Complex Perianal Fistulas and Crohn's Disease - Management Algorithm
Factors for Operative Strategy
• Fistula Classification and Location
• Sphincter Involvement
• Active Abscess
• Failure of Medical Tx/Prior Op Tx
• History of Incontinence
• Active Proctitis
Horseshoe Abscess*
• Commonly refractory to standard drainage techniques & diversion
• Modified Hanley Procedure: sphincter- preserving multifaceted drainage
o Consider large penrose drain
o Prolonged post-op care
TDM & IFX **
• IFX TL target > 15mcg/ml if no response to standard dosing for PAF
VDZ/UST & PAF **
• ENTERPRISE: 43% pts. with PAF closure @ week 30 in DB-RCT of two VDZ arms
• GETAID BIOLAP: MCT cohort studies: UST success (38.5%) > VDZ success (22.5%)
Patient Experience
• 66% patients report that pain or chronic/relapsing symptoms most impacted physical/emotional health/QOL
• 25% report inadequate emotional support
• Pt. report that emotional, social, body image, relational impact of perianal disease often overlooked by clinicians
• Pt. report feeling stigmatized, ashamed b/o their perianal disease
Algorithm by Dr. Waseem Ahmed @Waseem_AhmedMD
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