Perianal fistula complication of Crohn’s disease: “Treatment is required first”

Successful management of perianal fistulas in Crohn’s disease requires proper abscess drainage and controlled healing, according to presenters at GUILD Conference 2022.

“Despite our treatments and the decline in surgeries that have been noted, there is still a high rate of fistula formation and penetrating complications occurring over time. We also know that the cure rate is actually very low.” Dr. Miguel Regueiro, FACG, AGAF, said the director of the Cleveland Clinic’s Gastroenterology and Surgery Institute. “Despite our aggressive and better treatments, many of these patients fail and the damage has already progressed or tissue destruction has occurred and continues to occur. I am.”

From a staged perspective, the initial approach to fistula diagnosis and evaluation depends on an accurate assessment of whether the patient’s fistula is simple or complex. In Regueiro’s experience, and working closely with colorectal surgeons, the deciding factor is whether the fistula involves a sphincter.

“A simple single fistula does not necessarily define Crohn’s disease,” Regueiro advised attendees. “These complex fistulas are associated with deeper abscesses, which are usually penetrating complications.”

Once the complexity of the fistula has been identified, the next step in management is to define the fistula.

“The first and most important aspect to remember, and perhaps the key point of this entire talk, is that when a perianal fistula is seen, it is often an abscess or some kind of infectious complication that must be treated first. ,” Regueiro said. . “If you don’t treat it properly first, a lot of tissue destruction, damage, and narrowing will occur. These diseases are ones where the damage is too advanced to resolve.”

Treatment options change after the use of imaging modalities such as MRI. Professor Regueiro suggested that an effective first step is combination therapy with Seton, which prevents premature closure of the fistula opening, and biologics such as infliximab, adalimumab, and certolizumab. Additional management strategies include surgical treatment, antibiotics, and immunosuppressants.

“Crohn’s disease fistulas are notoriously difficult to treat,” concluded Dr. Regelio. “I think this is one of the most difficult areas we have. We’re making progress, but it’s still a difficult time. … We need to heal inflammation, but Once the inflammation has subsided, the question is whether there are other approaches.

“Stem cell therapy, especially one that does not close the gap despite the best efforts of medical treatments, is probably the way of the future, but we still need to wait for data and clinical trials to be completed.”

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