Nuha A. Yassin

Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review

Over the last 5 years, the ligation of the intersphincteric fistula tract (LIFT) procedure has become increasingly popular as a sphincter‐preserving technique for the treatment of anal fistula. The aim of this article was to review the published literature on the LIFT procedure.

Multimodal treatment of perianal fistulas in Crohn’s disease: seton versus anti-TNF versus advancement plasty (PISA): study protocol for a randomized controlled trial

BackgroundCurrently there is no guideline for the treatment of patients with Crohn’s disease and high perianal fistulas. Most patients receive anti-TNF medication, but no long-term results of this expensive medication have been described, nor has its efficiency been compared to surgical strategies. With this study, we hope to provide treatment consensus for daily clinical practice with reduction in costs.Methods/DesignThis is a multicentre, randomized controlled trial. Patients with Crohn’s disease who are over 18 years of age, with newly diagnosed or recurrent active high perianal fistulas, with one internal opening and no anti-TNF usage in the past three months will be considered. Patients with proctitis, recto-vaginal fistulas or anal stenosis will be excluded. Prior to randomisation, an MRI and ileocolonoscopy are required. All treatment will start with seton placement and a course of antibiotics. Patients will then be randomised to: (1) chronic seton drainage (with oral 6-mercaptopurine (6MP)) for one year, (2) anti-TNF medication (with 6MP) for one year (seton removal after six weeks) or (3) advancement plasty after eight weeks of seton drainage (under four months anti-TNF and 6MP for one year). The primary outcome parameter is the number of patients needing fistula-related re-intervention(s). Secondary outcomes are the number of patients with closed fistulas (based on an evaluated MRI score) after 18 months, disease activity, quality of life and costs.DiscussionThe PISA trial is a multicentre, randomised controlled trial of patients with Crohn’s disease and high perianal fistulas. With the comparison of three generally accepted treatment strategies, we will be able to comment on the efficiency of the various treatment strategies, with respect to several long-term outcome parameters.Trial registrationNederlands Trial Register identifier: NTR4137 (registered on 23 August 2013).

Seven‐year experience of enterocutaneous fistula with univariate and multivariate analysis of factors associated with healing: development of a validated scoring system

The management of enterocutaneous fistulae (ECF) is complex and challenging. We examined factors associated with fistula healing at a National Intestinal Failure Centre and devised the first scoring system to predict spontaneous fistula healing prior to surgery.

ECCO-ESCP Consensus on Surgery for Crohn's Disease

Willem A. Bemelman, Janindra Warusavitarne, Gianluca M. Sampietro, Zuzana Serclova, Oded Zmora, Gaetano Luglio, Anthony de Buck van Overstraeten, John P. Burke, Christianne J. Buskens, Francesco Colombo, Jorge Amil Dias, Rami Eliakim, Tomás Elosua, I. Ethem Gecim, Sanja Kolacek, Jaroslaw Kierkus, Kaija-Leena Kolho, Jérémie H. Lefevre, Monica Millan, Yves Panis, Thomas Pinkney, Richard K. Russell , Chaya Shwaartz, Carolynne Vaizey, Nuha Yassin, André D’Hoore, On behalf of the European Crohns and Colitis Organisation (ECCO) and the European Society of Coloproctology (ESCP)

Results of the Fifth Scientific Workshop of the ECCO [II]: Clinical Aspects of Perianal Fistulising Crohn’s Disease—the Unmet Needs

BACKGROUND AND AIMS Perianal fistulas affect up to one-third of Crohns patients during the course of their disease. Despite the considerable disease burden, current treatment options remain unsatisfactory. The Fifth Scientific Workshop [SWS5] of the European Crohns and Colitis Organisation [ECCO] focused on the pathophysiology and clinical impact of fistulas in the disease course of patients with Crohns disease [CD]. METHODS The ECCO SWS5 Working Group on clinical aspects of perianal fistulising Crohns disease [pCD] consisted of 13 participants, gastroenterologists, colorectal surgeons, and a histopathologist, with expertise in the field of inflammatory bowel diseases. A systematic review of literature was performed. RESULTS Four main areas of interest were identified: natural history of pCD, morphological description of fistula tracts, outcome measures [including clinical and patient-reported outcome measures, as well as magnetic resonance imaging] and randomised controlled trials on pCD. CONCLUSIONS The treatment of perianal fistulising Crohns disease remains a multidisciplinary challenge. To optimise management, a reliable classification and proper trial endpoints are needed. This could lead to standardised diagnosis, treatment, and follow-up of Crohns perianal fistulas and the execution of well-designed trials that provide clear answers. The prevalence and the natural history of pCD need further evaluation.

Clinical outcomes of colo-anal pull-through procedure for complex rectal conditions.

Pull‐through with colo‐anal sleeve anastomosis may be used as a last resort to avoid permanent diversion in patients with complex rectal conditions. This procedure allows the preservation of intestinal continuity by minimizing the hazards of deep dissection in an inflamed and fibrosed pelvis.

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.

Managing perianal Crohn’s fistula in the anti-TNFα era

Perianal fistulas in Crohn’s disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.

Sepsis, CT, and the Deep Postanal Space: A Riddle, Wrapped in a Mystery, Inside an Enigma.

1111 Diseases of the Colon & ReCtum Volume 58: 11 (2015) When evaluating anorectal sepsis, we depend on adequate physical imaging alongside an image in our mind’s eye of anorectal anatomy. imaging is frequently used as an adjunct to clinical examination and examination under anesthesia, aiding understanding and hence management. the surgeon seeks to understand the anal canal and fistula anatomy, identify secondary tracts and high extensions, and discriminate between granulation tissue and abscesses/trapped pus. ortega et al have supplied interesting evidence based on an extensive experience of evaluating anorectal sepsis using Ct scanning. one central reason is to help guide the surgeon in the important and difficult decision regarding whether to drain sepsis directly into the rectum or via the ischiorectal fossa. the image in their minds’ eye has the deep postanal space as central. in the united states, hanley proposed the deep postanal space as central to the management of some complex fistulas. this teaching has been at the core of the article by ortega et al but in our view is based on an enigma. the boundaries of this hypothetical space are the levator ani above, the external anal sphincter anteriorly, and the anococcygeal ligament below. from a european perspective, a ligament with an origin from 1 bone (here the coccyx) would by definition have an insertion into another. We europeans do not have a bone in our anuses, but cannot speak with authority about north americans. We supply both cadaveric and magnetic resonance evidence that there is no structure inferiorly that might serve as a boundary to an anatomically definable deep postanal space. We believe the original question to be a riddle (albeit important), the imaging method selected (Ct) a mystery (mRi is so much better), and the deep postanal space itself an enigma (and probably a myth). in our view, such a riddle wrapped in a mystery inside an enigma cannot forecast action. We have attached images to make the following points: 1) Ct does not have the quality of mR, 2) anatomic dissection shows no evidence of an anococcygeal ligament, and 3) matching mRi scanning also fails to demonstrate a ligament or a true deep postanal space.

P575 A new tool for the surveillance of Crohn's perianal fistulae

Background: Magnetic Resonance Imaging (MRI) is the tool used to assess response to medical therapy for the treatment of perianal Crohn’s fistulae. Quantifying fistula volumes would be more beneficial than relying on subjective MRI reports. We aim to use computer software and MRI segmentation to design 3D models of fistula tracks and measure baseline and post-biologics treatment fistula volumes. Methods: Ten baseline and post-biologics MRI images of Crohn’s perianal fistulae were randomly selected. Three-Dimensional fistula models were independently created by a surgeon and radiologist • Manual fistula volumes were calculated for each patient and the results compared • Data were obtained on Perianal Disease Activity Index (PDAI) scores, clinical and radiological healing for these patients. Data were analysed using Spearman’s correlation to determine whether a change in fistula volume over a one-year period correlated with a change in PDAI score over the same time period. Fistula volumes and PDAI score were also correlated with degrees of clinical healing. Results: Baseline volumes for the surgeon showed a median of 9766mm3 (IQR 4636, 30980). Post-biologics volumes had a median of 4200mm3 (IQR 2720, 20070). A change in baseline and post-treatment volumes was also observed by the radiologist; the median volume was 9207mm3 (IQR 5132, 21710) for the baseline MRIs and 2872mm3 (IQR 1827, 18830) for the post-treatment ones.