Endorectal Advancement Flaps for Perianal Fistulae in Crohn’s Disease: Careful Patient Selection Leads to Optimal Outcomes

Roper, Michelle T.; Trinidad, Stephen M; Ramamoorthy, Sonia; Parry, Lisa; Lopez, Nicole; Khaitov, Sergey; Steinhagen, Randolph; Eisenstein, Samuel

doi:10.1007/s11605-019-04205-0

Cited by 11 publications

(9 citation statements)

References 22 publications

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“…One of the largest and most contemporary series includes a highly selected cohort of 39 CD patients undergoing 41 AFs with initial healing achieved in 80% after a median of 27 months. This study emphasized the importance of preoperative immunotherapy (used in 73% of their study cohort) and assurance of no active CD elsewhere in the small bowel or colon prior to surgery [10]. In another study of 36 AFs performed for [5].…”

Section: Discussionmentioning

confidence: 90%

“…A few small, single-armed retrospective series of AF in CD have been published [4,10,15,16]. One of the largest and most contemporary series includes a highly selected cohort of 39 CD patients undergoing 41 AFs with initial healing achieved in 80% after a median of 27 months.…”

Section: Discussionmentioning

confidence: 99%

“…Historically, success rates for management of complex anal fistula with sphincter preservation in patients without CD have been highest with AF [5][6][7]. However, data on AF in CD is limited to small series with healing rates of 59-80% [8][9][10]. Since it was first reported in 2007 by Rojanasakul [11], LIFT has emerged as a sphincter-preserving approach for transsphincteric fistulas.…”

Section: Introductionmentioning

confidence: 99%

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Long-term healing after complex anal fistula repair in patients with Crohn’s disease

et al. 2020

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Background Complex anal fistula in Crohn's disease (CD) poses a challenging problem. We sought to evaluate long-term surgical healing of complex anal fistula in CD through the two robust repair options-ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF). Methods A single-center retrospective study was conducted evaluating long-term healing rates in patients with CD with complex anal fistula undergoing LIFT or AF in 2008-2018. Fistula healing was defined as closure of external wounds, cessation of drainage and absence of pain. Short-term and long-term healing rates were compared. Cox proportional hazards model was performed to identify independent predictors of fistula healing. ResultsThe study cohort included 60 CD patients undergoing LIFT (n = 38) or AF (n = 22). The AF group included 8 dermal flaps. Patients having LIFT were younger (35 years vs 43 years; p = 0.007), more likely to have a seton at the time of repair (92% vs 68%; p = 0.03) and less likely to have had prior repair attempts (34% vs 68%; p = 0.02). Short-term fistula healing occurred in 65% (n = 39) of the overall study cohort. However, at final follow-up, median 36 months (range 6-192 months), only 46% (n = 28) of repaired fistulas were healed. Considering the overall status of the cohort's perianal health at final followup, including both repaired, secondary or novel anal fistulas, only 50% (n = 30) of all patients in the cohort had all fistula sites healed and maintained bowel continuity at final follow-up. On Cox proportional hazards analysis, LIFT independently predicted long-term fistula healing (hazard ratio 2.3; 95% confidence interval 1.1-4.9; p = 0.03). Only a small number of patients (n = 5; 8%) required fecal diversion (n = 3) and/or proctectomy (n = 2). Conclusions Repair of complex anal fistula in CD results in modest healing rates. LIFT independently predicts long-term healing. However, these results must be taken in context, considering differences in patient and fistula characteristics between groups. These results ought to be kept in mind when counseling CD patients with complex anal fistula.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Long-term healing after complex anal fistula repair in patients with Crohn’s disease

et al. 2020

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“…46 Interestingly, in a multicenter retrospective review, patients undergoing an endorectal advancement flap procedure with some use of postoperative immunotherapy had a 92% success rate from their endorectal advancement flap. 47 Despite low incontinence rates and higher success rates of this procedure, careful patient selection must be taken into consideration. 47…”

Section: Endorectal Advancement Flapmentioning

confidence: 99%

“…47 Despite low incontinence rates and higher success rates of this procedure, careful patient selection must be taken into consideration. 47…”

Section: Endorectal Advancement Flapmentioning

confidence: 99%

Managing Complex Perianal Fistulizing Disease

Pedersen

Lightner

2021

Journal of Laparoendoscopic & Advanced Surgical Techniques

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Perianal disease is a particularly morbid phenotype of Crohn's disease, affecting up to one third of patients, with a significantly diminished quality of life. Conventional medical therapy and surgical interventions have limited efficacy. Medical treatment options achieve long-term durable remission in only a third of patients. Therefore, most patients undergo an operation, leaving them with a chronic seton or at risk of incontinence with multiple interventions. Mesenchymal stem cell therapy is an emerging therapy without risk of incontinence and improved efficacy as compared with conventional therapy. Laser therapy is another new intervention. Unfortunately, up to 40% of patients still require a stoma related to perianal fistulizing disease.

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Managing complex perianal disease after anti-TNF failure: Where to go next?

Yzet

Brazier

Sabbagh

et al. 2022

Current Research in Pharmacology and Drug Discovery

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Crohn's disease is a chronic inflammatory bowel disease that affects various intestinal segments and can involve the perianal region. Although anti-tumor necrosis factor (TNF) agents have revolutionized the management of Crohn's disease and improved the prognosis for patients with perianal Crohn's disease (pCD), their long-term effectiveness is limited: over 60% of patients relapse after one year of maintenance therapy. In recent years, significant advances have been made in the treatment of complex perianal fistulas after anti-TNF failure. Concomitant treatment with antibiotics and immunosuppressants improves the effectiveness of anti-TNF agents. Therapeutic drug monitoring and dose adjustment of anti-TNF therapy (targeting a higher trough level) might also improve treatment response. Novel therapeutic strategies might provide new opportunities for pCD management; for example, ustekinumab might be effective after anti-TNF treatment failure, although more studies are needed. As suggested in recent international guidelines, mesenchymal stem cell injection might be an effective, safe treatment for complex pCD.

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Endorectal Advancement Flaps for Perianal Fistulae in Crohn’s Disease: Careful Patient Selection Leads to Optimal Outcomes

Cited by 11 publications

References 22 publications

Long-term healing after complex anal fistula repair in patients with Crohn’s disease

Long-term healing after complex anal fistula repair in patients with Crohn’s disease

Managing Complex Perianal Fistulizing Disease

Managing complex perianal disease after anti-TNF failure: Where to go next?

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