Guidelines for the Multidisciplinary Management of Crohnʼs Perianal Fistulas

Schwartz, David A.; Ghazi, Leyla; Regueiro, Miguel; Fichera, Alessandro; Zoccali, Marco; Ong, Eugene M. W.; Mortelé, Koenraad J.

doi:10.1097/mib.0000000000000315

Cited by 71 publications

(43 citation statements)

References 32 publications

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“…PFCD can be present in up to 43% of CD cases and in some cases (~5%) it can be the patient’s only manifestation of CD 4. In approximately 10% of patients, the presence of perianal fistulas can be the initial manifestation of CD 5.…”

Section: Introductionmentioning

confidence: 99%

“…With the knowledge that active rectal inflammation is an important driver of the pathogenesis, and persistence of inflammation a barrier to fistula healing, there remains a need to optimise medical therapy to achieve mucosal healing in order to maximise the chance for successful outcomes 4. In addition, surgery is often needed to correct mechanical abnormalities in the perineum, mostly secondary to chronic inflammatory disease, and several surgical options have been studied and described 8.…”

Section: Introductionmentioning

confidence: 99%

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Modern management of perianal fistulas in Crohn’s disease: future directions

Kotze

Shen

Lightner

et al. 2018

Gut

141

104

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Perianal fistulae in patients with Crohn's disease (CD) can be associated with significant morbidity resulting in negative impact on quality of life. The last two decades have seen significant advancements in the management of perianal fistulas in CD, which has evolved into a multidisciplinary approach that includes gastroenterologists, colorectal surgeons, endoscopists and radiologists. Despite the introduction of new medical therapies such as antitumour necrosis factor and novel models of care delivery, the best fistula healing rates reported with combined medical and surgical approaches are approximately 50%. More recently, newer biologics, cell-based therapies as well as novel endoscopic and surgical techniques have been introduced raising new hopes that outcomes can be improved upon. In this review, we describe the modern management and the most recent advances in the management of complex perianal fistulising CD, which will likely impact clinical practice. We will explore optimal use of both older and newer biological agents, as well as new data on cell-based therapies. In addition, new techniques in endoscopic and surgical approaches will be discussed.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Modern management of perianal fistulas in Crohn’s disease: future directions

Kotze

Shen

Lightner

et al. 2018

Gut

141

104

View full text Add to dashboard Cite

show abstract

“…Perianal fistulae are observed in 10–26% of patients with Crohn's disease (CD), and generally denote a more destructive phenotype, with higher rates of corticosteroid dependence, surgery and hospitalisations . Management of perianal CD requires a multidisciplinary approach with a combination of immunosuppressive therapy, antibiotics and surgery for adequate control of sepsis and sometimes surgical resection . In the pre‐biological era, over two‐thirds of patients with perianal CD required surgical intervention, with nearly one‐third of patients requiring major abdominal surgery …”

Section: Introductionmentioning

confidence: 99%

Systematic review with meta‐analysis: faecal diversion for management of perianal Crohn's disease

Singh

Ding

Mathis

et al. 2015

Aliment Pharmacol Ther

157

118

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Summary Background Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success. Aims To perform a systematic review with meta‐analysis to evaluate the effectiveness, long‐term outcomes and factors associated with success of temporary faecal diversion for perianal CD. Methods Through a systematic literature review through 15 July 2015, we identified 16 cohort studies (556 patients) reporting outcomes after temporary faecal diversion. We estimated pooled rates [with 95% confidence interval (CI)] of early clinical response, attempted and successful restoration of bowel continuity after temporary faecal diversion (without symptomatic relapse), and rates of re‐diversion (in patients with attempted restoration) and proctectomy (with or without colectomy and end‐ileostomy). We identified factors associated with successful restoration of bowel continuity. Results On meta‐analysis, 63.8% (95% CI: 54.1–72.5) of patients had early clinical response after faecal diversion for refractory perianal CD. Restoration of bowel continuity was attempted in 34.5% (95% CI: 27.0–42.8) of patients, and was successful in only 16.6% (95% CI: 11.8–22.9). Of those in whom restoration was attempted, 26.5% (95% CI: 14.1–44.2) required re‐diversion because of severe relapse. Overall, 41.6% (95% CI: 32.6–51.2) of patients required proctectomy after failure of temporary faecal diversion. There was no difference in the successful restoration of bowel continuity after temporary faecal diversion in the pre‐biological or biological era (13.7% vs. 17.6%, P = 0.60), in part due to selection bias. Absence of rectal involvement was the most consistent factor associated with restoration of bowel continuity. Conclusions Temporary faecal diversion may improve symptoms in approximately two‐thirds of patients with refractory perianal Crohn's disease, but bowel restoration is successful in only 17% of patients.

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“…A PDAI score >4 suggests active fistula drainage or local inflammation, with an accuracy of 87% [20]. This score has been validated in several clinical trials [21]. A simple way to evaluate fistula activity is the so-called “fistula drainage assessment” based on the examiner’s perception.…”

Section: Classification and Diagnosis Of Cpcdmentioning

confidence: 99%

Management of complex perianal Crohn’s disease

Aguilera

Ferre‐Aracil

Paredes

et al. 2016

aog

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Patients with Crohn’s disease often develop perianal disease, successfully managed in most cases. However, its most aggressive form, complex perianal disease, is associated with high morbidity and a significant impairment in patients’ quality of life. The aim of this review is to provide an updated approach to this condition, reviewing aspects of its epidemiology, diagnosis and therapeutic alternatives. Emerging treatment options are also discussed. A multidisciplinary assessment of these patients with a coordinated medical and surgical approach is crucial.

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Guidelines for the Multidisciplinary Management of Crohnʼs Perianal Fistulas

Cited by 71 publications

References 32 publications

Modern management of perianal fistulas in Crohn’s disease: future directions

Modern management of perianal fistulas in Crohn’s disease: future directions

Systematic review with meta‐analysis: faecal diversion for management of perianal Crohn's disease

Management of complex perianal Crohn’s disease

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