Surgical Management of Patients with Complex Perianal Fistula: Results of a US National Case-based Survey to Determine Future Educational Needs

Introduction: Crohn’s-related perianal fistulas (CPF) are major contributors to lowered quality of life (QoL) for patients with Crohn’s disease. This study aimed to identify practice patterns and knowledge gaps in CPF management. Methods: To understand the perspectives of colorectal surgeons (CRS) managing patients with CPF, we developed a case-based survey related to management of initial presentation and recurrence of CPF. Surveys were distributed online during Sep/Oct 2020 to US CRS experienced with CPF (≥1 CPF patient/month). Results: Seventy-eight CRS responses were collected. In patients who initially presented with fistula, there was no standardized approach for CPF evaluation or classification. While the majority (71%) chose seton plus medical management as initial intervention, there was no standard approach to seton removal. No consensus existed on preferred medical/surgical treatment in patients with a partial biologic response or for recurrent fistula. CRS prioritized long-term CPF goals of improved QoL and avoiding major surgery/preserving continence, while fistula healing had the lowest priority. COVID-19 did not have a major effect on patient management. Barriers to optimal CPF management were perceived to be lack of effective medical therapies, poor surgical outcomes/complication risks, patient reluctance, delayed referral/diagnosis, and lack of guidelines/treatment algorithms. Significant barriers to multidisciplinary management included lack of access to CPF specialists and treatment plan communication, and difficulty coordinating care between specialists/centers. A lack of familiarity exists with newer/potential treatments. Conclusion: There is no consensus on how to best manage CPF. Education is needed to improve outcomes in CPF treatment.