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Yamamoto-Furusho JK, López-Gómez JG, Bosques-Padilla FJ, Martínez-Vázquez MA, De-León-Rendón JL. First Mexican Consensus on Crohn's disease. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:280-311. [PMID: 38762431 DOI: 10.1016/j.rgmxen.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown. OBJECTIVE The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico. MATERIAL AND METHODS Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement. RESULTS The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established. CONCLUSIONS Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - J G López-Gómez
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Centro Médico Nacional 20 de Noviembre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - F J Bosques-Padilla
- Departamento de Gastroenterología, Hospital Universitario de la Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - J L De-León-Rendón
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Coloproctología, Hospital General de México, Mexico City, Mexico
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Lin C, Lin H, Chen H, Chen N, Shih I, Hung J, Yueh T, Chiang F, Lin P, Tsai Y, Wei S. Perioperative optimization of Crohn's disease. Ann Gastroenterol Surg 2022; 7:10-26. [PMID: 36643355 PMCID: PMC9831910 DOI: 10.1002/ags3.12621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/07/2022] [Indexed: 01/18/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disease mainly affecting the gastrointestinal tract. With the increased availability of modalities in the last two decades, the treatment of CD has advanced remarkably. Although medical treatment is the mainstay of therapy, most patients require surgery during the course of their illness, especially those who experience complications. Nutritional optimization and ERAS implementation are crucial for patients with CD who require surgical intervention to reduce postoperative complications. The increased surgical risk was found to be associated with the use of corticosteroids, but the association of surgical risk with immunomodulators, biologic therapy, such as anti-TNF mediations, anti-integrin medications, and anti-IL 12/23 was low in certainty. Decisions about preoperative medication must be made on an individual case-dependent basis. Preoperative imaging studies can assist in the planning of appropriate surgical strategies and approaches. However, patients must be informed of any alterations to their treatment. In summary, the management of perioperative medications and surgery-related decision-making should be individualized and patient-centered based on a multidisciplinary approach.
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Affiliation(s)
- Chun‐Chi Lin
- Division of Colon & Rectal Surgery, Department of SurgeryTaipei Veterans General HospitalTaipeiTaiwan,Department of Surgery, Faculty of Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Hung‐Hsin Lin
- Division of Colon & Rectal Surgery, Department of SurgeryTaipei Veterans General HospitalTaipeiTaiwan,Department of Surgery, Faculty of Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Hui‐Chuen Chen
- National Taiwan University Hospital, Dietetics DepartmentTaipeiTaiwan
| | - Nai‐Chia Chen
- National Taiwan University Hospital, Dietetics DepartmentTaipeiTaiwan
| | - I‐Lun Shih
- Department of Medical ImagingNational Taiwan University HospitalTaipeiTaiwan,Department of Radiology, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Ji‐Shiang Hung
- Division of Colorectal Surgery, Department of SurgeryNational Taiwan University Hospital and College of MedicineTaipeiTaiwan
| | - Te‐Cheng Yueh
- Division of Colon and Rectal SurgeryTaichung Armed Forces General HospitalTaichungTaiwan,National Defense Medical CenterTaipeiTaiwan
| | - Feng‐Fan Chiang
- Division of Colorectal Surgery, Department of SurgeryTaichung Veterans General HospitalTaichungTaiwan,Department of Food and NutritionProvidence UniversityTaichungTaiwan
| | - Ping‐Wei Lin
- Division of colorectal surgery, Department of SurgeryMackay Memorial HospitalTaipeiTaiwan
| | - Yuan‐Yao Tsai
- Department of Colorectal SurgeryChina Medical University HospitalTaichungTaiwan
| | - Shu‐Chen Wei
- Division of Hepatology and Gastroenterology, Department of Internal MedicineNational Taiwan University Hospital and College of MedicineTaipeiTaiwan
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3
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Nazari H, Naei VY, Tabasi AH, Badripour A, Akbari Asbagh R, Keramati MR, Sharifi A, Behboudi B, Kazemeini A, Abbasi M, Keshvari A, Ahmadi Tafti SM. Advanced Regenerative Medicine Strategies for Treatment of Perianal Fistula in Crohn's Disease. Inflamm Bowel Dis 2022; 28:133-142. [PMID: 34291798 DOI: 10.1093/ibd/izab151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Indexed: 12/15/2022]
Abstract
Regenerative medicine is an emerging therapeutic method that aims to reconstruct tissues and organs. This advanced therapeutic approach has demonstrated great potential in addressing the limitations of medical and surgical procedures for treating perineal fistula in patients with Crohn's disease. Recent developments in stem cell technology have led to a massive good manufacturing practices (GMPs) production of various stem cells, including mesenchymal and embryonic cells, along with induction of pluripotent stem cells to repair damaged tissues in the fistula. The recent advances in separation and purification of exosomes, as biologic nanovesicles carrying anti-inflammatory and regenerative agents, have made them powerful tools to treat this inflammatory disease. Further, tremendous advances in nanotechnology, biomaterials, and scaffold fabrication methods enable tissue engineering methods to synthesize tissue-like structures to assist surgical techniques. This review focuses on advanced regenerative-based methods including stem cell therapy, exosome therapy, and tissue engineering used in the treatment of perianal fistula. Relevant in vitro and in vivo studies and the latest innovations in implementation of regenerative medicine for this disease are also separately reviewed. Additionally, current challenges regarding implementation of g stem cells, exosomes, and tissue engineering methods for bridging the gaps between laboratory findings and clinic application will be discussed.
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Affiliation(s)
- Hojjatollah Nazari
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Advanced Technologies in Cardiovascular Medicine, Tehran Heart Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Yaghoubi Naei
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Asieh Heirani Tabasi
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.,Department of Cell Therapy and Hematology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Abolfazl Badripour
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Akbari Asbagh
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Keramati
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirsina Sharifi
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Behboudi
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemeini
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amir Keshvari
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Lee JL, Yoon YS, Yu CS. Treatment Strategy for Perianal Fistulas in Crohn Disease Patients: The Surgeon's Point of View. Ann Coloproctol 2021; 37:5-15. [PMID: 33730796 PMCID: PMC7989558 DOI: 10.3393/ac.2021.02.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Perianal fistula is a frequent complication and one of the subclassifications of Crohn disease (CD). It is the most commonly observed symptomatic condition by colorectal surgeons. Accurately classifying a perianal fistula is the initial step in its management in CD patients. Surgical management is selected based on the type of perianal fistula and the presence of rectal inflammation; it includes fistulotomy, fistulectomy, seton procedure, fistula plug insertion, video-assisted ablation of the fistulous tract, stem cell therapy, and proctectomy with stoma creation. Perianal fistulas are also managed medically, such as antibiotics, immunomodulators, and biologics including anti-tumor necrosis factor-alpha agents. The current standard treatment of choice for perianal fistula in CD patients is the multidisciplinary approach combining surgical and medical management; however, the rate of long-term remission is low and is reported to be 50% at most. Therefore, the optimum management strategy for perianal fistulas associated with CD remains controversial. Currently, the goal of management for CD-related perianal fistulas are controlling symptoms and maintaining long-term anal function without proctectomy, while monitoring progression to anorectal carcinoma. This review evaluates perianal fistula in CD patients and determines the optimal surgical management strategy based on recent evidence.
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Affiliation(s)
- Jong Lyul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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5
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Long-term healing after complex anal fistula repair in patients with Crohn's disease. Tech Coloproctol 2020; 24:833-841. [PMID: 32537672 DOI: 10.1007/s10151-020-02238-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/13/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Complex anal fistula in Crohn's disease (CD) poses a challenging problem. We sought to evaluate long-term surgical healing of complex anal fistula in CD through the two robust repair options-ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF). METHODS A single-center retrospective study was conducted evaluating long-term healing rates in patients with CD with complex anal fistula undergoing LIFT or AF in 2008-2018. Fistula healing was defined as closure of external wounds, cessation of drainage and absence of pain. Short-term and long-term healing rates were compared. Cox proportional hazards model was performed to identify independent predictors of fistula healing. RESULTS The study cohort included 60 CD patients undergoing LIFT (n = 38) or AF (n = 22). The AF group included 8 dermal flaps. Patients having LIFT were younger (35 years vs 43 years; p = 0.007), more likely to have a seton at the time of repair (92% vs 68%; p = 0.03) and less likely to have had prior repair attempts (34% vs 68%; p = 0.02). Short-term fistula healing occurred in 65% (n = 39) of the overall study cohort. However, at final follow-up, median 36 months (range 6-192 months), only 46% (n = 28) of repaired fistulas were healed. Considering the overall status of the cohort's perianal health at final follow-up, including both repaired, secondary or novel anal fistulas, only 50% (n = 30) of all patients in the cohort had all fistula sites healed and maintained bowel continuity at final follow-up. On Cox proportional hazards analysis, LIFT independently predicted long-term fistula healing (hazard ratio 2.3; 95% confidence interval 1.1-4.9; p = 0.03). Only a small number of patients (n = 5; 8%) required fecal diversion (n = 3) and/or proctectomy (n = 2). CONCLUSIONS Repair of complex anal fistula in CD results in modest healing rates. LIFT independently predicts long-term healing. However, these results must be taken in context, considering differences in patient and fistula characteristics between groups. These results ought to be kept in mind when counseling CD patients with complex anal fistula.
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Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A, Ellul P, Fiorino G, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gisbert JP, Gomollon F, González Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Kucharzik T, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B, Zmora O. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2020; 14:155-168. [PMID: 31742338 DOI: 10.1093/ecco-jcc/jjz187] [Citation(s) in RCA: 273] [Impact Index Per Article: 68.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Alessandro Armuzzi
- IBD Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS - Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland; Department of Human Medicine, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | | | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa', IIS Aragón, CIBEREHD, Zaragoza, Spain
| | | | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Sub-department of Gastroenterology and Hepatology, University Hospital Bratislava and Faculty of Medicine, Comenius University Bratislava, Slovakia
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal Medicine, Riga Stradiņš University, Riga, Latvia
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Faculty of Medicine, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
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Abstract
Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.
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Affiliation(s)
- Adam Truong
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA.
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