Improving the assessment of anorectal fistula
File(s)
Author(s)
Iqbal, Nusrat
Type
Thesis
Abstract
This thesis takes a multi-faceted approach towards improving the assessment of anorectal fistula.
A classification system for perianal fistulising Crohn’s Disease (pCD) developed through systematic review of the literature and an expert-consensus panel addresses the challenges of establishing management pathways and conducting clinical trials in this heterogenous patient group.
A minimum dataset for MRI reporting of anal fistula was developed through systematic review of the literature and a clinician survey. A multi-disciplinary expert consensus panel used these results to determine the final minimum dataset and developed subsets for patients with pCD and those being assessed for surgical treatment.
A randomised controlled pilot study investigated the use of 3D printed anal fistula models in outpatient clinic appointments. The models were viewed favourably by patients and resulted in improved objective understanding of their fistula and proposed surgery.
Flow cytometry experiments characterised the T-cell subsets residing in pCD and cryptoglandular fistulae. Similarities in the cellular and cytokine profiles and the presence of unconventional T-cells were identified, furthering our understanding of fistula immunopathogenesis.
A prospective pilot study examined the logistics of administering Mesenchymal Stem Cells (MSC) for pCD, their long-term outcomes, and whether MSC apoptosis can be used as a biomarker of clinical response. MSC treatment resulted in similar outcomes to those demonstrated in clinical trials and outcomes correlated with host induced MSC apoptosis.
Qualitative interviews investigated the impact of having a fistula on Quality of Life (QoL) and identified patient priorities for treatment; focussing on relieving the physical and psycho-social impacts of disease. These interviews informed the development of a Core Outcome Set and a QoL measurement instrument.
The Anal Fistula Core Outcome Set (AFCOS) addresses heterogeneity of outcome reporting in fistula research. Systematic review and patient interviews produced a longlist of candidate outcomes that were prioritised by stakeholders in an online Delphi survey. A consensus meeting established the final 10-item COS, representing a multi-disciplinary, patient-centred approach to establishing standards in fistula research.
A lack of validated, disease-specific QoL measurement instruments for cryptoglandular anal fistula drove the development of a cryptoglandular Anal Fistula Quality of Life measurement instrument (AF-QoL), informed by qualitative and cognitive patient interviews and refined through psychometric testing. AF-QoL demonstrates internal consistency, construct validity, reliability and responsiveness.
This thesis establishes standards for assessing anal fistula, facilitating a more structured and systematic approach to management and research. Future work will focus on establishing the utility and validity of these systems
A classification system for perianal fistulising Crohn’s Disease (pCD) developed through systematic review of the literature and an expert-consensus panel addresses the challenges of establishing management pathways and conducting clinical trials in this heterogenous patient group.
A minimum dataset for MRI reporting of anal fistula was developed through systematic review of the literature and a clinician survey. A multi-disciplinary expert consensus panel used these results to determine the final minimum dataset and developed subsets for patients with pCD and those being assessed for surgical treatment.
A randomised controlled pilot study investigated the use of 3D printed anal fistula models in outpatient clinic appointments. The models were viewed favourably by patients and resulted in improved objective understanding of their fistula and proposed surgery.
Flow cytometry experiments characterised the T-cell subsets residing in pCD and cryptoglandular fistulae. Similarities in the cellular and cytokine profiles and the presence of unconventional T-cells were identified, furthering our understanding of fistula immunopathogenesis.
A prospective pilot study examined the logistics of administering Mesenchymal Stem Cells (MSC) for pCD, their long-term outcomes, and whether MSC apoptosis can be used as a biomarker of clinical response. MSC treatment resulted in similar outcomes to those demonstrated in clinical trials and outcomes correlated with host induced MSC apoptosis.
Qualitative interviews investigated the impact of having a fistula on Quality of Life (QoL) and identified patient priorities for treatment; focussing on relieving the physical and psycho-social impacts of disease. These interviews informed the development of a Core Outcome Set and a QoL measurement instrument.
The Anal Fistula Core Outcome Set (AFCOS) addresses heterogeneity of outcome reporting in fistula research. Systematic review and patient interviews produced a longlist of candidate outcomes that were prioritised by stakeholders in an online Delphi survey. A consensus meeting established the final 10-item COS, representing a multi-disciplinary, patient-centred approach to establishing standards in fistula research.
A lack of validated, disease-specific QoL measurement instruments for cryptoglandular anal fistula drove the development of a cryptoglandular Anal Fistula Quality of Life measurement instrument (AF-QoL), informed by qualitative and cognitive patient interviews and refined through psychometric testing. AF-QoL demonstrates internal consistency, construct validity, reliability and responsiveness.
This thesis establishes standards for assessing anal fistula, facilitating a more structured and systematic approach to management and research. Future work will focus on establishing the utility and validity of these systems
Version
Open Access
Date Issued
2022-11
Date Awarded
2023-09
Copyright Statement
Creative Commons Attribution NonCommercial Licence
License URL
Advisor
Tozer, Philip
Hart, Ailsa
Lung, Phillip
Sponsor
Royal College of Surgeons of England
Publisher Department
Department of Surgery & Cancer
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)