Background: There is no clear consensus on the management of Crohn's disease related perianal fistulae (CD-PAF) in paediatric and adolescent onset CD due to paucity of data on management approaches. We aimed to evaluate therapeutic interventions and their efficacy in a multicentre cohort with paediatric and adolescent onset CD-PAF.
Methods: 7 centres in Europe participated in the study. Patients with paediatric and adolescent onset CD-PAF diagnosed since 2010 with followup of at least 6 months since onset of CD-PAF were included. Patients with non-fistulising perianal CD and those with rectovaginal or recto-vesical fistulas were excluded. Data were collected on demographics, clinical variables, pelvic MRI and surgical interventions. Complete clinical fistula healing was defined as the absence of any draining fistulas on clinical examination. Reinterventions were defined as the need for repeat abscess drainage, seton reinsertion, diverting stoma or proctectomy. Univariate and multivariate analysis was done for predictors of fistula healing and reintervention.
Results: 116 patients were included (74 boys and 42 girls). The mean age at diagnosis of fistula was 12.9 years. MRI was done in 85 of the patients with complex fistula in 57 (67%). Proctitis was evident at presentation in 33%. 55% had an abscess drainage but only 17 having a seton inserted. After onset of CD-PAF there was significant increase in the use of biologics (13.7% before and 83% after) and immunosuppressant (29% before and 80% after). Antibiotics were used 67% of the patients with median number of courses being 4 (range 1–8). Clinical fistula healing data was available in 78 patients of which 55 had complete and 18 had partial healing. There was significant difference in healing based on type of fistula (simple fistula 78%, complex fistula 26%, p=0.001). Follow up MRI scan (n=40) demonstrated partial healing in 29 and but complete healing in only 6 patients. Anti TNFs were continued in majority (86) of the patients. In the 10 patients stopping anti TNFs (6 – planned withdrawal, 4 – patient preference), 7 had recurrence of perianal fistula. Repeat surgical intervention was required only in 16% of the patients (repeat EUA and abscess drainage – 9, diverting stoma = 3 and reinsertion of seton = 2). Complex fistula type (p=0.015), those with proctitis (p=0.04) and those needing abscess drainage (p=0.02) were more likely to need reintervention and patients with anti TNF therapy (0.01) less likely to need repeat surgery.
Conclusions: Perianal fistula in paediatric onset CD is managed with combined medical and surgical management in majority of patients. Significant proportion of patients had complete or partial clinical healing. Repeat surgical intervention in CD-PAF is only required in 16% of the patients.