, whatever her
mother decided, she would be just and allow only big reasons to
weigh with her.
Mrs. Grant thought it over and that night talked it over with her
husband.
“She’s absurdly young—only fifteen,” he objected.
“Yes, but absurdly natural, too, and strong in her desires. I fear, if I
refuse, it may only surround boys with a mysterious glamour for her,
and she might then be tempted to associate with them in spite of me,
and any secrecy or deceit just now is dangerous. And you know our
Alice is growing pretty.”
Mr. Grant regretted and bemoaned the loss of his little girl, but
agreed. “But who is this boy?” he demanded. “Do you know him?”
“No. But I’m going to know all her friends from now on.”
And next morning, when Alice, pink-cheeked and eager-eyed,
sought her mother’s decision, she welcomed the “Yes” with a little
squeal of delight.
“But I’ve been thinking, Alice,” her mother added, “that I’d like to
know the boys and girls you’re going with. Wouldn’t you like to ask
some of them over here some evening before the party?”
“Would I? Well, rather! Mother, you’re a dear.”
“And what about a dress. I suppose you’d like a new one?” Further
question was stifled by an enthusiastic hug.
So they talked of the party and the dress, and then it was not far to
“the boys” and Alice’s new feeling for them. And Mrs. Grant felt that
the sweet intimacy she was entering with this new daughter more
than compensated for the loss of the little girl, who had suddenly
become a young woman.
When Alice returned from the party her mother showed interest in
each detail that her daughter related. She remarked: “You must have
had loads of fun—what did you have to eat? What did you especially
like in the conduct of your classmates?” It is while such concrete
subjects are being discussed that much guidance can be given the
daughter in her formation of opinions as to what is proper or
improper conduct. A teacher who brings about such intimacy as this
incident illustrates has done much for both mother and daughter.
ILLUSTRATION 2 (HIGH SCHOOL)

Miss Canfield took hold of her work with genuine interest as

science teacher in the James Fisk High School. Her knowledge of girl
nature was sufficient to save her from many blunders. Mary Turner
was her problem. A giddy set was overturning nearly all of the
constructive work done for her by her teachers.
Miss Canfield decided to go over matters with Mrs. Turner, Mary’s
mother. In the conversation, Mrs. Turner saw where she must take a
hand in Mary’s affairs.
There was no doubt but what Cecily Overcoming
Gregg, a classmate, was having a bad Undesirable
influence on Mary. Mrs. Turner rocked Influences
fitfully between stitches and remembered how sweet and natural
Mary had been before she got so intimate with Cecily. But now she
was catching some of that young lady’s affected ways, and, Mrs.
Turner feared, some of her lack of modesty with boy companions.
Cecily was seventeen, and Mary, a year younger, respected her
opinions greatly, and gloated over her popularity with certain
overdressed and rather sporty youths who took her about to picture
shows and ice cream parlors. Cecily was slowly convincing Mary that
theirs was the type to admire.
And Mrs. Turner had unwittingly let Mary drift so far from her
influence of late, that she felt helpless. She dared say nothing openly
against Cecily. Mary would only flare up in defense and stand more
staunchly for her friend. If she laid down rules, Mary might secretly
break them, and if she tried to make subtle suggestions, the girl was
certain to pounce on her meaning and resent it.
Mary came home from school that day full of plans for her
birthday party.
“Cecily says I must get some new dance records for the victrola.
Ours are all passé. And I’m going to make little crepe paper favors, by
a cute pattern that Cecily knows. And she wants me to ask Cousin
Ralph. Do you think he’d think us too young for him, since he’s
finished college? I’m crazy to have him meet Cecily! He’ll be ‘dippy’
about her.”
 While Mary chattered, a thought lodged by Miss Canfield came to
Mrs. Turner. If she couldn’t influence her daughter herself, unaided,
she must reach her through others.
She answered: “Why, I think it would be lovely to ask him, and I’m
sure he’d like to come.”
And so Mary wrote a cordial invitation to Cousin Ralph and her
mother quietly added a postscript that night—a postscript that grew
into an epistle as she told her nephew, a clean-souled and manly
young fellow, of her problem about Mary.
“Can you help me?” she wrote. “A word from you would weigh
much with her. You’re her ideal of young manhood. Let her see that
you are not fascinated by Cecily; she believes her irresistible. Say no
more than you can judge by seeing her at the party, though. That will
be enough.”
His answer to Mary, his “sweet little cousin,” was frank and warm.
His answer to Mrs. Turner was earnest and sympathetic. He would
try.
The great evening came, and with it a gay and brightly dressed
bevy of Mary’s friends. Some were rollicking; some were bashful; but
Mrs. Turner fancied she saw the Cecily stamp on all of them. On all
except Evelyn Lewis, a simple, attractive girl with fine manners. If
Mary would only prefer her to Cecily!
Cousin Ralph arrived late and created a sensation, for he was tall
and good-looking and possessed of polish and charm. He led all the
fun after that and Mrs. Turner saw Mary’s eyes sparkling with pride
in him.
At a late hour the guests took their leave. But Ralph, lingering after
the others had left, talked over the party with Mary and her mother,
for the former was too excited to want the evening to end.
“How did you like the girls?” Mary inquired, eagerly. And just then
Mrs. Turner found an excuse to leave the room.
“Very much, little cousin. They’re a jolly lot of youngsters. And I’m
quite struck with one of them.”
“Oh, I knew you would be. Cecily, of course!”
“Cecily! O, no!” His emphasis was expressive.
“Not Cecily?” Mary was bewildered.
 “That would-be chorus girl with come-hither eyes?” he demanded,
and then, seeing her stricken face, added hurriedly, “But maybe she’s
a special friend of yours.”
“Oh, no,—that is,—not so very. But she’s awfully popular.”
“With only one kind of boys, then, and that’s not the sort I’d like to
see you running round with, cousin mine. The girl that took my eye
was—her name was—Evelyn. She’s a peach. Ask me over some time
again when she’s here, will you?”
Mary nodded a little uncertainly, and then promised.
“Mother,” she said, wonderingly, as Mrs. Turner entered the room,
“Ralph likes Evelyn. And she certainly did look pretty tonight. I’m—
crazy about her myself!”
And as Mrs. Turner squeezed her nephew’s hand, she felt
somehow that a new name was about to be substituted for “Cecily” in
Mary’s vocabulary.
Miss Canfield listened attentively to the mother’s report of the
party and of Mary’s drift into better companionship and naturally
lent aid to the scheme in a dozen little ways—assignments of team
work, comments to Mary on certain lovely qualities in Evelyn and
her type of girl, recommendation of books and magazine articles, etc.
Mother and teacher accomplished an important piece of work by
this campaign in which they substituted, in the unformed mind of a
school girl, a correct model of young womanhood in place of a
degraded type.
4. Falling in Love with the Teacher
When pupils fall in love with their teachers, the problem is not
nearly so serious as the same event would be out of school, for the
reason that every normal tradition of school relations is against such
a state of affairs. The teacher stands, as is said so often, in loco
parentis; and if teachers are fit to bear this relation to their pupils,
they can, and will, easily handle any tendencies toward too intimate
relations with their pupils. The treatment for a pupil who develops
too ardent an admiration for a teacher is based upon the process of
de-personalizing the relations between them; for almost always it
will be found that when pupils have fallen in love with their teachers,
it is because, purposely or unconsciously, the relations have been too
personal.
 There are two typical cases—that of young girls who fall in love
with an attractive young man teacher, whom usually they hope to
captivate and marry; and that of boys, relatively less mature, who
rarely reach the ridiculousness of such plans, but shower such
attentions as they may upon the object of their affections, and go to
any length to please her. Most young women teachers have the tact
and good sense to manage such cases wisely, keeping the boys within
the bounds of a normal and fairly platonic regard, and often using
their power to bring about the development of a fine idealism and
many manly virtues in their admirers. But the vain young woman
who likes this kind of popularity is not unknown in schools; she is a
nuisance, doing more harm by her vanity than a dozen sensible
colleagues can undo through every means known to good pedagogy.
The teacher is to blame, as a rule, when either of these conditions
develops. Being older and more experienced, he has the upper hand
and can cure the malady, if he will, especially as he has every sane
tradition on his side. The elimination of the dangerous personal
attitude, of opportunities for the expression of regard, of the
personal appeal, and of subtle suggestions of a sentimental nature,
are all in the power of the teacher. It is just a question of whether he
cares to exercise his will and his ingenuity in the interest of a healthy
relation, or whether he chooses rather to have his vanity flattered by
attentions and popularity.

CASE 156 (HIGH SCHOOL)

Annabel Kingsley was an English teacher Appeals to Vanity

in a small, prosperous town. She was a tiny,
sharp-faced girl of about twenty-five, keenly intelligent, clever and
selfseeking. She dressed well; she sought social opportunities; she
made the most of her friends. Before she had been teaching a month
she had won the devoted admiration of all the boys and most of the
girls in her classes and by Thanksgiving the other women teachers
would hardly speak to her, regarding her with that silent scorn which
intelligent women have for their sisters who will not play fair. The
superintendent was divided between amusement and contempt.
 Miss Sperry, the mathematics teacher, went to Miss Bulwer, who
had had the Latin and German for years, and had a talk with her.
“My boys and girls come day after day with their algebra only half
learned,” she complained. “They say they don’t have time for it, and
they are losing all their interest, too. But they write great long
compositions for Miss Kingsley that must take hours to do, and now
she talks of getting up a play to be given at Christmas. She seems to
have captured them completely. How does she do it?”
“When you’ve seen as much of teachers as I have you’ll know,”
Miss Bulwer replied, grimly. “I haven’t heard her talk to them, but I
can tell you just how she goes about it. She makes every one of them
think he’s the budding genius of the century. She has Verne Gibbs
reading Ibsen and planning to write a tragedy. I’ll be bound! She has
persuaded Morris Talbot that he can write short stories. Warren
Hughes thinks he’s very remarkable because she told him he could
appreciate Francis Thompson. Maybe he can, but he can also
appreciate Cicero when he’s given half a chance. Every one of those
youngsters thinks that at last he has found a teacher who really sees
what is in him, the great promise to which the rest of us are blind.
Then he proceeds to fall in love with Miss Kingsley to show her that
her interest is not lost. She appeals to the adolescent vanity that they
all have so much of, and she’s making them so insufferably self-
conscious and sentimental and onesided that you and I can’t do
anything with them.”
Miss Sperry watched Miss Kingsley. She saw that the boys who
could use their father’s automobiles vied with each other for the
honor of taking her home on Friday nights—she lived in a
neighboring town; that they hung over her desk before and after
sessions, engaged in interminable discussions of the value of poetry
or the madness of Hamlet. On her birthday her desk was banked
with roses; Miss Sperry wondered how they found out when her
birthday came. Miss Kingsley’s work went very well, but she robbed
every other teacher of the time and energy that fairly belonged to the
other subjects taught. The result was that the poor work caused by
her selfish policy showed in the classes of other teachers. In her own
there was a constant and lively interest, fanned continuously by the
numberless “conferences” with which she kept her hold on her
students. The school was badly demoralized by Christmas, and yet
the real cause of all the trouble appeared to be the one brilliantly
successful teacher on the force.

CONSTRUCTIVE TREATMENT

The principal of a school should see to it that each teacher and

each subject has a fair share of the attention of the students. In this
case, the principal should say to Miss Kingsley, “I notice that a
number of our boys are falling behind with their mathematics, and
Miss Bulwer tells me that Howard Grimes failed in Latin last month
—something never heard of before. I have been looking for the cause,
and I find that most of those who are failing are spending more time
on their English than is fair. You are stimulating them by a personal
appeal to put time on English which really belongs to other studies.
So I am asking you to discontinue your private conferences for the
present; and, moreover, it is not dignified for you to accept
attentions from the boys as though they were your own age; it will
lead to criticism which will hurt your work and your influence.”
Private talks to the boys and girls about their work, following this
restriction of the English teacher’s demands, may help to bring
results. The other teachers should be encouraged to make their work
as appealing as possible, and to show a personal interest in the
bringing up of grades in the neglected studies. Most important of all,
wholesome social conditions may be stimulated by a series of parties
among the high school students, in which normal relations amongst
themselves are encouraged. Such regulations for study as are needed
to keep the boys from too much contact with Miss Kingsley are to be
adopted, without making their object obvious to the pupils.

COMMENTS

The amative impulses of youth are not vicious, but need direction
and control. Self-control, above all else, is to be taught, and the
teaching must often be reinforced by wise, friendly restraint. Frank
friendships are to be encouraged; sickly, silly sentimentality laughed
out of court. If a teacher, instead of standing ready to give this help
and guidance when it is needed, encourages a sentimental devotion,
as Miss Kingsley did, the most fundamental safeguard of youth is
sacrificed—the ideal of controlled emotion, of a conscious saving of a
sacred experience for the future. A large range of interests, a healthy
balance of activities, and a wholesome unconsciousness of self, tend
to keep young people simple and child-like in their emotional lives.
Above all, no teacher has any business to give the impression that he
alone appreciates youth and its promise, or to make his relations
with impressionable boys and girls unduly personal.

ILLUSTRATION (HIGH SCHOOL)

Clarence Miller was an exceedingly “A Wet Blanket”

handsome young teacher in a small village for Infatuation
high school. In his second year of service, Carolyn Brush, daughter of
the great man of the town, decided that she would not return to the
fashionable boarding school which she had been attending, but
would go to the village school and subjugate Clarence Miller, whom
she met during the Christmas vacation. She was very pretty and very
clever, and her stay in a girl’s boarding school had not made her less
romantic than other girls are.
The lessons were easy for her, and during the first few days she
recited brilliantly, hoping to win special attention from the young
principal. He accepted her most studied efforts with the same
pleasant courtesy he gave to all, and then Carolyn tried another plan.
She failed to recite altogether, looking at Mr. Miller with a pitiful,
hurt look whenever he called upon her, and shaking her pretty head
sadly. The village boys and girls, somewhat awed at best by Carolyn’s
pretty clothes and polished manners, and keenly conscious of
everything she did, observed all this with much interest. Carolyn
became more and more enamored of Mr. Miller the more she saw of
him.
One morning she stepped to the desk when there were no other
pupils near. “Mr. Miller,” she said, “I wonder if I may speak to you—
alone—some time? Tonight, after school, perhaps? Just for a
moment. I am in such trouble.”
 “Of course you may, Miss Carolyn,” said Mr. Miller, heartily. “I’ll
be glad to help you if I can.”
But Carolyn was not at school that afternoon. She called up the
school by telephone at five after four, however, said that her mother
had required her help that afternoon, and added that they all wanted
Mr. Miller to come up for supper. “And I hope you will, for I do feel
that you can help me. We can talk after supper.”
“Sorry, but I have some work that is going to take my whole
evening, Miss Carolyn. You can tell me about that matter at recess
tomorrow. Please thank your mother for the invitation, and tell her
how sorry I am I can’t come.”
At recess the next morning, Carolyn said, when she was sure no
prying boy lingered near:
“Oh, Mr. Miller, I have been so worried lately I just couldn’t study.
I have a dear friend at school, whom I’ve trusted and loved for two
years more than anyone else. And now I find that she has deceived
me, and it almost breaks my heart. It seems as if everything has just
stopped, you know; life isn’t the same. What can one do? If one can’t
trust one’s friends, what is there one can count upon?” She looked up
at him with tears in her eyes, the lovely picture of disillusioned youth
in its most appealing form. “I just had to talk to some one about it,
and you’re the only person here who is—you know—like myself—who
would understand.”
Mr. Miller neither fell into this fair trap nor shied at it. He said,
“Now, I’ll tell you just what I would do if I were you. You talk to your
father. He knows all about people, and he’ll give you more good
advice in a minute than I could in a year. If it were I, and a girl had
treated me like that, I’d find a better chum and let her go, and not
weep over it either. Just stop worrying about her. You can’t afford to
lose out on your lessons for a snip of a girl who doesn’t know a good
friend when she has one. Oh—you’ll excuse me, won’t you? I
promised the boys to show them a new curve, and here they are for
me.” And the cautious, sensible principal vanished out-of-doors.
Carolyn, being really infatuated, made one more attempt. “I know
you don’t like me,” she told the principal one day. “But why is it?
What have I done, that you should hate me so? I have tried to get my
lessons, and tried to be good in school; but you seem to hate the very
sight of me.”
“Now, that’s all nonsense,” Mr. Miller averred. “I like you just as
well as anyone else in the room, and, so far as I know and intend, I
treat you just as I do the others.”
To be treated just as the others were treated, was exactly what
Carolyn did not want. She suddenly discovered that the principal was
not handsome, and that she did not care for him. She told her father
that the school was so much poorer than Grey Gables that she
wanted to go back there, and at the Easter vacation she left the high
school. So Carolyn came and went, and not one of the other pupils
knew of the little comedy of sentiment and sense that had taken
place there that winter.
The quickly-veering emotion of youth is easily stimulated or
inhibited by suggestion. Mr. Miller saw through the schemes of his
pupil, and, instead of falling in with them, as he might have done had
he wanted excitement or adulation or romantic adventure, he cut
them off in a friendly, but matter-of-fact way that nipped expectation
in the bud. A flirtation with his pretty pupil might have been a great
deal of fun, but it would have marred his influence with the people of
the village and with his pupils; and he was wise enough to deny
himself that fun for the sake of his professional duty. He might have
stimulated an adventure in half a dozen ways; he steadily declined
even to suggest the thought of such a thing until Carolyn was cured
of her fancy. Without humiliating her in any way, before the other
students, he kept his relations with her impersonal and free of
romantic elements, and so gradually overcame her infatuation by
giving it nothing to feed upon.
 DIVISION X

Who breaks his faith no faith is held with him.

—Cervantes

Always act in such a way as to secure the love of your neighbor.

—Cato
 AN ILLUSTRATIVE CONTRAST BETWEEN
FAILURE AND SUCCESS

Mr. Bradley was principal for two years of the Newcastle school.
He revealed his characteristics as a teacher so fully that we find in
him an example of the type not to be recommended and yet one that
is very instructive for students of school discipline.
In stature he was slightly below medium height. He came from
rural ancestry and was fairly well equipped as to physique. He had
black hair and eyes, somewhat mobile features and a wandering
gaze. His movements could hardly be called quick, but they were
prompt and without distinct mannerisms.
He had a most gracious manner when meeting people on the street
or in their homes. He spoke kindly to everyone and had the
reputation among the townspeople of being a royal, good fellow.
Even his pupils could not deny that he treated them very courteously
and jovially outside of school hours.
Despite all this he used essentially the method of the hen-pecking
incompetent when handling disciplinary matters in school. The
moment he entered the school precincts he was a different man. His
countenance then betrayed the sternness of the schoolmaster who
dwelt within and apart from the polite gentleman he seemed to be
when outside the school-room. His eyebrows gathered and his
muscles reverberated with the sense of authority that flooded his
whole nature.
His eye was on the lookout for misdemeanors and if a pupil made a
misstep in the realm where Mr. Bradley thought he had jurisdiction,
that harsh, strident voice, with but the slightest trace of fellow-
feeling, spoke the word of correction or announced an impending
penalty.
In the school-room it was his delight to slip up behind an offender
and pluck him by the ear as a reminder of duty. Being the only
instructor who indulged in this practice it soon came to be one of the
most odious signals of his presence in the room. When absorbed in
his subject he made instruction interesting; his pupils could not fail
to learn if they did not venture to vary the program by misconduct.
However, their recollection of his general attitude toward them, the
ease with which they could upset his plans by introducing a few
school pranks, the certainty that he would lose his temper on slight
provocation, always hung as a barrage screen between them and
undivided concentration on the subject-matter of their lessons.
Mr. Bradley made it a practice to watch for accumulating offenses.
He felt incompetent to handle minor evils, but attempted to squelch
a wayward pupil by reciting a list of grievances and applying
penalties for the same. He had a good memory for facts of this sort.
He could shake his finger in the face of a boy or girl and say, “Didn’t
you pull Esther’s hair yesterday ... trip up Jimmie on the way to class
in geometry and purposely spill the crayons when you were at the
board? Now, I have had enough of this. I want to know what you are
going to do about it.”
This gentleman could not catch the drift of things. Early in his first
year Mr. Bradley’s attention rested upon Ted. Ted was a short,
heavy-set chap of some fourteen years, incapable of any
revolutionary propensities, but able to interest himself with a variety
of aggravating tricks. His pranks were individually almost too small
to command severe penalties, but they were too annoying to escape
the principal’s eye.
Unfortunately, Mr. Bradley hit upon the lash as a cure for Ted.
Selecting a more pronounced misdemeanor as an opportunity for
settling accounts with the troublesome pupil, he gave him a sound
whipping.
There was some ground for the general protest that arose from the
high school. Ted was a favorite with every one. The crude principal
had struck one but he had wounded all. His untactfulness had made
him abhorrent to all, even to those who had not hitherto drawn upon
themselves his specific disapproval and useless punishments. Mr.
Bradley, perhaps, never knew that he had undermined his own
usefulness as much by this treatment of a school favorite as by any
single deed that transpired during his whole stay in Newcastle.
He had his own method of handling the problem of whispering. He
made it a rule that every pupil in high school must answer at roll call
at the end of the day on the matter of whispering. If a pupil had
whispered he must answer “Present,” and specify the number of
times during the day he had whispered. If he had a clear record on