scholarly journals Minor Sphincter Sparing Surgery for Successful Closure of Perianal Fistulas in Patients with Crohn’s Disease

2021 ◽  
Vol 10 (20) ◽  
pp. 4721
Author(s):  
Jennifer Merten ◽  
Ann-Kathrin Eichelmann ◽  
Rudolf Mennigen ◽  
Isabelle Flammang ◽  
Andreas Pascher ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Surgical Procedures ◽  
Surgical Techniques ◽  
Advancement Flap ◽  
University Hospital ◽  
High Rate ◽  
Surgical Interventions ◽  
Perianal Fistulas ◽  
Fistula Plug

The purpose of this study is to demonstrate that repetitive minor surgical procedures allow for a high rate of permanent closure of perianal fistulas in patients with Crohn’s disease (CD). Patients with perianal fistulizing CD (PFCD) who underwent perianal surgery at the University Hospital of Muenster between 2003 and 2018 were assessed for fistula characteristics and surgical procedures. We included 45 patients (m:f = 28:17) with a mean age of 27 years at first fistula appearance. Of these, 49% suffered from a complex fistula. An average of 4.2 (1–14) procedures were performed, abscess incisions and fistula-seton-drainages included. Draining setons were left in place for 5 (1–54) months, until fistula closure. Final surgical techniques were fistulotomy (31.1%), seton removal with sustained biological therapy (26.7%), Anal Fistula Plug (AFP) (17.8%), Over-The Scope-Clip proctology (OTSC) (11.1%), and mucosa advancement flap (4.4%). In 8.9% of cases, the seton was kept as permanent therapy. The time from first to last surgery was 18 (0–182) months and the median follow-up time after the last surgery was 90 (15–200) months. The recurrence rate was 15.5% after 45 (17–111) months. Recurrent fistulas healed after another 1.86 (1–2) surgical re-interventions. The final success rate was 80%. Despite biological treatment, PFCD management remains challenging. However, by repeating minor surgical interventions over a prolonged period of time, high permanent healing rates can be achieved.

scholarly journals Ligation of the Intersphincteric Fistula Tract and Endorectal Advancement Flap for High Perianal Fistulas in Crohn’s Disease: A Retrospective Cohort Study

2019 ◽  
Vol 14 (6) ◽  
pp. 757-763 ◽  
Author(s):  
Elise M van Praag ◽  
Merel E Stellingwerf ◽  
Jarmila D W van der Bilt ◽  
Wilhelmus A Bemelman ◽  
Krisztina B Gecse ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Advancement Flap ◽  
Fistula Tract ◽  
Recurrence Rates ◽  
Perianal Fistulas ◽  
Radiological Healing ◽  
Intersphincteric Fistula ◽  
Clinical Healing ◽  
Postoperative Incontinence

Abstract Background and Aims Ligation of the intersphincteric fistula tract [LIFT] and advancement flap [AF] procedures are well-established, sphincter-preserving procedures for closure of high perianal fistulas. As surgical fistula closure is not commonly offered in Crohn’s disease patients, long-term data are limited. This study aims to evaluate outcomes after LIFT and AF in Crohn’s high perianal fistulas. Methods All consecutive Crohn’s disease patients ≥18 years old treated with LIFT or AF between January 2007 and February 2018 were included. The primary outcome was clinical healing and secondary outcomes included radiological healing, recurrence, postoperative incontinence and Vaizey Incontinence Score. Results Forty procedures in 37 patients [LIFT: 19, AF: 21, 35.1% male] were included. A non-significant trend was seen towards higher clinical healing percentages after LIFT compared to AF [89.5% vs 60.0%; p = 0.065]. Overall radiological healing rates were lower for both approaches [LIFT 52.6% and AF 47.6%]. Recurrence rates were comparable: 21.1% and 19.0%, respectively. In AF a trend was seen towards higher clinical healing percentages when treated with anti-tumour necrosis factor/immunomodulators [75.0% vs 37.5%; p = 0.104]. Newly developed postoperative incontinence occurred in 15.8% after LIFT and 21.4% after AF. Interestingly, 47.4% of patients had a postoperatively improved Vaizey Score [LIFT: 52.9% and AF: 42.9%]. The mean Vaizey Score decreased from 6.8 [SD 4.8] preoperatively to 5.3 [SD 5.0] postoperatively [p = 0.067]. Conclusions Both LIFT and AF resulted in satisfactory closure rates in Crohn’s high perianal fistulas. However, a discrepancy between clinical and radiological healing rates was found. Furthermore, almost half of the patients benefitted from surgical intervention with respect to continence.

scholarly journals A253 ADMINISTRATIVE DATA CAN ACCURATELY IDENTIFY PATIENTS WITH PERIANAL CROHN’S DISEASE

2020 ◽  
Vol 3 (Supplement_1) ◽  
pp. 130-131
Author(s):  
J Fairclough ◽  
T Tang ◽  
M Fung ◽  
S Golden ◽  
A Kukaswadia ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Surgical Procedures ◽  
Gold Standard ◽  
Population Based ◽  
Case Definition ◽  
Similar Proportion ◽  
Case Definitions ◽  
Perianal Fistulas ◽  
Youden’S Index

Abstract Background Perianal fistulas (PAF) are a frequent complication of Crohn’s disease (CD) associated with substantial morbidity. Population-based studies with CD are lacking, in part due to the difficulty in identifying these patients from health administrative databases. Aims To determine if administrative claims and diagnostic codes can reliably identify patients with perianal fistulas in a cohort of patients with CD. Methods A retrospective cohort study was performed using data from The Ottawa Hospital (TOH), which was linked to The Institute for Clinical Evaluative Sciences (ICES) Ontario Crohn’s and Colitis Cohort (OCCC) data using Ontario Health Insurance Plan (OHIP) numbers. Patients admitted with CD from 1 Jan 2009 to 31 Dec 2016 were identified from TOH data warehouse using the ICD-10 code K50.x. Confirmation of CD diagnosis and determination of the presence or absence of PAF was achieved by a longitudinal, manual chart review. Patients with and without PAF were abstracted in a 1:2 ratio to serve as a reference gold standard for PAF status. ICES captures all publicly reimbursed diagnostic tests, interventional procedures and physician billing codes, including MRI pelvis utilization and surgical procedures associated with perianal fistulas in Ontario. Sixteen case definitions for PAF in ICES were specified a priori. Two by two contingency tables were constructed to assess the sensitivity, specificity, positive predictive value (PPV) and negative predicative value (NPV) of each case definition against the gold standard PAF status as determined by TOH data. Youden’s index and Kappa were used to select a case definition that best identified TOH PAF patients. Results: A total of 136 patients with active PAF and 351 without PAF were included in the linked analysis. There were a similar proportion of male patients with and without PAF (49% vs. 43%). Patients with PAF were slightly younger; 69% were aged 18–44 compared to 58% of patients without PAF. Sensitivity of the case definitions ranged from 0.44 to 0.98, and specificity from 0.45 to 1.00. A case definition that combined at least two of fistula diagnosis code, perianal surgical procedures associated with fistulas, and radiologic imaging codes of the pelvis, all within 2 years, had the best performance using Youden’s index and Kappa. It discriminated between patients with or without PAF with sensitivity of 0.80 and specificity of 0.92. Conclusions Using a cohort of CD patients from a single tertiary care center we derived a case definition that could accurately distinguish CD patients with and without PAF in a provincial health administrative database. Once validated this will allow for future population-based studies to assess trends in PAF. Funding Agencies Takeda Pharmaceuticals

scholarly journals Treatment of Crohn’s disease-related high perianal fistulas combining the mucosa advancement flap with platelet-rich plasma: a pilot study

2015 ◽  
Vol 19 (8) ◽  
pp. 455-459 ◽  
Author(s):  
K. W. A. Göttgens ◽  
R. R. Smeets ◽  
L. P. S. Stassen ◽  
G. L. Beets ◽  
M. Pierik ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Pilot Study ◽  
Crohn's Disease ◽  
Platelet Rich Plasma ◽  
Advancement Flap ◽  
Perianal Fistulas

Statement of the polish expert group on the current practice and prospects for the treatment of complex perianal fistulas in Crohn's disease. Update 2021

2021 ◽  
Vol 93 (4) ◽  
pp. 70-79
Author(s):  
Tomasz Banasiewicz ◽  
Piotr Eder ◽  
Grażyna Rydzewska ◽  
Jarosław Reguła ◽  
Agnieszka Dobrowolska ◽  
...  
Keyword(s):  
Stem Cells ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Neutralizing Antibodies ◽  
Complex Interventions ◽  
Pharmacological Therapy ◽  
Hematopoietic Stem ◽  
Pressure Therapy ◽  
Surgical Interventions ◽  
Perianal Fistulas

Perianal fistulas in Crohn’s disease (CD) are a major problem. In majority of patient, inflammation involves the rectum. Perianal fistulas in CD pose a diagnostic and therapeutic challenge due to severe symptoms and worse prognosis compared to cryptogenic fistulas. The accurate diagnosis is crucial for an effective treatment of CD-related perianal fistulas, and the following should be determined: anatomy of the fistula, possible strictures and inflammation of the alimentary tract, including the rectum and the anal canal. Treatment of fistulas might be challenging and requires cooperation between the colorectal surgeon and the gastroenterologist. The combination of surgical and pharmacological therapy is more effective than surgical or pharmacological therapy alone. In conservative treatment, aminosalicylates or steroids have little significance. In everyday practice, antibacterial chemotherapeutics, antibiotics and thiopurines are applied. The most effective are TNF-neutralizing antibodies, i.e. infliximab (IFX), adalimumab (ADA) and certolizumab (CER). Surgical management can be urgent including drainage. Elective procedures include dissection of the fistula (simple fistula) or more complex interventions such as mucosal flap or ligation of the intersphincteric portion of the fistula. Surgical interventions can be enhanced using the video-assisted anal fistula treatment (VAAFT) or negative-pressure therapy. In extreme cases, creation of a stoma may be necessary. Also, tissue glues or so-called plugs may be applied in managing perianal fistulas. The use of stem cells seems promising, i.e. application of multipotent non-hematopoietic stem cells around the fistula in order to induce immunomodulation and wound healing.

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

Gut ◽  
2018 ◽  
Vol 67 (6) ◽  
pp. 1181-1194 ◽  
Author(s):  
Paulo Gustavo Kotze ◽  
Bo Shen ◽  
Amy Lightner ◽  
Takayuki Yamamoto ◽  
Antonino Spinelli ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Negative Impact ◽  
Care Delivery ◽  
Surgical Techniques ◽  
Models Of Care ◽  
Surgical Approaches ◽  
Perianal Fistulas ◽  
Modern Management ◽  
Perianal Fistulae

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.

Cell-based Therapy for Perianal Fistulising Crohn’s Disease

2019 ◽  
Vol 25 (1) ◽  
pp. 41-46 ◽  
Author(s):  
Paulo Gustavo Kotze ◽  
Antonino Spinelli ◽  
Amy Lee Lightner
Keyword(s):  
Stem Cells ◽  
Mesenchymal Stem Cells ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Therapeutic Option ◽  
Surgical Techniques ◽  
Phase Iii ◽  
Perianal Fistulas ◽  
Cell Based Therapy ◽  
Future Challenges

Background: The management of complex perianal fistulas in Crohn’s disease (CD) represents a challenge for patients, gastroenterologists and colorectal surgeons. There are clear limitations with current medical and surgical options, and healing rates remain far from what is expected. A multidisciplinary approach with optimized medical therapy, usually anti-TNF agents, associated with setons and additional surgical techniques is currently the best strategy to aim fistula healing. Methods: A comprehensive review of the literature was conducted on the use of mesenchymal stem cells (MSCs). Results: The use of mesenchymal stem cells (MSCs) has recently emerged as a promising new therapeutic strategy for complex fistulas in CD patients. This review summarizes the evidence of the use of MSCs in complex CD fistulas, by exploring in detail the types of cells that can be used and their modes of delivery. Additionally, the results of the most recent phase III randomized trial with local MSCs injection are described, and future challenges of this therapeutic option are discussed. Conclusion: The use of MSCs represents hope for better outcomes in patients with CD-related perianal fistulas. More research in the field will help to position this specific therapy in treatment algorithms.

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