Perianal Crohn’s Fistula

Steering committee: South Yorkshire Surgical Research Group, Northwest Research Collabortaive, Lee, MJ, Heywood NA, Sagar PM, Brown SR, Fearnhead NS,

Contributors: Abbas A, Adegbola S, Alfa-Wali M, Ashken L, Barrow P, Brady RR, Couch D, Engledow A, Gammeri E, Gill M, Kadhum M, Kankam H, Kaptanis S, Labib P, Luck J, Majid K, Martin J, Moss A, Nicholson J, Iqbal MR, Singh B, Sengupta N, Sproson C, Stubbs B, Suker F, Tozer P, van Boxel G, Ventham N.

Background

Around one-third of patients with Crohn’s disease are affected by Crohn’s fistula-in-ano (pCD). It typically follows a chronic course and patients often undergo both long-term medical and surgical therapy. This treatment is not always universally consistent across the country.

Aims

This was a collaborative project run by both the South Yorkshire Surgical Research Group (SySURG) and the Northwest Research Collaborative (NWRC) which set out to describe the current surgical practice in the management of pCD in the UK.

Methods

A survey of surgical management of pCD was designed by an expert group of colorectal surgeons and gastroenterologists to assess acute, elective, multidisciplinary and definitive surgical management. After an initial pilot of the questionnaire at the Digestive Disease Federation 2015 meeting, the survey was refined and distributed nationally through the trainee collaborative networks.

Results

National rollout obtained responses from 133 surgeons of 179 approached (response rate 74.3%). At first operation, 32% surgeons would always consider drainage of sepsis and 31.1% would place a draining seton. At first elective operation, 66.6% would routinely insert of draining seton, and 84.4% would avoid cutting seton. The IBD multidisciplinary team was available to 87.6% respondents, although only 25.1% routinely discussed pCD patients. Anti-TNF-α therapy was routinely considered by 64.2%, although 44.2% left medical management to gastroenterology. Common definitive procedures were removal of seton only (70.7%), fistulotomy (57.1%), advancement flap (38.9%), fistula plug (36.4%) and ligation of intersphincteric track (LIFT) procedure (31.8%). Indications for diverting stoma or proctectomy were intractable sepsis, incontinence, and poor quality of life.

Conclusion

The survey highlighted the variation in practice including the differences in choices of definitive surgery and multimodal management. There is a need to develop practical guidelines to support clinicians in the UK.

Output

The above work was presented as a poster at the Association of Coloproctologists of Great Britain and Ireland Conference, July 2016 in Edinburgh and has been published in the journal. Colorectal Disease. The following are the references for this work

Poster

MJ Lee, N Heywood, P Sagar, SR Brown, N Fearnhead and the FPCD collaborators. Surgical Management of Fistulating Perianal Crohn’s Disease – Results of a UK Survey, ACPGBI July 2016

Manuscript

Lee, M. J., Heywood, N., Sagar, P. M., Brown, S. R., Fearnhead, N. S. and pCD Collaborators (2017), Surgical management of fistulating perianal Crohn’s disease: a UK survey. Colorectal Dis, 19: 266–273. doi:10.1111/codi.13462

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