Treatment of fistulizing Crohn's disease Gary R. Lichtenstein  Gastroenterology  Volume 119, Issue 4, Pages 1132-1147 (October 2000) DOI: 10.1053/gast.2000.18165 Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 1 (A) Normal anatomy of anorectal region with relationship to pelvic musculature depicted schematically. (Reprinted with permission from Gordon PH. The anorectum: anatomic and physiologic consideration in health and disease. In: Anorectal disorders. Gastroenterol Clin North Am 1987;16:1–15.) (B) Classic location of several fistulas and their relationship to pelvic musculature depicted schematically. Anorecetal anatomy: PR, puborectalis (i.e., deep portion of external sphincter muscle [E.S.]); I.S., internal sphincter; D.L., dentate line; A.V., anal verge. (Reprinted with permission from Fazio VW. Complex anal fistulae. Gastroenterol Clin North Am 1987;16:93–114.) Gastroenterology 2000 119, 1132-1147DOI: (10.1053/gast.2000.18165) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 1 (A) Normal anatomy of anorectal region with relationship to pelvic musculature depicted schematically. (Reprinted with permission from Gordon PH. The anorectum: anatomic and physiologic consideration in health and disease. In: Anorectal disorders. Gastroenterol Clin North Am 1987;16:1–15.) (B) Classic location of several fistulas and their relationship to pelvic musculature depicted schematically. Anorecetal anatomy: PR, puborectalis (i.e., deep portion of external sphincter muscle [E.S.]); I.S., internal sphincter; D.L., dentate line; A.V., anal verge. (Reprinted with permission from Fazio VW. Complex anal fistulae. Gastroenterol Clin North Am 1987;16:93–114.) Gastroenterology 2000 119, 1132-1147DOI: (10.1053/gast.2000.18165) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 2 Depiction of rectal advancement flap procedure. This procedure requires a rhomboid-shaped incision of the mucosa of the rectum extending beyond the internal OS and dentate line. After elevation of the flap is performed, the fistula tract is excised or debrided and the internal muscular opening is sutured as illustrated. The distal portion of the flap containing the internal mucosal OS is excised; the remaining flap is drawn over the now-closed opening and secured in a tension-free manner. (Reprinted with permission from Fazio VW, Strong SA. The surgical management of Crohn's disease. In: Kirsner JB, Shorter RG, eds. Inflammatory bowel disease. 4th ed. Philadelphia: Lippincott, Williams & Wilkins, 1995:830–887.) Gastroenterology 2000 119, 1132-1147DOI: (10.1053/gast.2000.18165) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 3 (A) Algorithm for suggested management of patients with perianal Crohn's disease. Classification is based on patients' primary symptomatic lesion. (Adapted with permission from Steinhart AH, McLeod RS. Clinical review: medical and surgical management of perianal Crohn's disease. Inflamm Bowel Dis 1996;2:200–210.) (B) Algorithm for suggested medical management of patients with perianal Crohn's disease. Classification is based on patients' primary symptomatic lesion. Gastroenterology 2000 119, 1132-1147DOI: (10.1053/gast.2000.18165) Copyright © 2000 American Gastroenterological Association Terms and Conditions