EP522 - Virtual 3D reconstruction technology to improve the surgical management of perianal Crohn's Disease- a trial l protocol and initial results.

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Purpose/Background: The management of perianal Crohn’s disease (pCD) has progressed little in the last two decades. Usual treatment involves draining collections, control of tracts with setons and biologic drugs to control inflammation once sepsis is controlled. Rapid 3D reconstruction of the fistula and surrounding anatomy is now available, to supplement the radiologist’s written report This allows the surgeon to perform a ‘virtual examination under anaesthetic’ (vEUA) prior to surgery for pCD, with the hope this will improve control of sepsis and fistula tracts leading to better outcomes for patients.

Funding was obtained from Crohn’s and Colitis UK to undertake a randomised study to assess the feasibility of a 3D MRI reconstruction of perianal Crohn’s disease in peri-surgical setting.

Methods/Interventions: 30 patients with pCD will be randomised to standard care (standard MRI report) or vEUA. Patient reported outcomes (IBD quality of life scores; Hospital Anxiety and Depression Scale; Incontinence score) will be compared between groups before and after surgery. Clinical outcomes will be assessed via the Perineal Disease Activity Index, the number of surgical interventions (EUAs) needed to obtain disease control and the number of antibiotic courses. Biochemical disease activity will be assessed by faecal calprotectin and crp pre- and post- surgery.

To understand the benefit of vEUA in explaining disease anatomy to the patient and in obtaining informed consent for intervention, patients will be presented with a decisional conflict scale to evaluate their uncertainty related to their surgery after consultation with a surgeon reviewing their MRI report or vEUA images.

Disease control post-surgery will be evaluated via a pelvis MRI at 4-6 weeks post procedure to look for undrained collections, the size of remaining collections or untreated fistula.

To assess surgical confidence prior to the procedure, surgeons will be asked to document a likely pre-operative plan based on their understanding of the anatomy of the disease informed by either a standard MRI report or vEUA. Their confidence in this plan will be scored from 1 (no confidence) to 10 (extremely confident). Immediately following surgery, the surgeons will complete a survey of interventions completed, adherence to preoperative plan and confidence in having adequately and safely treated all fistula and collections.

Results/Outcomes: In the first month, three patients have been randomised, with two surgeons having access to the pre-operative 3D virtual reconstruction. Feedback has been extremely positive, the technology has reduced operative time and increased surgical confidence in the pre-operative plan and in achieving control of all tracts and collections.

Conclusion/Discussion: vEUA may offer improved surgical control of fistula tracts and collections in pCD. Initial results from this randomised trial are promising, with surgeons reporting high confidence in the technology’s ability to improve surgical outcomes.