A collaborative effort between clinical physicians and surgeons has resulted in the first published surgical care plan focused on the management of septic perianal Crohn’s disease (SPCD).

This evidence-based care plan is described in the study “Combined Medical and Surgical Approach Improves Healing of Septic Perianal Crohn’s Disease,” published in the latest edition of the Journal of American College of Surgeons.

In the study, researchers from Penn State College of Medicine (PSCM) discuss the timeline of how the plan was created and the results when it was implemented at the clinic level.

Patients with SPCD have infected abscesses that can develop into fistulas, open wounds that are notoriously hard to treat and are a cause of discomfort.

The plan, which took more than a decade to develop, according to the study’s authors, is based on results from the clinical outcomes of 114 patients. These patients all had SPCD, a significant complication that negatively impacts up to 40 percent of the Crohn’s disease patients.

The team reviewed each patient’s chart and medical history with the aim of understanding what constitutes successful management of SPCD to make the condition more bearable, as well as identifying the clinical factors such as administration of anti-TNF medications, and genetic factors predictive of healing.

Researchers defined “healing” as having a normal clinical exam and no pain for up to six months. The authors assessed specific gene variants (single nucleotide polymorphisms [SNPs]) as potential genetic indicators.

The findings included:

• Identification of 135 episodes of SPCD;
• 80 of 135 episodes healed and did not differ between those receiving anti-TNF and those who did not;
• Patients who were surgically managed and also received anti-TNF showed consistent improvement in healing;
• Being a female patient was a predictive factor of healing;
• Several SNPs in Crohn’s disease-associated genes were observed to be linked to healing, but this was not a definitive finding and needs further investigation.

The primary findings associated with patient outcomes and study design was that the rate of healing for SPCD patients was found to be 60 percent when the combined medical and surgical protocol was used. Of the 40 percent of patients who did not experience healing, half did not heal and needed a permanent ostomy bag, and the other half saw some improvement but did not heal completely.

These findings led the researchers to develop the study’s decision tree with the aim of providing clinicians and surgeons with a protocol that describes when and what types of surgical treatment could be used for fistulas that do not respond to medical management, and the chances for healing.

“What we did with this study is look at a combined medical and surgical protocol for managing this problem, recognizing that there’s a role for the medicines, and there’s a role for the surgery,” Dr. Walter A. Koltun, professor of surgery and the study’s senior investigator, said in a PSCM press release. “Although this is acknowledged by most surgeons and gastroenterologists, no one had written down a protocol to follow that is predictable in its outcome.”

“Our protocol provides a paradigm for when you perhaps should stop the drug and when to consider surgery with or without medication,” Koltun added.