Expert advises: ‘We must treat first’ with Crohn’s perianal fistula complications
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Successful management of Crohn’s perianal fistulas relies on adequate abscess drainage and controlled healing, according to a presenter at the GUILD conference 2022.
“Even though our treatment and, as indicated, surgeries are going down, we are still seeing a high rate of fistulizing and penetrating complications over time. We also know that our durable healing rates of perianal fistula are actually quite poor,” Miguel Regueiro, MD, FACG, AGAF, chair of the Digestive Diseases and Surgery Institute at the Cleveland Clinic, said. “Despite even our aggressive and better therapies, a lot of these patients will fail, and the damage is too far gone, or the tissue destruction has occurred and is continuing to occur.”
From a stepwise standpoint, the approach to initial fistula diagnosis and assessment relies on precise evaluation: Does the patient have a simple fistula or is it complex? In Regueiro’s experience, and in working closely with colorectal surgeons, whether a fistula includes the sphincteric muscles is a defining factor.
“A simple single fistula does not necessarily define Crohn's,” Regueiro advised attendees. “Whereas these complex fistula tracts with deeper abscesses, that's usually a penetrating complication.”
After determining the complexity of the fistula, the next step in management is defining it.
“The most important first aspect to remember, and probably the key take-home point for this entire talk, is that when we see a perianal fistula it is often associated with an abscess or some infectious complication that we must treat first,” Regueiro said. “If we don't treat it first and adequately, that's when you get a lot of tissue destruction, damage and stricturing, and these are the diseases where the damage is too far gone for us to achieve resolution.”
Following the use of imaging modalities such as MRI, options for therapy vary; Regueiro suggested an effective first step is combination therapy with setons, which prevent premature closure of fistula openings, and biologics, including infliximab, adalimumab and certolizumab. Additional management strategies include surgical treatment, antibiotics and immunosuppressives.
“Crohn's fistulas are notoriously difficult to treat,” Reguerio concluded. “I think this is one of the most challenging areas that we have, and although we're making advancements it's still a difficult time. ... We need to heal the inflammation and when inflammation is healed, the question is do we have other approaches.
“Stem cell therapy, especially for the tracks that aren't closing despite our best efforts with medical therapy, is probably the way of the future, but we still need to wait on the data and the trials to be completed.”
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Regueiro, M. Presentation: How I do it – Management of perianal fistula. Presented at: GUILD 2022; Feb. 20-23, 2022 (hybrid meeting).
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