M.L. Corman observed that, "More surgeons' reputations have been impugned because of problems with fistula operations than from any other operative procedure" . In general, anal fistulae present symp-tomatically (Fig. 6). In Crohn's disease, they have the reputation of being difficult to treat with a high rate of recurrence.
Patients are more concerned with postoperative incontinence, even if minor. Many authors advise the most cautious attitude in regards to surgical treatment [12, 18, 22, 47]. Many of these assertions are rooted in the surgical practices of the fifties and sixties and have been accepted without much challenge, particularly in the Anglo-Saxon literature. Anal disease should not be considered simply as a complication of intestinal Crohn's disease. It should be considered, in the same way as terminal ileal and colonic Crohn's disease, as a localisation of the disease to an anatomical site within the gastrointestinal tract. Taking this into account, diverse surgical treatment options can be proposed for the management of anal fistulae in Crohn's disease.
In the presence of active rectal Crohn's disease, proctitis may complicate the clinical situation and lower the rate of healing. On the other hand, patients with simple fistulae may experience higher rates of improvement and/or healing compared to a complex fistulising disease . Fistulae decrease the quality of life, increase the likelihood of total colectomy and frequently require surgery . Surgery may consist of:
2. Non-cutting setons: used in high fistulae involving a significant portion of the external anal sphincter (Fig. 7).
3. Endorectal advancement flap: as an alternative to fistulotomy in patients with low fistulae or an alternative to non-cutting setons in patients with high fistulae who do not have macroscopic evidence of rectal inflammation.
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