title: Surgical management of fistulating perianal Crohn's disease: a UK survey.
abstract: OBJECTIVE
  Around one-third of patients with Crohn's disease are affected by Crohn's fistula-in-ano (pCD). It typically follows a chronic course and patients undergo long-term medical and surgical therapy. We set out to describe current surgical practice in the management of pCD in the UK.
  
  
  METHODS
  A survey of surgical management of pCD was designed by an expert group of colorectal surgeons and gastroenterologists. This assessed acute, elective, multidisciplinary and definitive surgical management. A pilot of the questionnaire was undertaken at the 2015 meeting of the Digestive Disease Federation. The survey was refined and distributed nationally through the trainee collaborative networks.
  
  
  RESULTS
  National rollout obtained responses from 133 of 179 surgeons approached (response rate 74.3%). At first operation, 32% of surgeons would always consider drainage of sepsis and 31.1% would place a draining seton. At first elective operation, 66.6% would routinely insert of draining seton, and 84.4% would avoid cutting seton. An IBD multidisciplinary team was available to 87.6% of respondents, although only 25.1% routinely discussed pCD patients. Anti-tumour necrosis factor-alpha therapy was routinely considered by 64.2%, although 44.2% left medical management to gastroenterologists. Common definitive procedures were removal of the seton only (70.7%), fistulotomy (57.1%), advancement flap (38.9%), fistula plug (36.4%) and ligation of intersphincteric track (LIFT) procedure (31.8%). Indications for diverting stoma or proctectomy were intractable sepsis, incontinence and poor quality of life.
  
  
  CONCLUSIONS
  This survey has demonstrated areas of common practice, but has also highlighted divergent practice including choices of definitive surgery and multimodal management. Practical guidelines are required to support colorectal surgeons in the UK.
authors.affiliation: Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK.|Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK.|South Yorkshire Surgical Research Group, Department of General Surgery, Northern General Hospital, Sheffield, UK.
authors.forename: M J
authors.identifier: http://orcid.org/0000-0001-9971-1635
authors.initials: MJ
authors.lastname: Lee
authors.affiliation: University Hospital South Manchester, Manchester, UK.|North-West Research Collaborative, University Hospital South Manchester, Manchester, UK.
authors.forename: N
authors.initials: N
authors.lastname: Heywood
authors.affiliation: St James University Hospital, Leeds, UK.
authors.forename: P M
authors.initials: PM
authors.lastname: Sagar
authors.affiliation: Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK.
authors.forename: S R
authors.initials: SR
authors.lastname: Brown
authors.affiliation: Addenbrooke's Hospital, Cambridge, UK.
authors.forename: N S
authors.initials: NS
authors.lastname: Fearnhead
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003107:Colorectal Surgery / Q000379:methods*; D003125:Colostomy / Q000706:statistics & numerical data; D003424:Crohn Disease / Q000150:complications / Q000628:therapy*; D004322:Drainage / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures; D005242:Fecal Incontinence / Q000209:etiology; D005762:Gastroenterology; D006801:Humans; D007412:Intestinal Fistula / Q000628:therapy; D010818:Practice Patterns, Physicians'; D019919:Prosthesis Implantation / Q000706:statistics & numerical data; D011788:Quality of Life; D012003:Rectal Fistula / Q000209:etiology / Q000628:therapy*; D018805:Sepsis / Q000209:etiology; D013524:Surgical Flaps / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D006113:United Kingdom
chemical_list: D000900:Anti-Bacterial Agents; D014409:Tumor Necrosis Factor-alpha
keywords: Crohn's disease; anal fistula; survey