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Hanna LN, Anandabaskaran S, Iqbal N, Geldof J, LeBlanc JF, Dige A, Lundby L, Vermeire S, D'Hoore A, Verstockt B, Bislenghi G, De Looze D, Lobaton T, Van de Putte D, Spinelli A, Carvello M, Danese S, Buskens CJ, Gecse K, Hompes R, Becker M, van der Bilt J, Bemelman W, Sebastian S, Moran G, Lightner AL, Wong SY, Colombel JF, Cohen BL, Holubar S, Ding NS, Behrenbruch C, Sahnan K, Misra R, Lung P, Hart A, Tozer P. Perianal Fistulizing Crohn's Disease: Utilizing the TOpClass Classification in Clinical Practice to Provide Targeted Individualized Care. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00692-X. [PMID: 39134293 DOI: 10.1016/j.cgh.2024.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/26/2024] [Accepted: 06/11/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND & AIMS Perianal fistulation is a challenging phenotype of Crohn's disease, with significant impact on quality of life. Historically, fistulae have been classified anatomically in relation to the sphincter complex, and management guidelines have been generalized, with lack of attention to the clinical heterogenicity seen. The recent 'TOpClass classification system' for perianal fistulizing Crohn's disease (PFCD) addresses this issue, and classifies patients into defined groups, which provide a focus for fistula management that aligns with disease characteristics and patient goals. In this article, we discuss the clinical applicability of the TOpClass model and provide direction on its use in clinical practice. METHODS An international group of perianal clinicians participated in an expert consensus to define how the TOpClass system can be incorporated into real-life practice. This included gastroenterologists, inflammatory bowel disease surgeons, and radiologists specialized in PFCD. The process was informed by the multi-disciplinary team management of 8 high-volume fistula centres in North America, Europe, and Australia. RESULTS The process produced position statements to accompany the classification system and guide PFCD management. The statements range from the management of patients with quiescent perianal disease to those with severe PFCD requiring diverting-ostomy and/or proctectomy. The optimization of medical therapies, as well as the use of surgery, in fistula closure and symptom management is explored across each classification group. CONCLUSION This article provides an overview of the system's use in clinical practice. It aims to enable clinicians to have a pragmatic and patient goal-centered approach to medical and surgical management options for individual patients with PFCD.
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Affiliation(s)
- Luke N Hanna
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom.
| | - Sulak Anandabaskaran
- Department of Gastroenterology, School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, Australia
| | - Nusrat Iqbal
- Department of Colorectal Surgery, St Mark's Hospital, London, United Kingdom
| | - Jeroen Geldof
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Jean-Frédéric LeBlanc
- Department of Gastroenterology, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Anders Dige
- Department of Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Lilli Lundby
- Department of Colorectal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals of Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Colorectal Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Gastroenterology, University Hospitals of Leuven, Leuven, Belgium
| | - Gabriele Bislenghi
- Department of Colorectal Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Danny De Looze
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Triana Lobaton
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Dirk Van de Putte
- Department of Colorectal Surgery, University Hospital Ghent, Ghent, Belgium
| | - Antonino Spinelli
- Department of Colorectal Surgery, Humanitas Research Hospital, Milan, Italy
| | - Michele Carvello
- Department of Colorectal Surgery, Humanitas Research Hospital, Milan, Italy
| | - Silvio Danese
- IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | | | - Krisztina Gecse
- Department of Gastroenterology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Colorectal Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marte Becker
- Department of Gastroenterology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Wilhelmus Bemelman
- Department of Colorectal Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Gordan Moran
- Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Amy L Lightner
- Department of Colorectal Surgery, Scripps Clinic, San Diego, California
| | - Serre-Yu Wong
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frédéric Colombel
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Benjamin L Cohen
- Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio
| | - Stefan Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nik S Ding
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
| | - Cori Behrenbruch
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Australia
| | - Kapil Sahnan
- Department of Colorectal Surgery, St Mark's Hospital, London, United Kingdom
| | - Ravi Misra
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom
| | - Phillip Lung
- Department of Radiology, St Mark's Hospital, London, United Kingdom
| | - Ailsa Hart
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom
| | - Phil Tozer
- Department of Colorectal Surgery, St Mark's Hospital, London, United Kingdom
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Schaad M, Schoepfer A, Rossel JB, Barry MP, Rogler G, Hahnloser D. Long-Term Outcome of Surgery for Perianal Crohn's Fistula. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1035. [PMID: 39064464 PMCID: PMC11279190 DOI: 10.3390/medicina60071035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Patients with perianal Crohn's (CD) fistula often need repetitive surgeries and none of the established techniques was shown to be superior or preferable. Furthermore, the long-term outcome of fistula Seton drainage is not well described. The aims of this study were to analyze the long-term healing and recurrence rate of CD perianal fistulas in a large patient cohort. Materials and Methods: Database analysis of the Swiss IBD (Inflammatory Bowel Disease) cohort study. Results: 365 perianal fistula patients with 576 surgical interventions and a median follow-up of 7.5 years (0-12.6) were analyzed. 39.7% of patients required more than one procedure. The first surgical interventions were fistulectomies ± mucosal sliding flap (59.2%), Seton drainage (29.6%), fistula plugs or fibrin glue installations (2.5%) and combined procedures (8.8%). Fistulectomy patients required no more surgery in 69%, one additional surgery in 25% and more than one additional surgery in 6%, with closure rates at 7.5 years follow-up of 77.1%, 74.1% and 66.7%, respectively. In patients with Seton drainage as index surgery, 52% required no more surgery, and over 75% achieved fistula closure after 10 years. Conclusions: First-line fistulectomies, when feasible, achieved the highest healing rates, but one-third of patients required additional surgeries, and one-fourth of patients will remain with a fistula at 10 years. Initial Seton drainage and concurrent medical therapy can achieve fistula closure in 75%. However, in 50% of patients, more surgeries are needed, and fistula closure is achieved in only two-thirds of patients.
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Affiliation(s)
- Marie Schaad
- Service of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Bugnon 46, 1005 Lausanne, Switzerland
| | - Alain Schoepfer
- Service of Gastroenterology, Lausanne University Hospital (CHUV), University of Lausanne, Bugnon 46, 1005 Lausanne, Switzerland
| | - Jean-Benoît Rossel
- Unisanté, University Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Mamadou Pathé Barry
- Unisanté, University Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Gerhard Rogler
- Service of Gastroenterology and Hepatology, University Hospital Zürich, University of Zürich, 8091 Zurich, Switzerland
| | - Dieter Hahnloser
- Service of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Bugnon 46, 1005 Lausanne, Switzerland
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Khalil C, van Deen WK, Dupuy T, Syal G, Arnold C, Cazzetta SE, Nazarey PP, Almario CV, Spiegel BMR. Patients' Perspectives, Experiences, and Concerns With Perianal Fistulae: Insights From Online Targeted-Disease Forums. CROHN'S & COLITIS 360 2023; 5:otad073. [PMID: 38046445 PMCID: PMC10693318 DOI: 10.1093/crocol/otad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Indexed: 12/05/2023] Open
Abstract
Background Perianal fistulae can undermine physical, emotional, and social well-being in patients with Crohn's disease and are challenging to manage. Social media offers a rich opportunity to gain an in-depth understanding of the impact of perianal fistulae on patients' daily lives outside of controlled environments. In this study, we conducted social media analytics to examine patients' experiences with perianal fistulae and assessed the impact of perianal fistulae on patients' behavior and overall well-being. Methods We used a mixed-method approach to examine 119 986 publicly available posts collected from 10 Crohn's disease forums in the United States between January 01, 2010 and January 01, 2020. Discussions related to Crohn's perianal fistulae were retrieved. We randomly selected 700 posts and qualitatively analyzed them using an inductive thematic approach. We then applied a latent Dirichlet allocation probabilistic topic model to explore themes in an unsupervised manner on the collection of 119 986 posts. Results In the qualitative analysis, 5 major themes were identified: (1) burden of perianal fistula; (2) challenges associated with treatment; (3) online information seeking and sharing; (4) patient experiences with treatments; and (5) patients' apprehension about treatments. In the quantitative analysis, the percentages of posts related to the major themes were (1) 20%, (2) 29%, (3) 66%, and (4) 28%, while the topic model did not identify theme 5. Conclusions Social media reveals a dynamic range of themes governing patients' perspectives and experiences with Crohn's perianal fistulae. In addition to the biopsychosocial burden, patients frequently express dissatisfaction with current treatments and often struggle to navigate among available management options.
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Affiliation(s)
- Carine Khalil
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Welmoed K van Deen
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
- Erasmus School of Health Policy & Management, Rotterdam, The Netherlands
| | - Taylor Dupuy
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Gaurav Syal
- Cedars-Sinai Medical Center, Department of Medicine, Los Angeles, CA, USA
| | - Corey Arnold
- Medical Imaging Informatics, Department of Radiology, UCLA, Los Angeles, CA, USA
| | | | | | - Christopher V Almario
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Brennan M R Spiegel
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
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