Appropriate therapy for fistulizing and fibrostenotic Crohn's disease: Results of a multidisciplinary expert panel — EPACT II
Received 13 March 2009; received in revised form 5 June 2009; accepted 5 June 2009. published online 13 July 2009.
Abstract
Introduction
Many therapeutic decisions in the management of fistulizing and fibrostenotic Crohn's disease (CD) have to be taken without the benefit of strong scientific evidence. For this reason, explicit appropriateness criteria for CD fistula and stenosis treatment were developed by a multidisciplinary European expert panel in 2004 with the aim of making them easily available on the Internet and thus allowing individual case scenario evaluation; these criteria were updated in 2007.
Methods
Twelve international experts convened in Geneva, Switzerland in December 2007. Explicit clinical scenarios, corresponding to real daily practice, were rated on a 9-point scale based on evidence from the published literature and panelists' own expertise. Median ratings were stratified into three categories: appropriate (7–9), uncertain (4–6) and inappropriate (1–3).
Results
Overall, panelists rated 60 indications pertaining to fistulas. Antibiotics, azathioprine/6-mercaptopurine and conservative surgery are the mainstay of therapy for simple and complex fistulas. In the event of previous failure of azathioprine/6-mercaptopurine therapy, methotrexate and infliximab were considered appropriate for complex fistulas. The panel also rated 72 indications related to the management of fibrostenotic CD. The experts considered balloon dilation, if the stricture was endoscopically accessible, stricturoplasty and bowel resection to be appropriate for small bowel fibrostenotic Crohn's disease, and balloon dilation and bowel resection appropriate for fibrostenotic colonic disease. In the presence of an ileocolonic or ileorectal anastomotic stricture of <7 cm, endoscopic balloon dilation, and bowel resection were considered appropriate.
Conclusion
Antibiotics, azathioprine/6-mercaptopurine, and conservative surgery are the mainstay of therapy for fistulizing Crohn's disease. Infliximab is a therapeutic option in patients without prior response to immunosuppressant therapy. In fibrostenotic Crohn's disease, endoscopic balloon dilation, if feasible, or surgical therapy should be considered. These expert recommendations are available online (www.epact.ch). Prospective evaluation is now needed to test the validity of these appropriateness criteria in clinical practice.
aDepartment of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
bHealthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
cDepartment of Gastroenterology, University of Basle, Basle, Switzerland
dGastroenterology Office, Adelaide & Meath Hospital and Trinity College Dublin, Dublin, Ireland
eService de chirurgie colorectale, Hôpital Beaujon, Clichy, France
fDivision of Gastroenterology, University Hospital Rebro, Zagreb, Croatia
Corresponding author. Christian Felley, MD, Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, CH-1001 Lausanne, Switzerland. Tel.: +41 21 314 0690; fax: +41 21 314 0707.
1 The EPACT II Study Group (in alphabetical order): Erika Angelucci (Italy), Willem Bemelman (The Netherlands), Miquel Gassull (Spain), Franz Josef Heil (Germany), Marc Lémann (France), Tom Öresland (Norway), Colm O'Morain (Ireland), Yves Panis (France), Frank Seibold (Switzerland), Eduard Stange (Germany), Reinhold Stockbrügger (The Netherlands) and Boris Vucelic (Croatia).
ABSTRACT