A131 SURGICAL DRAINAGE OF PERIANAL FISTULAS PRIOR TO INITIATING ANTI-TNF THERAPY IS ASSOCIATED WITH LOWER RATES OF FECAL DIVERSION

The management of complex perianal Crohn’s disease (PCD) can be challenging and a proportion of patients ultimately require fecal diversion. Recent studies have suggested that surgical drainage of fistulas prior to initiating anti-tumor necrosis factor (TNF) therapy may improve fistula healing. However, it remains unclear if this treatment strategy improves long-term outcomes by reducing the rates of fecal diversion. We examined if surgical drainage of fistula tracts prior to anti-TNF therapy impacted the rates of fecal diversion. A retrospective observational study was performed at a Canadian academic institution between 2006 and 2016. Patients with PCD were identified from our institutional radiology and discharge databases. A manual chart review was performed to determine study eligibility, disease characteristics, medication exposure, surgical interventions, and requirement for fecal diversion. Adults with complex PCD, treated with anti-TNF therapy (infliximab or adalimumab) were grouped into two cohorts: surgery before TNF antagonist (SBT) or no surgery before TNF antagonist (NSBT). Surgery was defined as an exam under anesthesia (EUA), with or without a seton. The rates of fecal diversion were compared between both groups by chi squared test and Kaplan-Meier method with log-rank test. A total of 143 patients with PCD met our inclusion criteria: 60/143 (42%) in the SBT group and 83/143 (58%) in the NSBT group. An EUA was performed in 108/143 (75.5%) of patients; while 79/143 (55.2%) of patients received at least one seton. The proportion of patients in the SBT and NSBT groups exposed to infliximab (80% vs 76%, p =0.56) or adalimumab (20% vs 24%, p =0.56) as their index anti TNF were comparable. A greater proportion of patients in the NSBT group were treated with more than one anti-TNF (21.7% vs. 39.8%; p=0.02). Likewise, more patients in the NSBT group were treated with biologics other than adalimumab or infliximab (1.6% vs. 19.3%; p=0.001). Twenty-eight patients (19.6%) underwent fecal diversion for medically refractory PCD. A greater proportion of patients in the SBT group did not require fecal diversion when compared to the NSBT group (90% vs 73.5%; p=0.014). This difference was not seen in the subgroup of SBT patients whose index EUA included seton placement (86% vs. 73.5%; p=0.131). Within the limits of this small retrospective study it appears that surgical drainage when performed prior to initiating anti-TNF therapy may result in lower rates of fecal diversion in patients with PCD. None

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