Anal Fistulas in Severe Perineal Crohn's Disease: Mri Assessment in the Determination of Long-Term Healing Rates

Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021

BACKGROUND

We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD.

METHODS

PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021.

RESULTS

Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD.

CONCLUSIONS

These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.

The Effects of Phellodendron Decoction on Wound Healing of Anal Fistula after Anal Fistulotomy

Objective

To analyze the therapeutic effect of Compound Phellodendron decoction on wounds after anal fistulotomy.

Methods

100 patients with anal fistula who underwent anal fistulotomy from April 2019 to April 2021 were included in the study group and control group according to the random number table method. 50 patients in the study group were treated with Compound Phellodendron decoction by fumigation and sitting bath, while warm water replaced Compound Phellodendron decoction in the control group. Perianal pain, wound edema, and exudation were scored on postoperative days 3 and 7, and wound healing time was recorded. Interleukin-2(IL-2), IL-5, IL-6, and IL-12 were measured via a double-antibody sandwich enzyme-linked immunosorbent assay. Hematoxylin-eosin (HE) staining and immunofluorescence were used to quantitatively analyze the capillary number and CD4+ and CD8+ lymphocytes in granulation tissue on postoperative days 7.

Results

The scores of pain, edema, and exudation in 2 groups on postoperative day 7 were lower than those on the 3rd postoperative day. Compared with the control group, the pain, edema, and exudation scores in the study group were decreased, and the wound healing time was shortened; the expressions of IL-2 and IL-12 in the study group were significantly increased, while the expressions of IL-5 and IL-6 were decreased; the number of capillaries and CD4+ lymphocytes in the study group was increased, while the number of CD8+ lymphocytes was decreased.

Conclusion

Compound Phellodendron decoction had efficacy in promoting wound healing, reducing complications, and changing lymphocyte aggregation and alleviating local inflammatory response.

Surgical closure, mainly with glue injection and anti-tumour necrosis factor α, in fistulizing perianal Crohn's disease: A multicentre randomized controlled trial

AIM

In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab.

METHODS

This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities.

RESULTS

Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000).

CONCLUSIONS

Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution.

Perianal Imaging in Crohn Disease: Current Status With a Focus on MRI, From the AJR Special Series on Imaging of Inflammation

Fistulizing perianal disease is a frequent, chronic, and often debilitating manifestation of Crohn disease (CD) in adults and children, which in the past was relatively refractory to treatment. The advent of biologic agents such as anti-tumor necrosis factor-α and cellular therapies, used in conjunction with a range of surgical interventions, has greatly improved disease outcomes, although complete remission can still be elusive. This review considers current perianal imaging options, specifically pelvic MRI and endoanal and transperineal ultrasound, and their roles in diagnosis, management, and assessment of treatment response. Pelvic MRI is the first line technique for imaging of perianal CD given the complexity of fistulas encountered in CD. MRI technical acquisition parameters for adults and children and an approach to MRI interpretation and reporting are provided. Anatomic classification systems for fistulising perianal disease are presented. We also explore the history, current landscape, and future developments of MRI features of perianal disease as imaging biomarkers to quantify activity and severity, and consider CD MRI-based inflammatory activity scores. We discuss the reliability and validation of a number of indices (including PEMPAC, MAGNIFI-CD, mVAI, and Van Assche Index), their potential to quantify treatment response, and possible prognostic capabilities.

Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors

AIM

The medico-surgical strategy for the treatment of perianal fistulizing Crohn's disease (CD) following surgical drainage remains challenging and debated. Our aims were to describe the failure rate of therapeutic interventions after drainage of the fistula tract and determine the factors associated with failure to optimize medico-surgical strategies.

METHOD

All consecutive patients with perianal fistulizing CD who underwent surgical drainage with at least a 12-week follow-up were included. Failure was defined as the occurrence of at least one of the following items: abscess recurrence, purulent discharge from the tract, visible external opening and further drainage procedure(s).

RESULTS

One hundred and sixty-nine patients were included. The median follow-up was 4.0 years. The cumulative failure rates were 20%, 30% and 36% at 1, 3 and 5 years, respectively. The cumulative failure rates in patients who had sphincter-sparing surgeries or seton removal were significantly higher than in those who had a fistulotomy. Anterior fistula [hazard ratio (HR) = 2.52 (1.13-5.61), P = 0.024], supralevator extension [HR = 20.78 (3.38-127.80), P = 0.001] and the absence or discontinuation of immunosuppressants after anal drainage [HR = 3.74 (1.11-12.5), P = 0.032] were significantly associated with failure in the multivariate analysis model.

CONCLUSION

Combined strategies for perianal fistulizing CD lead to a failure rate of 36% at 5 years. Where advisable, fistulotomy may be preferred because it has a lower rate of recurrence. The benefits of immunosuppressants require a dedicated prospective randomized trial.

Endorectal Advancement Flap With Muscular Plication in Anovaginal and Anterior Perineal Fistulas

Purpose

Endorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas.

Methods

This retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms.

Results

Thirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%).

Conclusion

This study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.

Tumor Necrosis Factor Inhibitors May Have Limited Efficacy for Complex Perianal Fistulas Without Luminal Crohn's Disease

BACKGROUND

Complex perianal fistulas occurring in the absence of luminal inflammation (isolated perianal disease, IPD) may represent a specific phenotype of Crohn's disease (CD).

AIM

We assessed the effectiveness of tumor necrosis factor (TNF)-antagonists in patients with IPD compared to those with perianal CD (PCD) with luminal inflammation.

METHODS

Patients were identified through our institutional radiology database and were classified as PCD or IPD based on the presence or absence of luminal inflammation by ileocolonoscopy and abdominal enterography. Consecutive adults (> 17 years) with recurrent IPD who were treated with TNF antagonists were matched by age and gender to patients with complex PCD (1:2 ratio). Fistula remission was defined as an absence of fistula drainage. Surgery-free survival was assessed by Cox proportional hazard models.

RESULTS

Twenty-two patients with IPD treated with a TNF antagonist were compared with 44 matched patients with PCD. A similar proportion of patients with IPD and PCD were treated with concomitant immunomodulators (55% vs. 66%) and underwent examinations under anesthesia prior to therapy (36% vs. 46%). Fistula remission at 3, 6, and 12 months was lower for the IPD cohort: 9.5% versus 34%; 19% versus 39%; and 19% versus 43%. Surgical intervention after initiating anti-TNF therapy was more common for patients with IPD (HR 3.99: 95% CI, 1.62-9.83; p = 0.0026).

CONCLUSIONS

Fewer patients with IPD achieved fistula remission, and more required surgical intervention after anti-TNF therapy, suggesting that TNF antagonists may not be as effective in these patients.

Sphincter-sparing surgery for complex anal fistulas: radiofrequency thermocoagulation of the tract is of no help

AIM

To compare the rate of failure of radiofrequency thermocoagulation for anal fistula with that of rectal advancement flap in a case-matched study.

METHOD

Patients who underwent radiofrequency treatment were compared with age- and sex-matched patients with Crohn's disease (CD) who underwent a rectal flap procedure. Fistula features, general characteristics and the main clinical events were recorded in a prospective database. Failure was defined by at least one of following: abscess, purulent discharge, visible external opening or further drainage procedure.

RESULTS

A total of 62 patients [median age 45 (range 36.8-57.5) years; 22 women, 40 men; 22 with CD] were analysed. The failure rate of radiofrequency treatment was higher than that of rectal flap treatment (74.2% vs 32.2%; P = 0.004). The cumulative probabilities of failure of the radiofrequency treatment were 53.8% (38.8-68.3), 71.8% (55.3-84.0) and 87.4% (70.6-95.3) at 3, 6 and 12 months, respectively. Three patients in the radiofrequency group required drainage for an abscess and one had severe thermal ulceration. The Cox proportional hazards regression model (surgical procedure, obesity, CD) showed rectal flap treatment [3.48 (1.60-8.07); P = 0.001] and CD [2.60 (1.16-6.41); P = 0.02] to be the main independent predictors of healing.

CONCLUSION

Radiofrequency thermocoagulation is a less satisfactory sphincter-sparing treatment for the management of anal fistula than a rectal flap procedure.