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Shehab M, De Marco D, Lakatos PL, Bessissow T. The potential for medical therapies to address fistulizing Crohn's disease: a state-of-the-art review. Expert Opin Biol Ther 2024; 24:733-746. [PMID: 39045643 DOI: 10.1080/14712598.2024.2383882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/25/2024] [Accepted: 07/20/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic, relapsing immune mediated disease, which is one of the two major types of inflammatory bowel disease (IBD). Fistulizing CD poses a significant clinical challenge for physicians. Effective management of CD requires a multidisciplinary approach, involving a gastroenterologist and a GI surgeon while tailoring treatment to each patient's unique risk factors, clinical representations, and preferences. AREAS COVERED This comprehensive review explores the intricacies of fistulizing CD including its manifestations, types, impact on quality of life, management strategies, and novel therapies under investigation. EXPERT OPINION Antibiotics are often used as first-line therapy to treat symptoms. Biologics that selectively target TNF-α, such infliximab (IFX), have shown high efficacy in randomized controlled trials. However, more than 50% of patients lose response to IFX, prompting them to explore alternative strategies. Current options include adalimumab and certolizumab pegol combination therapies, as well as small-molecule drugs targeting Janus kinases such as Upadacitinib. Furthermore, a promising treatment for complex fistulas is mesenchymal stem cells such as Darvadstrocel (Alofisel), an allogeneic stem cell-based therapy. However, surgical interventions are necessary for complex cases or intra-abdominal complications. Setons and LIFT procedures are the most common surgical options.
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Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Al-Kabeer University Hospital, Kuwait University, Kuwait City, Kuwait
| | - Davide De Marco
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
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Perez S, Eisenstein S. Cancer in Anal Fistulas. Clin Colon Rectal Surg 2024; 37:41-45. [PMID: 38188072 PMCID: PMC10769575 DOI: 10.1055/s-0043-1762928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Fistula-associated anal cancer in Crohn's disease (CD) can be challenging to diagnose and treat. Patients with longstanding fistulas in the setting of CD who present with a sudden change in their symptoms should undergo biopsy under anesthesia with extensive sampling, followed by staging imaging. Pelvic magnetic resonance imaging (MRI) can be helpful in identifying the extent of the disease locally. Patients often present in the later stages due to the challenges associated with diagnosing these patients. Two subtypes of this disease include squamous cell carcinoma and adenocarcinoma, and treatment depends on diagnosis. Small sample size and lack of uniform data on treatments make it difficult to say which treatment modalities are optimal, but aggressive combined therapy is likely the best approach for survival. This will include chemotherapy and radiation and often radical resection as well. Despite this, survival is poor, although more recent data suggest that outcomes are improving.
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Affiliation(s)
- Sean Perez
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Samuel Eisenstein
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
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Zhan Y, Cheng X, Mei P, Wu J, Ou Y, Cui Y. Risk and incidence of colorectal stricture progressing to colorectal neoplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2023; 35:1075-1087. [PMID: 37577790 DOI: 10.1097/meg.0000000000002614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
This study aims to assess the risk of colorectal stricture progressing to colorectal neoplasia (CRN) in patients with inflammatory bowel disease (IBD). The literature from PubMed, Embase, Web of Science, and Cochrane Library databases was searched from the date of databases' creation to 5 November 2022. The Newcastle-Ottawa Scale was used to evaluate the quality of the included literature. Meta-analysis was conducted using the Stata 15 software and R 4.04 software. Two case-control studies and 12 cohort studies were eventually included. Colorectal stricture in patients with IBD increased the risk of progressing to CRN [odds ratio (OR): 1.52, 95% confidence interval (CI): 1.02-2.29, P = 0.042], but was irrelevant to the risk of progressing to ACRN (OR: 3.56, 95% CI 0.56-22.70, P = 0.180). The risk of CRN were further distinguished in patients with ulcerative colitis (UC) and Crohn's disease (CD) Our findings showed that colorectal stricture may increase the risk of progressing to CRN in patients with UC (OR = 3.53, 95%CI 1.62-7.68, P = 0.001), but was irrelevant to the risk of progressing to CRN in patients with CD (OR = 1.09, 95% CI 0.54-2.21, P = 0.811). In conclusion, colorectal stricture in patients with IBD can be used as a risk factor for predicting CRN but cannot be used as a risk factor for predicting ACRN. Stricture is a risk factor for CRN in patients with UC but not in patients with CD. More prospective, multi-center studies with large samples are expected to confirm our findings.
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Affiliation(s)
- Yanrong Zhan
- Shaanxi University of Chinese Medicine, Xianyang
| | - Xianwen Cheng
- Ankang Hospital of Traditional Chinese Medicine, Ankang
| | - Pingping Mei
- Shaanxi University of Chinese Medicine, Xianyang
| | - Jiyun Wu
- Shaanxi University of Chinese Medicine, Xianyang
| | - Yan Ou
- Shaanxi University of Chinese Medicine, Xianyang
| | - Yaping Cui
- Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
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Remmel P, Gros L, Mortier J, Freiche V. Congenital Partial Colonic Agenesis in Dogs and Cats: Clinical, Biological, Diagnostic Imaging, Endoscopic and Histopathologic Characterization, a Retrospective Study. Vet Sci 2023; 10:577. [PMID: 37756099 PMCID: PMC10536647 DOI: 10.3390/vetsci10090577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Congenital diseases of the large intestine of dogs and cats have scarcely been reported and mostly include fistula, atresia or colonic duplication. Cases of partial colonic agenesis have rarely been described. The purpose of this study was to report a cohort of dogs and cats diagnosed with partial colonic agenesis. The colon was measured during colonoscopy or contrast-radiography and compared to the average length described in the literature. Six dogs and 17 cats were retrospectively included. Depending on the case, partial colonic agenesis could represent an incidental finding or the likeliest cause of clinical signs. Diarrhea was reported in most cases, and no specific clinical or biological abnormality was observed. Median age of presentation was variable and long asymptomatic periods were common. Abdominal ultrasound was useful and identified a short colon in 14/17 cats but only in one dog. Endoscopy was useful to confirm the diagnosis and to identify associated lesions and complications. Among others, colonic stenosis was reported in 8/9 cases that had lifelong clinical signs and the shortest colon length. This anatomical abnormality could promote chronic inflammation that might generate fibrosis and ultimately stenosis.
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Affiliation(s)
- Paul Remmel
- Unité de Médecine Interne, Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), École Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France;
| | - Lucile Gros
- Service d’imagerie Médicale, Département d’Élevage et Pathologie des Équidés et Carnivores (DEPEC), Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), École Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Jérémy Mortier
- Service d’imagerie Médicale, Département d’Élevage et Pathologie des Équidés et Carnivores (DEPEC), Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), École Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Valérie Freiche
- Unité de Médecine Interne, Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), École Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France;
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Vu JV, Kurowski JA, Achkar JP, Hull TL, Lipman J, Holubar SD, Steele SR, Lightner AL. Long-term Outcomes of Perianal Fistulas in Pediatric Crohn's Disease. Dis Colon Rectum 2023; 66:816-822. [PMID: 36856689 DOI: 10.1097/dcr.0000000000002690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Approximately 30% of Crohn's disease-related perianal fistulas heal in the adult population with conventional medical and surgical interventions. This healing rate remains unknown in pediatric patients. OBJECTIVE This study aimed to determine the healing rate of pediatric perianal Crohn's fistulas and identify factors associated with healing. DESIGN Retrospective case series. SETTING A quaternary referral center. PATIENTS Patients aged <18 years with a Crohn's perianal fistula, seen between January 1, 1991, and August 1, 2021, were included in the study. INTERVENTIONS Multivariable logistic regression to identify factors independently associated with perianal fistula healing. MAIN OUTCOME MEASURES Healing of Crohn's perianal fistula at the date of last clinical encounter, defined as the clinical note reporting a healed fistula or normal perianal examination. RESULTS A total of 91 patients aged <18 years with a Crohn's disease-related perianal fistula were identified (59% female, 76% white). The mean (SD) age at Crohn's diagnosis was 12 (±4) years. The mean follow-up after Crohn's diagnosis was 10 (±7) years. Overall, 89% of patients had a perianal fistula, 2% had an anovaginal fistula, and 10% had an ileal pouch-associated fistula. Patients underwent a median (interquartile range) of 2 (1-5) operations. A seton was placed in 60% of patients, 47% underwent abscess drainage, and 44% underwent fistulotomy or fistulectomy. Fistula healing occurred in 71% of patients over a median of 1.3 (0.4-2.5) years. Seven patients (7%) underwent proctectomy, and 3 (3%) underwent ileal pouch excision. After multivariable adjustment, younger age at diagnosis of perianal fistula was associated with an increased likelihood of healing (OR 0.56 for each increased year; 95% CI, 0.34-0.92). LIMITATIONS Retrospective, single institution. CONCLUSIONS Over two-thirds of fistulas heal in pediatric Crohn's disease patients with conventional surgical and medical intervention. Younger age at fistula development is associated with an increased likelihood of healing. See Video Abstract at http://links.lww.com/DCR/C185 . RESULTADOS A LARGO PLAZO DE LAS FSTULAS PERIANALES EN LA ENFERMEDAD DE CROHN EN PACIENTES PEDITRICOS ANTECEDENTES:Aproximadamente el 30% de las fístulas perianales relacionadas con la enfermedad de Crohn se curan en la población adulta con intervenciones médicas y quirúrgicas convencionales. Esta tasa de curación sigue siendo desconocida en pacientes pediátricos.OBJETIVO:Determinar la tasa de curación de las fístulas de Crohn perianales en población pediátrica e identificar los factores asociados con la curación.DISEÑO:Serie de casos retrospectiva.ESCENARIO:Un centro de referencia cuaternario.PACIENTES:Pacientes menores de 18 años con fístula(s) perianal(es) por enfermedad de Crohn, atendidos entre el 1 de enero de 1991 y el 1 de agosto de 2021.INTERVENCIONES:Regresión logística multivariable para identificar factores asociados de forma independiente con la cicatrización de la fístula perianal.PRINCIPALES MEDIDAS DE RESULTADO:Curación de la fístula perianal de Crohn en la fecha del último encuentro clínico, definida como la nota clínica que informa una fístula curada o un examen perianal normal.RESULTADOS:Se identificó un total de 91 pacientes <18 años de edad con una fístula perianal relacionada con la enfermedad de Crohn (59% mujeres, 76% blancos). La edad media (DE) al diagnóstico de Crohn fue de 12 (±4) años. El seguimiento medio tras el diagnóstico de Crohn fue de 10 (±7) años. En general, el 89 % de los pacientes tenía fístula perianal, el 2 % tenía fístula anovaginal y el 10 % de los pacientes tenía fístula asociada a reservorio ileal. Los pacientes fueron sometidos a una mediana (RIC) de 2 (1-5) operaciones. En el 60% de los pacientes se colocó sedal, en el 47% se drenó el absceso y en el 44% se realizó fistulotomía o fistulectomía. La curación de la fístula se produjo en el 71% de los pacientes durante una mediana de 1,3 (0,4-2,5) años. Siete pacientes (7%) se sometieron a proctectomía y 3 (3%) se sometieron a escisión del reservorio ileal. Después del ajuste multivariable, la edad más joven en el momento del diagnóstico de la fístula perianal se asoció con una mayor probabilidad de curación (OR 0,56 por cada año de aumento, IC del 95%, 0,34-0,92).LIMITACIONES:Retrospectivo, institución única.CONCLUSIONES:Más de dos tercios de las fístulas se curan en pacientes pediátricos con enfermedad de Crohn con intervención médica y quirúrgica convencional. Una edad más joven en el momento del desarrollo de la fístula se asocia con una mayor probabilidad de curación. Consulte Video Resumen en http://links.lww.com/DCR/C185 . (Traducción--Dr. Felipe Bellolio ).
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Affiliation(s)
- Joceline V Vu
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jacob A Kurowski
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jean-Paul Achkar
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeremy Lipman
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Natural History of Perianal Crohn's Disease: Long-term Follow-up of a Population-Based Cohort. Clin Gastroenterol Hepatol 2022; 20:e102-e110. [PMID: 33359730 DOI: 10.1016/j.cgh.2020.12.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The natural history of perianal Crohn's disease (PCD) remains poorly described and is mainly based on retrospective studies from referral centers. The aim of this study was to assess the incidence, outcomes and predictors of the onset of PCD. METHODS All incident cases of patients diagnosed with possible CD were prospectively registered from 1994 to 1997 in Brittany, a limited area in France. At diagnosis, the clinical features of perianal disease were recorded. All patient charts were reviewed from the diagnosis to the last clinic visit in 2015. RESULTS Among the 272 out of 331 incident CD patients followed up, 51 (18.7%) patients had PCD at diagnosis. After a mean follow-up of 12.8 years, 93 (34%) patients developed PCD. The cumulative probabilities of perianal CD occurrence were 22%, 29%, and 32% after 1 year, 5 years, and 10 years, respectively. The cumulative probabilities of anal ulceration were 14%, and 19% after 1 year and 10 years, respectively. Extraintestinal manifestations were associated with the occurrence of anal ulceration. The cumulative probabilities of fistulizing PCD were 11%, 16%, and 19% after 1 year, 5 years, and 10 years, respectively. Extraintestinal manifestations, rectal involvement and anal ulceration were predictors of fistulizing PCD. The cumulative probability of developing anal stricture was 4% after 10 years. CONCLUSIONS PCD is frequently observed during CD, in approximately one-third of patients. These data underline the need for targeted therapeutic research on primary perianal lesions (proctitis, anal ulceration) to avoid the onset of fistulizing perianal disease.
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Abramowitz L, Brochard C, Pigot F, Roumeguere P, Pillant H, Vinson Bonnet B, Faucheron JL, Senéjoux A, Bonnaud G, Meurette G, Fayette JM, Train C, Staumont G, Siproudhis L, Bouchard D. Surgical closure, mainly with glue injection and anti-tumour necrosis factor α, in fistulizing perianal Crohn's disease: A multicentre randomized controlled trial. Colorectal Dis 2022; 24:210-219. [PMID: 34623746 DOI: 10.1111/codi.15947] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022]
Abstract
AIM In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab. METHODS This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities. RESULTS Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000). CONCLUSIONS Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution.
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Affiliation(s)
- Laurent Abramowitz
- Service d'Hépato-gastroentérologie et Proctologie, Hôpital Bichat-Claude Bernard, Paris, France.,Ramsay Général de Santé, Clinique Blomet, Paris, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - François Pigot
- Service de Proctologie, Hôpital Bagatelle, Maison de Santé Protestante Bagatelle, Talence, France
| | | | - Hélène Pillant
- Service de Proctologie, Groupe Hospitalier Paris Saint Joseph, Institut Léopold-Bellan, Paris, France
| | - Béatrice Vinson Bonnet
- Service de Chirurgie Viscérale et Digestive, CHI, Poissy-St-Germain-en-Laye, Paris, France
| | - Jean Luc Faucheron
- Unité de Chirurgie Colo-rectale, Service de Chirurgie Digestive et de l'Urgence, Hôpital Michallon, CHUGA, Grenoble, France
| | | | | | - Guillaume Meurette
- Clinique de Chirurgie Digestive et Endocrinienne (CCDE), Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France
| | | | | | | | - Laurent Siproudhis
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Dominique Bouchard
- Service de Proctologie, Hôpital Bagatelle, Maison de Santé Protestante Bagatelle, Talence, France
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Lightner AL, Regueiro M. Anorectal Strictures in Complex Perianal CD: How to Approach? Clin Colon Rectal Surg 2022; 35:44-50. [PMID: 35069029 PMCID: PMC8763464 DOI: 10.1055/s-0041-1740037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anorectal strictures are a notoriously difficult to treat phenotype of perianal Crohn's disease. Quality of life is diminished due to ongoing pain, incontinence, difficulty with stool evacuation, and recurrent medical and surgical treatments. Medical therapy is aimed at treating luminal disease and mucosal ulceration to prevent worsening of fibrosis. Clinical examination and endoscopic intervention can be used for serial dilations of strictures. Unfortunately, despite optimal medical therapy and endoscopic intervention with serial anal dilations, surgery with intestinal diversion or proctocolectomy may be required as part of the treatment algorithm in a significant proportion of patients.
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Affiliation(s)
- Amy L. Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio,Address for correspondence Amy L. Lightner, MD Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic9500 Euclid Ave, Cleveland, OH 44195
| | - Miguel Regueiro
- Department of Gastroenterology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
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Buscail E, Le Cosquer G, Gross F, Lebrin M, Bugarel L, Deraison C, Vergnolle N, Bournet B, Gilletta C, Buscail L. Adipose-Derived Stem Cells in the Treatment of Perianal Fistulas in Crohn's Disease: Rationale, Clinical Results and Perspectives. Int J Mol Sci 2021; 22:ijms22189967. [PMID: 34576129 PMCID: PMC8470328 DOI: 10.3390/ijms22189967] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/07/2021] [Accepted: 09/12/2021] [Indexed: 12/16/2022] Open
Abstract
Between 20 to 25% of Crohn’s disease (CD) patients suffer from perianal fistulas, a marker of disease severity. Seton drainage combined with anti-TNFα can result in closure of the fistula in 70 to 75% of patients. For the remaining 25% of patients there is room for in situ injection of autologous or allogenic mesenchymal stem cells such as adipose-derived stem/stromal cells (ADSCs). ADSCs exert their effects on tissues and effector cells through paracrine phenomena, including the secretome and extracellular vesicles. They display anti-inflammatory, anti-apoptotic, pro-angiogenic, proliferative, and immunomodulatory properties, and a homing within the damaged tissue. They also have immuno-evasive properties allowing a clinical allogeneic approach. Numerous clinical trials have been conducted that demonstrate a complete cure rate of anoperineal fistulas in CD ranging from 46 to 90% of cases after in situ injection of autologous or allogenic ADSCs. A pivotal phase III-controlled trial using allogenic ADSCs (Alofisel®) demonstrated that prolonged clinical and radiological remission can be obtained in nearly 60% of cases with a good safety profile. Future studies should be conducted for a better knowledge of the local effect of ADSCs as well as for a standardization in terms of the number of injections and associated procedures.
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Affiliation(s)
- Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France;
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Fabian Gross
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Marine Lebrin
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Laetitia Bugarel
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Céline Deraison
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Nathalie Vergnolle
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
- Correspondence: ; Tel.: +33-561323055
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Abstract
BACKGROUND Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. OBJECTIVE To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. DATA SOURCES An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. STUDY SELECTION Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. INTERVENTION(S) Medical and surgical management. MAIN OUTCOME MEASURES Symptomatic relief, need for proctocolectomy. RESULTS Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. LIMITATIONS Limited literature published, all retrospective in nature. CONCLUSIONS Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.
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Dumont LM, Landman C, Sokol H, Beaugerie L, Cosnes J, Seksik P, Guégan S. Increased risk of permanent stoma in Crohn's disease associated with hidradenitis suppurativa: a case-control study. Aliment Pharmacol Ther 2020; 52:303-310. [PMID: 32525586 DOI: 10.1111/apt.15863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/27/2020] [Accepted: 05/15/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Crohn's disease (CD) and hidradenitis suppurativa (HS), a chronic inflammatory skin disease, induce similar inflammatory lesions of the groin and gluteal area. Both diseases are characterised by an inadequate immune response to commensal bacteria in genetically predisposed subjects and can be associated. AIM To assess whether HS was associated with clinical and prognostic factors in CD. METHODS A retrospective case-control study included 4645 patients with CD referred to Saint-Antoine Hospital gastroenterology tertiary care centre between 2003 and 2016. Matching variables were sex, age, age and the presence of perianal lesions at CD diagnosis, follow-up quality. HS was confirmed by dermatological examination; location, phenotype and severity (Hurley staging) were recorded. RESULTS Hidradenitis suppurativa prevalence was 0.95% (44 cases); 80% of patients displayed Hurley stage II or III disease. CD preceded HS in 70% of cases with a median interval of 9 years (IQR 5.25-12.75). CD with HS was more active (56% vs 40% years with active disease, P < 0.001) and required more anti-TNF agents (39% vs 23% years spent with anti-TNF treatment, P < 0.001) than CD without HS. HS was associated with a higher risk of permanent stoma, 16.8% (IQR 7.5-33.3) vs 2.5% (IQR 0.8-7.4) in the control group (P = 0.002). Multivariate analysis confirmed HS as independent risk factor for permanent stoma (odds ratio 6.19; 95% CI, 2.30-38.33; P < 0.001). CONCLUSIONS Hidradenitis suppurativa is associated with worse CD prognosis, more active disease and increased risk of permanent stoma, despite a higher use of anti-TNF agents.
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Affiliation(s)
- Louis-Marie Dumont
- Department of Gastroenterology, Saint-Antoine Hospital, AP-HP, Paris, France
| | - Cécilia Landman
- Department of Gastroenterology, Saint-Antoine Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, France
| | - Harry Sokol
- Department of Gastroenterology, Saint-Antoine Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, France
| | - Laurent Beaugerie
- Department of Gastroenterology, Saint-Antoine Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, France
| | - Jacques Cosnes
- Department of Gastroenterology, Saint-Antoine Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, France
| | - Philippe Seksik
- Department of Gastroenterology, Saint-Antoine Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, France
| | - Sarah Guégan
- Department of Dermatology, Cochin Hospital, AP-HP, Paris, France.,University of Paris, Paris, France
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12
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Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol 2020; 5:393-405. [PMID: 31954438 DOI: 10.1016/s2468-1253(19)30366-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/09/2019] [Accepted: 09/17/2019] [Indexed: 02/08/2023]
Abstract
Stricture formation is a common complication of Crohn's disease, resulting from the disease process, surgery, or drugs. Endoscopic balloon dilation has an important role in the management of strictures, with emerging techniques, such as endoscopic electroincision and stenting, showing promising results. The underlying disease process, altered bowel anatomy from disease or surgery, and concurrent use of immunosuppressive drugs can make endoscopic procedures more challenging. There is an urgent need for the standardisation of endoscopic procedures and peri-procedural management strategies. On the basis of an extensive literature review and the clinical experience of the consensus group, which consisted of representatives from the Interventional Inflammatory Bowel Disease Group, we propose detailed guidance on all aspects of the principles and techniques for endoscopic procedures in the treatment of inflammatory bowel disease-associated strictures.
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13
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Yamamoto T, Kotze PG, Spinelli A, Panaccione R. Fistula-associated anal carcinoma in Crohn's disease. Expert Rev Gastroenterol Hepatol 2018; 12:917-925. [PMID: 29999429 DOI: 10.1080/17474124.2018.1500175] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fistula-associated anal carcinoma in patients with Crohn's disease (CD) is a rare condition. More recently, this entity has been increasingly reported likely due to increased recognition, and the incidence may be greater than once appreciated. There remains a paucity of data regarding the incidence, diagnosis, treatment, and outcome of fistula-associated anal carcinoma. Area covered: This review evaluates the clinical features, pathology, treatment, and prognosis of fistula-associated anal carcinoma in patients with CD. A strategy for surveillance of this carcinoma is proposed by the authors based on the evidence obtained from this review. Expert commentary: Clinicians caring for patients with CD and perianal involvement need to be aware of the rare yet extremely important association of long-standing perianal disease and fistula-associated carcinoma. Only through awareness, a high level of suspicion will be diagnosed in a timely manner. This involves a thorough history, a proper, and complete anorectal examination, along with early imaging and examination under anesthesia. Through this approach, it is hoped that early diagnose can be achieved in at-risk patients and change the significant morbidity and mortality associated with this diagnosis.
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Affiliation(s)
- Takayuki Yamamoto
- a Inflammatory Bowel Disease Center & Department of Surgery , Yokkaichi Hazu Medical Center , Yokkaichi , Japan
| | - Paulo Gustavo Kotze
- b Colorectal Surgery Unit , Catholic University of Parana (PUCPR) , Curitiba , Brazil.,c Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology , University of Calgary , Calgary , Canada
| | - Antonino Spinelli
- d Department of Biomedical Sciences , Humanitas University , Milano , Italy.,e Division of Colon and Rectal Surgery , Humanitas Clinical and Research Center , Milano , Italy
| | - Remo Panaccione
- c Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology , University of Calgary , Calgary , Canada
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14
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Beaugerie L, Carrat F, Nahon S, Zeitoun JD, Sabaté JM, Peyrin-Biroulet L, Colombel JF, Allez M, Fléjou JF, Kirchgesner J, Svrcek M. High Risk of Anal and Rectal Cancer in Patients With Anal and/or Perianal Crohn's Disease. Clin Gastroenterol Hepatol 2018; 16:892-899.e2. [PMID: 29199142 DOI: 10.1016/j.cgh.2017.11.041] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Little is known about the magnitude of the risk of anal and rectal cancer in patients with anal and/or perineal Crohn's disease. We aimed to assess the risk of anal and rectal cancer in patients with Crohn's perianal disease followed up in the Cancers Et Surrisque Associé aux Maladies Inflammatoires Intestinales En France (CESAME) cohort. METHODS We collected data from 19,486 patients with inflammatory bowel disease (IBD) enrolled in the observational CESAME study in France, from May 2004 through June 2005; 14.9% of participants had past or current anal and/or perianal Crohn's disease. Subjects were followed up for a median time of 35 months (interquartile range, 29-40 mo). To identify risk factors for anal cancer in the total CESAME population, we performed a case-control study in which participants were matched for age and sex. RESULTS Among the total IBD population, 8 patients developed anal cancer and 14 patients developed rectal cancer. In the subgroup of 2911 patients with past or current anal and/or perianal Crohn's lesions at cohort entry, 2 developed anal squamous-cell carcinoma, 3 developed perianal fistula-related adenocarcinoma, and 6 developed rectal cancer. The corresponding incidence rates were 0.26 per 1000 patient-years for anal squamous-cell carcinoma, 0.38 per 1000 patient-years for perianal fistula-related adenocarcinoma, and 0.77 per 1000 patient-years for rectal cancer. Among the 16,575 patients with ulcerative colitis or Crohn's disease without anal or perianal lesions, the incidence rate of anal cancer was 0.08 per 1000 patient-years and of rectal cancer was 0.21 per 1000 patient-years. Among factors tested by univariate conditional regression (IBD subtype, disease duration, exposure to immune-suppressive therapy, presence of past or current anal and/or perianal lesions), the presence of past or current anal and/or perianal lesions at cohort entry was the only factor significantly associated with development of anal cancer (odds ratio, 11.2; 95% CI, 1.18-551.51; P = .03). CONCLUSIONS In an analysis of data from the CESAME cohort in France, patients with anal and/or perianal Crohn's disease have a high risk of anal cancer, including perianal fistula-related cancer, and a high risk of rectal cancer.
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Affiliation(s)
- Laurent Beaugerie
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, GRC-UPMC 03, Sorbonne Université, Paris, France.
| | - Fabrice Carrat
- Department of Public Health, Hôpital Saint-Antoine, Assistance Publique, Hôpitaux de Paris, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Stéphane Nahon
- Department of Gastroenterology, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Jean-David Zeitoun
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, GRC-UPMC 03, Sorbonne Université, Paris, France; Department of Surgical Proctology, Croix Saint-Simon Hospital, Paris, France
| | - Jean-Marc Sabaté
- Department of Gastroenterology, APHP, Hôpital Avicenne and Sorbonne Paris Cité, Univ Paris Diderot, Paris, France
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Jean-Frédéric Colombel
- The Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthieu Allez
- APHP, Hôpital Saint Louis, Department of Gastroenterology, INSERM UMRS 1160, Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Jean-François Fléjou
- Department of Pathology, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Julien Kirchgesner
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, GRC-UPMC 03, Sorbonne Université, Paris, France
| | - Magali Svrcek
- Department of Pathology, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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15
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Kotze PG, Shen B, Lightner A, Yamamoto T, Spinelli A, Ghosh S, Panaccione R. Modern management of perianal fistulas in Crohn's disease: future directions. Gut 2018; 67:1181-1194. [PMID: 29331943 DOI: 10.1136/gutjnl-2017-314918] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/20/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
Perianal fistulae in patients with Crohn's disease (CD) can be associated with significant morbidity resulting in negative impact on quality of life. The last two decades have seen significant advancements in the management of perianal fistulas in CD, which has evolved into a multidisciplinary approach that includes gastroenterologists, colorectal surgeons, endoscopists and radiologists. Despite the introduction of new medical therapies such as antitumour necrosis factor and novel models of care delivery, the best fistula healing rates reported with combined medical and surgical approaches are approximately 50%. More recently, newer biologics, cell-based therapies as well as novel endoscopic and surgical techniques have been introduced raising new hopes that outcomes can be improved upon. In this review, we describe the modern management and the most recent advances in the management of complex perianal fistulising CD, which will likely impact clinical practice. We will explore optimal use of both older and newer biological agents, as well as new data on cell-based therapies. In addition, new techniques in endoscopic and surgical approaches will be discussed.
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Affiliation(s)
- Paulo Gustavo Kotze
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Bo Shen
- Interventional IBD Unit, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amy Lightner
- Division of Colorectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Subrata Ghosh
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Adegbola SO, Pisani A, Sahnan K, Tozer P, Ellul P, Warusavitarne J. Medical and surgical management of perianal Crohn's disease. Ann Gastroenterol 2018; 31:129-139. [PMID: 29507460 PMCID: PMC5825943 DOI: 10.20524/aog.2018.0236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/24/2017] [Indexed: 12/16/2022] Open
Abstract
Crohn's disease is increasingly thought to encompass multiple possible phenotypes. Perianal manifestations account for one such phenotype and represent an independent disease modifier. In its more severe form, perianal Crohn's disease confers a higher risk of a severe and disabling disease course, relapses, hospital admissions and operations. This, in turn, imposes a considerable burden and disability on patients. Identification of the precise manifestation is important, as management is nuanced, with both medical and surgical components, and is best undertaken in a multidisciplinary setting for both diagnosis and ongoing treatment. The introduction of biologic medication has heralded a significant addition to the management of fistulizing perianal Crohn's disease in particular, albeit with modest results. It remains a very challenging condition to treat and further work is required to optimize management in this group of patients.
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Affiliation(s)
- Samuel O. Adegbola
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Anthea Pisani
- Department of Gastroenterology, Mater dei Hospital, Malta (Pierre Ellul)
| | - Kapil Sahnan
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Phil Tozer
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Pierre Ellul
- Department of Gastroenterology, Mater dei Hospital, Malta (Pierre Ellul)
| | - Janindra Warusavitarne
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
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17
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Wallenhorst T, Brochard C, Le Balch E, Bodere A, Garros A, Merlini-l'Heritier A, Bouguen G, Siproudhis L. Anal ulcerations in Crohn's disease: Natural history in the era of biological therapy. Dig Liver Dis 2017; 49:1191-1195. [PMID: 28847470 DOI: 10.1016/j.dld.2017.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/22/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The natural history of anal ulcerations in Crohn's disease remains unknown. AIMS To assess the long-term outcomes of anorectal ulcerations. METHODS Data from consecutive patients with perineal Crohn's disease were prospectively recorded. The data of patients with anal ulceration were extracted. RESULTS Anal ulcerations were observed in 154 of 282 patients (54.6%), and 77 cases involved cavitating ulcerations. The cumulative healing rates were 47%, 70% and 82% at 1, 2 and 3 years, respectively. Patients with a primary fistula phenotype had a shorter median time to healing of their anal ulceration (28 [13-83] weeks) than those with a stricture (81 [28-135] weeks) or those with isolated ulceration (74 [31-181] weeks) (p=0.004). Among patients with ulcerations but no fistula at referral (n=67), only 4 (6%) developed de novo abscesses and/or fistula during follow-up. There was no benefit associated with introducing or optimising biologics, nor with combining immunosuppressants and biologics. CONCLUSION Anal ulceration in Crohn's disease usually requires a long time to achieve sustained healing. Determining the impact of biologics on healing rates will require dedicated randomised trials although it does not show a significant healing benefit in the present study.
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Affiliation(s)
| | - Charlène Brochard
- Department of Gastroenterology, University Hospital of Rennes, Rennes, France; Department of Digestive Physiology, University Hospital of Rennes, Rennes, France; INSERM U991, University of Rennes, Rennes, France; CIC-1414, University of Rennes, Rennes, France.
| | - Eric Le Balch
- Department of Gastroenterology, University Hospital of Rennes, Rennes, France
| | - Anaïs Bodere
- Department of Gastroenterology, University Hospital of Rennes, Rennes, France
| | - Aurélien Garros
- Department of Gastroenterology, University Hospital of Rennes, Rennes, France
| | | | - Guillaume Bouguen
- Department of Gastroenterology, University Hospital of Rennes, Rennes, France; INSERM U991, University of Rennes, Rennes, France; CIC-1414, University of Rennes, Rennes, France
| | - Laurent Siproudhis
- Department of Gastroenterology, University Hospital of Rennes, Rennes, France; INSERM U991, University of Rennes, Rennes, France; CIC-1414, University of Rennes, Rennes, France
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19
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Wisniewski A, Fléjou JF, Siproudhis L, Abramowitz L, Svrcek M, Beaugerie L. Anal Neoplasia in Inflammatory Bowel Disease: Classification Proposal, Epidemiology, Carcinogenesis, and Risk Management Perspectives. J Crohns Colitis 2017; 11:1011-1018. [PMID: 28379306 DOI: 10.1093/ecco-jcc/jjx035] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/09/2017] [Indexed: 12/31/2022]
Abstract
Patients with inflammatory bowel disease [IBD] may develop, similarly to individuals from general population, rare cases of human papilloma virus [HPV]-related anal canal squamous cell carcinoma [SCC] and intra-epithelial precursor lesions, as well as very rare cases of anal canal adenocarcinoma. Patients with chronic perianal Crohn's disease [CD] are at substantial risk of developing SCC or adenocarcinoma from the fistula-lining epithelium, as well as SCC or adenocarcinoma arising from chronic anorectal ulcerations or strictures. Based on this lesion stratification, we provide in this review tailored incidence estimates and we propose an IBD-specific classification of all types of anal neoplasia that may occur in patients with IBD. After reviewing putative carcinogenesis of all types of neoplasia, we conclude that HPV vaccination could reduce the incidence of HPV-related lesions, although an anal screening programme related to these lesions is not mandatory on the sole basis of IBD. By contrast, we point out that all patients with chronic perianal CD should be explored in depth, including biopsies under anaesthesia and fistula curettage when necessary, in case of any change in anal symptoms ─in particular new, increasing, unexplained pain. Finally, we conclude that there is an urgent need for elaborating and evaluating surveillance algorithms in patients with chronic perianal CD, in order to avoid cancers with late diagnosis and poor prognosis.
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Affiliation(s)
- Andrew Wisniewski
- Department of Gastroenterology, Hôpital Saint-Antoine, UPMC Univ Paris 06, Paris, France.,Hôpital Charles-Lemoyne and Université de Sherbrooke, Montréal, QC, Canada
| | | | | | - Laurent Abramowitz
- Department of Gastroenterology and Proctology, CHU Bichat, Paris, France
| | - Magali Svrcek
- Department of Pathology, Hôpital Saint-Antoine,UPMC Univ Paris, France
| | - Laurent Beaugerie
- Department of Gastroenterology, Hôpital Saint-Antoine, UPMC Univ Paris 06, Paris, France
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20
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Lamoureux A, Maurey C, Freiche V. Treatment of inflammatory rectal strictures by digital bougienage: a retrospective study of nine cases. J Small Anim Pract 2017; 58:293-297. [PMID: 28245059 DOI: 10.1111/jsap.12638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 11/20/2016] [Accepted: 11/28/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Inflammatory rectal strictures in dogs and cats have been rarely reported. The aim of this study was to describe nine cases and their treatment by digital bougienage. METHODS Medical records of dogs and cats referred for constipation, dyschezia or tenesmus and diagnosed with an inflammatory rectal stricture were obtained from the database of two referral centres between 2007 and 2014 and reviewed. RESULTS Four dogs and five cats met the inclusion criteria. Four of the five cats were purebred kittens. Three cats and two dogs had a history of diarrhoea and two dogs had a history of bone ingestion. Digital rectal examination revealed rectal strictures in all cases. Histopathology revealed a lymphoplasmacytic infiltration in all four dogs and in two cats. All cases were treated by digital bougienage. A psyllium-enriched diet was prescribed in all cats and in two dogs. A complete resolution of clinical signs was reported in all eight cases for which follow-up information was available. CLINICAL SIGNIFICANCE Benign rectal strictures associated with gastrointestinal inflammation should be routinely included in the differential diagnosis of constipation, tenesmus and dyschezia, especially after an episode of acute or chronic diarrhoea. The treatment described here is simple, minimally invasive and effective in the long term.
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Affiliation(s)
- A Lamoureux
- Université Paris Est, Ecole nationale vétérinaire d'Alfort, Unité de médecine interne, 94700, Maisons Alfort, France
| | - C Maurey
- Université Paris Est, Ecole nationale vétérinaire d'Alfort, Unité de médecine interne, 94700, Maisons Alfort, France
| | - V Freiche
- Université Paris Est, Ecole nationale vétérinaire d'Alfort, Unité de médecine interne, 94700, Maisons Alfort, France
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21
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Chon HK, Shin IS, Kim SW, Lee ST. High grade anorectal stricture complicating Crohn's disease: endoscopic treatment using insulated-tip knife. Intest Res 2016; 14:285-8. [PMID: 27433152 PMCID: PMC4945534 DOI: 10.5217/ir.2016.14.3.285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/19/2015] [Accepted: 11/03/2015] [Indexed: 12/04/2022] Open
Abstract
Endoscopic treatments have emerged as an alternative to surgery, in the treatment of benign colorectal stricture. Unlike endoscopic balloon dilatation, there is limited data on endoscopic electrocautery incision therapy for benign colorectal stricture, especially with regards to safety and long-term patency. We present a case of a 29-year-old female with Crohn's disease who had difficulty in defecation and passing thin stools. A pelvic magnetic resonance imaging scan, gastrograffin enema, and sigmoidoscopy showed a high-grade anorectal stricture. An endoscopic insulated-tip knife incision was successfully performed to resolve the problem. From our experience, we suggest that endoscopic insulated-tip knife treatment may be a feasible and effective modality for patients with short-segment, very rigid, fibrotic anorectal stricture.
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Affiliation(s)
- Hyung Ku Chon
- Division of Gastroenterology, Department of Internal Medicine, Chonbuk National University College of Medicine and Hospital, Jeonju, Korea
| | - Ik Sang Shin
- Division of Gastroenterology, Department of Internal Medicine, Chonbuk National University College of Medicine and Hospital, Jeonju, Korea
| | - Sang Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Chonbuk National University College of Medicine and Hospital, Jeonju, Korea
| | - Soo Teik Lee
- Division of Gastroenterology, Department of Internal Medicine, Chonbuk National University College of Medicine and Hospital, Jeonju, Korea
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Abstract
PURPOSE Perianal Crohn's disease (CD) encompasses a variety of lesion similar to luminal disease, which are usually not distinctly assessed. Links between luminal and perianal CD phenotype remains therefore underreported, and we aimed to describe both luminal and perianal phenotype and their relationships. METHODS From January 2007, clinical data of all consecutive patients with CD seen in a referral center were prospectively recorded. Data recorded until October 2011 were extracted and reviewed for study proposal. RESULTS A total of 282 patients (M/F, 108/174; aged 37.8 ± 16.2 years) were assessed that included 154 cases (54.6%) with anal ulceration, 118 cases (41.8%) with fistula, 49 cases (17.4%) with stricture, and 94 cases without anal lesion (33.3%). Anal ulcerations were associated with fistulas (N = 87/154) in more than half of patients (56.5%) and were isolated in 55 patients (35.7%). Most of strictures (94%) were associated with other lesions (N = 46/49). Harvey-Bradshaw score was significantly higher in patients with ulcerations (p < 0.001) as compared to those with perianal fistulas (p = 0.15) or with anal strictures (p = 0.16). Proportions of complicated behavior (fistulizing or stricturing) of luminal CD were similar according to anal lesions: anal fistulas were not significantly associated to penetrating Montreal phenotype (N = 4/31 p = 0.13) as well as anal stricture and stricturing Montreal phenotype (N = 3/49, p = 0.53). CONCLUSIONS The phenotype of luminal disease does not link with the occurrence and the phenotype of perianal Crohn's disease. Anal ulcerations denote a more severe disease on both luminal and perianal locations and should consequently be taking into account in physician decision-making.
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Abstract
There is no cure for Crohn disease. Newer treatments, such as biological therapy, have led to an improved quality of life. This article focuses on the surgical management of Crohn disease of the colon, rectum, and anus. Restorative and nonrestorative surgical options for colonic Crohn disease are discussed. Treatment options for perianal Crohn disease are also reviewed.
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Affiliation(s)
- William J Harb
- The Colorectal Center, 2011 Church Street, Suite 703, Nashville, TN 37203, USA.
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24
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Seifarth C, Kreis ME, Gröne J. Indications and Specific Surgical Techniques in Crohn's Disease. VISZERALMEDIZIN 2015; 31:273-9. [PMID: 26557836 PMCID: PMC4608647 DOI: 10.1159/000438955] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Crohn's disease (CD) as one of the major entities of chronic inflammatory bowel diseases can affect all segments of the gastrointestinal tract but occurs most often in the small bowel, the terminal ileum, the colon, and the rectum. Typical symptoms include tiredness, lower abdominal pain, fever, and diarrhea, which are initially treated by conservative measures. Most patients will eventually develop complications such as fistulas, abscesses, or strictures. Surgery is often unavoidable in these cases. Methods This review considers studies on the treatment of CD, published from 1979 up to now. The literature regarding the course, complications, and surgical therapy of CD was reviewed. Searches were performed in PubMed, using the following key words: CD, surgery, immunosuppression, guidelines, malnutrition as well as appropriate sub-items. In most cases the literature is limited to detailed information on specific therapeutic or diagnostic topics. Moreover, many studies are designed retrospectively and with a small number of patients. Additionally, our long-standing experience with patients suffering from CD is taken into consideration in this review. Results There is a wide variety of indications for surgery in CD which includes complications like strictures, fistulas and abscess formation, neoplasia, or refractoriness to medical therapy. The risk of developing complications is about 33% after 5 years, and 50% after 20 years. Furthermore, one-third of CD patients need surgical therapy within the first 5 years of diagnosis. The treatment requires close cooperation between gastroenterologists and surgeons. When indicated, surgery should be performed in a ‘conservative’ fashion, i.e. as limited as possible, in order to achieve the required result and to avoid small bowel syndrome. Conclusion This article provides a complete overview of indications and specific surgical treatment in patients with CD. Surgery is typically indicated when complications of CD occur. An interdisciplinary collaboration is necessary in order to ensure optimal indications and timing of surgery. This is of paramount importance to achieve the ultimate goal, i.e. a good quality of life of the patients.
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Affiliation(s)
- Claudia Seifarth
- Department of General, Visceral- and Vascular Surgery, Charité - University Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Martin E Kreis
- Department of General, Visceral- and Vascular Surgery, Charité - University Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Jörn Gröne
- Department of General, Visceral- and Vascular Surgery, Charité - University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Malgras B, Pautrat K, Dray X, Pasquier P, Valleur P, Pocard M, Soyer P. Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease. Dig Dis Sci 2015; 60:1152-68. [PMID: 25381203 DOI: 10.1007/s10620-014-3421-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.
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Affiliation(s)
- Brice Malgras
- Department of Surgery, Laiboisiere Hospital, Paris 7 University and AP-HP, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France,
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Gasparetto M, Angriman I, Guariso G. The multidisciplinary health care team in the management of stenosis in Crohn's disease. J Multidiscip Healthc 2015; 8:167-79. [PMID: 25878504 PMCID: PMC4388000 DOI: 10.2147/jmdh.s38729] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Stricture formation is a common complication of Crohn’s disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD. Methods A Medline search was performed, using “Inflammatory Bowel Disease”, “stricture”, “Crohn’s Disease”, “Ulcerative Colitis”, “endoscopic balloon dilatation” and “strictureplasty” as keywords. A selection of clinical cohort studies and systematic reviews were reviewed. Results Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery. Conclusion Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment.
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Affiliation(s)
- Marco Gasparetto
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
| | - Imerio Angriman
- Department of Surgery, Gastroenterology and Oncology, Padua University, Padova, Italy
| | - Graziella Guariso
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
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