A new protocolised treatment strategy optimising medical and surgical care leads to improved healing of Crohn's perianal fistulas

Background & aims: Crohn's perianal fistula healing rates remain low. We evaluated the efficacy of a protocolised multidisciplinary treatment strategy optimising care in adults with Crohn's perianal fistulas.

Methods: A new treatment strategy was established at a single tertiary centre. The strategy comprised three dynamic stages of care directed towards achieving and maintaining fistula healing. Stage A, active disease, focused on early commencement and proactive escalation of biologic therapies and structured surgical reviews ensuring adequate fistula drainage and conditioning. Stage B, optimised disease with a seton in situ, focused on consideration for seton removal and appropriateness of definitive surgical closure and/or ablative techniques. Stage C, healed disease, focused on proactive care maintenance. Sixty patients were sequentially enrolled and prospectively followed for ≥12 months. Endpoints included clinical healing and radiologic remission in those with clinically active fistulas, and relapse in those with healed fistulas.

Results: At baseline, 52% (n=31) and 48% (n=29) had clinically active and healed fistulas, respectively. For patients with clinically active fistulas, 71% achieved clinical healing after 22 months, with estimated healing rates of 39% and 84% at 1 and 2 years, respectively. Radiologic remission was achieved in 25%, significantly higher than baseline inclusion rates of 6%. For patients with healed fistulas, 7% experienced clinical relapse after 23 months, with no significant change in radiologic remission, 80% versus 86% at baseline.

Conclusions: A protocolised treatment strategy proactively optimising care resulted in high rates of clinical healing and improved radiologic remission of Crohn's perianal fistulas. Controlled-matched studies are needed.