treatment algorithms in case of perianal complications of ... · treatment algorithms in case of...

InflammationInflammation inin thethe IntestinalIntestinal TractTract: : PathogenesisPathogenesis andand TreatmentTreatmentMayMay 1515––16, 2009 K16, 2009 Kyiyiv, v, UkraineUkraine

Falk Symposium 169

Y. LozynskyY. LozynskyyyLviv National Medical University of Lviv National Medical University of Danylo HalytskyiDanylo HalytskyiDepartment surgery and Department surgery and coloproctologycoloproctology

Lviv, UkraineLviv, Ukraine

Treatment algorithms in case of Treatment algorithms in case of perianal complications of Crohnperianal complications of Crohn’’s s diseasedisease

THE AIM OF THE STUDYTHE AIM OF THE STUDY

ImprovementImprovement thethe algorythmalgorythm ofof thethetreatmenttreatment tacticstactics, , whichwhich wouldwouldincludeinclude modernmodern conservativeconservative andandsurgicalsurgical methodsmethods

VARIOUS TYPES OF PERIANAL LESIONS IN VARIOUS TYPES OF PERIANAL LESIONS IN PATIENTS WITH CROHNPATIENTS WITH CROHN’’S DISEASES DISEASE

SkinSkin tagtagHemorrhoidsHemorrhoidsFissureFissureAnalAnal ulcerulcer

Low fistulaLow fistulaHigh fistulaHigh fistulaRectovaginal Rectovaginal

fistulafistula

Perianal abscessPerianal abscessAnorectal strictureAnorectal strictureCancerCancer

William J Sandborn , Victor W Faziob, Brian G Feagan, Stephen B Hanauer. AGA technical review on perianal Crohn’s disease. Gastroenterology 2003;125:1508-1530

MONTREAL CLASSIFICATION

Resection limited to any colonic location between Resection limited to any colonic location between cecum and rectumcecum and rectum

Resection limited to the terminal ileum (the lower Resection limited to the terminal ileum (the lower third of small bowel)third of small bowel)

Resection proximal to the terminal ileum Resection proximal to the terminal ileum (excluding mouth)(excluding mouth)

Resection limited to the terminal ileum AND any Resection limited to the terminal ileum AND any location between ascending colon and rectumlocation between ascending colon and rectum

R4R4

R3R3

R2R2

R1R1

Site of resections:Site of resections:

P P = Perianal disease modifier is = Perianal disease modifier is defined when concomitant defined when concomitant perianal disease is present. perianal disease is present. Includes perianal fistulas and Includes perianal fistulas and perianal abscesses.perianal abscesses.

Penetrating disease is defined as the occurrence of intraabdominPenetrating disease is defined as the occurrence of intraabdominal or perianal fistulas, inflammatory masses al or perianal fistulas, inflammatory masses and/or abscesses at any time in the course of disease. Perianal and/or abscesses at any time in the course of disease. Perianal ulcers are also included. Excluded are ulcers are also included. Excluded are postoperative intraabdominal complications and perianal skintagspostoperative intraabdominal complications and perianal skintags..

B3B3

Stricturing disease is defined as the occurrence of constant lumStricturing disease is defined as the occurrence of constant luminal narrowing demonstrated by radiologic, inal narrowing demonstrated by radiologic, endoscopic or surgicalendoscopic or surgical--pathologic methods with prestenotic dilatation or obstructive sipathologic methods with prestenotic dilatation or obstructive signs/symptoms witout gns/symptoms witout presence of penetrating disease at any time in the course of dispresence of penetrating disease at any time in the course of diseaseease

B2B2

Inflammatory disease which never has been complicated at any timInflammatory disease which never has been complicated at any time in the course of diseasee in the course of diseaseB1B1

BehaviourBehaviour

Any disease limited to oesophagos, stomach and Any disease limited to oesophagos, stomach and duodenumduodenum

L4L4

Desiase of the terminal ileum with or without spill over Desiase of the terminal ileum with or without spill over into cecum and any location between ascending into cecum and any location between ascending colon and rectumcolon and rectum

L3 L3

Any colonic location between cecum and rectum with Any colonic location between cecum and rectum with no small bowel or upper gastrointestinal (GI)no small bowel or upper gastrointestinal (GI)

L2L2

Disease limited to the terminal ileum (the lower third Disease limited to the terminal ileum (the lower third of the small bowel) with or without spill over into of the small bowel) with or without spill over into cecum.cecum.

L1L1

L=LocationL=LocationThe maximum extent of disesse involvement at any time The maximum extent of disesse involvement at any time before the first resection.before the first resection.Minimum involvement for a location is defined as any Minimum involvement for a location is defined as any aphtous lesion or ulceration. Mucosal erythema and edema aphtous lesion or ulceration. Mucosal erythema and edema are insufficient. For classification at least both, a small are insufficient. For classification at least both, a small bowell and large bowel examination are required.bowell and large bowel examination are required.

Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal Classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006;55:749-53

CDAICDAI

×20

± × 1

± × 6

Number of categories:

×10

×30

±]×100Body weight___Standart weight

[1-Body weight (kg)

±[47 - Ht] [42 - Ht]

Hematocrit: males:females:

CDAI =

0=none2=questionable 5=definite

Abdominal mass

0=No1=Yes

Taking opioid-like drugs for diarrhea?

anal fissure, fistula or abscessother bowel-related fistulafever over 37.5ºC (rectal) during the past week

arthritis/arthralgia iritis/uveitiserythema nodosum/pyoderma gangrenosum/aphthous

stomatitis

Number of the following categories which the patient now has:

×7General well-being – sum of daily scores over the last week

×5Abdominal pain – sum of daily scores over the last week

×2Number of liquid of soft stools in the last week

Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a CBest WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohnrohn’’s disease activity index. s disease activity index. National Cooperative CrohnNational Cooperative Crohn’’s Disease Study . Gastroenterology 1976;70:439s Disease Study . Gastroenterology 1976;70:439--444444

PERIANAL CROHNPERIANAL CROHN’’S DISEASE ACTIVITY INDEXS DISEASE ACTIVITY INDEX

00--44Degree of indurationDegree of induration

00--44Type of perianal diseaseType of perianal disease

00--44Restriction of sexual activityRestriction of sexual activity

00--44Pain/restriction of activitiesPain/restriction of activities00--44DischargeDischarge

ScoreScoreCategories affected by fistulasCategories affected by fistulas

IrvineIrvine EJ. Usual therapy improves perianal CrohnEJ. Usual therapy improves perianal Crohn’’s disease as measured by a new disease activity s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 1995; 20:2index. McMaster IBD Study Group. J Clin Gastroenterol 1995; 20:277--3232

THE THE PARTPART OF THE PATIENTS OF THE PATIENTS WITHWITH THE THE PERIANAL COMPLICATIONSPERIANAL COMPLICATIONS

310310

PERIANAL PERIANAL COMPLICATIONSCOMPLICATIONS

14414446,45%46,45%

NO PERIANAL NO PERIANAL COMPLICATIONSCOMPLICATIONS

16616663,66%63,66%

THE MOST FREQUENT COMBINATIONS THE MOST FREQUENT COMBINATIONS PERIANAL COMPLICATIONSPERIANAL COMPLICATIONS

33Cancer (anal ulcer, strictura, Cancer (anal ulcer, strictura, fistula)fistula)

6161Perianal absceses (skin tag, Perianal absceses (skin tag, fistula, fissura)fistula, fissura)

6060Fissura (haemorroids)Fissura (haemorroids)52 52 Fistula (strictura)Fistula (strictura)

Y.Lozynskyy. The CrohnY.Lozynskyy. The Crohn’’s disease. Treatment of perianal complications.s disease. Treatment of perianal complications. Proctology. 2004; 1: 40Proctology. 2004; 1: 40--41.41.

GENDER DIFFERENCES:GENDER DIFFERENCES:

310310TotalTotal116262Females Females 114848Quantity of patientsQuantity of patients

MalesMalesGenderGender

AVERAGEAVERAGE AGEAGE

32,1 32,1 ±± 8,3 8,3 yearsyears

DURATION OF CROHNDURATION OF CROHN’’S DISEASES DISEASE

9,9 9,9 ±± 5,3 5,3 yearsyears

THE DISPENTION OF THE PATIENTS THE DISPENTION OF THE PATIENTS BY SEVERITY OF THE DISEASEBY SEVERITY OF THE DISEASE

310310TotalTotal145145MildMild113113ModeratModeratee5252SevereSevere

Quantity of patients Quantity of patients with with the diseasethe disease

Severity of Severity of diseasedisease

LOCALIZATION OF THE DISEASELOCALIZATION OF THE DISEASE

310310TOTALTOTAL5959Colon Colon 3737Small intestineSmall intestine6868Colon and small intestineColon and small intestine6565Rectum and ColonRectum and Colon4848Rectum and small intestine Rectum and small intestine 3333

Quantity of the Quantity of the patientspatients

RectumRectum

LocalizationLocalization

METHODS OF EXAMINATIONS:METHODS OF EXAMINATIONS:

Digital rectal and vaginal eDigital rectal and vaginal exxaminationamination (under (under anesthesia)anesthesia)EndoscopyEndoscopy (under anesthesia), Capsule (under anesthesia), Capsule endoscopyendoscopyHistologycalHistologycal examination examination EndorectalEndorectal ultrasonographyultrasonographyMRIMRIXX--ray examination (ray examination (irrigographyirrigography, , fistulographyfistulography))SphincterometrySphincterometryLaboratory examinationLaboratory examination

CLINICAL APPROACH CLINICAL APPROACH FOR TREATMENT OF FISSURESFOR TREATMENT OF FISSURES

ConserConservativevative

OperationOperation

ConserConservativevative

EUA EUA EUSEUSMRIMRI

TreatmentTreatment

Posterizan forte (supp. and Posterizan forte (supp. and liniment )liniment )Salofalk (supp.1g)Salofalk (supp.1g)Metronidazol (gel)Metronidazol (gel)Dioxyzol (emul)Dioxyzol (emul)Sol PovidonumSol Povidonum--Iodum 10%Iodum 10%

Salofalk (supp.,enemas, Salofalk (supp.,enemas, foam foam –– 2g)2g)Dioxyzol (emul)Dioxyzol (emul)Sol PovidonumSol Povidonum--Iodum 10%Iodum 10%Budesonid (Foam Budesonid (Foam 22mg)mg)Metronidasol (gel)Metronidasol (gel)RectoRectogesicgesic0.4%Nitrogliceryn Ung.0.4%Nitrogliceryn Ung.

LocalLocalSystemicSystemic

Salofalk (2g)Salofalk (2g)Ciprofloxacin (600mg)Ciprofloxacin (600mg)EnterolEnterol--250 250 22Azatioprin (2mg/kg)Azatioprin (2mg/kg)

IIIIII

CDAICDAI << 150 150 PCDAIPCDAI ≤≤ 77IIII

Prednizolon (40Prednizolon (40--60mg) or60mg) orSalofalk (3Salofalk (3--44g)g)Azatioprin (2mg/kg)Azatioprin (2mg/kg)Metronidazol (2g)Metronidazol (2g)Ciprofloxacin 600mgCiprofloxacin 600mgEnterolEnterol--250 250 22

DiagnDiagnosticostic

II

TherapyTherapyMethodsMethodsStagesStages

During last 5 years there are any surgical treated patients withDuring last 5 years there are any surgical treated patients with fissurasfissuras

ММaslyakaslyak’’s methods method10%10%


FISSURA EXCISION FISSURA EXCISION BY BY ММASLYAKASLYAK’’S METHODS METHOD

TYPES OF ABSCESSESTYPES OF ABSCESSES

Subcutaneus 36 (32,7%)

Intrasphincteric 14 (12,7%)

Pelviorectal 13 (11,8%)

Іschiorectal 43 (39,2%)

Retrorectal 4 (3%)

CLINICAL APPROACH CLINICAL APPROACH FOR TREATMENT OF PERIANAL ABSCESSESFOR TREATMENT OF PERIANAL ABSCESSES

FAILUREFAILURE

TreatmentTreatmentDiagnosticDiagnostic

EUAEUAEUSEUSMRIMRI

SurgicalSurgical

SurgicalSurgical

ConservativeConservative

Dioxyzol Dioxyzol (emul)(emul)Sol PovidonumSol Povidonum--Iodum 10%Iodum 10%(lavement of the wound)(lavement of the wound)Salofalk (supp.1g)Salofalk (supp.1g)Relif Advance, Betadine (supp) Relif Advance, Betadine (supp) Metronidazol gelMetronidazol gel

LocalLocal

Salofalk (3g)Salofalk (3g)Azatioprin (50mg)Azatioprin (50mg)EnterolEnterol--250250 22Ciprofloxacin 600mgCiprofloxacin 600mgMetronidazol 1.5gMetronidazol 1.5g

SystemicSystemic

IIII

±±Colostomy, Colostomy, ±± EnterostomyEnterostomy,, ProctectomyProctectomyIIIIII

Incision Incision –– drainagedrainageExcision Excision –– drainagedrainageII

TreatmentTreatmentMethodsMethods

StagesStages

±±NonNon--cutting seton, cutting seton, Mushroom catheterMushroom catheter

}


PARAPROCTITISPARAPROCTITIS

Schwartz DA, Pemberton JH, Sandborn WJ. Diagnosis and treatment of perianal fistulas in crohn disease. Ann Intern Med. 2001;135:906–918.

DAY 0DAY 0

WEEK 8WEEK 8

DIFFERENT TYPES OF THE FISTULAS DIFFERENT TYPES OF THE FISTULAS IN PATIENTS WITH CDIN PATIENTS WITH CD

77RRectovaginal ectovaginal 5252TotalTotal

1515Suprasphincteric, transSuprasphincteric, trans-- and and extrasphinctericextrasphincteric

ССomplex:omplex:3030Superficial and intersphinctericSuperficial and intersphincteric

Simple:Simple:QQuantityuantityCharacter of fistulasCharacter of fistulas


Physical Exam for Pain, Fluctuation, StrictureEndoscopic Exam for Rectal Inflammation

EUA + EUS or MRI ifPain, Fluctuation,Stricture Present No Pain, fluctuation

Stricture

Simple* FistulaNo Rectal Inflammation

Complex* FistulaNo Rectal Inflammation

Simple* or Complex FistulaWith Rectal Inflammation

EUA + EUSor MRI

Antibiotics,Azathioprine

Infliximab


Infliimab

EUA + EUSor MRI

EUA + EUSor MRI


Infliximab

FistulotomyConsider

TacrolimusIn Selected

PatientsSeton

Consider TacrolimusIn Selected

Patients

AdvancementFlap

TREATMENT ALGORITHM FOR MANAGING PATIENTSTREATMENT ALGORITHM FOR MANAGING PATIENTSWITH CROHNWITH CROHN’’S PERIANAL FISTULAS S PERIANAL FISTULAS

William J Sandborn , Victor W Faziob, Brian G Feagan, Stephen B Hanauer. AGA technical review on perianal Crohn’s disease. Gastroenterology 2003;125:1508-1530

Physical Exam for Pain, Fluctuation, StrictureEndoscopic Exam for Rectal Inflammation

EUA + EUS or MRI ifPain, Fluctuation,Stricture Present

No Pain, fluctuationStricture

Simple* FistulaNo Rectal Inflammation

Complex* FistulaNo Rectal Inflammation

Simple* or Complex FistulaWith Rectal Inflammation

EUA + EUSor MRI


Infliximab


Infliximab

EUA + EUSor MRI

EUA + EUSor MRI


Infliximab

Fistulotomy NoncuttingSETON

Advancement

FLAP *

Local TreatmentSalofalk, Metronidasolum, Dioxidin+Lidokain, Sol Povidonum-Iodum 10%

Temporary Colostoma *, Enterostoma *. Proctectomy

TREATMENT ALGORITHM FOR MANAGING PATIENTSTREATMENT ALGORITHM FOR MANAGING PATIENTSWITH CROHNWITH CROHN’’S PERIANAL FISTULAS S PERIANAL FISTULAS

FAILUREFAILURE

William J Sandborn et al. 2003 , with changed by Lozynskyy Y., Leoshyk O. 2008

CLINICAL APPROACH CLINICAL APPROACH FOR TREATMENT OF FISTULASFOR TREATMENT OF FISTULAS

OperaOperationtion

ConseConservativervative

OperaOperationtion

ConseConservativervative

EUAEUAEUSEUSMRIMRI

TreatTreatmentment

Dioxyzol (emul) Sol Dioxyzol (emul) Sol PovidonumPovidonum--Iodum 10%Iodum 10%Posterizan forte (supp. and Posterizan forte (supp. and liniment ) liniment ) Salofalk (supp.1g)Salofalk (supp.1g)Metronidazol (gel)Metronidazol (gel)

Salofalk (3g)Salofalk (3g)Azatioprin (50mg)Azatioprin (50mg)Ciprofloxacin (600mg)Ciprofloxacin (600mg)Metronidazol (1.5g)Metronidazol (1.5g)EnterolEnterol--250 250 22

IIIIII

Salofalk (supp.,enemas, Salofalk (supp.,enemas, foam foam –– 3g)3g)Metronidazol (gel) Metronidazol (gel) Dioxyzol (emul)Dioxyzol (emul)Sol PovidonumSol Povidonum--Iodum 10%Iodum 10%(lavement of the fistula)(lavement of the fistula)

LocalLocalSystemicSystemic

CDAICDAI >> 250, 250, PCDAIPCDAI >12>12IVIV

CDAICDAI << 150, 150, PCDAIPCDAI ≤≤ 77IIII

Salofalk (3g)Salofalk (3g)Ciprofloxacin (400)mg Ciprofloxacin (400)mg Metronidazol (1.5g) Metronidazol (1.5g) Azatioprin (50mg)Azatioprin (50mg)EnterolEnterol--250 250 22Infliximab (5 mg/kg week Infliximab (5 mg/kg week 0,2,6)0,2,6)

DiagnDiagnosticostic

II

TherapyTherapyMethodsMethodsStagesStages

Non cutting seton, FistulotomiaNon cutting seton, FistulotomiaAdvancement flapAdvancement flap

Enterostoma, Colostoma, Enterostoma, Colostoma, ProctectomiaProctectomia


IN THE ABSENCE OF ACTIVE PROCTOCOLITIS, SIMPLE LOW IN THE ABSENCE OF ACTIVE PROCTOCOLITIS, SIMPLE LOW TRANSSPHINCTERIC, INTERSPHINCTERIC, AND SUPERFICIAL TRANSSPHINCTERIC, INTERSPHINCTERIC, AND SUPERFICIAL

FISTULAS CAN BE TREATED WITH A FISTULOTOMY. FISTULAS CAN BE TREATED WITH A FISTULOTOMY.

Schwartz DA, Pemberton JH, Sandborn WJ. Diagnosis and treatment of perianal fistulas in crohn disease. Ann Intern Med. 2001;135:906–918.

Not statedNot statedNot statedNot statedNot statedNot stated27(82)27(82)3333Michelassi et al., 2000Michelassi et al., 2000

10(29)10(29)–– 7 proctectomy 7 proctectomy

+3 stoma+3 stomaNot statedNot stated4(18)4(18)21(62)21(62)3434McKee et al., 1996McKee et al., 1996

5(19) 5(19) 3 3 –– proctectomy proctectomy

+2 stoma+2 stoma5(19)5(19)Not statedNot stated22(81)22(81)2727Scott et al., 1996Scott et al., 1996

1(10)1(10)5(50)5(50)4(40)4(40)10(100)10(100)1010Halme et al., 1995Halme et al., 1995

3 patients (9)3 patients (9)7 patients 7 patients (21)(21)Not statedNot stated38 (93)38 (93)4141Williams et al., 1991Williams et al., 1991

Not statedNot stated6(50)6(50)Not statedNot stated1(8)1(8)1212Keightly et al., 1986Keightly et al., 1986

3(15)3(15)Not statedNot stated4(22)4(22)18(90)18(90)3232Hobbis et al., 1982Hobbis et al., 1982

ProctProct--ectomy(%)ectomy(%)

IncontinenIncontinen--ce (%)ce (%)

Recurrence Recurrence (%)(%)Healed (%)Healed (%)No. of No. of

patientspatientsStudyStudy

RESULTS OF CONVECTIONAL FISTULOTOMY RESULTS OF CONVECTIONAL FISTULOTOMY BY LAYING OPEN THE TRACT FOR LOW PERIANAL FISTULAS BY LAYING OPEN THE TRACT FOR LOW PERIANAL FISTULAS

IN PATIENTS WITH CROHNIN PATIENTS WITH CROHN’’S DISEASES DISEASE

3(10) stoma:3(10) stoma:(1 ileostoma)(1 ileostoma)(2 colostoma)(2 colostoma)

2(7) proctectomy2(7) proctectomy

3(10)3(10)55((117)7)25(83)25(83)3030Lozynskyy Y., et al. 2004Lozynskyy Y., et al. 2004

NONCUTTING SETONNONCUTTING SETON

00Not statedNot stated3(50)3(50)3(50)3(50)Transanal Transanal advancement flapadvancement flap66Robertson et al., Robertson et al.,

19981998

2(9)2(9)Not statedNot stated7(27)7(27)19(73)19(73)Transanal Transanal advancement flapadvancement flap2626Joo et al., 1998Joo et al., 1998

00004(20)4(20)16(80)16(80)Transanal Transanal advancement flapadvancement flap2020Makowiec et al., Makowiec et al.,

19951995

Not Not statedstatedNot statedNot stated2(22)2(22)22(22)(22)SetonSeton99Williamson et al., Williamson et al.,

19951995

7(33)7(33)Not statedNot stated1177(63)(63)22(92)22(92)SetonSeton2424Sangwan et al., Sangwan et al., 19961996

3(14)3(14)14(66)14(66)9(47)9(47)19(86)19(86)SetonSeton2222Williams et al., Williams et al., 19911991

ProctProct--ectomy(ectomy(

%)%)

IncontineIncontinence (%)nce (%)

RecurreRecurrence (%)nce (%)

Healed Healed (%)(%)TreatmentTreatmentNo. of No. of

pat.pat.StudyStudy

RESULTS OF TREATMENT OF HIGH OR COMPLEX RESULTS OF TREATMENT OF HIGH OR COMPLEX FISTULAS IN PATIENTS WITH CROHNFISTULAS IN PATIENTS WITH CROHN’’S DISEASES DISEASE

2(50)2(50)002(50)2(50)

Cr rectiCr recti2 (50)2 (50)Non cutting setonNon cutting seton44

2(18)2(18)3(27)3(27)6(55)6(55)5(45)5(45)Transanal Transanal advancement flapadvancement flap1111

Lozynskyy Y., et al. Lozynskyy Y., et al. 20042004

THE THE MMODIFIODIFICATION CATION BY BY ММASLYAKASLYAK’’SS

OFOFJADDJADD--ROBLEROBLE

METHODMETHOD

RESULTS OF SURGICAL TREATMENT OF RECTOVAGINAL RESULTS OF SURGICAL TREATMENT OF RECTOVAGINAL FISTULAS IN PATIENTS WITH CROHNFISTULAS IN PATIENTS WITH CROHN’’S DISEASES DISEASE

1 ileostomy (7)1 ileostomy (7)13(93)13(93)Transvaginal flapTransvaginal flap1414Sher et al., 1998Sher et al., 1998

0000SetonSeton11Michelassi et al., 2000Michelassi et al., 2000

11(69)11(69)4(25)4(25)Transanal advancement Transanal advancement flapflap1616Michelassi et al., 2000Michelassi et al., 2000

003(50)3(50)Transanal advancement Transanal advancement flapflap66

OO’’Leary et al.,1998Leary et al.,1998

0010(83)10(83)Transanal advancement Transanal advancement flapflap1212Makowiec et al., 1995Makowiec et al., 1995

Proctectomy (%)Proctectomy (%)Healed Healed (%)(%)Type of repairType of repairNo of No of

patientspatientsStudyStudy

002(100)2(100)SetonSeton22

22 1 colproctectomy 1 colproctectomy ileostomy (50)ileostomy (50)1(50)1(50)Transvaginal flapTransvaginal flap

2(100)2(100)00Transanal advancement Transanal advancement flapflap22

Lozynskyy Y., et al. Lozynskyy Y., et al. 20042004

COLLAGEN PLUGCOLLAGEN PLUG

We have no experience of using collagen plug in our clinicWe have no experience of using collagen plug in our clinic

FIBRIN GLUEFIBRIN GLUE

We have no experience of using fibrin glue in our clinicWe have no experience of using fibrin glue in our clinic

INFLIXIMABINFLIXIMAB

Infliximab is rarely used in Ukraine, because of high price

and the absence of reimbursement

CONCLUSIONCONCLUSIONPlanned surgical treatment of the Planned surgical treatment of the perianalperianalcomplications requires complex examination of complications requires complex examination of the the gastroingastrointtestinalestinal tract.tract.

The The pararectalpararectal fistulas should be operated in the fistulas should be operated in the period of complete remission (clinical and period of complete remission (clinical and edoscopicedoscopic))

Surgical treatment of Surgical treatment of perianalperianal complications complications should be should be microinvasivemicroinvasive: using : using noncuttingnoncutting setonseton, , fistulotomyfistulotomy and advancement flap.and advancement flap.

CONCLUSIONCONCLUSIONIncontinence and decrease of life quality Incontinence and decrease of life quality appears due to aggressive local surgical appears due to aggressive local surgical treatment.treatment.

Colostomy and Colostomy and enterostomyenterostomy in combination with in combination with systemic treatment is an effective method to systemic treatment is an effective method to achieve remission and decrease the frequency achieve remission and decrease the frequency of recurrences of of recurrences of perianalperianal CrohnCrohn’’ss diseasedisease

In severe cases In severe cases –– colproctectomycolproctectomy is the final is the final stage of treatment of the stage of treatment of the perianalperianal CrohnCrohn’’ssdiseasedisease

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