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P186. Treatment of perianal disease in Crohn's disease: Efficacy and safety of a multidisciplinary approach in a tertiary referral centre

G. Solina1, A. Orlando2, S. Renna2, F. Mocciaro2, F. Gioia3, M. Olivo2, G. Rizzuto2, E. Sinagra2, M. Cottone2

1Department of Surgery, “Villa Sofia-V. Cervello” Hospital, Palermo, Italy; 2Department of Medicine, “Villa Sofia-V. Cervello” Hospital, Palermo University, Palermo, Italy; 3Department of Radiology, “Villa Sofia-V. Cervello” Hospital, Palermo, Italy

Aim: Perianal disease affect up to 20%-30% of Crohn's disease (CD) patients. Its management is often difficult needing radiological, surgical and medical approach. The aim of this study is to report the experience of a multidisciplinary team in management of perianal CD.

Materials and Methods: We prospectively enrolled 40 CD patients with perianal involvement. All the patients were evaluated simultaneously by an experienced surgeon and three gastroenterologists with the help of a trained radiologist. We performed each visit in a dedicated outpatients clinic specializing in inflammatory bowel disease (IBD). We evaluated the rate of healing after surgical and medical treatment of perianal disease. We evaluated also the rate of adverse events, the efficacy/safety of biological treatment in complex perianal disease.

Results: Twenty-six male and 14 female (mean age of 35 years, range 14–60), followed-up for a mean of 22.3 months (range 4–62) were evaluated. Site of CD was: jejuno-ileal in 13 patients, ileo-colonic in 17 and colonic in 10. Nine patients were treated for simple fistula and 31 for complex perianal disease (5 inter-sphincteric fistulas, 24 trans-sphincteric fistulas and 2 perianal abscesses) for a total of 180 surgical procedures. All patients with complex perianal disease were evaluated with surgical inspection and with pelvic MRI before surgical treatment. Simple fistulas were treated with fistulotomy, complex perianal fistulas with partial fistulectomy/fistulotomy and loose seton drenage of the sphinterial tract, and abscesses with surgical drainage. After surgical treatment simple fistulas and abscesses were treated with antibiotics. In complex fistulas, after healing of septic disease and setons placement: 16 patients were treated with biologics (infliximab or adalimumab), 1 with azathioprine, 12 with antibiotics (at least 2 months). Simple fistulas and perianal abscesses resolved with a single procedure. Regarding complex fistulas: setons were removed in 16 patients, in 12 setons are still in situ, while 1 underwent major surgery (Miles procedure). After setons removal, 14/16 (87.5%) patients achieved a complete fistula closure while the others underwent ileostomy. Nine of the 14 responders were been treated with biologics. At the end of the follow up from the setons removal (mean: 17.8 months, range 1–55) 12/14 (85.7%) maintained the fistula healing while only 2/14 (14.3%), one of which treated with biologic, experienced a clinical and surgical recurrence. No major adverse event were observed.

Conclusion: Our experience, although in a small number of patients, confirms that a multidisciplinary approach by a dedicated team experienced in the treatment of IBD, is the best and safe approach in the management of patients with simple or complex perianal disease, and that the biological therapy is effective in the treatment of complex perianal disease after surgery.