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RADIOLOGICAL REMISSION IN PERIANAL FISTULIZING CROHN’S DISEASE: BASELINE MRI PREDICTORS AND IMPACT ON CLINICAL OUTCOMES

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Introduction

Deep remission in complex perianal fistulizing Crohn’s disease (PFCD) is defined by both clinical and radiological remission. As the ultimate therapeutic goal for this condition, deep remission requires thorough assessment. MRI is the gold standard for evaluating complex perianal involvement.

Aims & Methods

Our aim was to identify baseline MRI factors linked to deep remission in PFCD and assess its impact on clinical outcomes. All patients with complex PFCD treated with anti-TNF-α agents at the gastroenterology department underwent baseline MRI and clinical evaluation. Radiological assessment included the number and type of fistula tracts (per Parks classification), presence/size of pelvic collections, horseshoe tracts (encircling more than 75% of the anal circumference), and rectal wall thickening. The Van Assche score was calculated. Follow-up MRIs were obtained only after clinical remission to assess radiological remission.

Results

Out of 105 patients, 80 were included in the study (male-to-female ratio: 1.33), with a mean age of 32.35 years. On average, patients had 1.7 fistula tracts (range: 1–6), with trans-sphincteric fistulas accounting for 65% of cases. Specific subtypes included ano-vulvar tracts in 8 women (9.5%), rectovaginal in 5 patients (6%), and anorectal tracts extending to the scrotum in 2 men (2.4%). Pelvic collections were present in 14 individuals (16.7%), averaging 23.8 mm in size. Horseshoe-shaped tracts were identified in 19 patients (22.6%), and rectal wall thickening greater than 3 mm was seen in 49 (58.3%). The mean Van Assche MRI score was 14.9. All patients underwent seton placement. The majority (88.1%) received infliximab, while the remainder were treated with adalimumab. Clinical remission was achieved after a mean of 5.8 months. Radiological remission occurred in 24 patients (28.6%). Presence of horseshoe tracts (p=0.013) and Van Assche scores more than 14 (p=0.027) were significantly associated with failure to reach radiological remission. These factors were confirmed as independent predictors by multivariate analysis. Among those who initially achieved radiological remission, 13 experienced recurrence during an average follow-up of 65.8 months. Radiological remission was associated with improved outcomes: recurrence-free survival rates were 81.3% at 1 year, 62.7% at 3 years, and 50.1% at 5 years, compared to 62.2%, 35.8%, and 23.2%, respectively, in patients with clinical remission but without radiological remission.

Conclusion

Deep remission was achieved in about one-third of PFCD patients following clinical remission. Horseshoe fistulas and Van Assche score more than 14 predict failure to reach this goal, correlating with worse long-term outcomes. These findings support the Top-Class classification designating such cases as unsuitable for curative repair, emphasizing symptom control instead.

RADIOLOGICAL REMISSION IN PERIANAL FISTULIZING CROHN’S DISEASE: BASELINE MRI PREDICTORS AND IMPACT ON CLINICAL OUTCOMES

Sarra Laabidi 1, Amal Ghamougui 1, DONIA GOUIAA 1, sahar chtioui 1, Nadia Ben Mustapha 1, Meriem Serghini Ep Ghachem 1, Asma Labidi 1, Monia Fekih 1

1 Rabta Hospital, Tunis, Tunisia

Event

UEG Week Berlin 2025

Topics

IBD

Submission format

Abstract

Session

Treatment of fistulas in Crohn's disease

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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When to call the surgeon?

Bas P.L. Wijnhoven 1

1 Erasmus MC Rotterdam Dept. of Surgery, Rotterdam, Netherlands

Event

UEG Week Berlin 2025

Topics

Endoscopy Nurses Paediatrics Surgery

Session

Crash course: Foreign bodies

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Introduction: UEG Journal Session

Albrecht Neesse 1

1 Universitätsklinikum Göttingen, Hamburg, Germany

Event

UEG Week Berlin 2025

Topics

Nurses Pancreas Radiology & Imaging

Session

Hot topics in European gastroenterology

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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The usefulness of target trial emulations to enhance the field of Gastroenterology

Louise Emilsson 1

1 County Council of Värmland, Värmlands, Sweden

Event

UEG Week Berlin 2025

Topics

Mechanisms & Personalised Medicine Standards & Guidelines

Session

The art of making clinical research precise: Options for study design

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Infection risks of immunosuppressive therapy: Tuberculosis with TNF blockers and Hepatitis B with CD20 blockers

Marina Berenguer 1, Elena Sonnenberg 2

1 La Fe University Hospital, Valencia, Spain

2 Charité – Universitätsmedizin Berlin, Berlin, Germany

Event

UEG Week Berlin 2025

Session

Never waste a good disaster

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Update on hepatorenal syndrome

Raj Mookerjee 1

1 UCL Institute of Hepatology, University College London, UK, London, United Kingdom

Event

UEG Week Berlin 2025

Topics

Hepatobiliary

Session

What's new in complications in chronic liver disease in 2025?

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

UEG Presentation

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IMPACT OF DIAPHRAGMATIC RELAXING INCISION ON RECURRENCE RATE AFTER PARAESOPHAGEAL HERNIA REPAIR; 1 YEAR RESULTS OF A DOUBLE-BLIND, RANDOMIZED CLINICAL TRIAL

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Introduction

The optimal surgical approach to reduce recurrence rates after laparoscopic repair of paraesophageal hernia (PEH) is yet to be defined. The crural repair is challenged by both axial and transverse-lateral tension, which may compromise durability. The aim of this double-blind randomized clinical trial was to investigate whether a left-sided diaphragmatic relaxing incision in addition to standard crural repair and fundoplication reduces anatomical recurrence rates at one year postoperatively.

Aims & Methods

This study was conducted at two high-volume Swedish centers—Ersta Hospital (Stockholm) and Sahlgrenska University Hospital (Gothenburg)—between August 2019 and August 2023. Adult patients undergoing surgery for PEH were randomized 1:1 to either standard crural repair with total (360°) fundoplication (control) or the same procedure with the addition of a left-sided diaphragmatic relaxing incision covered by synthetic mesh (intervention). Patients with prior hiatal surgery, ASA class IV or above, type I hernia, major esophageal motility disorders, or any contraindication to fundoplication were excluded. Blinding for patients and assessors was maintained throughout follow-up. Pre- and postoperative assessments included computed tomography (CT), symptom questionnaires (Dakkak dysphagia score, Gastrointestinal Symptom Rating Scale [GSRS]), and quality of life (QoL, RAND-36). The primary outcome was radiologically confirmed PEH recurrence at 12 months.

Results

Of 103 patients screened, 76 were randomized (38 per group). Baseline characteristics were well balanced. CT was completed in 72 patients (95%) at 12 months. The recurrence rate was 66% in the control group and 54% in the intervention group (p=0.313). Three patients in the intervention group had asymptomatic CT verified herniation at the site of the diaphragmatic incision. There were no differences in recurrence size distribution (<4 cm vs >4 cm) between groups. Postoperative symptom assessment revealed significant improvements in dysphagia, reflux, indigestion, and abdominal pain in both groups, without intergroup differences. Physical QoL (PCS) improved significantlywhereas mental QoL (MCS) remained unchanged. Two deaths occurred within 90 days postoperatively (1 per group), yielding a 90-day mortality of 2.6%. Other complications included mediastinal abscess (n=1, intervention group) and need for postoperative endoscopic dilatation (n=5 in total). Operation time tended to be longer in the intervention group (150 vs 133 min; p=ns).

	Crural repair alone	Crural repair with relaxing diaphragmatic incision	P value
Completed CT chest at 1 year	35/38	37/38
Radiological recurrence	23 (66%)	20 (54%)	.313
Recurrence<4cm	12 (34%)	11 (30%)	.522
Recurrence>4cm	11 (31%)	9 (24%)	.457

Table 1: Radiological recurrences 1 year after surgical repair of PEH

Conclusion

In this randomized, double-blind trial, the addition of a left-sided diaphragmatic relaxing incision to standard laparoscopic PEH repair did not improve anatomical recurrence rates, symptom relief or QoL at 12 months after surgery and should not be recommended for routine use. Alternative strategies to improve recurrence rates after PEH need to be explored in the future.