1
|
Ahuja V, Hilmi I, Ye BD, Ling KL, Ng SC, Leong RW, Kumar P, Khoo XH, Makharia GK, Sollano J, Pisespongsa P, Mustaffa N, Banerjee R, Leow AHR, Raja Ali RA, Chuah SW, Palaniappan S, Ooi CJ, Leung WK. Ten missteps in the management of inflammatory bowel disease in Asia: An expert report by the Asian Pacific Association of Gastroenterology Working Group on Inflammatory Bowel Disease. J Gastroenterol Hepatol 2024; 39:1500-1508. [PMID: 38725188 DOI: 10.1111/jgh.16599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/27/2024] [Accepted: 04/22/2024] [Indexed: 08/10/2024]
Abstract
Inflammatory bowel disease (IBD) is rapidly emerging in the Asia Pacific region. However, there are many challenges in the diagnosis and management of this condition. The Asian Pacific Association of Gastroenterology (APAGE) Working Group on IBD conducted a round table meeting to identify 10 common mistakes in the management of IBD in Asia. To summarize, many physicians still over rely on a definitive histological diagnosis before starting treatment and do not fully establish disease extent such as perianal and proximal gastrointestinal involvement in Crohn's disease (CD) or extent of involvement in ulcerative colitis (UC). It is also essential to actively look for evidence of extra-intestinal manifestations, which may influence choice of therapy. In terms of conventional therapy, underuse of topical 5 aminosalicylates (5-ASAs) in UC and inappropriate dosing of corticosteroids are also important considerations. Acute severe UC remains a life-threatening condition and delay in starting rescue therapy after inadequate response to intravenous steroids is still common. Anti-tumor necrosis factors should be considered first line in all cases of complex perianal fistulizing CD. Most patients with IBD are on potent immunosuppressive therapy and should be screened for latent infections and offered vaccinations according to guidelines. Under-recognition and management of significant complications such as anemia, osteoporosis, malnutrition, and thromboembolism should also be addressed. Colonoscopy is still not properly performed for dysplasia/cancer surveillance and for evaluating post-op recurrence of CD. Another common misstep is inappropriate withdrawal of medications during pregnancy leading to increased complications for the mother and the newborn.
Collapse
Affiliation(s)
- Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ida Hilmi
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Byong Duk Ye
- Department of Gastroenterology and Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Khoon Lin Ling
- Mount Elizabeth Medical Centre, Duke-NUS Medical School, Singapore
| | - Siew C Ng
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, University of Sydney, Concord Hospital, Sydney, New South Wales, Australia
| | - Peeyush Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Xin Hui Khoo
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Govind K Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Pises Pisespongsa
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bumrungrad International Hospital, Bangkok, Thailand
| | - Nazri Mustaffa
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Gelugor, Malaysia
| | - Rupa Banerjee
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Alex Hwong-Ruey Leow
- Department of Gastroenterology, Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | | | - Sai Wei Chuah
- Duke-NUS Medical School, Gleneagles Medical Centre, Singapore
| | - Shanthi Palaniappan
- Department of Gastroenterology, Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Choon Jin Ooi
- Duke-NUS Medical School, Gleneagles Medical Centre, Singapore
| | - Wai K Leung
- Department of Medicine, School of Clinical Medicine, University of Hong Kong, Hong Kong, China
| |
Collapse
|
2
|
Mathias H, Rohatinsky N, Murthy SK, Novak K, Kuenzig ME, Nguyen GC, Fowler S, Benchimol EI, Coward S, Kaplan GG, Windsor JW, Bernstein CN, Targownik LE, Peña-Sánchez JN, Lee K, Ghandeharian S, Jannati N, Weinstein J, Khan R, Im JHB, Matthews P, Davis T, Goddard Q, Gorospe J, Latos K, Louis M, Balche N, Dobranowski P, Patel A, Porter LJ, Porter RM, Bitton A, Jones JL. The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care. J Can Assoc Gastroenterol 2023; 6:S111-S121. [PMID: 37674496 PMCID: PMC10478809 DOI: 10.1093/jcag/gwad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.
Collapse
Affiliation(s)
- Holly Mathias
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Noelle Rohatinsky
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
| | - Kerri Novak
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Geoffrey C Nguyen
- Mount Sinai IBD Centre of Excellence, Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sharyle Fowler
- Department of Gastroenterology and Hepatology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Coward
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Juan-Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kate Lee
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | | | - Nazanin Jannati
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jake Weinstein
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rabia Khan
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - James H B Im
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Tal Davis
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Quinn Goddard
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julia Gorospe
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kate Latos
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | | | - Naji Balche
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | | | - Ashley Patel
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | | | | | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre IBD Centre, McGill University, Montréal, Quebec, Canada
| | - Jennifer L Jones
- Departments of Medicine, Clinical Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
3
|
Morales-Cruz M, Ali M, Christou C, Crothers H, McNulty D, Ward ST. Repeat operations in patients with anal fistula, a retrospective study across England and Wales. Int J Colorectal Dis 2023; 38:174. [PMID: 37349532 DOI: 10.1007/s00384-023-04467-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
AIM This article reports the frequency of repeat operations including waiting times within the National Health Service (NHS) of England and Wales. METHODS Retrospective study on repeat operations for anal fistula (AF) performed between 1st January 2010 and 31st December 2016. Data were extracted from the national registry of data entered into Hospital Episode Statistics (HES). Patient factors (age, sex, self-declared ethnicity) and geographical location were tested for association with repeat operations and time to the second operation. RESULTS We analysed 36,223 patients that had an operation for AF within 148 NHS trusts. The median follow-up time was 28 months. The majority of patients (67.4%) had only one operation. Eighty-five per cent of them remained under the care of a single consultant. Six per cent of the repeat surgeries occurred in at least three different treatment sites. Young age and female sex were associated with higher rates of repeat operations. Non-declared and Black or Black British ethnicity were associated with fewer operations. The median waiting time between the first and second operations was 27.4 weeks (IQR: 14.7-55.3); between the second and third 28.0 weeks (IQR: 14.7-57.0); between the third and fourth 29.0 weeks. CONCLUSION This large real world population-based study shows that the majority of patients with AF undergo only one operation. Patients requiring multiple procedures tend to stay under the care of a small number of consultants but waiting times between operations are long. There is a geographical variation in the number of operations and the time between them.
Collapse
Affiliation(s)
- M Morales-Cruz
- University of Birmingham NHS Foundation Trust, Birmingham, UK.
| | - M Ali
- University of Birmingham NHS Foundation Trust, Birmingham, UK
| | - C Christou
- Department of General Surgery, University Hospital of Limoges, 87000, Limoges, France
- Laboratory INSERM U1308, CAPTuR, Faculty of Medicine, University of Limoges, Limoges, France
| | - H Crothers
- University of Birmingham NHS Foundation Trust, Birmingham, UK
| | - D McNulty
- University of Birmingham NHS Foundation Trust, Birmingham, UK
| | - S T Ward
- University of Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
4
|
Lamidi S, Coe PO, Bordeianou LG, Hart AL, Hind D, Lindsay JO, Lobo AJ, Myrelid P, Raine T, Sebastian S, Fearnhead NS, Lee MJ, Adams K, Almer S, Ananthakrishnan A, Bethune RM, Block M, Brown SR, Cirocco WC, Cooney R, Davies RJ, Atici SD, Dhar A, Din S, Drobne D, Espin‐Basany E, Evans JP, Fleshner PR, Folkesson J, Fraser A, Graf W, Hahnloser D, Hager J, Hancock L, Hanzel J, Hargest R, Hedin CRH, Hill J, Ihle C, Jongen J, Kader R, Karmiris K, Katsanos KH, Keller DS, Kopylov U, Koutrabakis IE, Lamb CA, Landerholm K, Lee GC, Litta F, Limdi JK, Lopes EW, Madoff RD, Martin ST, Martin‐Perez B, Michalopoulos G, Millan M, Münch A, Nakov R, Noor NM, Oresland T, Paquette IM, Pellino G, Perra T, Porcu A, Roslani AC, Samaan MA, Sebepos‐Rogers GM, Segal JP, de Silva SD, Söderholm AM, Spinelli A, Speight RA, Steinhagen RM, Stenström P, Tsimogiannis KE, Varma MG, Verma AM, Verstockt B, Warden C, Yassin NA, Zawadzki A, Carr P, Devlin B, Avery MSP, Gecse KB, Goren I, Hellström PM, Kotze PG, McWhirter D, Naik AS, Sammour T, Selinger CP, Stein SL, Torres J, Wexner SD, Younge LC. Development of a core descriptor set for Crohn's anal fistula. Colorectal Dis 2022; 25:695-706. [PMID: 36461766 DOI: 10.1111/codi.16440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/21/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
AIM Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research. METHOD Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting. RESULTS One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life. CONCLUSION The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.
Collapse
Affiliation(s)
-
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials. J Clin Med 2022; 11:jcm11113045. [PMID: 35683433 PMCID: PMC9181669 DOI: 10.3390/jcm11113045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Fistulizing Crohn’s disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30–50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.
Collapse
|
6
|
Vasudevan A, Bruining DH, Loftus EV, Faubion W, Ehman EC, Raffals L. Approach to medical therapy in perianal Crohn's disease. World J Gastroenterol 2021; 27:3693-3704. [PMID: 34321838 PMCID: PMC8291021 DOI: 10.3748/wjg.v27.i25.3693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
Collapse
Affiliation(s)
- Abhinav Vasudevan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Edward V Loftus Jr
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - William Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Eric C Ehman
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| |
Collapse
|
7
|
Adegbola SO, Sahnan K, Twum-Barima C, Iqbal N, Reza L, Lung P, Warusavitarne J, Tozer P, Hart A. Current review of the management of fistulising perianal Crohn's disease. Frontline Gastroenterol 2020; 12:515-523. [PMID: 34712470 PMCID: PMC8515276 DOI: 10.1136/flgastro-2020-101489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 02/04/2023] Open
Abstract
Perianal manifestations of Crohn's disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-date surgical and medical management of perianal fistulas, highlighting current consensus management guidelines and the evidence behind them, as well as future directions in management.
Collapse
Affiliation(s)
- Samuel O Adegbola
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kapil Sahnan
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Charlene Twum-Barima
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nusrat Iqbal
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lillian Reza
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phillip Lung
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Janindra Warusavitarne
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phil Tozer
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ailsa Hart
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
8
|
Ambulatory Surgery for Perianal Crohn's Disease: Study of Feasibility. Gastroenterol Res Pract 2018; 2018:5249087. [PMID: 30671093 PMCID: PMC6323458 DOI: 10.1155/2018/5249087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/01/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022] Open
Abstract
Background One-third of Crohn's disease (CD) patients present perianal fistula. The gold standard in the diagnosis and treatment of symptomatic perianal disease (PAD) in CD is the exploration of the anal canal and distal rectum under anesthesia (EUA). This procedure is mainly conducted as a day case surgery. Unfortunately, it is not always possible to proceed within the ideal timing and any delay may well represent a relevant clinical issue. The aim of this study was to evaluate the feasibility of outpatient treatment of symptomatic perianal fistulas in CD patients. Methods All CD patients under regular follow-up at our inflammatory bowel disease referral center, presenting with symptomatic perianal fistulas, were offered surgical consultation. The data of patients were prospectively collected for three years (February 2014 to February 2017) for the purpose of the study. All clinical information, including previous EUA and/or records from MRI and endoscopic ultrasound, was included. Outpatient anal canal and distal rectum exploration and treatment (OE) were undertaken during the specialist surgical consultation. Fistulas were classified according to Parks's classification; the type of outpatient treatment and compliance of patients were recorded. Pain was assessed by VAS at the time of the procedure and during the first control. Patients were followed up in the surgical clinic in relation to the study. Results Ninety-two CD patients with symptomatic perianal fistulas had surgical consultation during the study period. OE was offered to all but 18 patients who fulfilled the exclusion criteria or had an extremely severe disease; six patients refused the OE (8.11%). Of the 68 patients undergoing OE, eleven (16.18%) had previous surgery for perianal disease. The OE was accomplished in sixty-one patients (89.71%), while in 7 patients, it was abandoned for scarce compliance. Nine patients (14.75%) underwent drainage of perianal abscess; in 3 of them, it was possible to probe the fistula tract, find the internal orifice, and pass a loose seton. Overall, setonage was performed in 50 patients (81.97%). Rectovaginal setons were placed in 3 patients and more than one seton (up to 3) in 6 cases. Fistulotomy was performed in 4 simple subcutaneous fistulous tracts. Concordance with the preoperative findings was found in 54 out of 61 patients. EUA was scheduled at the time of OE for the 7 patients who did not complete the procedure. All sixty-one patients who had the OE were followed up for a minimum of 12 months. Conclusions This preliminary study indicates that OE in CD patients with symptomatic perianal fistulas is safe and feasible in a high-volume referral center. It might provide several benefits, including patients' logistics, reduce or remove patients' symptoms and discomfort, allow for a timely start of medical therapy, and avoid further complications.
Collapse
|
9
|
Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
Collapse
Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | |
Collapse
|
10
|
Lee MJ, Fearnhead NS, Knowles CH, Brown SR. Waiting times. Colorectal Dis 2018; 20:348-349. [PMID: 29419906 DOI: 10.1111/codi.14042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 01/24/2018] [Indexed: 02/08/2023]
Affiliation(s)
- M J Lee
- Department of General Surgery, Northern General Hospital, Sheffield, UK
| | - N S Fearnhead
- Department of Surgery, Addenbrookes Hospital, Cambridge, UK
| | - C H Knowles
- Centre for Neuroscience and Trauma, Blizard Institute, London, UK
| | - S R Brown
- Department of General Surgery, Northern General Hospital, Sheffield, UK
| |
Collapse
|