ECCO IBD Curriculum
9.2. Is aware of the importance of joint medical-surgical management of complex fistulae, and of nutritional support for high output fistulae
This course has been developed by physicians who had recently participated in the writing of the ECCO Crohn's disease consensus Guidelines. This course is intended for those who are interested in Inflammatory Bowel Disease(s) (IBD). One major aim of this e-learning activity is to increase competence and knowledge with regard to Luminal disease in order to improve patient outcomes.
Upon completion of this case you will:
- Know the evidence for induction of remission in mild-to-moderate Crohn’s disease;
- Know the evidence for maintaining remission in Crohn’s disease;
- Know the evidence on how to react upon disease flares, immediately after induction therapy or during maintenance therapy;
- Understand the benefits and risks of several medical therapies;
- Achieve familiarity how to use immunomodulatory agents in mono- or combination therapy;
- Achieve familiarity how to monitor Crohn’s disease patients who initiated medical therapy or who underwent surgery;
- Recognise indications for surgical management.
This course has been developed for gastroenterologists, surgeons, paediatricians, pathologists and other interdisciplinary medical experts interested in Inflammatory Bowel Disease(s) (IBD). One major aim of this e-learning activity is to increase competence and knowledge with regard to the management of CD patients and to harmonise indications and technical considerations for surgery in order to improve patient outcomes.
Upon completion of this activity learners will:
- - Know how to identify surgical indications in patients with Crohn's Disease (CD)
- - Be able to adequately treat different complications in CD patients that require surgery
- - Be able to recommend appropriate changes in perioperative treatment and management
This presentation will provide an overview of current surgical management of IBD with a focus on abdominal and perianal manifestations and treatment of colitis ulcerosa and Crohn's disease, capitalizing on the most recent ECCO guidelines.
Perianal manifestation in Crohn’s disease patients is likely to complicate the disease course with extra intestinal manifestations, abscesses, deep anal canal ulcers, luminal fistulas and strictures, steroid resistance, and need for multiple surgeries. Diagnosis and management of perianal Crohn’s disease implies a multidisciplinary team approach. Diagnosis and definition of perianal disease requires optimal imaging modality, ideally a pelvic magnetic resonance imaging, with an exam under anesthesia (EUA). However, the lack of a definition consensus on perianal fistula in Crohn’s disease may affect standardization of therapeutic approaches and patients inclusion within clinical trial.
The synergic approach by a surgeon and a gastroenterologist is crucial with perianal Crohn’s disease. Drainage of an abscess and possible seton placement to prevent future septic complications is the basic first step of the treatemnt. Ani-TNF drug have shown the best evidence for decreasing perianal drainage and promote fistula healing. Attempting surgical repair is possibile for selected patients. Surgical strategies include subcutaneous fistulotomy, Ligation of the Intersphincteric Tract (LIFT) procedure, or endorectal advancement flap (ERAF). These surgical strategies work best when associated with anti-TNF or immunomodulation and when mild to moderate proctitis is present. More aggressive interventions include diversion of the fecal stream with loop ileostomy and proctectomy; Mesenchymal stem cells have emerged as possible effective treatment and long term results have been demonstrated by randomized clinical trial.