P145 Biologics are inferior to surgery in isolated internal penetrating Crohn’s disease: a single centre experience

Abstract

Introduction 50% of patents with Crohn’s disease (CD) develop fistulae, resulting in significant morbidity. Isolated internal penetrating CD (IPCD), without enterocutaneous manifestations, is the second most prevalent fistulating phenotype after perianal CD(Schwartz et al., 2019) yet the management of isolated IPCD remains poorly characterised in therapeutic trials. This study aims to assess outcomes of IPCD at a large, tertiary IBD centre. Methods All adult patients with penetrating CD were screened from imaging reports and corroborated with radiology meeting, surgical and biologic databases between January 2016 and April 2019. Concurrent perianal or enterocutaneous fistulation was excluded from analysis. Complete, partial or no resolution of fistula was an assessed composite of imaging, symptoms and nutritional independence(Samimi et al., 2010). Statistics: categorical variables, Fisher’s exact. Results 29 patients had IPCD diagnosed between 2008 and 2018. 28% had undergone prior gastrointestinal surgery. At fistula diagnosis, 41% had prior biologic exposure including 6 on their third line biologic, and 66% on a previous or current immunomodulator. Only 4 (14%) were on a current biologic. IPCD was diagnosed at median 62 months [IQR 24–117] after IBD diagnosis with the majority enterocolonic (47%) and enteroenteric (27%) in configuration. 69% had documented distal obstruction or stenosis, 7% had a confirmed abscess. 52%, 24% and 24% underwent medical, surgical or no additional intervention, respectively, as primary management of their IPCD. Compared with no intervention, only the presence of symptoms was predictive of medical (14% vs 93%, p=0.0006) or surgical (14% vs 100%, p=0.0047) intervention, whereas prior surgery, current or prior biologic therapy, IPCD configuration were not. Of medically treated IPCD, 73% (11/15) had a biologic at median duration 29 months with Adalimumab 1st line in 64% (7/11) and Ustekinumab 2nd line in 67% (4/6). There was a trend to greater complete or partial fistula resolution by surgery versus medical management (86% (6/7) vs 47% (7/15), p=0.1649) and surgery versus biologics (86% (6/7) vs 64% (7/11), p=0.596) at reassessment interval (17 [12–43] vs 8 [7–17] months, respectively) (figure 1). Of medical and no intervention cohorts, 53% and 29% eventually had surgery at median intervals 6 and 72 months. Of the whole cohort, 59% had surgery, in whom 35% had a pre-operative biologic, 12% pre-operative parenteral nutrition (PN), 18% post-operative PN (duration 14, 41, 8 months respectively), and 18% post-operative intra-abdominal septic complications within 30 days. Conclusion Most patients in this cohort require surgery to achieve complete of resolution of IPCD with medical therapy including biologics offering limited temporising effect. For those predominantly asymptomatic patients, no intervention can be a suitable management option.