P934 A delphi consensus on the optimisation of medical and surgical therapy in perianal fistulising Crohn’s disease, targeted at individual TOpCLASS classification groups
Bibliographic record
Abstract
Abstract Background Perianal fistulising Crohn’s Disease (PFCD) is a challenging phenotype of IBD associated with poor outcomes. Classically, fistulae have been classified anatomically and guidelines have been generalised, with a lack of appreciation of disease heterogenicity. The recent ‘TOpCLASS classification system’ (Geldof et al. (2022) - figure below) addresses this and categorises patients based on clinical features and patient goals. There is a need to provide management guidance for PFCD that aligns with this approach, targeting differing PFCD manifestations seen in real-life. We present a consensus exercise delivering that guidance. Methods Position statements on ‘optimal’ PFCD management within the TOpCLASS classes were made via a consensus meeting in Apr 2023. The expert panel were members of the TOpCLASS Consortium, a group of PFCD specialists and researchers. This included 15 surgeons and 16 gastroenterologists, from IBD centres in Europe, North America, and Australia. Prior to the meeting, to inform provisional statements: 1) a systematic review of the literature was conducted (Oct 2021), 2) multidisciplinary team responses on the management of fictional PFCD cases from 8 leading IBD centres were obtained, and 3) an open discussion on PFCD management with the expert panel was conducted. Consensus was predefined as ≥80% ‘strongly agree’ [A+] or ‘agree with minor reservation’ [A]. Results 53 position statements were agreed by the expert panel. For Class 1 (minimal, asymptomatic) disease the panel agreed, given the lack of symptoms, there is no role for seton insertion (A+ 50%, A 50%), and no role for routine MRI monitoring in the absence of new fistula symptoms (A+ 46%, A 54%). Regarding Class 2 (chronic, symptomatic) disease, the panel agreed on detailed guidance for when fistulae are suitable for a repair attempt and where differing surgical modalities are best utilised in fistula repair. Additionally, statements on seton removal in PFCD were made, alongside statements on optimised medical therapy in Class 2 patients. Specifically, the panel suggest Infliximab first-line (A+ 80%, A 20%), ideally commenced within 30 days of initial drainage +/- seton insertion (A+ 100%). Statements were also produced regarding second-line options, topical therapy, and loss of response to biologics in PFCD. Specific statements were also developed for Class 2b, 2c-i, 2c-ii, and 4 disease, as well as on the psychological burden of PFCD. Conclusion The generated statements come from a highly expert Western group of PFCD specialists. We believe they provide pragmatic advice to gastroenterologists and IBD surgeons managing the full breadth of PFCD encountered in day-to-day practice.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.233 | 0.234 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.003 |
| Bibliometrics | 0.003 | 0.002 |
| Science and technology studies | 0.004 | 0.004 |
| Scholarly communication | 0.004 | 0.004 |
| Open science | 0.003 | 0.015 |
| Research integrity | 0.005 | 0.006 |
| Insufficient payload (model declined to judge) | 0.008 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".