Amy Lightner, MD, Presents on Perianal Crohn Disease Today and Tomorrow

“We all know that perianal Crohn’s disease is phenotype of Crohn’s that’s really difficult to treat. It affects about 25-30% of our patients, and interestingly it’s very variable in its phenotype and presentation,” Dr Amy Lightner said in opening her presentation on “Perianal Crohn’s Disease Today and Tomorrow” at the Advances in Inflammatory Bowel Disease virtual regional meeting.

Amy Lightner, MD, is a colorectal surgeon at the Cleveland Clinic in Cleveland, Ohio.

“Part of the difficulty with getting an anal fistula to heal is, how do you expect a medication to close an anatomic defect? Some medications that we use, like antibiotics, immune modulatory agents, biologics … they are quite effective in symptom control and reducing inflammation, but you’re still left with a defect—this is why over 90% of these patients will end up coming to a colorectal surgeon,” Dr Lightner continued.

She also expressed the importance of balancing communication and treatment between the gastroenterologist and the surgeon to approach perianal fistula disease in a multimodal fashion.

“One of the most common things we do is incision and drainage of abscess,” which is usually the symptom of a fistula, Dr Lightner explained. “If there is a fistula there, it needs to be controlled with a seton or with a drain so that it prevents an abscess.”

“The most common thing we do with perianal Crohn’s, as a surgeon, is place setons. And the idea of seton placement is to allow for drainage and prevent sepsis or an abscess from building up,” Dr Lightner explained. She said the most common question is “How long do we leave these setons in? Which can be difficult to answer,” She explained that it varies by patient, depending on therapy induction, symptoms, chronic long-standing disease, communication, and other factors. “This becomes a little bit of a gray area and requires ongoing discussion,” she continued.

Dr Lightner stated that Fibrin glue and fistula plugs are usually ineffective. “These plugs are not effective in treating perianal Crohn’s, and largely not used,” she explained. Another therapy, a fistulotomy, can be effective in very specific circumstances, Dr Lightner explained, adding, “it’s not something we use often with our patients,” Dr Lightner continued.

Although the mucosal advancement flap can be effective in non-Crohn’s patients (60-80%), Dr Lightner stated that is has lower efficacy in Crohn’s patients, who may have more than 1 fistula tract and rectal or anal canal involvement. Ligation of intersphincteric fistula tract was another surgical remedy discussed, and displayed with video presentation, which is again only effective within a limited patient population.

Dr Lightner also explained how proctitis can change management of the disease, as surgical performance can be limited. “These are the patients that may require diversion—these are the patients that we are limited with what we can do,” she explained.

She also discussed the effectiveness of stem cells, and the minimal invasiveness of mesenchymal stem cells (MSCs.) “MSCs are safe. No trial has reported systemic complications, and no trial has reported systemic infections. There has been some abscess formation (5-13%) at the injection site, but the dropout rate is low—certainly safe,” Dr Lightner reported.

Healing with MSCs is sustained, “and interestingly, even though the patients only received 1 dose of cells, at times 0 at the treatment date, this efficacy was maintained out to 1 year,” she explained. “It offers a novel approach which seems to be quite effective. So safe, outpatient, minimal pain, and we’re seeing it’s quite effective.”

Dr Lightner concluded by reiterating the fact that perianal fistulas are notoriously difficult to treat, and the optimal treatment practice is multidisciplinary. “It really takes a team working to treat the patient to optimize their understanding of outcomes, and manage expectations,” she said. “We really need to understand their symptoms, expectations, and how we can best treat them. It’s difficult because many different treatment options are limited efficacy, but stem cell therapy may be more commonly utilized in the future. It’s a promising new therapy, and we will have to see what the data shows in the next year or two.”

—Angelique Platas

Lightner A. Perianal Crohn’s disease today and tomorrow. Presented at: Advances in Inflammatory Bowel Disease regional meeting. August 7, 2021. Virtual.