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Dawoud C, Widmann KM, Czipin S, Pramhas M, Scharitzer M, Stift A, Harpain F, Riss S. Efficacy of cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease-A prospective nationwide multicenter cohort study. Wien Klin Wochenschr 2024; 136:289-294. [PMID: 37823920 PMCID: PMC11078846 DOI: 10.1007/s00508-023-02283-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The use of mesenchymal stem cells is considered a novel and promising therapeutic option for patients with perianal fistulizing Crohn's disease; however, data on its clinical application remain scarce. This multicenter nationwide study aimed to assess the clinical efficacy of mesenchymal stem cells in closing complex anal fistulas. METHODS In this study 14 Crohn's disease patients (3 males, 11 females) with complex anal fistulas treated in 3 tertiary hospitals in Austria were included between October 2018 and April 2021. Injection of 120 million allogeneic expanded adipose-derived mesenchymal stem cells (Cx601-darvadstrocel) was performed in each patient. Closure of the external fistula opening without secretion by external manual compression was defined as treatment success. RESULTS The median age of the patient population at the time of surgery was 32 years (range 26-53 years) with a median body mass index of 21.7 kg/m2 (range 16.7-26.6 kg/m2). Of the patients 12 (86%) received monoclonal antibodies (infliximab, adalimumab, ustekinumab, vedolizumab) at the time of surgery. The median number of complex fistulas was 1.4 (range 1-2), The median operative time was 20 min (range 6-50 min) with no perioperative complications. After a median follow-up of 92 weeks, we found successful fistula closure in 57.1% (n = 8) of treated patients. The perianal disease activity index did not improve significantly from initially 7 to a median of 6 after 52 weeks (p = 0.495). CONCLUSION Darvadstrocel is a safe, minimally invasive surgical technique without significant perioperative complications. Clinical success can be expected in about half of the treated patients.
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Affiliation(s)
- Christopher Dawoud
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Kerstin Melanie Widmann
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sascha Czipin
- Department of Visceral, Transplant and Thoracic Surgery, Centre for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Pramhas
- First Surgical Department, Klinik Landstraße, Vienna, Austria
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Riss
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Ye ML, Cheng F. Comments on: "Efficacy of cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease-A prospective nationwide multicenter cohort study". Wien Klin Wochenschr 2024; 136:295-296. [PMID: 38600334 DOI: 10.1007/s00508-024-02359-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Man-Ling Ye
- Division of Gastroenterology, Zigong First People's Hospital, 42 Shangyihao Road, 643000, Zigong, Sichuan Province, China
| | - Fang Cheng
- Division of Gastroenterology, Zigong First People's Hospital, 42 Shangyihao Road, 643000, Zigong, Sichuan Province, China.
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Riss S, Dawoud C. Reply to comments on: "Efficacy of cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease-A prospective nationwide multicenter cohort study". Wien Klin Wochenschr 2024; 136:297. [PMID: 38652312 DOI: 10.1007/s00508-024-02363-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Stefan Riss
- Department of General Surgery, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Christopher Dawoud
- Department of General Surgery, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Vuyyuru SK, Solitano V, Narula N, Lee MJ, MacDonald JK, McCurdy JD, Singh S, Ma C, Jairath V. Pharmacological Therapies for the Management of Fistulizing Crohn's Disease: A Systematic Review and Meta-Analysis. J Crohns Colitis 2024; 18:589-603. [PMID: 37933849 DOI: 10.1093/ecco-jcc/jjad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Fistulas are a debilitating complication of Crohn's disease [CD]. We conducted a systematic review to assess the efficacy of medical therapies for fistulizing CD. METHODS MEDLINE, Embase, and CENTRAL were searched on May 26, 2022, for randomized controlled trials [RCTs] of pharmacological therapy in adults with fistulizing CD. The primary outcome was induction and maintenance of fistula response. Pooled risk ratios [RRs] and 95% confidence intervals [CIs] were calculated. GRADE was used to assess the certainty of evidence. RESULTS Thirty-eight RCTs were included. Nineteen trials [50%] exclusively involved perianal fistula. The remaining studies included some participants with non-perianal fistula. Pooled RRs for anti-tumour necrosis factor [TNF] agents were not statistically significant for induction [RR 1.36, 95% CI 0.97-1.91] or maintenance of fistula response [RR 1.48, 95% CI 0.97-2.27]. However, in a sensitivity analysis of studies with fistula response as the primary outcome, anti-TNFs were superior to placebo for induction [RR 1.94, 95% CI 1.10-3.41] and maintenance [RR 1.88, 95% CI 1.23-2.88] of fistula response. Oral small molecules [RR 2.56, 95% CI 1.18-5.53] and mesenchymal stem cell [MSC] therapy [RR 1.26, 95% CI 1.01-1.57] were effective for induction of fistula response. Ustekinumab was associated with maintenance of fistula response [RR 1.80, 95% CI 1.04-3.11]. Vedolizumab was not superior to placebo. The certainty of evidence ranged from very low to moderate. CONCLUSION Very low- to moderate-certainty evidence suggests that anti-TNF therapy, oral small molecules, ustekinumab, and MSCs are effective for perianal fistulizing CD. Dedicated fistula studies evaluating biologics and small molecules are needed.
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Affiliation(s)
- Sudheer K Vuyyuru
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Alimentiv Inc, London, ON, Canada
| | - Virginia Solitano
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Alimentiv Inc, London, ON, Canada
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Neeraj Narula
- Department of Medicine, Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Matthew J Lee
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | | | - Jeffrey D McCurdy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Christopher Ma
- Alimentiv Inc, London, ON, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Ben Azouz S, Elleuch N, Dahmeni W, Hammami E, Braham A, Jaziri H, Ben Slema A, Ksiaa M, Jmaa A. Traitement des fistules anales réfractaires à l’Infliximab au cours de la maladie de Crohn : Mise au point. Tunis Med 2024; 102:181-188. [PMID: 38746955 DOI: 10.62438/tunismed.v102i4.4699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/03/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab. AIM Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab. METHODS A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded. RESULTS Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated. CONCLUSION Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.
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Affiliation(s)
- Sarra Ben Azouz
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Nour Elleuch
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Wafa Dahmeni
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Eya Hammami
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Ahlem Braham
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Hanene Jaziri
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Aida Ben Slema
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Mehdi Ksiaa
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
| | - Ali Jmaa
- Department of gastroenterology, Sahloul Hospital, Sousse, Tunisia
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Du W, Chen W, Yao W. Clinical Study on the Treatment of Complex Anal Fistula by Phased Chinese Herbal Sitz Bath Based on "Fuzheng Quxie" Theory. Altern Ther Health Med 2024; 30:50-55. [PMID: 37856804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Objective To evaluate the clinical efficacy of a phased Chinese herbal sitz bath for the treatment of complex anal fistula based on the traditional Chinese medicine theory of "Fuzheng Quxie." Methods We enrolled 200 patients with complex anal fistula who were hospitalized and treated surgically in the Department of Anorectal Medicine of Suining Central Hospital from June 2021 to December 2022. The patients were randomly divided into 2 groups of 100 patients each: sitz bath group 1 (postoperation, the patients used a sitz bath with a self-formulated decoction of "Qingre Zaoshi Zhitong" formula, once in the morning and once in the evening) and sitz bath group 2 (postoperation, the patients used the same decoction as the sitz bath group 1, and when the incision began to heal, the patients then used a sitz bath with a self-formulated decoction of "Yiqi Fuzheng" formula, once in the morning and once in the evening). Both groups were treated for 6 weeks. The assessments included wound symptom score, incision healing time, clinical efficacy after treatment, and serum-related growth factor concentrations and anorectal dynamics indicators before and after treatment. Results After treatment, sitz bath group 2 had less wound pain, edema, exudate, and granulation growth scores than sitz bath group 1 (P < .05). Postoperative incision healing time was faster in sitz bath group 2 22.96 (1.96) d than in sitz bath group 1 26.19 (2.62) d (t = 9.872, P < .001). The total effective rate after treatment was higher in sitz bath group 2 96% (96/100) than in sitz bath group 1 88% (88/100) (χ2 = 4.4, P = .04). Serum transforming growth factor β, epidermal growth factor, and basic fibroblast growth factor concentrations were higher in both groups after treatment than before treatment, and the concentrations of the growth factors after treatment were higher for sitz bath group 2 than for sitz bath group 1 (P < .001). Anal rest pressure and anal maximum contraction pressure were higher in both groups after treatment than before treatment, and the pressures after treatment were higher for sitz bath group 2 than for sitz bath group 1 (P < .05). Conclusion Based on the theory of Fuzheng Quxie, the effectiveness and superiority of a phased Chinese herbal sitz bath for the treatment of complex anal fistula were remarkable, which could promote the improvement of wound symptoms and anal function. This may be related to increases in growth factor concentrations and anorectal dynamics indicators.
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Lightner AL, Otero-Pineiro A, Reese J, Ream J, Nachand D, Adams AC, VanDenBossche A, Kurowski JA. A Phase I Study of Ex Vivo Expanded Allogeneic Bone Marrow-Derived Mesenchymal Stem Cells for the Treatment of Pediatric Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2023; 29:1912-1919. [PMID: 37263018 DOI: 10.1093/ibd/izad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Perianal fistulizing Crohn's disease is notoriously difficult to treat. Recent studies of mesenchymal stem cells have demonstrated safety and efficacy of this novel treatment approach. However, no studies to date have included pediatric patients. We sought to determine safety and efficacy of mesenchymal stem cells for pediatric perianal fistulizing Crohn's disease. METHODS This was a phase I clinical trial to evaluate safety and feasibility of mesenchymal stem cells in pediatric perianal Crohn's patients 13 to 17 years of age. At the time of an exam under anesthesia, following curettage of the fistula tract and closure of the internal opening with absorbable suture, 75 million mesenchymal stem cells were administered with a 22-gauge needle. This was repeated at 3 months if complete clinical and radiographic healing were not achieved. Adverse and serious adverse events at were measured at postprocedure day 1, week 2, week 6, month 3, month 6, and month 12. Clinical healing, radiographic healing per magnetic resonance imaging, and patient-reported outcomes were measured at the same time points. RESULTS Seven pediatric patients were enrolled and treated (6 male; median age of 16.7 years). There were no adverse or serious adverse events related to the investigational product or injection procedure. At 6 months, 83% had complete clinical and radiographic healing. The perianal Crohn's Disease Activity Index, Wexner incontinence score, and Van Assche score had all decreased at 6 months. CONCLUSIONS Bone marrow-derived mesenchymal stem cells offer a safe, and likely effective, treatment approach for pediatric perianal fistulizing Crohn's disease.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ana Otero-Pineiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jane Reese
- National Center for Regenerative Medicine, Cleveland, OH, USA
| | - Justin Ream
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas Nachand
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ashley C Adams
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra VanDenBossche
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacob A Kurowski
- Department of Pediatrics, Pediatric Institute, Cleveland Clinic, Cleveland, OH, USA
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Keung C, Nguyen TC, Lim R, Gerstenmaier A, Sievert W, Moore GT. Local fistula injection of allogeneic human amnion epithelial cells is safe and well tolerated in patients with refractory complex perianal Crohn's disease: a phase I open label study with long-term follow up. EBioMedicine 2023; 98:104879. [PMID: 38042747 PMCID: PMC10755113 DOI: 10.1016/j.ebiom.2023.104879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/29/2023] [Accepted: 11/03/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Local fistula injection of mesenchymal stromal/stem cells (MSC) is effective for complex perianal Crohn's fistulas but is also expensive and requires specialised facilities for cell revival before administration. Human amnion epithelial cells (hAEC) are non-MSC cells with therapeutic properties. The primary aim of this study was safety of hAEC therapy. Secondary aims included hAEC efficacy, feasibility of the protocol and impact on quality of life. METHODS A phase I open label study of ten adults with active complex Crohn's perianal fistulas refractory to conventional treatment, including anti-tumour necrosis factor alpha therapy, was undertaken. A single dose of hAEC was injected into the fistula tract(s) after surgical closure of the internal opening(s). Study outcomes were assessed at week 24 with follow up for at least 52 weeks. FINDINGS Local injection of hAEC was safe, well tolerated and the injection procedure was feasible. Complete response occurred in 4 patients, and a partial response in an additional 4 patients. There was a mean reduction in the Perianal Disease Activity Index of 6.5 points (95% CI -9.0 to -4.0, p = 0.0002, paired t-test), modified Van Assche MRI Index of 2.3 points (95% CI -3.9 to -0.6, p = 0.012, paired t-test) and a mean improvement of 15.8 points (95% CI 4.9 to 26.8, p = 0.010, paired t-test) in quality of life using the Short IBD-Questionnaire in complete responders. INTERPRETATION Local injection of hAEC therapy for refractory complex perianal fistulising Crohn's disease appears safe, well-tolerated, feasible and demonstrated improvement. Quality of life is improved in those who achieve complete fistula healing. FUNDING This study was funded by competitive research grant funding from the Gastroenterological Society of Australia Seed Grant 2018.
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Affiliation(s)
- Charlotte Keung
- School of Clinical Sciences, Monash University, Australia; Department of Gastroenterology, Monash Health, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Australia.
| | | | - Rebecca Lim
- The Ritchie Centre, Hudson Institute of Medical Research, Australia
| | | | - William Sievert
- School of Clinical Sciences, Monash University, Australia; Department of Gastroenterology, Monash Health, Australia
| | - Gregory T Moore
- School of Clinical Sciences, Monash University, Australia; Department of Gastroenterology, Monash Health, Australia
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Chen YM, Cheng F. Re: Autologous fat graft injections for the treatment of perianal fistulas in Crohn's disease: a systematic review and single-arm meta-analysis. ANZ J Surg 2023; 93:3028. [PMID: 37859566 DOI: 10.1111/ans.18731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Yu-Mei Chen
- Department of Respiratory Medicine, Zigong First People's Hospital, Zigong, China
| | - Fang Cheng
- Division of Gastroenterology, Zigong First People's Hospital, Zigong, China
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Zhang DL, Shao XX, Hu DY, Lin DP, Wu H, Jiang Y. [Analysis on the efficacy of dual vein induction therapy of Ustekinumab in complex perianal fistulizing Crohn's disease]. Zhonghua Yi Xue Za Zhi 2023; 103:3301-3306. [PMID: 37926575 DOI: 10.3730/cma.j.cn112137-20230502-00707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Objectives: To analyze the efficacy of dual vein induction therapy of Ustekinumab (UST) in complex perianal fistulizing Crohn's disease (PFCD). Methods: Clinical data of patients diagnosed with complex PFCD in the Second Affiliated Hospital of Wenzhou Medical University from January 2022 to March 2023 were retrospectively analyzed. After sufficient single intravenous infusion of UST (6 mg/kg) at week 0 and 8, every patient received single subcutaneous injection of UST 90 mg every 8 weeks for maintenance treatment. At week 8, 16, and 22-26, clinical outcomes of anal fistula were evaluated using perianal disease activity index (PDAI), and overall activity of the patients was evaluated using Harvey Bradshaw index (HBI). At week 22-26, Van Assche Index (VAI) was used to evaluate imaging outcome of anal fistula, and simplified endoscopic score of Crohn's disease (SES-CD) was employed to assess intestinal outcome events. The above indexes were compared in the patients before and after UST treatment. PFCD patients were divided into first-line UST treatment group and non first-line UST treatment group according to whether first-line UST treatment was used, the differences in anal fistula response rate and remission rate, intestinal response rate and remission rate as well as overall activity response rate and remission rate were compared between the two groups. Results: A total of 60 PFCD patients were included, including 46 males and 14 females, aged [M (Q1, Q3)] 25.0 (20.8, 30.0) years old. The clinical response rates of anal fistula [41.7% (25/60), 55.0% (33/60) and 63.3% (38/60), respectively, P=0.056] and the clinical remission rates of anal fistula [21.7% (13/60), 31.7% (19/60) and 43.3% (26/60), respectively, P=0.002] gradually increased at week 8, 16, 22-26. The overall activity response rates [53.3% (32/60), 70.0% (42/60), 83.3% (50/60), respectively, P=0.040] and the overall activity response rates [41.7% (25/60), 61.7% (37/60), 75.0% (45/60), respectively, P=0.001] also gradually increased at week 8, 16, 22-26. At week 22-26, the partial response rate and fistula healing rate of anal fistula imaging were 45.0% (27/60) and 38.3% (23/60), respectively. The endoscopic response rate and endoscopic response rate were 73.7% (44/60) and 45.0% (27/60), respectively. The endoscopic response rate of patients receiving first-line UST treatment [23 males and 8 females, aged 22.0 (21.0, 39.0) years] was higher than that of patients receiving non first-line UST treatment[23 males and 6 females, aged 26.5 (20.0, 30.0) years,87.1% vs 58.6%, P=0.013]. Conclusion: The dual vein induction therapy of UST could effectively improve the clinical efficacy in patients with complex PFCD.
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Affiliation(s)
- D L Zhang
- Department of Gastroenterology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - X X Shao
- Department of Gastroenterology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - D Y Hu
- Department of Gastroenterology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - D P Lin
- Department of Gastroenterology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - H Wu
- Department of Gastroenterology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Y Jiang
- Department of Gastroenterology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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Maas L, Gao R, Cusumano V, Spartz E, Chowdhury R, Krishna M, Lazarev M, Melia J, Selaru F, Sharma S, Limketkai B, Parian A. Superior Efficacy of Infliximab Versus Adalimumab for First-Line Treatment of Crohn's Perianal Fistulae. Dig Dis Sci 2023; 68:3994-4000. [PMID: 37540392 DOI: 10.1007/s10620-023-08060-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Crohn's disease perianal fistulae (CD-PAF) occur in 25% of patients and are notoriously challenging to manage. Tumor necrosis factor inhibitors are first line agents. AIMS The aim of this study was to compare infliximab (IFX) versus adalimumab (ADA) efficacy in CD-PAF healing over time. METHODS A retrospective study at two large-tertiary medical centers was performed. Inclusion criteria were actively draining CD-PAF and initial treatment with IFX or ADA following CD-PAF diagnosis. The primary endpoints were perianal fistula response and remission at 6 and 12 months. Secondary endpoints included biologic persistence over time and dose escalation at 6 and 12 months. RESULTS Among 151 patients included in the study, 92 received IFX and 59 received ADA as first line agents after CD-PAF diagnosis. At 6 months, the 64.9% of the IFX group and 34.8% of the ADA group demonstrated CD-PAF clinical improvement (p < 0.01). Univariate and multivariate analyses demonstrated significant differences among the IFX and ADA groups for clinical response at 6-months and 12-months (p = 0.002 and p = 0.042, respectively). There were no factors that predicted response, with the exception of concomitant immunomodulator affecting the 6-month clinical response (p = 0.021). Biologic persistence, characterized by Kaplan Meier methods, was significantly longer in the IFX group compared to the ADA group (Log-rank p = 0.01). CONCLUSION IFX induction and maintenance is associated with higher rates of response and remission in CD-PAF healing as well as higher treatment persistence compared to ADA. Additionally, our study supports the use of concomitant immunomodulator therapy for CD-PAF healing and remission.
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Affiliation(s)
- Laura Maas
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Ruiyi Gao
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Vivy Cusumano
- Division of Digestive Diseases, Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian, UCLA School of Medicine, Los Angeles, CA, USA
| | - Ellen Spartz
- Division of Digestive Diseases, Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian, UCLA School of Medicine, Los Angeles, CA, USA
| | - Reezwana Chowdhury
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Mahesh Krishna
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Mark Lazarev
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Joanna Melia
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Florin Selaru
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Sowmya Sharma
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Berkeley Limketkai
- Division of Digestive Diseases, Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian, UCLA School of Medicine, Los Angeles, CA, USA
| | - Alyssa Parian
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
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12
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MEI P, FENG W, SHI P, ZHANG W, ZHUANG Y. Clinical research progress in Traditional Chinese Medicine in treating wound healing after anal fistula surgery. J TRADIT CHIN MED 2023; 43:1047-1054. [PMID: 37679994 PMCID: PMC10465834 DOI: 10.19852/j.cnki.jtcm.20230630.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/18/2022] [Indexed: 09/09/2023]
Abstract
In the study of the mechanism of wound healing after anal fistula surgery, how to scientifically and efficiently promote wound healing is of great significance. At present, modern medical treatment of wounds after anal fistula surgery mostly focuses on physical therapy intervention, new wound dressing and packing, and external application of growth factors. However, these therapies have many problems, and there is still no consensus on their clinical use. Traditional Chinese Medicine (TCM) has several methods to promote wound healing, such as oral administration, rubbing, and fumigation, which have a long history and obvious efficacy, but research in this area is relatively scattered and lacks classification and summarizing. Therefore, this paper analyzes and summarizes the existing research on TCM for promotion of wound healing after anal fistula surgery, carries out targeted analyses according to different clinical syndromes and treatment methods, and analyzes the defects in current research and anticipates future research trends in order to provide theoretical support for the advantages of TCM in promoting wound healing after anal fistula surgery.
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Affiliation(s)
- Pingping MEI
- 1 the First Clinical Medical College Department, Shaanxi University of Chinese Medicine, Xianyang 712046, China
| | - Wenzhe FENG
- 2 Department of anorectal, Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang 712000, China
| | - Peng SHI
- 2 Department of anorectal, Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang 712000, China
| | - Wenxiu ZHANG
- 1 the First Clinical Medical College Department, Shaanxi University of Chinese Medicine, Xianyang 712046, China
| | - Yu ZHUANG
- 1 the First Clinical Medical College Department, Shaanxi University of Chinese Medicine, Xianyang 712046, China
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13
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Gubatan J, Frost S, Levitte S, Keyashian K. Rates and Predictors of Long-term Clinical Outcomes in Patients With Perianal Crohn's Disease on Biologic Therapy. J Clin Gastroenterol 2023; 57:617-623. [PMID: 35703262 DOI: 10.1097/mcg.0000000000001729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 05/15/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND GOALS Perianal Crohn's disease (pCD) represents an aggressive phenotype with limited studies on long-term outcomes. We evaluated 5-year outcomes of these patients on biologic therapies. METHODS We performed a retrospective analysis of patients with pCD at a tertiary medical center. We used Kaplan-Meier curves to estimate rates and multivariate logistic regression to identify predictors of long-term outcomes. RESULTS We included 311 patients with pCD of which 168 patients were started on biologics [138 anti-tumor necrosis factor (TNF) α, 14 vedolizumab, 16 ustekinumab] at the time of diagnosis. Anti-TNF use at the time of diagnosis was associated with decreased rates of perianal abscess recurrence [hazard ratio (HR)=0.48, 95% confidence interval (CI): 0.32-0.74], whereas ustekinumab use was associated with increased rates of perianal fistula closure (HR=3.58, 95% CI: 1.04-12.35) and decreased rates of perianal abscess recurrence (HR=0.20, 95% CI: 0.07-0.56) at follow-up. Among patients who failed their first anti-TNF, switching to another anti-TNF was associated with decreased rates of colectomy (HR=0.20, 95% CI: 0.04-0.90) and permanent diversion (HR=0.16, 95% CI: 0.03-0.94) compared with ustekinumab, whereas vedolizumab use was associated with decreased perianal fistula closure (HR=0.22, 95% CI: 0.05-0.96) compared with ustekinumab. Predictors of colectomy included colonic disease (odds ratio=2.71, 95% CI: 1.36-5.38) and anal stenosis (odds ratio=4.44, 95% CI: 1.59-12.43). CONCLUSION Type of biologic use at the time of pCD diagnosis or after first anti-TNF failure may be associated with long-term outcomes in patients with pCD.
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Affiliation(s)
| | | | - Steven Levitte
- Division of Pediatric Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
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14
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Cazelles A, Collard MK, Lalatonne Y, Doblas S, Zappa M, Labiad C, Cazals-Hatem D, Maggiori L, Treton X, Panis Y, Jarry U, Desvallées T, Eliat PA, Pineau R, Motte L, Letourneur D, Simon-Yarza T, Ogier-Denis E. A Preclinical Validation of Iron Oxide Nanoparticles for Treatment of Perianal Fistulizing Crohn's Disease. Int J Mol Sci 2022; 23:8324. [PMID: 35955465 PMCID: PMC9368411 DOI: 10.3390/ijms23158324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022] Open
Abstract
Fistulizing anoperineal lesions are severe complications of Crohn's disease (CD) that affect quality of life with a long-term risk of anal sphincter destruction, incontinence, permanent stoma, and anal cancer. Despite several surgical procedures, they relapse in about two-thirds of patients, mandating innovative treatments. Ultrasmall particles of iron oxide (USPIO) have been described to achieve in vivo rapid healing of deep wounds in the skin and liver of rats thanks to their nanobridging capability that could be adapted to fistula treatment. Our main purpose was to highlight preclinical data with USPIO for the treatment of perianal fistulizing CD. Twenty male Sprague Dawley rats with severe 2,4,6-trinitrobenzenesulfonic acid solution (TNBS)-induced proctitis were operated to generate two perianal fistulas per rat. At day 35, two inflammatory fistulas were obtained per rat and perineal magnetic resonance imaging (MRI) was performed. After a baseline MRI, a fistula tract was randomly drawn and topically treated either with saline or with USPIO for 1 min (n = 17 for each). The rats underwent a perineal MRI on postoperative days (POD) 1, 4, and 7 and were sacrificed for pathological examination. The primary outcome was the filling or closure of the fistula tract, including the external or internal openings. USPIO treatment allowed the closure and/or filling of all the treated fistulas from its application until POD 7 in comparison with the control fistulas (23%). The treatment with USPIO was safe, permanently closed the fistula along its entire length, including internal and external orifices, and paved new avenues for the treatment of perianal fistulizing Crohn's disease.
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Affiliation(s)
- Antoine Cazelles
- Département of Chirurgie Colorectale, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France; (A.C.); (M.K.C.); (C.L.); (L.M.); (Y.P.)
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
| | - Maxime K. Collard
- Département of Chirurgie Colorectale, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France; (A.C.); (M.K.C.); (C.L.); (L.M.); (Y.P.)
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
| | - Yoann Lalatonne
- Laboratory for Vascular Translational Science, Université Paris Cité, Université Sorbonne Paris Nord, LVTS, INSERM, UMR 1148, 75018 Paris, France; (Y.L.); (L.M.); (D.L.); (T.S.-Y.)
- Départements of Biochimie and de Médecine Nucléaire, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, 93009 Bobigny, France
| | - Sabrina Doblas
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Laboratory of Imaging Biomarkers, Université Paris Cité, BP 416, 75018 Paris, France; (S.D.); (M.Z.)
| | - Magaly Zappa
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Laboratory of Imaging Biomarkers, Université Paris Cité, BP 416, 75018 Paris, France; (S.D.); (M.Z.)
- Département of Radiologie, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France
| | - Camélia Labiad
- Département of Chirurgie Colorectale, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France; (A.C.); (M.K.C.); (C.L.); (L.M.); (Y.P.)
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
| | - Dominique Cazals-Hatem
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
- Département of Pathologie, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France
| | - Léon Maggiori
- Département of Chirurgie Colorectale, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France; (A.C.); (M.K.C.); (C.L.); (L.M.); (Y.P.)
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
| | - Xavier Treton
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
- Département Gastroentérologie, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France
| | - Yves Panis
- Département of Chirurgie Colorectale, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, CEDEX, 92110 Clichy, France; (A.C.); (M.K.C.); (C.L.); (L.M.); (Y.P.)
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
| | - Ulrich Jarry
- Université Rennes, CNRS, INSERM, BIOSIT UAR 3480, US_S 018, Oncotrial, 35000 Rennes, France; (U.J.); (T.D.)
- Biotrial Pharmacology, Unité De Pharmacologie Préclinique, 35000 Rennes, France
| | - Thomas Desvallées
- Université Rennes, CNRS, INSERM, BIOSIT UAR 3480, US_S 018, Oncotrial, 35000 Rennes, France; (U.J.); (T.D.)
| | - Pierre-Antoine Eliat
- Université Rennes, CNRS, INSERM, BIOSIT UAR 3480, US_S 018, PRISM, 35000 Rennes, France;
- INRAE, INSERM, Institute NUMECAN, UMR_A 1341, Université Rennes, UMR_S 1241, 35000 Rennes, France
| | - Raphaël Pineau
- INSERM, CLCC Eugène Marquis, Oncogenesis, Stress Signaling, Université Rennes, UMR_S 1242, 35000 Rennes, France;
| | - Laurence Motte
- Laboratory for Vascular Translational Science, Université Paris Cité, Université Sorbonne Paris Nord, LVTS, INSERM, UMR 1148, 75018 Paris, France; (Y.L.); (L.M.); (D.L.); (T.S.-Y.)
| | - Didier Letourneur
- Laboratory for Vascular Translational Science, Université Paris Cité, Université Sorbonne Paris Nord, LVTS, INSERM, UMR 1148, 75018 Paris, France; (Y.L.); (L.M.); (D.L.); (T.S.-Y.)
| | - Teresa Simon-Yarza
- Laboratory for Vascular Translational Science, Université Paris Cité, Université Sorbonne Paris Nord, LVTS, INSERM, UMR 1148, 75018 Paris, France; (Y.L.); (L.M.); (D.L.); (T.S.-Y.)
| | - Eric Ogier-Denis
- Centre de Recherche sur l’Inflammation, INSERM, U1149, CNRS, ERL8252, Université Paris Cité, Team Gut Inflammation, BP 416, 75018 Paris, France; (D.C.-H.); (X.T.)
- INSERM, CLCC Eugène Marquis, Oncogenesis, Stress Signaling, Université Rennes, UMR_S 1242, 35000 Rennes, France;
- INSERM U1242, Centre Eugène Marquis, Rue de la Bataille de Flandres-Dunkerque, 35042 Rennes, France
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15
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Meima-van Praag EM, van Rijn KL, Wasmann KATGM, Snijder HJ, Stoker J, D'Haens GR, Gecse KB, Gerhards MF, Jansen JM, Dijkgraaf MGW, van der Bilt JDW, Mundt MW, Spinelli A, Danese S, Bemelman WA, Buskens CJ. Short-term anti-TNF therapy with surgical closure versus anti-TNF therapy in the treatment of perianal fistulas in Crohn's disease (PISA-II): a patient preference randomised trial. Lancet Gastroenterol Hepatol 2022; 7:617-626. [PMID: 35427495 DOI: 10.1016/s2468-1253(22)00088-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Guidelines on Crohn's perianal fistulas recommend anti-tumour necrosis factor (TNF) treatment and suggest considering surgical closure for patients with surgically amenable disease. However, long-term outcomes following these two strategies have not been directly compared. The aim of this study was to assess radiological healing in patients who received short-term anti-TNF treatment and surgical closure compared with those who received anti-TNF treatment alone. METHODS The PISA-II trial was a multicentre, patient preference study done in nine hospitals in the Netherlands and one hospital in Italy. Adult patients with Crohn's disease and an active high perianal fistula with a single internal opening were eligible for inclusion. After counselling, patients with no treatment preference were randomly assigned (1:1) using random block randomisation (block sizes of six without statification), to 4-month anti-TNF therapy and surgical closure or anti-TNF therapy for 1 year, after seton insertion. Patients with a treatment preference received their preferred therapy. The primary outcome was radiological healing assessed by MRI at 18 months, defined as a complete fibrotic tract or a MAGNIFI-CD (Magnetic Resonance Index for Fistula Imaging in Crohn's Disease) score of 0, assessed according to the intention-to-treat principle. Secondary outcomes included clinical closure, number of patients undergoing surgical reintervention and number of reinterventions, recurrences, and impact on quality of life measured by the Perianal Disease Activity Index (PDAI). Analyses were performed on an intention-to-treat basis and additionally an as-treated analysis for radiological healing and clinical closure. This study was registered at the Dutch Trial Registry, NL7625, and with EudraCT, 2018-002064-15, and is closed to accrual due to completion. FINDINGS Between Sept 14, 2013, and Dec 7, 2019, 94 patients were enrolled onto the trial, of whom 32 (34%) were randomly assigned and 62 (66%) chose a specific treatment. 38 (40%) patients were assigned to the surgical closure group and 56 (60%) patients to the anti-TNF group. At 18 months, radiological healing was significantly more common in the surgical closure group (12 [32%] patients) than in the anti-TNF group (five [9%] patients; p=0·005). By contrast, clinical closure was not significantly different between the two treatment groups (26 [68%] patients in the surgical closure group vs 29 [52%] patients in the anti-TNF group; p=0·076). Significantly fewer patients required a reintervention in the surgical closure group than in the anti-TNF therapy group (five [13%] patients in the surgical closure group, median one reintervention [IQR one to three] vs 24 [43%] patients in the anti-TNF group, median two reinterventions [one to two]; p=0·005). Among patients who reached clinical closure during follow-up, four (14%) of 29 in the surgical closure group and five (16%) of 31 in the anti-TNF therapy group had a recurrence, which occurred only in patients without radiological healing. PDAI was significantly lower in the surgical closure group than in the anti-TNF group after 18 months (p=0·031). Adverse events and serious adverse events were similar in both treatment groups and mostly entailed reinterventions. Ten (11%) patients had side-effects associated with anti-TNF treatment. Two serious adverse events unrelated to study treatment occurred (appendicitis and myocardial infarction). One patient died from a tongue base carcinoma, unrelated to study treatment. INTERPRETATION Short-term anti-TNF treatment combined with surgical closure induces long-term MRI healing more frequently than anti-TNF therapy in patients with Crohn's perianal fistulas. These data suggest that patients with Crohn's perianal fistula amenable for surgical closure should be counselled for this therapeutic approach. FUNDING Netherlands Organisation for Health Research and Development and Broad Medical Research Program.
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Affiliation(s)
- Elise M Meima-van Praag
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Kyra L van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Karin A T G M Wasmann
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Harmanna J Snijder
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Marco W Mundt
- Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, Netherlands
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Christianne J Buskens
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
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16
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Gu B, Venkatesh K, Williams AJ, Ng W, Corte C, Gholamrezaei A, Ghaly S, Xuan W, Paramsothy S, Connor S. Higher infliximab and adalimumab trough levels are associated with fistula healing in patients with fistulising perianal Crohn’s disease. World J Gastroenterol 2022; 28:2597-2608. [PMID: 35949350 PMCID: PMC9254145 DOI: 10.3748/wjg.v28.i23.2597] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/21/2021] [Accepted: 05/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn’s disease (CD), but not all patients achieve fistula healing.
AIM To determine the correlation between perianal fistula healing and closure with infliximab and adalimumab trough levels.
METHODS In this multicentre retrospective study conducted across four tertiary inflammatory bowel disease centres in Australia, we identified CD patients with perianal fistulae on maintenance infliximab or adalimumab who had a trough level within twelve weeks of clinical assessment. Data collected included demographics, serum infliximab and adalimumab trough levels (mg/L) within 12 wk before or after their most recent clinical assessment and concomitant medical or surgical therapy. The primary outcome was fistula healing, defined as cessation in fistula drainage. The secondary outcome was fistula closure, defined as healing and closure of all external fistula openings. Differences between patients who did or did not achieve fistula healing were compared using the chi-square test, t test or Mann-Whitney U test.
RESULTS One hundred and fourteen patients (66 infliximab, 48 adalimumab) were included. Forty-eight (72.7%) patients on maintenance infliximab achieved fistula healing and 18 (27.3%) achieved fistula closure. Thirty-seven (77%) patients on maintenance adalimumab achieved fistula healing and 17 (35.4%) achieved fistula closure. Patients who achieved fistula healing had significantly higher infliximab and adalimumab trough levels than patients who did not [infliximab: 6.4 (3.8-9.5) vs 3.0 (0.3-6.2) mg/L, P = 0.003; adalimumab: 9.2 (6.5-12.0) vs 5.4 (2.5-8.3) mg/L, P = 0.004]. For patients on infliximab, fistula healing was associated with lower rates of detectable anti-infliximab antibodies and younger age. For patients on adalimumab, fistula healing was associated with higher rates of combination therapy with an immunomodulator. Serum trough levels for patients with and without fistula closure were not significantly different for infliximab [6.9 (4.3-10.2) vs 5.5 (2.5-8.3) mg/L, P = 0.105] or adalimumab [10.0 (6.6-12.0) vs 7.8 (4.2-10.0) mg/L, P = 0.083].
CONCLUSION Higher maintenance infliximab and adalimumab trough levels are associated with perianal fistula healing in CD.
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Affiliation(s)
- Bonita Gu
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
| | - Kavya Venkatesh
- Department of Medicine, University of Newcastle, Newcastle 2308, New South Wales, Australia
| | - Astrid-Jane Williams
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
| | - Watson Ng
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
| | - Crispin Corte
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
- Central Clinical School, University of Sydney, Sydney 2050, New South Wales, Australia
| | - Ali Gholamrezaei
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney 2170, New South Wales, Australia
| | - Simon Ghaly
- Department of Gastroenterology, St Vincent’s Hospital Sydney, Sydney 2010, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney 2010, New South Wales, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney 2170, New South Wales, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney 2139, New South Wales, Australia
- Concord Clinical School, University of Sydney, Sydney 2139, New South Wales, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney 2170, New South Wales, Australia
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17
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Gao J, Wang J, Chen P, Ding P, Tian L, Liang B, Shi Z. The Effect of Qingre Huayu Recipe on Wound Healing after Anal Fistulotomy in Sprague-Dawley Rats. Comput Math Methods Med 2022; 2022:9397478. [PMID: 35495890 PMCID: PMC9042638 DOI: 10.1155/2022/9397478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/16/2022] [Accepted: 02/25/2022] [Indexed: 12/29/2022]
Abstract
Anal fistula is a common anorectal disease. At present, most scholars believe that its pathogenesis is related to anal gland infection. Anal fistula cannot heal on its own after the onset and must be treated surgically. The wound of anal fistula surgery is open and polluted, and it belongs to three types of three-stage healing; it is the most difficult to heal among all surgical incisions, with a long course of disease, a lot of exudation, and pain for the patient; traditional Chinese medicine has rich experience in the treatment of postoperative wound healing of anal fistula. The study aimed to evaluate the mechanism of Qingre Huayu (QRHY) Recipe on wound healing after fistulotomy on SD rats. SD rats (n = 72) were randomized into three groups post-anorectal surgery. The rats in the positive control group were given potassium permanganate (PP), treatment group were given QRHY, and trauma model group were given 0.9% normal salinity. The changes in wound secretion, granulated tissue, and epithelium tissue were observed, and wound healing rates were evaluated by the discrepancies in wound area. HE and Masson's staining as well as transmission electron microscopy were also performed. The localization as well as the measurement of Ang1, Src, and VE cadherin expression in each group adopted real-time PCR, western blot, and immunohistochemistry (IHC) assays. Statistically higher wound healing rates were observed in QRHY group on days 3, 7, and 14 compared with other groups. Histological analyses showed highly significant increase in collagen and fibroblasts, less inflammatory cells, and vascular endothelial permeability in QRHY rats. The transmission electron microscopy revealed that the intact structure of tight junctions in endothelial cells and well-organized collagen and VE-cadherin, Ang1, and Tie-2 were upregulated by QRHY, while Src was inhibited. This study showed that QRHY can promote wound healing after anal fistulas.
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Affiliation(s)
- Jiazhi Gao
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
| | - Jiandong Wang
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
| | - Ping Chen
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
| | - Peilin Ding
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
| | - Liang Tian
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
| | - Biao Liang
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
| | - Zhan Shi
- Department of Proctology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, No. 164 Lanxi Road, Shanghai 200333, China
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18
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Sirmai L, Pelletier AL, Gault N, Zallot C, Bouguen G, Bouchard D, Roland Nicaise P, Peyneau M, Sironneau S, Bittencourt MDC, Petitcollin A, Fernandez P, Roblin X, Siproudhis L, Abramowitz L. Relationship between clinical remission of perianal fistulas in Crohn’s disease and serum adalimumab concentrations: A multi-center cross-sectional study. World J Gastroenterol 2022; 28:961-972. [PMID: 35317057 PMCID: PMC8908286 DOI: 10.3748/wjg.v28.i9.961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/25/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn’s disease (CD) is complicated by perianal fistulas in approximately 20% of patients. Achieving permanent fistula closure remains a challenge for physicians. An association between serum anti-tumor necrosis factor-α concentrations and clinical outcomes in patients with CD has been demonstrated; however, little information is available on serum adalimumab (ADA) concentrations and remission of perianal fistulas in such patients.
AIM To study the relationship between serum ADA concentrations and clinical remission of CD-associated perianal fistulas.
METHODS This cross-sectional study of patients with CD-associated perianal fistulas treated with ADA was performed at four French hospitals between December 2013 and March 2018. At the time of each serum ADA concentration measurement, we collected information about the patients and their fistulas. The primary study endpoint was clinical remission of fistulas defined as the absence of drainage (in accordance with Present’s criteria), with a PDAI ≤ 4, absence of a seton and assessment of the overall evaluation as favorable by the proctologist at the relevant center. We also assessed fistula healing [defined as being in clinical and radiological (magnetic resonance imaging, MRI) remission] and adverse events.
RESULTS The study cohort comprised 34 patients who underwent 56 evaluations (patients had between one and four evaluations). Fifteen patients had clinical remissions (44%), four of whom had healed fistulas on MRI. Serum ADA concentrations were significantly higher at evaluations in which clinical remission was identified than at evaluations in which it was not [14 (10-16) vs 10 (2-15) μg/mL, P = 0.01]. Serum ADA concentrations were comparable at the times of evaluation of patients with and without healed fistulas [11 (7-14) vs 10 (4-16) μg/mL, P = 0.69]. The adverse event rate did not differ between different serum ADA concentrations.
CONCLUSION We found a significant association between high serum ADA concentrations and clinical remission of CD-associated perianal fistulas.
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Affiliation(s)
- Laura Sirmai
- Division of Hepato-Gastroenterology and Digestive Oncology, Bichat Claude Bernard University Hospital, Paris 75018, France
- Division of Hepato-Gastroenterology, Hospital Croix Saint Simon, Paris 75020, France
| | - Anne-Laure Pelletier
- Division of Hepato-Gastroenterology and Digestive Oncology, Bichat Claude Bernard University Hospital, Paris 75018, France
| | - Nathalie Gault
- Division of Epidemiology, Biostatistics and Clinical Research, University Hospital Center Bichat, Paris 75018, France
- National Institute of Health and Medical Research CIC-EC1425, University Hospital Center Bichat, Paris 75018, France
| | - Camille Zallot
- Division of Gastroenterology, Nancy Regional and University Hospital Center, Nancy 54035, France
| | - Guillaume Bouguen
- Imphy CIC 1414 Group and Division of Gastroenterology and Hepatology, University Hospital of Rennes, Pontchaillou, Rennes 35033, France
| | | | | | - Marine Peyneau
- Division of Immunology, University Hospital Center Bichat, Paris 75018, France
- Inflammation, Microbiome and Immunosurveillance, Faculty of Pharmacy, Université Paris-Saclay, Châtenay-Malabry 92290, France
| | | | - Marcelo De Carvalho Bittencourt
- Division of Immunology, Nancy Regional and University Hospital Center, Nancy 54000, France
- University of Lorraine, CNRS UMR 7365, IMoPA, Nancy 54000, France
| | - Antoine Petitcollin
- Department of Clinical and Biological Pharmacology and Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, Rennes 35700, France
| | - Pedro Fernandez
- Division of Radiology, University Hospital Center Bichat, Paris 75018, France
- Orangerie Center, Le Perreux-sur-Marne 94170, France
| | - Xavier Roblin
- Division of Gastroenterology, CHU Saint Etienne, Saint-Priest-en-Jarez 42270, France
| | - Laurent Siproudhis
- Imphy CIC 1414 Group and Division of Gastroenterology and Hepatology, University Hospital of Rennes, Pontchaillou, Rennes 35033, France
| | - Laurent Abramowitz
- Division of Gastroenterology and Hepatology and Proctology, University Hospital Center Bichat, Paris 75018, France
- Ramsay GDS Clinique Blomet, Paris 75018, France
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Adegbola SO, Sarafian M, Sahnan K, Pechlivanis A, Phillips RKS, Warusavitarne J, Faiz O, Haddow J, Knowles C, Tozer P, Holmes E, Hart A. Lack of anti-TNF drugs levels in fistula tissue - a reason for nonresponse in Crohn's perianal fistulating disease? Eur J Gastroenterol Hepatol 2022; 34:18-26. [PMID: 33522723 DOI: 10.1097/meg.0000000000002032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Anti-TNF therapy is recommended as treatment for patients with Crohn´s perianal fistulas. However, a significant proportion of patients have a sub-optimal response to anti-TNF therapy. Higher serum levels of anti-TNF agents have been associated with improved outcomes in perianal Crohn's disease. Currently, it is unknown whether anti-TNF agent levels can be detected in tissue from fistula tracts themselves and whether this is associated with response. AIMS AND METHODS We undertook a pilot study to measure fistula tissue levels of anti-TNF medication (infliximab and adalimumab). We used a previously validated targeted proteomic technique, employing ultraperformance liquid chromatography-mass spectrometry, to detect/quantify anti-TNF drugs. Biopsies were obtained from fistula tracts of patients with Crohn's disease on maintenance treatment; with idiopathic (cryptoglandular) fistula tissues used as negative controls as well as positive controls (by spiking the latter tissues with anti-TNF drugs). RESULTS Tissue was sampled from the fistula tracts of seven patients with Crohn's perianal disease (five patients were on adalimumab and two patients were on infliximab). The anti-TNF drugs, infliximab and adalimumab, were not detected in fistula samples from any of the Crohn's patients despite detection in 'spiked' positive control samples. CONCLUSION Absence of detection of the anti-TNF drugs in fistula tissue raises the question on the role of tissue penetrance of anti-TNF drugs in response to therapy. Further work is required in a larger number of patients to validate the findings observed and investigate if any correlation exists between tissue and serum levels of anti-TNF and clinical outcome. SUMMARY Predicting response in Crohn's fistula patients on biologic therapy is difficult with no reliable biomarkers. This pilot study uses targeted proteomics to investigate the potential role of tissue drug levels in acting as a biomarker of treatment response.
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Affiliation(s)
- Samuel O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Magali Sarafian
- Computational Systems Division, Imperial College London, South Kensington Campus
| | - Kapil Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | | | - Robin K S Phillips
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Janindra Warusavitarne
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Omar Faiz
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - James Haddow
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Charles Knowles
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Phil Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
| | - Elaine Holmes
- Computational Systems Division, Imperial College London, South Kensington Campus
| | - Ailsa Hart
- Robin Phillips Fistula Research Unit, St Mark's Hospital & Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer, Imperial College London
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20
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Akturk R, Serinsöz S. The role of mesalazine co-treatment in the prevention of recurrence in subjects with subclinical inflammatory bowel disease and perianal fistula who are scheduled for surgical intervention. Ann Ital Chir 2022; 93:183-187. [PMID: 35311735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM To investigate the impact of mesalazine co-treatment in addition to the surgical intervention on recurrence rate in subjects with subclinical inflammatory bowel disease (SIBD) who present with perianal fistula (PAF). MATERIALS AND METHODS All consecutive patients who had undergone surgery for PAF in our institutes were included in this retrospective analysis. Ileal tissue samples were obtained during colonoscopy for pathological evaluation. Patients with active chronic ileitis, structural distortion, erosion, ulceration, cryptitis, crypt abscess, fibrosis, and Paneth cell hyperplasia were defined as SIBD. Patients were divided into two groups according to the presence or absence of SIBD on pathological evaluation of ileal tissue samples (Group 1: SIBD +; Group 2: SIBD -). Rectal 5-aminosalicylic acid (mesalazine) of 2 gr once daily was administered to half of the subjects in each group for 8 weeks. The difference in 6 months recurrence rates of subjects receiving or not receiving mesalazine was the primary outcome measure. RESULTS The overall recurrence rate of subjects not receiving mesalazine was significantly higher than that of the subjects receiving mesalazine (9.7% vs. 4.4%, p = 0.020). Recurrence rate of the subjects with SIBD who received mesalazine co-treatment was significantly lower than those without mesalazine (1.6% vs. 12.6%, p=0.002). However, recurrence rate of the subjects without SIBD who received and not received mesalazine co-treatment was similar (6.8% vs. 7.8%, p=0.764). CONCLUSION Mesalazine co-treatment in addition to the surgical intervention was associated with lower 6 months recurrence rate compared to surgical intervention alone in patients with SIBD and PAF. KEY WORDS Inflammatory bowel disease, Mesalazine, Perianal fistula.
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21
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Vasudevan A, Bruining DH, Loftus EV, Faubion W, Ehman EC, Raffals L. Approach to medical therapy in perianal Crohn's disease. World J Gastroenterol 2021; 27:3693-3704. [PMID: 34321838 PMCID: PMC8291021 DOI: 10.3748/wjg.v27.i25.3693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
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Affiliation(s)
- Abhinav Vasudevan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Edward V Loftus Jr
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - William Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Eric C Ehman
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
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22
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Gu B, De Gregorio M, Pipicella JL, Vande Casteele N, Andrews JM, Begun J, Connell W, D'Souza B, Gholamrezaei A, Hart A, Liew D, Radford-Smith G, Rimola J, Sutherland T, Toong C, Woods R, Wu Y, Xuan W, Williams AJ, Ng W, Ding NS, Connor S. Prospective randomised controlled trial of adults with perianal fistulising Crohn's disease and optimised therapeutic infliximab levels: PROACTIVE trial study protocol. BMJ Open 2021; 11:e043921. [PMID: 34210720 PMCID: PMC8252869 DOI: 10.1136/bmjopen-2020-043921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Perianal fistulising Crohn's disease (pfCD) can be somewhat treatment refractory. Higher infliximab trough levels (TLIs) may improve fistula healing rates; however, it remains unclear whether escalating infliximab therapy to meet higher TLI targets using proactive, or routine, therapeutic drug monitoring (TDM) improves outcomes. This randomised controlled trial aimed to assess whether infliximab therapy targeting higher TLIs guided by proactive TDM improves outcomes compared with standard therapy. METHODS AND ANALYSIS Patients with active pfCD will be randomised 1:1 to either the proactive TDM arm or standard dosing arm and followed up for 54 weeks. Patients in the proactive TDM arm will have infliximab dosing optimised to target higher TLIs. The targets will be TLI ≥ 25 µg/mL at week 2, ≥ 20 µg/mL at week 6 and ≥ 10 µg/mL during maintenance therapy. The primary objective will be fistula healing at week 32. Secondary objectives will include fistula healing, fistula closure, radiological fistula healing, patient-reported outcomes and economic costs up to 54 weeks. Patients in the standard dosing arm will receive conventional infliximab dosing not guided by TLIs (5 mg/kg at weeks 0, 2 and 6, and 5 mg/kg 8 weekly thereafter). Patients aged 18-80 years with pfCD with single or multiple externally draining complex perianal fistulas who are relatively naïve to infliximab treatment will be included. Patients with diverting ileostomies or colostomies and pregnant or breast feeding will be excluded. Fifty-eight patients per arm will be required to detect a 25% difference in the primary outcome measure, with 138 patients needed to account for an estimated 6.1% primary non-response rate and 10% dropout rate. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed journals and international conferences. Ethics approval has been granted by the South Western Sydney Local Health District Human Research Ethics Committee in Australia. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12621000023853); Pre-results.
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Affiliation(s)
- Bonita Gu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Michael De Gregorio
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Joseph Louis Pipicella
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Niels Vande Casteele
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jakob Begun
- Immunity, Infection, and Inflammation Program, Mater Research Institute, Brisbane, Queensland, Australia
- Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - William Connell
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Basil D'Souza
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ali Gholamrezaei
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jordi Rimola
- Inflammatory Bowel Disease Unit, Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Tom Sutherland
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Imaging Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Catherine Toong
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Immunology, NSW Health Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Rodney Woods
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Yang Wu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Watson Ng
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Nik Sheng Ding
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
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Yeh H, Kuo CJ, Wu RC, Chen CM, Tsai WS, Su MY, Chiu CT, Le PH. Vedolizumab in Crohn’s disease with rectal fistulas and presacral abscess: A case report. World J Gastroenterol 2021; 27:442-448. [PMID: 33584075 PMCID: PMC7856844 DOI: 10.3748/wjg.v27.i5.442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/08/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fistula and intraabdominal abscess are common complications of Crohn’s disease (CD), but complex rectal fistula with abscess formation is rare. Tumor necrosis factor antagonists combined with percutaneous drainage or surgical intervention is optimal treatment for fistulizing CD with intraabdominal abscess. There is no study showing the efficacy of vedolizumab in such complicated condition.
CASE SUMMARY A 47-year-old man has decompensated liver cirrhosis, Child B. He suffered from abdominal pain, bloody diarrhea, fever, and body weight loss. CD with rectoprostatic fistula, rectopresacral fistula, presacral abscess and cyto-megalovirus (CMV) infection were noted. He received antibiotics, anti-viral therapy, transverse colostomy and vedolizumab treatment. Six months later, he had deep remission and complete fistula tracts closure.
CONCLUSION Early vedolizumab and stool diversion are effective and safe in treating CD with complex rectal fistula with abscess formation.
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Affiliation(s)
- Heng Yeh
- School of Medicine, Chang Gung University, Taoyuan City 333323, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Taiwan Association of the Study of Small Intestine Disease, Taoyuan 333, Taiwan
| | - Ren-Chin Wu
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Chien-Ming Chen
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Wen-Sy Tsai
- Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Ming-Yao Su
- Taiwan Association of the Study of Small Intestine Disease, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, New Taipei City Municipal Tucheng Hospital, New Taipei City 236017, Taiwan
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Taiwan Association of the Study of Small Intestine Disease, Taoyuan 333, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Taiwan Association of the Study of Small Intestine Disease, Taoyuan 333, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
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24
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Chapuis-Biron C, Kirchgesner J, Pariente B, Bouhnik Y, Amiot A, Viennot S, Serrero M, Fumery M, Allez M, Siproudhis L, Buisson A, Pineton de Chambrun G, Abitbol V, Nancey S, Caillo L, Plastaras L, Savoye G, Chanteloup E, Simon M, Dib N, Rajca S, Amil M, Parmentier AL, Peyrin-Biroulet L, Vuitton L. Ustekinumab for Perianal Crohn's Disease: The BioLAP Multicenter Study From the GETAID. Am J Gastroenterol 2020; 115:1812-1820. [PMID: 33156100 DOI: 10.14309/ajg.0000000000000810] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION New therapeutic options for patients with Crohn's disease (CD) with perianal lesions failing anti-tumor necrosis factor (TNF) agents are needed. We aimed to assess the effectiveness of ustekinumab in perianal CD (pCD) and predictors of clinical success in a real-life multicenter cohort. METHODS We conducted a national multicenter retrospective cohort study in patients with either active or inactive pCD who received ustekinumab. In patients with active pCD at treatment initiation, the success of ustekinumab was defined by clinical success at 6 months assessed by the physician's judgment without additional medical or surgical treatment for pCD. Univariate and multivariable logistic regression analyses were performed to identify predictors of success. In patients with inactive pCD at ustekinumab initiation, the pCD recurrence-free survival was calculated using the Kaplan-Meier method. RESULTS Two hundred seven patients were included, the mean age was 37.7 years, the mean duration of CD was 14.3 years, and the mean number of prior perianal surgeries was 2.8. Two hundred five (99%) patients had previously been exposed to at least 1 anti-TNF and 58 (28%) to vedolizumab. The median follow-up time was 48 weeks; 56/207 (27%) patients discontinued therapy after a median time of 43 weeks. In patients with active pCD, success was reached in 57/148 (38.5%) patients. Among patients with setons at initiation, 29/88 (33%) had a successful removal. The absence of optimization was associated with treatment success (P = 0.044, odds ratio 2.74; 95% confidence interval: 0.96-7.82). In multivariable analysis, the number of prior anti-TNF agents (≥3) was borderline significant (P = 0.056, odds ratio 0.4; 95% confidence interval: 0.15-1.08). In patients with inactive pCD at initiation, the probability of recurrence-free survival was 86.2% and 75.1% at weeks 26 and 52, respectively. DISCUSSION Ustekinumab appears as a potential effective therapeutic option in perianal refractory CD. Further prospective studies are warranted.
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Affiliation(s)
- Constance Chapuis-Biron
- Department of Gastroenterology, University Hospital of Besançon, University Bourgogne Franche-Comté, Besançon, France
| | - Julien Kirchgesner
- Department of Gastroenterology, Saint-Antoine Hospital, Assitance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benjamin Pariente
- Department of Hepatogastroenterology, University Hospital of Lille, Lille, France
| | - Yoram Bouhnik
- Department of Gastroenterology, AP-HP, Hôpital Beaujon, Paris, France
| | - Aurélien Amiot
- Department of Gastroenterology, AP-HP, Hôpital Henri-Mondor, Paris, France
| | - Stéphanie Viennot
- Department of Hepatogastroenterology, University Hospital of Caen, Caen, France
| | - Mélanie Serrero
- Department of Gastroenterology, AP-HM, Hôpital Nord, Marseille, France
| | - Mathurin Fumery
- Department of Hepatogastroenterology, Peritox, University Hospital of Amiens, Amiens, France
| | - Matthieu Allez
- Department of Gastroenterology, AP-HP, Hôpital Saint Louis, Paris, France
| | - Laurent Siproudhis
- Department of Hepatogastroenterology, CHU Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Anthony Buisson
- Department of Hepatogastroenterology, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Vered Abitbol
- Department of Gastroenterology, AP-HP, Hôpital Cochin, Paris, France
| | - Stéphane Nancey
- Department of Gastroenterology, Hospices Civils de Lyon, Lyon Sud Hospital, Lyon, France
| | - Ludovic Caillo
- Department of Hepatogastroenterology, University Hospital of Nimes, Nimes, France
| | | | - Guillaume Savoye
- Department of Hepatogastroenterology, University Hospital of Rouen
| | - Elise Chanteloup
- Department of Gastroenterology, Hôpital Paris Saint Joseph, Paris, France
| | - Marion Simon
- Department of Gastroenterology, Institut Mutualiste Montsouris, Paris, France
| | - Nina Dib
- Department of Hepatogastroenterology, University Hospital of Angers, Angers, France
| | - Sylvie Rajca
- Department of Gastroenterology, AP-HP, Hôpital Louis-Mourier, Paris, France
| | - Morgane Amil
- Department of Hepatogastroenterology, Centre hospitalier La Roche-sur-Yon, La Roche-sur-Yon, France
| | | | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Inserm U954, University Hospital of Nancy, Lorraine University, Nancy, France
| | - Lucine Vuitton
- Department of Gastroenterology, University Hospital of Besançon, University Bourgogne Franche-Comté, Besançon, France
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Hafi M, Laabidi A, Fekih M, Ben Mustapha N, Serghini M, Boubaker J. Complex perianal fistulas in Crohn's disease: An anti-TNF α based medico-surgical treatment with magnetic imaging assessment. Tunis Med 2020; 98:823-830. [PMID: 33479980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Anti-TNFα associated to seton drainage has a central role in the treatment of complex perineal Crohn's fistulas (PAF). A precise treatment protocol is lacking. AIMS to evaluate the results of this combined treatment and identify predictive factors of response. METHODS It was a retrospective study which included all patients with complex PAF treated with Anti-TNFα. RESULTS We included 49 patients, mean age of 31.6 years. 17 patients had an active rectal involvement. 35 patients had azathioprin. After the induction, 43 patients had a clinical response. Maintenance therapy was started in 45 cases. After a median of 19 months of Anti-TNFα, 24 patients had a clinical remission (with radiological remission in 20), 17 a partial clinical response, and 4 were in failure. After clinico-radiologic remission setons were removed in all patients, 46% of patients who stopped Anti-TNFα treatment after clinico-radiologic remission relapsed. Absence of rectal involvement and Clinical remission after induction were the independent predictive factors of achieving a clinical remission under maintenance therapy with Anti-TNFα (p=0.016) and clinico-radiological remission (p=0.028). CONCLUSION An Anti-TNFα based treatment combined with long term loose seton drainage have contributed to the high rates of both clinical and radiological responses in this study. Obtaining a "deep" clinico-radiological remission should be the target of the treatment. Stopping the Anti-TNFα should be avoided even after obtaining such response.
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Sun XL, Chen SY, Tao SS, Qiao LC, Chen HJ, Yang BL. Optimized timing of using infliximab in perianal fistulizing Crohn's disease. World J Gastroenterol 2020; 26:1554-1563. [PMID: 32327905 PMCID: PMC7167413 DOI: 10.3748/wjg.v26.i14.1554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/20/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023] Open
Abstract
Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn’s disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.
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Affiliation(s)
- Xue-Liang Sun
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou 215000, Jiangsu Province, China
| | - Shi-Yi Chen
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Shan-Shan Tao
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Li-Chao Qiao
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Hong-Jin Chen
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Bo-Lin Yang
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
- Department of Colorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
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Iqbal A, Ahmed T, Khan I, Perveen S, Khan MI. Outcome Of Use Of 1% Silver Nitrate In Patients With Low Lying Perianal Fistula. J Ayub Med Coll Abbottabad 2019; 31:355-358. [PMID: 31535505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Anorectal fistula is a common illness which is seen among the middle-aged male patients. Various surgical procedures have been proposed and are associated with the recurrence of the fistula, repeated surgery and in some cases incontinence which may reach up to 43% in complicated fistulas. The purpose of this study was to assess and formulate a non-surgical procedure for fistula in ano through irrigation of the fistula tract with 1% of silver nitrate solution in healing the low perianal fistula. METHODS Seventy-nine patients presenting to the outpatient department of Ward 3, Surgical unit 1 in Jinnah Postgraduate Medical Centre during a period of 8 months from April to November 2017 with complain of perianal pain and pussy discharge were included in the study. Three patients of the total 79 patients lost to follow up. Outcome measure were cessation of the symptoms for consecutive 10 weeks. RESULTS Seventy-six patients were assessed and underwent irrigation using this 1% of silver nitrate solution. Out of 76 patients, 58 (76.3%) patients showed complete clinical healing while 18 (23.68%) of patients showed failure to clinical healing. Patients with continuous discharge had a significantly higher rate of complete clinical healing than those with intermittent discharge. CONCLUSIONS From this study it can be concluded that cauterizing and corrosive properties of silver nitrate are effective in treating the patients with low lying perianal fistula. We suggest that this method should be used as a first line treatment option for all the patients presenting with low lying anal fistula since it is simple, can be easily performed on an OPD basis is minimally invasive and avoids any complication.
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Affiliation(s)
- Abdullah Iqbal
- General Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Tanweer Ahmed
- General Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Imran Khan
- General Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Sughra Perveen
- General Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
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Fukumoto T, Hamada J, Matsudaira S, Yarita A, Sakano T, Kawarabayashi N, Fukushima J, Kamioka N, Nagumo H, Serizawa M, Osaka S, Hashimoto Y, Ogasawara A. [A Case of Primary Anal Fistula Cancer with Extensive Intrapelvic Spreading That Was Successfully Treated with Bevacizumab plus mFOLFOX6]. Gan To Kagaku Ryoho 2019; 46:717-720. [PMID: 31164514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The patient was a 68-year-old man who had an anal fistula for>10 years. He was referred to our institution after visiting a local physician with left femoral pain as the main complaint and received a diagnosis of high inflammatory response. We then found discharge of pus in the perianal region during a medical examination. We also found an extensive intrapelvic tumor during a computed tomography(CT)/magnetic resonance imaging examination. In addition, the level ofa tumor marker and inflammatory response were high. To control the inflammation, we performed seton drainage and sigmoid colostomy. On the basis of the pathological findings from the mucus component, we confirmed a diagnosis of fistula cancer. Considering that the progressive lesion had extensively spread, we decided to initiate chemotherapy alone because ofthe absence ofan indication for radiotherapy. We administered bevacizumab plus mFOLFOX6, and partial response was observed on a CT scan. We could control the progression ofthe disease for>6 months. The present case suggests that bevacizumab plus mFOLFOX6 can be an effective regimen for unresectable advanced fistula cancers.
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Kaya S, Altuntas YE, Kement M, Altın O, Kundes MF, Kaptanoglu L, Bildik N, Kucuk HF. Outcomes of silver nitrate use in perianal fistula: are perianal fistulas still a nightmare for surgeons? Ann Ital Chir 2019; 90:480-484. [PMID: 31617853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION In this study, we aimed to evaluate outcomes of % 20 silver nitrate (SNS) application in perianal fistula patients. MATERIAL AND METHOD All patients who received 20 % SNS treatment for intersphincteric and transsphincteric fistulas between January 2017 and December 2017 were included in our study. Patients were invited for control examinations after one week. Patients with continued discharges after single dose of SNS kept receiving solution six more times with one month intervals. Stopping of discharges were considered as finalization of the study. Cases with discharges after 6 episodes of SNS were described as insufficient healing. The patients were grouped according to healing status (healing patients in Group 1, non-healing patients in Group 2) .Gender, age, follow-up times, date of the complaint start, number of SNS application, type of fistula and frequency of fistula discharge were recorded. RESULTS A total of 49 patients were included in this study. Forty-four (% 89.8) of them were male. The mean age was 44.9. Twenty-eight patients (57.1%) had intersphincteric fistulas, while twenty-two patients (42.9%) had intersfinteric fistulas. Mean number of SNS application was 4.1 (1-6). Patients in Group 1 had mean number of SNS therapy as 3.42 (1-6), whereas cases in Group 2 this number was 5.5 (3-6). Patients were observed approximately for 8.84 months (6-12). We were able to reach sufficient healing in 13 (%26) cases via 2 times and 20 (%40) cases via 3-6 times application of SNS. CONCLUSION We were able to reach complete healing rates as % 67 with SNS application in perianal fistula. This is a non-invasive procedure and could be applied in out patient clinics, with low costs. Less complication rates enhances attraction. Patients will not loose chance of surgical treatment. Therefore, we believe SNS may be used as first line treatment in perianal fistulas. KEY WORDS Follow-up, Perianal fistula, Silver nitrate.
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Ruemmele FM, Rosh J, Faubion WA, Dubinsky MC, Turner D, Lazar A, Eichner S, Maa JF, Alperovich G, Robinson AM, Hyams JS. Efficacy of Adalimumab for Treatment of Perianal Fistula in Children with Moderately to Severely Active Crohn's Disease: Results from IMAgINE 1 and IMAgINE 2. J Crohns Colitis 2018; 12:1249-1254. [PMID: 29939254 PMCID: PMC6225974 DOI: 10.1093/ecco-jcc/jjy087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS Adalimumab has been shown to be more effective than placebo in healing fistulae in adults with moderately to severely active Crohn's disease. The efficacy and safety of adalimumab in healing fistulae in children/adolescents with Crohn's disease from the 52-week IMAgINE 1 clinical trial, and its open-label extension IMAgINE 2, are reported. METHODS Children/adolescents with perianal fistulae at baseline of IMAgINE 1 were assessed for fistula closure and improvement during IMAgINE 1 [Weeks 0-52] and from Week 0 of IMAgINE 2 [Week 52 of IMAgINE 1] through to Week 240 of IMAgINE 2 using non-responder imputation. RESULTS A total of 36 children/adolescents had fistulae at baseline of IMAgINE 1 and were included in the analysis. Fistula closure and improvement were observed in 44.4% and 52.8%, respectively, at Week 12. Rates of closure and improvement were maintained throughout the analysis period to Week 292. No new safety signals were identified. CONCLUSIONS In children/adolescents with moderately to severely active, fistulizing Crohn's disease, adalimumab induced perianal fistula closure and improvement within 12 weeks of treatment, with rates that were sustained for more than 5 years. The safety profile of adalimumab in patients with fistulae at baseline was similar to that of the overall population in IMAgINE 1/2. ClinicalTrials.gov identifiers: IMAgINE 1 (NCT00409682); IMAgINE 2 (NCT00686374).
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Affiliation(s)
- Frank M Ruemmele
- Université Sorbonne Paris Cité, Paris Descartes, APHP Hôpital Necker-Enfants Malades, Paris, France
| | - Joel Rosh
- Goryeb Children’s Hospital/Atlantic Health, Morristown, NJ, USA
| | | | | | - Dan Turner
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Andreas Lazar
- AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
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Abstract
INTRODUCTION This study aimed to evaluate the applicability, safety, results, and functional performance of Permacol™ collagen paste injection in patients with an anal fistula. METHODS Thirty-one patients with anal fistula underwent Permacol™ collagen paste injection between February 2015 and February 2017. The patients were followed up for a total of 12 months with recovery conditions monitored at intervals of 3, 6, and 12 months. Preoperative insertion of seton was performed in 15 patients for a period of 6-8 weeks and 2 patients for a period of 12 weeks. RESULTS A trans-sphincteric anal fistula was present in 20 patients and an intersphincteric fistula was present in 11 patients. There was a recurrence in 7 patients (22.5%): 1 patient (3.2%) after 1-month follow-up, 3 patients (9.7%) after 3-month follow-up, 2 patients (6.5%) after 6-month follow-up, and 1 patient (3.2%) after 12-month follow-up. A complete recovery was observed in 24 (77.5%) patients after a 12-month follow-up. The mean Fecal Incontinence Severity Index score was 0.29 ± 0.64 preoperatively and 0.55 ± 1.03 after 12 months. CONCLUSION In this study, we show that treatment of patients with an anal fistula by injection of Permacol™ is a safe and successful method that does not compromise continence.
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Papamichael K, Cheifetz AS. Defining and predicting deep remission in patients with perianal fistulizing Crohn’s disease on anti-tumor necrosis factor therapy. World J Gastroenterol 2017; 23:6197-6200. [PMID: 28974885 PMCID: PMC5603485 DOI: 10.3748/wjg.v23.i34.6197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
Perianal fistulas can occur to up to one-third of patients with Crohn’s disease (CD) leading to significant disabling disease and morbidity. Fistulising perianal CD treatment often necessitates a combined pharmacological and surgical approach. Anti-tumor necrosis factor (anti-TNF) therapy, particularly infliximab, has been shown to be very effective for both perianal and internal fistulising CD. Nevertheless, current data suggest that sustained remission and long-term complete fistula healing can be achieved in only 30% to 50% of patients. Moreover, these percentages refer mostly to clinical rather than deep remission, defined as endoscopic and radiologic remission, which is quickly emerging as the preferred goal of therapy. Unfortunately, the therapeutic options for perianal fistulising CD are still limited. As such, it would be of great value to be able to predict, and more importantly, prevent treatment failure in these patients by early and continued optimization of anti-TNF therapy. Similar to ulcerative colitis and luminal CD, recent data demonstrate that higher infliximab concentrations are associated with better clinical outcomes in patients with perianal fistulising CD. This suggests that therapeutic drug monitoring and a treat-to-trough therapeutic approach may emerge as the new standard of care for optimizing anti-TNF therapy in patients with perianal fistulising CD.
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Affiliation(s)
- Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Davidov Y, Ungar B, Bar-Yoseph H, Carter D, Haj-Natour O, Yavzori M, Chowers Y, Eliakim R, Ben-Horin S, Kopylov U. Association of Induction Infliximab Levels With Clinical Response in Perianal Crohn's Disease. J Crohns Colitis 2017; 11:549-555. [PMID: 28453755 DOI: 10.1093/ecco-jcc/jjw182] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 10/01/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The association of infliximab [IFX] trough levels with clinical and endoscopic outcomes in inflammatory bowel disease is well established. However, there is scarce data regarding the association of perianal fistula response with IFX. The aim of this study was to establish whether early induction infliximab levels and anti-infliximab antibodies [ATIs] are associated with perianal fistula response. METHODS Consecutive CD patients with perianal fistulae that were treated with IFX between 2008 and 2016 were included in the study. Response was defined as cessation or significant improvement of fistula drainage. Patients with unavailable IFX level or ATI measurements and/or missing clinical follow-up at Week 14 were excluded. RESULTS A total of 36 patients with perianal fistulae were included; 25/36 [69.4%] responded to treatment by Week 14. The median induction IFX levels at Weeks 2, 6 and 14 in the responders group at Week 14 were higher compared with those of the non-responders group [20/5.6 µg/mL, P = 0.0001; 13.3/2.55 µg/mL P = 0.0001; 4.1/0.14 µg/mL, P = 0.01]. On multivariate analysis, IFX leve at Weeks 2 and 6 were significantly associated with fistula response at Weeks 14 and 30. IFX drug levels of 9.25 µg/mL at Week 2 and 7.25 µg/mL at Week 6 were the best predictors of fistula response. CONCLUSION High IFX trough levels during induction are associated with favorable fistula response to anti-TNF treatment. If validated in a larger prospective study, our findings may help guide anti-TNF treatment in patients with perianal CD, and suggest serum level-guided treatment escalation in non-responders or prompt changing of biologic treatment in non-responders.
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Affiliation(s)
- Yana Davidov
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Haggai Bar-Yoseph
- Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa; Israel
| | - Dan Carter
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Ola Haj-Natour
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
| | - Miri Yavzori
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
| | - Yehuda Chowers
- Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa; Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
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Iwańczak BM, Ryżko J, Jankowski P, Sładek M, Wasilewska A, Szczepanik M, Sienkiewicz E, Szaflarska-Popławska A, Więcek S, Kwiecień J, Korczowski B, Maślana J. Induction and Maintenance Infliximab Therapy for the Treatment of Crohn's Disease with Perianal Fistulas in Children: Retrospective, Multicenter Study. ADV CLIN EXP MED 2016; 25:523-30. [PMID: 27629741 DOI: 10.17219/acem/36417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/20/2015] [Accepted: 03/23/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Infliximab is a biological drug used for the treatment of Crohn's disease in children. OBJECTIVES The aim of this retrospective study was the estimation of effectiveness and safety of infliximab in the treatment of Crohn's disease with perianal fistulas in children. MATERIAL AND METHODS Analysis comprised 50 children with Crohn's disease with perianal fistulas aged 9 to 18 years (16 girls and 34 boys) who failed to respond to conventional therapy. The children were divided into two groups: the first group contained 23 children with simple fistulas and the second - 27 children with complex fistulas. All children were treated with infliximab, administered in the dose of 5 mg per kilogram of the body mass. In the induction phase infliximab was administered at weeks 0, 2 and 6 and after clinical response in maintenance phase the drug was administered every 8 weeks; together for 12 months. RESULTS In 76% of children after induction therapy with infliximab and in 71.87% after maintenance therapy the complete closure of fistula occurred. During the first year after the treatment a recurrence of a fistula was observed in 30.43% of the children. In two children anaphylactic shock was observed during injection of infliximab. The remaining children tolerated the drug well. CONCLUSIONS The treatment with infliximab was effective in the majority of fistulazing Crohn's disease and caused the closure of perianal fistula which improved quality of life.
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Affiliation(s)
- Barbara M Iwańczak
- 2nd Department and Clinic of Pediatrics, Gastroenterology and Nutrition, Wroclaw Medical University, Poland
| | - Józef Ryżko
- Children's Memorial Health Institute, Warszawa, Poland
| | | | - Małgorzata Sładek
- Department of Pediatrics, Gastroenterology and Nutrition, Jagiellonian University School of Medicine, Kraków, Poland
| | - Agata Wasilewska
- Department of Pediatrics, Gastroenterology and Nutrition, Jagiellonian University School of Medicine, Kraków, Poland
| | - Mariusz Szczepanik
- Department of Pediatric Gastroenterology and Metabolic Disorders, Poznan Univeristy of Medical Sciences, Poland
| | - Edyta Sienkiewicz
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Anna Szaflarska-Popławska
- Department of Pediatrics, Allergology and Gastroenterology, L. Rydygiera Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
| | - Sabina Więcek
- Department of Pediatrics, Medical University of Silesia, Gastroenterology Unit, Upper-Silesian Child Health Care Center in Katowice, Poland
| | - Jarosław Kwiecień
- Gastroenterology Division, Department of Pediatrics, Medical University of Silesia, Zabrze, Poland
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Yassin NA, Askari A, Warusavitarne J, Faiz OD, Athanasiou T, Phillips RKS, Hart AL. Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn's disease. Aliment Pharmacol Ther 2014; 40:741-9. [PMID: 25115149 DOI: 10.1111/apt.12906] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/13/2014] [Accepted: 07/18/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND The management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required. AIM To review systematically the literature to assess fistula healing rates with medical treatment (anti-TNF-α therapies ± immunomodulators) or surgical treatment alone, compared with combined medical and surgical treatment in fistulising perianal Crohn's disease (CD). METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Two independent reviewers searched the literature. RESULTS Twenty-four articles were included. The total population was 1139 patients; 460 (40%) received single treatment with either medical or surgical therapy, and 679 (60%) received combined medical and surgical therapy. Eight studies compared single and combination therapy, with a total population of 797 patients (single therapy: n = 448, combination therapy: n = 349). In the single therapy group, 191/448 were in complete remission (43%). This was lower than the healing rate of the combination therapy group 180/349 (52%). No response to therapy was noted in 34% (153/448) of the single therapy group compared with 23% (80/349) of the combination group. CONCLUSIONS Combined surgical and medical (anti-TNF-α ± immunomodulators) therapy may have additional beneficial effects on perianal fistula healing in patients with Crohn's disease, compared with surgery or medical therapy alone. A well-designed Crohn's perianal fistula clinical trial is required in a multidisciplinary medical and surgical setting, with clearly defined end points of clinical (and likely patient reported outcomes) and radiological healing.
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Affiliation(s)
- N A Yassin
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK; IBD unit, St Mark's Hospital and Academic Institute, London, UK; Department of Cardiovascular Medicine, St Mary's Hospital, London, UK
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Cestaro G, De Rosa M, Gentile M. Treatment of fistula in ano with fibrin glue: preliminary results from a prospective study. MINERVA CHIR 2014; 69:225-228. [PMID: 24987970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIM This prospective study was done to evaluate the efficacy of commercial fibrin glue application in the healing of patients with fistulas-in-ano from a short follow up period (one year). METHODS This randomized clinical trial of 26 patients was performed during the period from January 2012 to July 2012. Nineteen men and seven women were treated for a fistula-in-ano with a commercial fibrin glue injection. In the operating room, the patients underwent an anorectal examination under spinal anesthesia. The external and internal fistula tract openings were then identified and the fistula tract was accurately curetted. Fibrin glue was introduced by a loaded double-channel syringe into the external fistula opening until the fibrin glue tip could be seen emerging from the internal opening. RESULTS The initial success rate was 76.9% (20/26). Recurrence rate was 23% (6/26). Four patients underwent a re-application of fibrin glue and the fistulas of these patients closed. Total recurrence rate was 7.6% (2/26). The overall success rate was 69.2% (18/26). CONCLUSION Fibrin glue application was thus found to be an easy, safe, successful alternative treatment in the management of fistulas-in-ano. Specifically, this therapeutic option demonstrated his efficacy for simple non-ramificated transsphincteric and intersphincteric fistulas. Multicentric randomized clinical trials with more representative sample seem to be necessary to investigate the best patients to treat by fibrin glue injection and the optimal application technique to improve these results.
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Affiliation(s)
- G Cestaro
- Unit of General Specialistic and Mini‑invasive Surgery Federico II University of Naples, Naples, Italy -
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Yang BL, Lin Q, Chen HJ, Sun GD, Zhu P, Chen YQ, Gu YF. [Efficacy of infliximab combined with surgery in the treatment of perianal fistulizing Crohn disease]. Zhonghua Wei Chang Wai Ke Za Zhi 2013; 16:323-327. [PMID: 23608791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To evaluate the efficacy of infliximab combined with surgery in the treatment of perianal fistulizing Crohn disease (CD). METHODS Clinical data of 15 patients with perianal fistulizing CD receiving infliximab combined with surgery in the Affiliated Hospital of Nanjing University of Chinese Medicine from March 2010 to June 2011 were analyzed retrospectively. One week after operation, all the patients received infliximab infusion thrice at weeks 0, 2, and 6. Crohn disease activity index (CDAI), perianal Crohn disease activity index (PDAI), body mass index (BMI), routine blood test and endoscopy were evaluated at week 0, 14. Adverse reactions and healing time were recorded. RESULTS At week 14, the response rate was 100% with 86.7% (13/15) complete responders. One patient had local improvement and one developed recurrent fistula. The mean healing time was 32.5 (20-45) d. Anorectal stenosis in 4 patients was significantly improved. At week 14, CDAI decreased to 114.0±90.3 from 230.5±97.5 after IFX treatment. PCDAI decreased to 2.8±3.2 from 9.9±3.4, and BMI increased to (21.5±3.0)kg/m(2) from (19.1±3.1)kg/m(2). C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), platelet and neutrophil were significantly decreased from baseline (all P<0.01). Intestinal mucosa healed completely in one patient. There were no serious adverse events except hypokalemia in one patient and severe infusion reaction in another. CONCLUSION Infliximab combined with surgery is effective and safe for perianal fistulizing CD.
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Affiliation(s)
- Bo-lin Yang
- Department of Anorectal, Nanjing University of Chinese Medicine, Nanjing, China
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Wang GF, Ren JA, Liu S, Chen J, Gu GS, Wang XB, Fan CG, Li JS. Clinical characteristics of non-perianal fistulating Crohn's disease in China: a single-center experience of 184 cases. Chin Med J (Engl) 2012; 125:2405-2410. [PMID: 22882911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND There is little information of non-perianal fistulating Crohn's disease in the consensus published by the European Crohn's and Colitis Organization in 2006 and 2010. This study was designed to demonstrate the clinical characteristics of non-perianal fistulating Crohn's disease among homogenous Chinese population. METHODS One-hundred-and-eighty-four patients were retrospectively collected. All of these patients were diagnosed of Crohn's disease between February 2001 and April 2011. RESULTS The male-to-female ratio was 2.7:1. The most common symptoms at onset were abdominal pain (88.0%), diarrhea (34.7%), and fever (28.3%). The most common disease location and behavior at diagnosis were small bowel (56.0%) and penetrating (51.6%). Among 324 non-perianal fistulae, the most common types were ileocolonic anastomotic (30.9%), terminal ileocutaneous (19.7%), and enteroenteric anastomotic (11.4%). One-hundred-and-thirty- eight (75.0%) patients received antibiotics, and β-lactam (85.5%) and metronidazole (67.4%) are most frequently used. One-hundred-and-seventy-eight (96.7%) patients suffered 514 surgical operations, and the cumulative surgical rates after 1, 3, and 5 years were 38.0%, 52.2%, and 58.7% respectively. Nine patients died during the follow-up period, and the cumulative survival rates after 1, 3, and 5 years were 97.8%, 96.7%, and 96.2% respectively. CONCLUSIONS This study displayed the clinical characteristics of non-perianal fistulating Crohn's disease in our center. Large population-based studies are required for further investigation in China.
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Affiliation(s)
- Ge-Fei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
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Lorenzetti R, Gruppo M, Piatto G, Militello V, Militello C. Timing and pharmacological support in the surgical treatment of multiple perianal fistulas in Crohn's disease. Acta Biomed 2011; 82:254-258. [PMID: 22783723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We present a case report on the management of a young woman affected by Crohn's Disease ever since childhood, complicated by complex, multiple perianal fistulas. In literature, there is increasing evidence to support the treatment of perianal fistulas using a combined association of medical and surgical strategies. In the case of our patient, the choice of surgery in association with pharmacological treatment was supported by the consideration of the fact that intervening during a quiescent phase of the disease, from the symptomatic, clinical-biohumoral and endoscopic standpoint, would have reduced the risk of complications and thus promoted healing. (www.actabiomedica.it).
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Affiliation(s)
- Renata Lorenzetti
- Dept. of Surgical Science and Gastroenterology, University of Padua, Italy
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Hvas CL, Dahlerup JF, Jacobsen BA, Ljungmann K, Qvist N, Staun M, Tøttrup A. Diagnosis and treatment of fistulising Crohn's disease. Dan Med Bull 2011; 58:C4338. [PMID: 21975159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A fistula is defined as a pathological connection between the intestine and an inner (bladder or other intestine) or outer (vagina or skin) epithelial surface. Fistulas are discovered in up to 25% of all Crohn's disease patients during long-term follow-up examinations. Most are perianal fistulas, and these may be classified as simple or complex. The initial investigation of perianal fistulas includes imaging (MRI of the pelvis and rectum), examination under anaesthesia (EUA) with digital imaging, endoscopy, probing and anal ultrasound. Non-perianal fistulas require contrast imaging and/or CT/MRI for complete anatomical definition. Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated. Treatment goals for perianal fistulas include reduced fistula secretion or none, evaluated by clinical examination; the absence of abscesses; and patient satisfaction. MR imaging is required to demonstrate definitive fistula closure. Fistulotomy is considered for simple perianal fistulas. In complex perianal fistulas, antibiotics and azathioprine or 6-mercaptopurine, which are often combined with a loose seton, constitute the first-line medical therapy. In cases with persistent secretion, infliximab at 5 mg/kg is given at weeks 0, 2, and 6 and subsequently every 8 weeks. Adalimumab may improve fistula response in both infliximab-naïve patients and following infliximab treatment failure. Local therapy with fibrin glue or fistula plugs is rarely effective. Definitive surgical closure of perianal fistulas using an advancement flap may be attempted, but this procedure is associated with a high risk of relapse. Colostomy and proctectomy are the ultimate surgical treatment options for fistulas. Intestinal resection is almost always needed for the closure of symptomatic non-perianal fistulas.
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Affiliation(s)
- Christian Lodberg Hvas
- Department of Medical Gastroenterology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark
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Nakase H, Matsuura M, Uza N, Chiba T. Tacrolimus suppresses IL-12/IL23 p40 in Crohn's disease and heals fistulae refractory to anti-TNF-α therapy. Aliment Pharmacol Ther 2011; 33:979-80; author reply 980-1. [PMID: 21434949 DOI: 10.1111/j.1365-2036.2011.04587.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Tursi A, Papa A, Maiorano M. Onset of severe perianal disease in Crohn's disease under treatment with infliximab: successful treatment with adalimumab and setons drainage. Inflamm Bowel Dis 2011; 17:676-8. [PMID: 20848475 DOI: 10.1002/ibd.21292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Ajayi AO, Chandrasekar T, Hammed AH. Crohn's disease presenting as a recurrent perianal fistula: a case report. Niger J Clin Pract 2010; 13:473-476. [PMID: 21220869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Crohn's disease (CD) is a multifactorial polygenic disease characterized by chronic inflammation of the gastrointestinal tract (GIT), often complicated by the development of intestinal strictures and/or formation of fistulas. Several diagnostic criteria have been proposed, usually relying on clinical, endoscopic, radiological or histological features. report a case of Crohn's disease of the entire colon with rectal sparing presenting with recurrent perianal fistula that had earlier on been misdiagnosed and treated for other things. The patient was treated successfully with corticosteroids and aminosalicylates and had since remained stable.
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Affiliation(s)
- A O Ajayi
- Gastroenterology Unit, Department of Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria
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de la Portilla F, Rada R, Vega J, Cisneros N, Maldonado VH, Sánchez-Gil JM. Long-term results change conclusions on BioGlue in the treatment of high transsphincteric anal fistulas. Dis Colon Rectum 2010; 53:1220-1. [PMID: 20628291 DOI: 10.1007/dcr.0b013e3181e10dbf] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
BACKGROUND Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence rates, minimal incontinence and good quality of life. OBJECTIVES To assess the efficacy and morbidity of operative procedures for chronic anal fistula, primary outcomes being recurrence and incontinence. SEARCH STRATEGY The following databases were searched: EMBASE (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); Medline (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); The Cochrane Central Register of Controlled Trials (2009 issue 4)and the IndMed ( Indian Medline, www.indmed.nic.in) database. We restricted our search to the English literature. The Indian Journal of Surgery was electronically searched (issues between 2003 and vol 71, Oct 2009). We also searched all primary trial registers (Indian, Australian, Chinese, WHO, ISRCTN and American). SELECTION CRITERIA Randomised controlled trials comparing operative procedures for anorectal fistulae were considered. Non randomised trials and cohort studies were examined where data on recurrence and function were available. DATA COLLECTION AND ANALYSIS Two reviewers (TJ and BP) independently selected the trials for inclusion in the review. Disagreements were solved by discussion. Where disagreement persisted and published results made data extraction difficult, we obtained clarification from the authors. REVMAN 5 was used for statistical analysis. Quality of the trials were assessed and allowances made for subgroup analysis and prevention of publication bias, using funnel plots if needed. MAIN RESULTS Ten randomised controlled trials were available for analysis. The quality of included studies was adequate, though in some trials the numbers were small and they were inadequately powered for equivalence or to detect significant differences. Comparisons were made between various modalities of treatments. There were no significant difference in recurrence rates or incontinence rates in any of the studied comparisons except in the case of advancement flaps. There were more recurrences in the glue plus flap group, a significant difference that favoured the flap only technique. It was also noted that Fibrin glue and advancement flap procedures report low incontinence rates.In the review of literature of non-randomised trials, most trials on fibrin glue indicate good healing in simple fistulae with low incontinence rates. AUTHORS' CONCLUSIONS There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.The use of Fibrin glue and advancement flaps are associated with low incontinence rates.There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.
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Affiliation(s)
- Tarun J Jacob
- Department of Surgery, Christian Medical College, Ida Scudder road, Vellore, Tamil Nadu, India, 632004
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Tamm TI, Datsenko AB, Babets EI, Datsenko EG. [Local treatment of operation wounds in patients with acute paraproctitis using preparation distreptase]. Klin Khir 2010:9-11. [PMID: 20568500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The results of local treatment of an acute paraproctitis in 37 patients, using suppositoria Distreptase (Biomed Sara and Vassinas Production Ltd., Lyublin, Poland) were analyzed. There were noted sufficiently high efficacy of treatment, in particular, the necrolysis resolution approaching, the wounds granulation and epithelization beginning as well as reduction of the patients treatment period.
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Stupart D, Goldberg P, Levy A, Govender D. Tuberculous anal fistulas--prevalence and clinical features in an endemic area. S AFR J SURG 2009; 47:116-118. [PMID: 20141068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION The aim of this study was to determine the prevalence of tuberculosis (TB) in anal fistulas at a referral hospital in Cape Town, and to document the clinical features and course of patients with tuberculous anal fistulas. PATIENTS AND METHODS This was a prospective study of all patients who underwent surgery for anal fistulas at the Colorectal Surgery Unit at Groote Schuur Hospital, Cape Town, from 2004 to 2006. Tissue was submitted for histopathological examination, Ziehl-Neelsen (ZN) staining and TB culture. The patients with proven TB were followed up until January 2008. RESULTS During the 3-year study period, 117 operations were performed on 96 patients. TB was diagnosed in 7 of the 96 patients (7.3%). In 5 of these 7 cases, the diagnosis of TB could be proven on histological examination and ZN staining, while in 2 cases the diagnosis could only be made on TB culture. None of the 7 patients had systemic features suggestive of TB, and only 1 had evidence of TB on a chest radiograph, Five patients were HIV-negative, and 2 declined testing. After a median follow-up of 2 years, 5 of 7 patients had evidence of recurrent or persistent fistulas, despite having completed 6 months of TB treatment. CONCLUSION At a referral hospital in an endemic area, TB was present in 7.3% of anal fistulas. Histopathological examination including ZN staining was inadequate to make the diagnosis in a third of these patients. Tissue from anal fistulas should therefore routinely be sent for TB culture as well as histopathological examination and ZN staining in areas where TB is prevalent.
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Affiliation(s)
- Douglas Stupart
- Department of Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town
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Milito G, Cadeddu F. Conservative treatment for anal fistula: collagen matrix injection. J Am Coll Surg 2009; 209:542-3; author reply 543. [PMID: 19801329 DOI: 10.1016/j.jamcollsurg.2009.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Accepted: 07/20/2009] [Indexed: 11/18/2022]
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Malesci A, Angelucci E, Bonifacio C, Sociale O, Omodei P, Repici A, Balzarini L, Danese S. Closure of perianal fistula using adalimumab in a Crohn's disease patient naive to antitumor necrosis factor alpha antibodies. Inflamm Bowel Dis 2009; 15:814-5. [PMID: 18831523 DOI: 10.1002/ibd.20739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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