Endoscopic therapy for Crohn’s fistula and abscess

Post written by Bo Shen, MD, FASGE, from the Interventional IBD Unit, the Cleveland Clinic Foundation, Cleveland, Ohio.

Shen_headshotTreatment of disease-related or surgery-related Crohn’s fistula, abscess, and surgical anastomotic leaks with endoscopy-guided fistulotomy and sinusotomy with electroincision, seton placement, through-the-scope or over-the-scope clipping, suturing, incision and drainage.

Crohn’s disease has 3 phenotypes: inflammatory, structuring, and fistulizing. The 3 phenotypes are interconnected. Chronic mucosal and transmural inflammation can lead to complications including stricture, fistula, and abscess, or anastomotic leak, if surgery takes place. The treatment of Crohn’s disease or inflammatory bowel disease traditionally consists of medical and surgical therapy. There are pros and cons of medical (less invasive and effective) vs surgical (more effective, with high risk for postsurgical complications and disease recurrence) therapy for Crohn’s disease. Endoscopic therapy is more effective than medical therapy and less invasive than surgical therapy in eligible patients. In addition, endoscopic therapy can be used in combination with medical and surgical treatment.

Shen_fig
Fistula and abscess represent penetrating disease phenotypes of Crohn’s disease (CD) and can develop in patients with or without prior history of CD-related surgery. While CD fistula and abscess have been traditionally treated with medical and surgical therapy, the role of endoscopic therapy in this particular phenotype of CD is expanding recently, thanks to advanced endoscopic techniques and a better understanding of pathogenesis and natural history of the disease and principle of treatment. The success of endoscopic treatment for inflammatory bowel disease depends on comprehension and appreciation of principles, then techniques, followed by instrument and device. Attempts should be made to temporarily or permanently close the feeding side (or the primary) orifice at the gut, by various forms of clipping. Endoscopic fistulotomy is feasible, particularly for perianal fistula and surgery-associated distal bowel fistula. Perianal abscess can be treated with endoscopic incision and drainage and even seton placement. Endoscopic treatment for fistula and abscess as well as for stricture has become an important part of the multidisciplinary approach to complex CD.

In this article, the author reviewed current literature and described techniques of main endoscopic treatment modalities used in the Interventional IBD (i-IBD) Unit, including endoscopic fistulotomy, endoscopic sinusotomy, endoscopy clipping, endoscopy-guided seton placement, and incision and drainage at endoscopy suite. This author also described the precautions to minimize procedure-associated complications. The techniques, however, still need modification and perfection. For example, current endoscopic clipping techniques and device are not very effective in treating disease-associated fistula in Crohn’s disease, despite the promising results in anastomotic leak. However, it is foreseeable that endoscopic therapy will play a growing role in multidisciplinary approach to complex inflammatory bowel diseases (IBD). The article may generate interest among the advanced endoscopy community and IBD community. Professional societies, such as ASGA, AGA, ACG, and Crohn’s Colitis Foundation, may create a task force to further explore endoscopic treatment, not only in fistula and abscess, but also in other IBD complications (such as stricture, bleeding, and colitis-associated neoplasia).

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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