Novel classification system for perianal fistulising Crohn’s disease

A new patient-oriented classification system for perianal fistulising Crohn’s disease (PFCD) has been developed by expert consensus. The new classification system includes treatment suggestions per class and patient-specific recommendations for clinical trial suitability.

“PFCD has a prevalence of 14 to 43% among patients with CD and significantly reduces the quality of life of these patients,” said Dr Jeroen Geldof (University Hospital Ghent, Belgium) [1]. “In addition, the current classification systems for PFCD lack a clear connection with the clinical practice. By means of a modified nominal group expert consensus process, 4 groups of patients with PFCD were identified.” The ‘treat to patient’ goal was the basis of each category. Dr Philip Tozer (St Mark’s Hospital and Academic Institute, UK) outlined the different classes of the new classification system [2].

• Class 1 – Patients with minimal disease: these patients have minimal symptoms or anorectal disease burden over time, and require minimal intervention.
• Class 2 – Patients with chronic symptomatic fistulae:
  
  
  
  • Class 2a – Patients with symptomatic fistulae that are suitable for combined medical/surgical closure. The goal is fistula closure.
  • Class 2b – Patients with chronic symptoms related to fistulae that are currently unsuitable for surgical repair. The goal is symptom control.
  • Class 2c-i – Patients with early and rapidly progressive disease. These patients may require early intervention with defunctioning ostomy or proctectomy.
  • Class 2c-ii – Patients with gradually debilitating disease who are unsuitable for surgical repair and experience severely reduced quality of life. Defunctioning ostomy is required to improve the quality of life. The goal is symptom control.

• Class 3 – Patients with exhausted perineum or adverse features: these patients have severely symptomatic disease despite defunctioning ostomy, with irreversible perineal destruction or adverse features such as concomitant anorectal stricture, refractory proctitis, or complex fistulae. These patients require proctectomy.
• Class 4 – Patients with perineal symptoms after proctectomy:
  
  
  
  • Class 4a – patients with symptomatic sinuses or wounds that are suitable for medical/surgical repair. The goal is sinus closure.
  • Class 4b – patients with chronic symptoms related to sinuses or wounds that are unsuitable for surgical repair. The goal is symptom control.

The clinical trial suitability of the patient is related to the goal of the class that the patient is sorted into. For example, a patient in class 2a is suitable for trials that investigate interventions in which the primary outcome measure is fistulae closure, whereas a patient in class 2b could participate in a clinical trial that has symptom control or quality of life gains as the primary outcome measure.

The authors aim to develop specific treatment algorithms per class and validate the classification system retrospectively and prospectively. Eventually, the study group also intends to evaluate the long-term impact of the classification system on patient satisfaction and clinical outcomes.

1. Tozer P, et al. Classifying perianal fistulising Crohn’s Disease: An expert-consensus to guide decision-making in daily practice and clinical trials. OP19, ECCO 2022, 16–19 February.
2. Geldof J, et al. Lancet Gastroenterol Hepatol. 2022;S2468-1253(22)00007–3.

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Posted on 12 April 20228 April 2024