The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials

Abstract

Fistulizing Crohn’s disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30–50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.

Evaluation of the Cutting Seton Technique in Treating High Anal Fistula

“…The study demonstrated comparable success rates between the two groups, with non-cutting seton showing a lower risk of fecal incontinence. These findings suggested that non-cutting seton techniques can be an effective treatment option for high anal fistulas while mitigating the risk of adverse functional outcomes [ 8 ]. This study aims to evaluate the outcomes of surgical interventions using the cutting seton technique in managing high anal fistulas at a hospital in Al-Madinah.…”

A complex presentation and successful management of fistulizing perianal Crohn’s disease extending to the mid-back

“…Patients with CD often have aggressive fistulizing perianal phenotypes that result in higher rates of surgery, hospitalizations and corticosteroid dependence as compared with the general population [ 6 ]. Unfortunately, there is a lack of convincing data on fistulizing CD; medical and surgical approaches can vary widely in clinical practice [ 7 , 8 , 9 ]. An aggressive approach to complex anal fistulas involving the sphincters may increase the risk of fecal incontinence; these fistulae often persist or recur if primary tracts and secondary extensions are not fully drained [ 9–11 ].…”

“…Conversely, seton treatment alone is associated with a fistula recurrence rate of up to 47%. In CD patients who have undergone fistulotomies after failure of medical management, fecal incontinence is reported in ~60% of patients [ 7 ].…”

“…A combination of surgical and medical treatment can yield complete fistula remission in 62% of patients as compared with 43% with monotherapy [ 7 ]. Critically, this also involves coordinating multidisciplinary care across specialists in gastroenterology, infectious disease, nutrition and navigating the complex social and psychological barriers that are common in patients with poor access to care.…”

Is surgery necessary for colonic fistulas and psoas abscesses in patients with Crohn's disease? A case report

“…Infliximab can be used early under the premise of infection control, and it is best to maintain long-term treatment, but it is not recommended to use it together with steroids. According to a meta-analysis of 15 observational studies [18] , the risk of serious infection increased with the combination of anti TNF and corticosteroids (in four cohorts; RR, 1.64; 95 % CI, 1.33–2.03).…”