Kapil Sahnan

Developing a core outcome set for fistulising perianal Crohn’s disease

Objective Lack of standardised outcomes hampers effective analysis and comparison of data when comparing treatments in fistulising perianal Crohn’s disease (pCD). Development of a standardised set of outcomes would resolve these issues. This study provides the definitive core outcome set (COS) for fistulising pCD. Design Candidate outcomes were generated through a systematic review and patient interviews. Consensus was established via a three-round Delphi process using a 9-point Likert scale based on how important they felt it was in determining treatment success culminating in a final consensus meeting. Stakeholders were recruited nationally and grouped into three panels (surgeons and radiologists, gastroenterologists and IBD specialist nurses, and patients). Participants received feedback from their panel (in the second round) and all participants (in the third round) to allow refinement of their scores. Results A total of 295 outcomes were identified from systematic reviews and interviews that were categorised into 92 domains. 187 stakeholders (response rate 78.5%) prioritised 49 outcomes through a three-round Delphi study. The final consensus meeting of 41 experts and patients generated agreement on an eight domain COS. The COS comprised three patient-reported outcome domains (quality of life, incontinence and a combined score of patient priorities) and five clinician-reported outcome domains (perianal disease activity, development of new perianal abscess/sepsis, new/recurrent fistula, unplanned surgery and faecal diversion). Conclusion A fistulising pCD COS has been produced by all key stakeholders. Application of the COS will reduce heterogeneity in outcome reporting, thereby facilitating more meaningful comparisons between treatments, data synthesis and ultimately benefit patient care.

A Systematic Review: The Management and Outcomes of Ileal Pouch Strictures

Background Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and stoma-free living. Pouch strictures are a complication with a reported incidence of 5-38%. The three areas where pouch strictures occur are in the pouch inlet, mid-pouch and pouch-anal anastomosis. Aim To undertake a systematic review of the literature and to identify management strategies available for pouch-anal, mid-pouch and pre-pouch ileal strictures and their outcomes. Methods A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was performed. Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded. Results Twenty-two articles were considered eligible. Pouch-anal strictures have been initially managed using predominately dilators which include bougie and Hegar dilators with various surgical procedures advocated when initial dilatation fails. Mid-pouch strictures are relatively unstudied with both medical, endoscopic and surgical management reported as successful. Pouch inlet strictures can be safely managed using a combined medical and endoscopic approach. Conclusion The limited evidence available suggests that pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical revision or resection. Management of mid-pouch strictures requires a combination of medical, endoscopic and surgical management. Pouch inlet strictures are best managed using a combined medical and endoscopic approach. Future studies should compare different treatment modalities on separate stricture locations to enable an evidenced-based treatment algorithm.

Innovation in the imaging of perianal fistula: a step towards personalised medicine:

Background: Perianal fistula is a topic both hard to understand and to teach. The key to understanding the treatment options and the likely success is deciphering the exact morphology of the tract(s) and the amount of sphincter involved. Our aim was to explore alternative platforms better to understand complex perianal fistulas through three-dimensional (3D) imaging and reconstruction. Methods: Digital imaging and communications in medicine images of spectral attenuated inversion recovery magnetic resonance imaging (MRI) sequences were imported onto validated open-source segmentation software. A specialist consultant gastrointestinal radiologist performed segmentation of the fistula, internal and external sphincter. Segmented files were exported as stereolithography files. Cura (Ultimaker Cura 3.0.4) was used to prepare the files for printing on an Ultimaker 3 Extended 3D printer. Animations were created in collaboration with Touch Surgery™. Results: Three examples of 3D printed models demonstrating complex perianal fistula were created. The anatomical components are displayed in different colours: red: fistula tract; green: external anal sphincter and levator plate; blue: internal anal sphincter and rectum. One of the models was created to be split in half, to display the internal opening and allow complexity in the intersphincteric space to better evaluated. An animation of MRI fistulography of a trans-sphincteric fistula tract with a cephalad extension in the intersphincteric space was also created. Conclusion: MRI is the reference standard for assessment of perianal fistula, defining anatomy and guiding surgery. However, communication of findings between radiologist and surgeon remains challenging. Feasibility of 3D reconstructions of complex perianal fistula is realized, with the potential to improve surgical planning, communication with patients, and augment training.

Anti-TNF Therapy in Crohn’s Disease

Crohn’s disease (CD) accounts for a variety of clinical manifestations or phenotypes that stem from chronic inflammation in the gastrointestinal tract. Its worldwide incidence is increasing including younger or childhood-onset of disease. The natural history of Crohn’s disease is characterized by a remitting and relapsing course that progresses to complications and surgery in most patients. The goals of treatment are to achieve clinical and endoscopic remission, to avoid disease progression and minimise surgical resections. Medical treatment usually features antibiotics, corticosteroids, immunomodulators (thiopurines, methotrexate). Anti-TNF (tumour necrosis factor) therapy was approved for use in Crohn’s disease in 1998, and has changed the paradigm of treatment, leading to improved rates of response and remission in patients. There are significant considerations that need to be borne in mind, when treating patients including immunogenicity, safety profile and duration of treatment.

The role of multimodal treatment in Crohn′s disease patients with perianal fistula: a multicentre retrospective cohort study

Treatment paradigms for Crohn′s disease with perianal fistulae (CD‐pAF) are evolving.

Management of Perianal Crohn’s Disease in the Biologic Era

Perianal Crohn’s disease represents a distinct, aggressive phenotype of Crohn’s disease associated with increased morbidity. It encompasses a variety of manifestations including perianal fistula which has a very significant on patient’s quality of life. Anti-TNF therapy has heralded a change in the management of these patients and a combination of medical and surgical treatment is required for most perianal manifestations. A multidisciplinary approach involving gastroenterologists, surgeons, radiologists, IBD nurse specialists and dieticians, and an understanding of all forms of perianal Crohn’s disease and options for treatment are crucial to minimise the often disabling morbidity that can potentially effect this group of patients.

OC-064 Therapeutic approaches for perianal fistula in paediatric and adolescent onset crohn`s disease-a multicentre cohort study

Introduction There is no clear consensus on the management of Crohn`s disease related perianal fistulae (CD-PAF) in paediatric and adolescent onset CD due to paucity of data on management approaches. We aimed to evaluate therapeutic interventions and their efficacy in a multicentre cohort with paediatric and adolescent onset CD-PAF. Method 7 centres in Europe participated in the study. Patients with paediatric and adolescent onset CD-PAF diagnosed since 2010 and having follow up data of at least 6 months since onset of CD-PAF were included. Complete clinical fistula healing was defined as the absence of any draining fistulas on clinical examination. Reinterventions were defined as the need for repeat abscess drainage, seton reinsertion, diverting stoma or proctectomy. Univariate and multivariate analysis was done for predictors of fistula healing and reintervention. Results 116 patients were included (74 boys and 42 girls). The mean age at diagnosis of fistula was 12.9 years. MRI was done in 85 of the patients with complex fistula in 57 (67%). Proctitis was evident at presentation in 33%. 55% had an abscess drainage but only 17 having a seton inserted. After onset of CD-PAF there was significant increase in the use of biologics (13.7% before and 83% after) and immunosuppressant (29% before and 80% after). There was significant difference in healing based on type of fistula (simple fistula 78%, complex fistula 26%, p=0.001). Follow up MRI scan (n=40) demonstrated partial healing in 29 and but complete healing in only 6 patients. Anti TNFs were continued in majority (86) of the patients.In the 10 patients stopping anti TNFs (6 -planned withdrawal, 4 -patient preference), 7 had recurrence of perianal fistula Repeat surgical intervention was required only in 16% of the patients (repeat EUA and abscess drainage-9, diverting stoma- 3 and reinsertion of seton −2). Complex fistula type (p=0.015), those with proctitis (p=0.04) and those needing abscess drainage (p=0.02) were more likely to need reintervention and patients with anti TNF therapy (0.01) less likely to need repeat surgery. Conclusion Perianal fistula in paediatric onset CD is managed with combined medical and surgical management in majority of patients. Significant proportion of patients had complete or partial clinical healing. Repeat surgical intervention in CD-PAF is only required in 16% of the patients. Disclosure of Interest C. Tzivinikos: None Declared, K. Ashton: None Declared, M. Nair: None Declared, T. Drskova: None Declared, K. Sahnan: None Declared, R. Muhammed: None Declared, D. Devadason: None Declared, O. Hradskys: None Declared, K. Crook: None Declared, R. Palmer: None Declared, A. Akbar: None Declared, M. Thomson: None Declared, A. Hart: None Declared, S. Sebastian Conflict with: Takeda, Abbvie, Warner Chilcott, Ferring, Cellgene, Bohringer Ingenheim, Conflict with: Ferring, Dr Falk, Pharmacocosmos, Takeda, Merk, Abbvie

PWE-033 Presentation and surgical interventions for crohn’s diseasewith perianal fistula in the biologics era: results from a multicentre study

Introduction Introduction of biologics particularly anti-TNF agents are thought to have resulted in changes in natural history of Crohn’s disease (CD). The impact of these in presentation of CD with perianal fistula (CD-PAF) and subsequent surgical approaches is not known. Method 11 IBD centres across Europe and Israel were invited to collect data on CD-PAF patients diagnosed since January 2010 to Dec 2015. Data on demographics, mode and route of presentation, type of fistula, MRI, prior treatment for CD were collected. Patients who had at least one surgical therapy for CD-PAF fistula were analysed for reasons and the type of interventions. Results 253 patients with CD-PAF (161 M, 92 F) were included. The mean age at diagnosis of CD was 28 years (SD: 13.3), and at diagnosis of CD-PAF was 32 years (SD: 13.92). 65% of the patients with CD-APF developed their fistulae in the period between 1 year before and 4 years after diagnosis of CD. 30% of patients were smokers at the onset of CD-PAF. 37.2% of the CD-PAF presented as emergency medical or surgical admission and 30% and 23.7% were identified in IBD clinics and colorectal clinics respectively. 77.1% has MRI pelvis done at diagnosis with 52.8% of patients having complex fistulae (38.7% trans-sphincteric, 10.3% extrasphincteric,3.8% with suprasphincteric).Proctitis and anal stenosis at presentation were identified in 43.1% and 9.5% respectively. Examination under Anaesthesia (EUA) +/- abscess drainage was required in 69.6% of patients but only 53.8% had Seton inserted at first EUA (median number of Setons=1, range 1–6). 96 patients (68% of those needing Seton insertion) had them removed and only 33 of these needed Seton re-insertion. he reasons for non-removal:surgeons’ preference (21);surgeon and physician preference (13) and patient preference (5).Overall repeat surgical intervention were required in 102 patients (40.3%):repeat abscess drainage (43), Reinsertion of Seton (33), Diverting stoma (20) and proctectomy (6). Conclusion Majority of CD-PAF present within 5 years of their diagnosis of CD with a third presenting as emergency. EUA with abscess drainage and Seton insertion is the main surgical intervention needed. Radical surgery appears to be less often requiring in comparison to previous studies. Disclosure of Interest None Declared