P946 Real life management of patients with active perianal fistulizing Crohn’s disease (ALERT-CD study)
Authors: Bak M , Stassen L , Buskens C , Pronk A , van der Bilt J , Gecse K , de Boer N , Witjes C , Fitzpatrick C , Nissen L , Verdaasdonk E , Pierik M , Breukink S , Gillissen L , Bloemen J , West R , Kortekaas R , Mares W , de Jong G , Jansen S , Bloemendaal B , Sikkema M , Zimmerman D , Peeters K , van der Meulen- de Jong A , van Schaik F , Richir M , van Dongen K , Duijvestein M , Hoogenboom F , Visschedijk M , de Vries A , van Ruler O 
Published: January 2024

Abstract

Background
The multitude of medical and surgical treatment options for perianal fistulizing Crohn’s disease (pCD) impels differences in management. This study aimed to assess management of pCD in current clinical practice in the Netherlands.

Methods
Patients with active pCD (i.e. visible external fistula opening or patent fistula tract on imaging) were included in a prospective multicenter cohort study in 41 Dutch academic and non-academic hospitals from September 2022 to March 2023. pCD-related clinical, radiological and surgical data were prospectively collected during a follow-up period of 6 months and retrospectively collected from pCD diagnosis until inclusion. Primary outcome of the study was adherence to the international guidelines on pCD management during the disease course (from pCD diagnosis until end of follow-up). Adequate adherence was defined as (I) imaging for pCD diagnosis using magnetic resonance imaging (MRI) and/or endo-anal ultrasound (EUS), (II) endoscopic evaluation of concomitant proctitis, (III) use of antibiotics for symptomatic response, (IV) initiation of an anti-tumour necrosis factor (TNF) agent for maintenance therapy, (V) fistula surgery aiming at fistula closure in case of surgically amendable disease and (VI) decision making by a multidisciplinary team (gastroenterologist and surgeon)(Figure 1).

Results
449 patients with active pCD (52% female) were included(Table 1). At inclusion, median age and median pCD duration were 37.2 years (IQR 28.8–49.4) and 3.1 years (IQR 1.1–7.1). 54% of patients were treated in a non-academic hospital. 89% of patients were treated with CD medication, which concerned anti-TNF agents in 82% of these patients. As recommended by guidelines, a MRI (99%) and/or EUS (9%) were performed in the vast majority of patients (97%) for pCD diagnosis. Following diagnosis, endoscopy was performed in 81% of patients. During the disease course, antibiotics were initiated in 55% of patients and at least one anti-TNF agent(s) was started in 84% of patients for maintenance therapy (73% infliximab, 53% adalimumab, 26% both agents). Surgery aiming for fistula closure was performed in 38% of patients during the disease course. 60% of patients were discussed in a multidisciplinary team (MDT).

Conclusion
This study demonstrated a high adherence to international guidelines on pCD management concerning imaging at diagnosis, endoscopic evaluation for concomitant proctitis and treatment with anti-TNF agents. Adherence to use of antibiotics for symptoms, performance of fistula surgery aiming at fistula closure and decision making in a MDT is moderate and standardization may optimize pCD management.