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Singh A, Midha V, Kochhar GS, Shen B, Sood A. Management of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2023:izad195. [PMID: 37672347 DOI: 10.1093/ibd/izad195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 09/08/2023]
Abstract
Perianal fistulizing Crohn's disease (CD) represents a severe phenotype of CD that is associated with significant morbidity and reduction in quality of life. Perianal fistulizing CD is caused by a complex interplay of genetic predisposition, immune dysregulation, gut dysbiosis, and various unknown physiological and mechanical factors. A multidisciplinary approach is hence required for optimal management . A detailed anatomical description and classification of perianal fistula, including comprehensive clinical, endoscopic, and radiological diagnostic workup, is an important prerequisite to treatment. For simple perianal fistulas, use of antibiotics and immunomodulators, with or without fistulotomy, are appropriate measures. The medical management of complex perianal fistula, on the other hand, requires adequate control of infection before initiation of therapy with immunomodulators. In active complex perianal fistula, anti-tumor necrosis factors remain the most accepted therapy, with concomitant use of antibiotics or immunomodulators enhancing the efficacy. For patients refractory to anti-tumor necrosis factors, treatment with anti-integrins, anti-interleukins, and small molecules is being evaluated. Mesenchymal stem cells, hyperbaric oxygen therapy, and exclusive enteral nutrition have also been investigated as adjunct therapies. Despite the expansion of the medical armamentarium, a large proportion of the patients require surgical interventions. In this review, we provide an up-to-date overview of the pathophysiology, clinical presentation, diagnosis, and medical management of perianal fistulizing CD. A brief overview of the surgical management of perianal fistulizing CD is also provided.
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Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Gursimran Singh Kochhar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
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2
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Greene C, Beaman HT, Stinfort D, Ramezani M, Monroe MBB. Antimicrobial PVA Hydrogels with Tunable Mechanical Properties and Antimicrobial Release Profiles. J Funct Biomater 2023; 14:jfb14040234. [PMID: 37103324 PMCID: PMC10146720 DOI: 10.3390/jfb14040234] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/24/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Hydrogels are broadly employed in wound healing applications due to their high water content and tissue-mimicking mechanical properties. Healing is hindered by infection in many types of wound, including Crohn's fistulas, tunneling wounds that form between different portions of the digestive system in Crohn's disease patients. Owing to the rise of drug-resistant infections, alternate approaches are required to treat wound infections beyond traditional antibiotics. To address this clinical need, we designed a water-responsive shape memory polymer (SMP) hydrogel, with natural antimicrobials in the form of phenolic acids (PAs), for potential use in wound filling and healing. The shape memory properties could allow for implantation in a low-profile shape, followed by expansion and would filling, while the PAs provide localized delivery of antimicrobials. Here, we developed a urethane-crosslinked poly(vinyl alcohol) hydrogel with cinnamic (CA), p-coumaric (PCA), and caffeic (Ca-A) acid chemically or physically incorporated at varied concentrations. We examined the effects of incorporated PAs on antimicrobial, mechanical, and shape memory properties, and on cell viability. Materials with physically incorporated PAs showed improved antibacterial properties with lower biofilm formation on hydrogel surfaces. Both modulus and elongation at break could be increased simultaneously in hydrogels after both forms of PA incorporation. Cellular response in terms of initial viability and growth over time varied based on PA structure and concentration. Shape memory properties were not negatively affected by PA incorporation. These PA-containing hydrogels with antimicrobial properties could provide a new option for wound filling, infection control, and healing. Furthermore, PA content and structure provide novel tools for tuning material properties independently of network chemistry, which could be harnessed in a range of materials systems and biomedical applications.
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Affiliation(s)
- Caitlyn Greene
- Department of Biomedical and Chemical Engineering, BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, NY 13244, USA
| | - Henry T Beaman
- Department of Biomedical and Chemical Engineering, BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, NY 13244, USA
| | - Darnelle Stinfort
- Department of Biomedical and Chemical Engineering, BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, NY 13244, USA
| | - Maryam Ramezani
- Department of Biomedical and Chemical Engineering, BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, NY 13244, USA
| | - Mary Beth B Monroe
- Department of Biomedical and Chemical Engineering, BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, NY 13244, USA
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Loras C, Mañosa M, Andújar X, Sánchiz V, Martí-Gallostra M, Zabana Y, Gutiérrez A, Barreiro-de Acosta M. Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:315-334. [PMID: 34274357 DOI: 10.1016/j.gastrohep.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Abstract
Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.
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Affiliation(s)
- Carme Loras
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España.
| | - Miriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Departamento de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Xavier Andújar
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Vicente Sánchiz
- Servicio de Medicina Digestiva. Hospital Clínico Universitario. Valencia, España
| | - Marc Martí-Gallostra
- Departamento de Cirugía Colorectal, General y Digestiva. Hospital Universitari de la Vall d'Hebron. Barcelona, España
| | - Yamile Zabana
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Hospital General Universitario de Alicante, Alicante, España
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Seivright JR, Villa NM, De DR, Hsiao JL, Shi VY. Intralesional biologics for inflammatory dermatoses: A systematic review. Dermatol Ther 2021; 35:e15234. [PMID: 34825744 DOI: 10.1111/dth.15234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/28/2022]
Abstract
Biologic medications are systemic therapeutic options for inflammatory dermatoses. Local forms of administration are less well-studied. To provide a summary of intralesional (IL) administration of biologics for various non-malignant inflammatory dermatologic conditions reported in the literature. A systematic review was performed in the PubMed and Embase databases from 2000 to 2020. Inclusion criteria included the local use of biologic medications for non-malignant cutaneous conditions. Quality was assessed with the modified Oxford Centre for Evidence-Based Medicine ratings. A total of 19 articles describing the use of 5 biologic medications in 9 dermatologic conditions were identified, comprising 172 patients. Conditions successfully treated with intralesional biologics included pemphigus vulgaris (rituximab), granuloma faciale (rituximab), perianal Crohn's disease (infliximab), lichen sclerosus (adalimumab), and necrobiosis lipoidica (etanercept and infliximab). Intralesional etanercept reduced pruritus associated with keloids. A case report of the use of infliximab for pyoderma gangrenosum did not demonstrate any efficacy. There was no consistent effect noted with treatments for sarcoidosis (infliximab) or cutaneous lymphoid hyperplasia (rituximab). Local administration of biologic medications may offer an additional method of treating refractory inflammatory dermatoses, but further study is needed to develop standardized dosing protocols, clarify efficacy rates, and identify optimal treatment candidates.
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Affiliation(s)
- Justine R Seivright
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Natalie M Villa
- Department of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Devea R De
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jennifer L Hsiao
- Department of Medicine, Division of Dermatology, University of California Los Angeles, Los Angeles, California, USA
| | - Vivian Y Shi
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Rubbino F, Greco L, di Cristofaro A, Gaiani F, Vetrano S, Laghi L, Bonovas S, Piovani D. Journey through Crohn's Disease Complication: From Fistula Formation to Future Therapies. J Clin Med 2021; 10:jcm10235548. [PMID: 34884247 PMCID: PMC8658128 DOI: 10.3390/jcm10235548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/19/2022] Open
Abstract
Crohn’s Disease (CD) is a chronic inflammatory disorder in which up to 50% of patients develop fistula within 20 years after the initial diagnosis, and half of these patients suffer perianal fistulizing disease. The etiopathogenesis of CD-related perianal fistula is still unclear, and its phenotypical and molecular characteristics are even more indefinite. A better understanding would be crucial to develop targeted and more effective therapeutic strategies. At present, the most accredited theory for the formation of CD-related fistula identifies the epithelial-to-mesenchymal transition (EMT) as the driving force. It has been well recognized that CD carries an increased risk of malignancy, particularly mucinous adenocarcinoma is often associated with long-standing fistula in CD patients. Despite the availability of multiple treatment options, perianal fistulizing CD represents a therapeutic challenge and is associated with an important impact on patients’ quality of life. To date, the most effective management is multidisciplinary with the cooperation of gastroenterologists, surgeons, radiologists, and nutritionists and the best recommended treatment is a combination of medical and surgical approaches.
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Affiliation(s)
- Federica Rubbino
- Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.G.); (A.d.C.); (L.L.)
- Correspondence: (F.R.); (S.B.)
| | - Luana Greco
- Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.G.); (A.d.C.); (L.L.)
| | - Alessio di Cristofaro
- Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.G.); (A.d.C.); (L.L.)
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy;
- Gastroenterology and Endoscopy Unit, University-Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy; (S.V.); (D.P.)
| | - Luigi Laghi
- Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (L.G.); (A.d.C.); (L.L.)
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy;
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy; (S.V.); (D.P.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
- Correspondence: (F.R.); (S.B.)
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy; (S.V.); (D.P.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
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Review: Local Tumor Necrosis Factor-α Inhibition in Inflammatory Bowel Disease. Pharmaceutics 2020; 12:pharmaceutics12060539. [PMID: 32545207 PMCID: PMC7356880 DOI: 10.3390/pharmaceutics12060539] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/28/2020] [Accepted: 06/09/2020] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) characterized by intestinal inflammation. Increased intestinal levels of the proinflammatory cytokine tumor necrosis factor-α (TNF-α) are associated with disease activity and severity. Anti-TNF-α therapy is administered systemically and efficacious in the treatment of IBD. However, systemic exposure is associated with adverse events that may impede therapeutic treatment. Clinical studies show that the efficacy correlates with immunological effects localized in the gastrointestinal tract (GIT) as opposed to systemic effects. These data suggest that site-specific TNF-α inhibition in IBD may be efficacious with fewer expected side effects related to systemic exposure. We therefore reviewed the available literature that investigated the efficacy or feasibility of local TNF-α inhibition in IBD. A literature search was performed on PubMed with given search terms and strategy. Of 8739 hits, 48 citations were included in this review. These studies ranged from animal studies to randomized placebo-controlled clinical trials. In these studies, local anti-TNF-α therapy was achieved with antibodies, antisense oligonucleotides (ASO), small interfering RNA (siRNA), microRNA (miRNA) and genetically modified organisms. This narrative review summarizes and discusses these approaches in view of the clinical relevance of local TNF-α inhibition in IBD.
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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8
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Boscá MM, Alós R, Maroto N, Gisbert JP, Beltrán B, Chaparro M, Nos P, Mínguez M, Hinojosa J. Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:155-168. [PMID: 31870681 DOI: 10.1016/j.gastrohep.2019.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/12/2019] [Accepted: 09/21/2019] [Indexed: 02/06/2023]
Abstract
Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.
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Affiliation(s)
- Marta M Boscá
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, España
| | - Rafael Alós
- Servicio de Cirugía General y Digestiva, Hospital Universitario La Fe, Valencia, España
| | - Nuria Maroto
- Servicio de Medicina Digestiva, Hospital Universitario de Manises, Manises, Valencia, España
| | - Javier P Gisbert
- Servicio de Medicina Digestiva, Hospital Universitario de La Princesa, Madrid, España
| | - Belén Beltrán
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España
| | - María Chaparro
- Servicio de Medicina Digestiva, Hospital Universitario de La Princesa, Madrid, España
| | - Pilar Nos
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España
| | - Miguel Mínguez
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, España
| | - Joaquín Hinojosa
- Servicio de Medicina Digestiva, Hospital Universitario de Manises, Manises, Valencia, España.
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Recommendations of the Crohn’s Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn’s disease. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.gastre.2019.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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10
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Laureti S, Gionchetti P, Cappelli A, Vittori L, Contedini F, Rizzello F, Golfieri R, Campieri M, Poggioli G. Refractory Complex Crohn's Perianal Fistulas: A Role for Autologous Microfragmented Adipose Tissue Injection. Inflamm Bowel Dis 2020; 26:321-330. [PMID: 31220252 PMCID: PMC6943693 DOI: 10.1093/ibd/izz051] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Complex perianal fistulas represent one of the most challenging manifestations of Crohn's disease. Combined surgical and medical therapy with biologic drugs today represent the first-line treatment option, but its efficacy does not exceed 60%. Recently, new therapeutic approaches, such as the use of mesenchymal stromal cells, have shown promising results. The adipose tissue is an abundant and easy to access source. The effectiveness, safety, and feasibility of local injections of microfragmented adipose tissue in patients with refractory complex fistulizing perianal Crohn's disease (PCD) were evaluated. METHODS Fifteen patients with persistent complex fistulizing PCD after biosurgical approach and subsequent surgical "rescue" repair were treated in S. Orsola-Malpighi Hospital with a single-local administration of microfragmented adipose tissue prepared using a minimal manipulation technique (Lipogems) in a closed system. Clinical outcomes were determined at 24-week follow-ups assessing success rate, defined as combined clinical and radiological remission. RESULTS Upon clinical examination at 24 weeks, 10 patients had combined remission (clinical and radiographic), 4 patients showed improvements, and 1 patient failed. The results were confirmed in all patients by pelvic MRI. No relevant postoperative complications nor adverse events were reported. CONCLUSION These results suggest that the local injection of autologous microfragmented adipose tissue is a safe and promising "rescue therapy" for patients with multiresistant complex fistulizing PCD. This approach might be proposed as routine because it is affordable, is minimally invasive, has no risk of sphincteric damage, and can be carried out in a day-surgery setting.
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Affiliation(s)
- Silvio Laureti
- Surgery of the Alimentary Tract, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences University of Bologna, Bologna, Italy,Address correspondence to: Silvio Laureti, MD, PhD, Associate Professor of Surgery, University of Bologna, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna, Italy. E-mail:
| | - Paolo Gionchetti
- IBD Unit, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Alberta Cappelli
- Radiology Unit, Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Laura Vittori
- Surgery of the Alimentary Tract, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences University of Bologna, Bologna, Italy
| | - Federico Contedini
- Plastic Surgery Unit, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Fernando Rizzello
- IBD Unit, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Massimo Campieri
- IBD Unit, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences University of Bologna, Bologna, Italy
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11
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Seyfried S, Herold A. Management of Perianal Fistulas in Crohn's Disease. Visc Med 2019; 35:338-343. [PMID: 31934580 DOI: 10.1159/000504103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/13/2019] [Indexed: 12/18/2022] Open
Abstract
Background Perianal fistulizing Crohn's disease is associated with severe symptoms such as pain, fecal incontinence, and a significant reduction in quality of life. Results In refractory cases, many patients face the decision of having a stoma and/or requiring proctectomy. In former years, the standard of care was a complete fistulectomy, bringing with it a high rate of continence disorders. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. Conclusion More recently, newer biologics, cell-based therapies as well as novel surgical techniques have been introduced, raising new hopes that outcomes can be improved upon.
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Affiliation(s)
- Steffen Seyfried
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Gareb B, Posthumus S, Beugeling M, Koopmans P, Touw DJ, Dijkstra G, Kosterink JGW, Frijlink HW. Towards the Oral Treatment of Ileo-Colonic Inflammatory Bowel Disease with Infliximab Tablets: Development and Validation of the Production Process. Pharmaceutics 2019; 11:pharmaceutics11090428. [PMID: 31450748 PMCID: PMC6781063 DOI: 10.3390/pharmaceutics11090428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022] Open
Abstract
Infliximab (IFX) is an intravenously administered monoclonal antibody antagonizing the effects of tumor necrosis factor-alpha (TNF) systemically and is efficacious in the treatment of inflammatory bowel disease (IBD). However, studies suggest that the anti-inflammatory effects result from local immunomodulation in the inflamed regions. Furthermore, topical inhibition of TNF in IBD ameliorates inflammation. We therefore hypothesized that orally administered IFX targeted to the ileo-colonic region in IBD may be an efficacious new treatment option. This study describes the development and validation of the production process of ileo-colonic-targeted 5 mg IFX tablets (ColoPulse-IFX) intended for the oral treatment of IBD by means of producing three consecutive validation batches (VAL1, VAL2, and VAL3, respectively). UV-VIS spectroscopy, HPLC-SEC analysis (content, fragments, aggregates), fluorescence spectroscopy (tertiary protein structure), and ELISA (potency) showed no noticeable deviations of IFX compounded to ColoPulse-IFX compared to fresh IFX stock. The average ± SD (n = 10) IFX content of VAL1, VAL2, and VAL3 was 96 ± 2%, 97 ± 3%, and 96 ± 2%, respectively, and complied with the European Pharmacopeia (Ph. Eur.) requirements for Content Uniformity. The average ± SD (n = 3) ColoPulse-IFX potency was 105 ± 4%, 96 ± 4%, and 97 ± 5%, respectively, compared to fresh IFX stock. The IFX release profile from the tablet core was complete (≥85%) after 10 min in simulated ileum medium. The in vitro coating performance of ColoPulse-IFX showed that the formulation was targeted to the simulated ileo-colonic region. Stability data showed that ColoPulse-IFX was stable for up to 6 months stored at 25 °C/60% RH. Based on these results, the production process can be considered validated and its application is discussed in light of the rationale and available evidence for the topical treatment of IBD with IFX.
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Affiliation(s)
- Bahez Gareb
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands.
| | - Silke Posthumus
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Max Beugeling
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Pauline Koopmans
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jos G W Kosterink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
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Wong DJ, Roth EM, Feuerstein JD, Poylin VY. Surgery in the age of biologics. Gastroenterol Rep (Oxf) 2019; 7:77-90. [PMID: 30976420 PMCID: PMC6454839 DOI: 10.1093/gastro/goz004] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023] Open
Abstract
Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.
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Affiliation(s)
- Daniel J Wong
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eve M Roth
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Feuerstein
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vitaliy Y Poylin
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Ribaldone DG, Resegotti A, Pellicano R, Astegiano M, Saracco GM, Morino M. The role of topical therapy for perianal fistulizing Crohn's disease: are we forgetting something? MINERVA GASTROENTERO 2019; 65:130-135. [PMID: 30759975 DOI: 10.23736/s1121-421x.19.02565-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Rectal inflammation is the principal risk factor for the development of perianal fistulizing Crohn's disease. However, no topical therapy direct to rectal healing is discussed in European' guidelines. The aim of this systematic review was to evaluate the role of topical therapy in healing the rectal inflammation in Crohn's disease. EVIDENCE ACQUISITION A MEDLINE search of all studies published in English until December 2018 was conducted. Articles were identified using the strings "Crohn's disease and topical therapy" or "perianal Crohn's disease and topical therapy." EVIDENCE SYNTHESIS Contradictory results about the efficacy of topical metronidazole were present. No benefit from topical tacrolimus use was demonstrated. Mesalazine suppositories induced and maintained remission of rectal inflammation in 50% of patients with rectal Crohn's disease. Few data were available about the role of local therapy for the fistulous tract in Crohn's disease. Local mesenchymal stem cells therapy could be a promising new approach. CONCLUSIONS Due to the disappoint success rate of current strategy in perianal fistulizing Crohn's disease, the role of rectal inflammation as a causative factor and the fair success rate of topical therapy with mesalazine suppositories in the healing of rectal inflammation without relevant side effects, more studies are advisable in this field.
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Affiliation(s)
| | - Andrea Resegotti
- General Surgery 1 U, Città della Salute e della Scienza, Turin, Italy
| | | | | | | | - Mario Morino
- Department of Surgical Sciences, University of Turin, Turin, Italy
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15
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Bermejo F, Guerra I, Algaba A, López-Sanromán A. Pharmacological Approach to the Management of Crohn's Disease Patients with Perianal Disease. Drugs 2018; 78:1-18. [PMID: 29139091 DOI: 10.1007/s40265-017-0842-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perianal localization of Crohn's disease involves significant morbidity, affects quality of life and results in an increased use of healthcare resources. Medical and surgical therapies contribute to its management. The objective of this review is to address the current understanding in the management of perianal Crohn's disease, with the main focus in reviewing pharmacological therapies, including stem cells. In complex fistulas, once local sepsis has been controlled by surgical drainage and/or antibiotics, anti-TNF drugs (infliximab, adalimumab) are the first-line therapy, with or without associated immunomodulators. Combining surgery and anti-TNF therapy has additional benefits for healing. However, response is inadequate in up to half of cases. A possible role of new biological drugs in this context (vedolizumab, ustekinumab) is an area of ongoing investigation, as is the local application of autologous or allogeneic mesenchymal stem cells. These are non-hematopoietic multipotent cells with anti-inflammatory and immunomodulatory properties, the use of which may successfully treat refractory patients, and seem to be a promising and safe alternative to achieving fistula healing in Crohn's disease, without known systemic effects.
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Affiliation(s)
- Fernando Bermejo
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain. .,Department of Medicine and Surgery, Universidad Rey Juan Carlos, Madrid, Spain.
| | - Iván Guerra
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain
| | - Alicia Algaba
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain
| | - Antonio López-Sanromán
- Department of Gastroenterology and Hepatology, University Hospital Ramón y Cajal, Madrid, Spain
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Panes J, Reinisch W, Rupniewska E, Khan S, Forns J, Khalid JM, Bojic D, Patel H. Burden and outcomes for complex perianal fistulas in Crohn's disease: Systematic review. World J Gastroenterol 2018; 24:4821-4834. [PMID: 30479468 PMCID: PMC6235801 DOI: 10.3748/wjg.v24.i42.4821] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/24/2018] [Accepted: 10/21/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To systematically review the literature on epidemiology, disease burden, and treatment outcomes for Crohn's disease (CD) patients with complex perianal fistulas. METHODS PubMed, Embase, and Cochrane were searched for relevant articles (published 2000-November 2016) and congress abstracts (published 2011-November 2016). RESULTS Of 535 records reviewed, 62 relevant sources were identified (mostly small observational studies). The cumulative incidence of complex perianal fistulas in CD from two referral-centre studies was 12%-14% (follow-up time, 12 years in one study; not reported in the second study). Complex perianal fistulas result in greatly diminished quality of life; up to 59% of patients are at risk of faecal incontinence. Treatments include combinations of medical and surgical interventions and expanded allogeneic adipose-derived stem cells. High proportions of patients experience lack of or inadequate response to treatment (failure and relapse rates, respectively: medical, 12%-73% and 0%-41%; surgical: 0%-100% and 11%-20%; combined medical/surgical: 0%-80% and 0%-50%; stem cells: 29%-47% and not reported). Few studies (1 of infliximab; 3 of surgical interventions) have been conducted in treatment-refractory patients, a population with high unmet needs. Limited data exist on the clinical value of anti-tumour necrosis factor-α dose escalation in patients with complex perianal fistulas in CD. CONCLUSION Complex perianal fistulas in CD pose substantial clinical and humanistic burden. There is a need for effective treatments, especially for patients refractory to anti-tumour necrosis factor-α agents, as evidenced by high failure and relapse rates.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona 08036, Spain
| | | | - Ewa Rupniewska
- RTI Health Solutions, Manchester M20 2LS, United Kingdom
| | - Shahnaz Khan
- RTI Health Solutions, Research Triangle Park, NC 27709, United States
| | - Joan Forns
- RTI Health Solutions, Barcelona 08028, Spain
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Standardization of mesenchymal stromal cell therapy for perianal fistulizing Crohn's disease. Eur J Gastroenterol Hepatol 2018; 30:1148-1154. [PMID: 30095479 DOI: 10.1097/meg.0000000000001208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Local administration of mesenchymal stromal cells (MSCs) into the fistula tract seems to improve patient outcome in perianal fistulas due to Crohn's disease (CD). In this paper we propose a standardized and validated protocol for the local administration of MSCs for CD perianal fistulas to be able to reliably assess efficacy. MATERIALS AND METHODS A working group consisting of gastroenterologists and surgeons with expertise in the treatment of perianal CD developed a consensus perianal fistula treatment protocol for local MSC treatment of perianal fistulizing CD. The treatment protocol was validated during a trial of allogeneic bone marrow-derived MSCs for the treatment of refractory perianal Crohn's fistulas. RESULTS Localization and classification of perianal fistulas with MRI and rectoscopy is of crucial importance prior to surgical intervention with local therapy administration. Examination under anesthesia is necessary to incise and drain abscesses when present. Optimization of medical treatment when active luminal CD is present, is the first step before embarking on surgery and local therapy administration. In addition, strictures preventing the surgeon from adequately performing the surgical procedure have to be endoscopically dilated. Curettage of the fistula tract has an important role as long-standing CD perianal fistulas close poorly without removal of their epithelial lining. To diminish bacterial contamination of the fistula, the internal opening has to be closed. The origin of the fistula is the internal opening, therefore, efficacy of MSCs is presumably the highest when they are injected into the tissue around the internal opening. CONCLUSION In this article, we propose a standardized method of local MSC administration for perianal fistulizing CD. The use of this standardized and validated protocol for the administration of local treatment of CD perianal fistulas will allow reliable comparison of the efficacy of local therapies in future.
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18
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Luther D, Lee Y, Nagaraj H, Scaletti F, Rotello V. Delivery approaches for CRISPR/Cas9 therapeutics in vivo: advances and challenges. Expert Opin Drug Deliv 2018; 15:905-913. [PMID: 30169977 PMCID: PMC6295289 DOI: 10.1080/17425247.2018.1517746] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/24/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Therapeutic gene editing is becoming a viable biomedical tool with the emergence of the CRISPR/Cas9 system. CRISPR-based technologies have promise as a therapeutic platform for many human genetic diseases previously considered untreatable, providing a flexible approach to high-fidelity gene editing. For many diseases, such as sickle-cell disease and beta thalassemia, curative therapy may already be on the horizon, with CRISPR-based clinical trials slated for the next few years. Translation of CRISPR-based therapy to in vivo application however, is no small feat, and major hurdles remain for efficacious use of the CRISPR/Cas9 system in clinical contexts. AREAS COVERED In this topical review, we highlight recent advances to in vivo delivery of the CRISPR/Cas9 system using various packaging formats, including viral, mRNA, plasmid, and protein-based approaches. We also discuss some of the barriers which have yet to be overcome for successful translation of this technology. EXPERT OPINION This review focuses on the challenges to efficacy for various delivery formats, with specific emphasis on overcoming these challenges through the development of carrier vehicles for transient approaches to CRISPR/Cas9 delivery in vivo.
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Affiliation(s)
- D.C. Luther
- Department of Chemistry, University of Massachusetts Amherst, 710 North Pleasant Street, Amherst, Massachusetts 01003, United States
| | - Y.W. Lee
- Department of Chemistry, University of Massachusetts Amherst, 710 North Pleasant Street, Amherst, Massachusetts 01003, United States
| | - H. Nagaraj
- Department of Chemistry, University of Massachusetts Amherst, 710 North Pleasant Street, Amherst, Massachusetts 01003, United States
- School of Chemical and Biotechnology, Sastra Deemed-to-be University, Tirumalaisamudram, Thanjavur 613 401,Tamil Nadu, India
| | - F. Scaletti
- Department of Chemistry, University of Massachusetts Amherst, 710 North Pleasant Street, Amherst, Massachusetts 01003, United States
| | - V.M. Rotello
- Department of Chemistry, University of Massachusetts Amherst, 710 North Pleasant Street, Amherst, Massachusetts 01003, United States
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Kotze PG, Shen B, Lightner A, Yamamoto T, Spinelli A, Ghosh S, Panaccione R. Modern management of perianal fistulas in Crohn's disease: future directions. Gut 2018; 67:1181-1194. [PMID: 29331943 DOI: 10.1136/gutjnl-2017-314918] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/20/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
Perianal fistulae in patients with Crohn's disease (CD) can be associated with significant morbidity resulting in negative impact on quality of life. The last two decades have seen significant advancements in the management of perianal fistulas in CD, which has evolved into a multidisciplinary approach that includes gastroenterologists, colorectal surgeons, endoscopists and radiologists. Despite the introduction of new medical therapies such as antitumour necrosis factor and novel models of care delivery, the best fistula healing rates reported with combined medical and surgical approaches are approximately 50%. More recently, newer biologics, cell-based therapies as well as novel endoscopic and surgical techniques have been introduced raising new hopes that outcomes can be improved upon. In this review, we describe the modern management and the most recent advances in the management of complex perianal fistulising CD, which will likely impact clinical practice. We will explore optimal use of both older and newer biological agents, as well as new data on cell-based therapies. In addition, new techniques in endoscopic and surgical approaches will be discussed.
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Affiliation(s)
- Paulo Gustavo Kotze
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Bo Shen
- Interventional IBD Unit, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amy Lightner
- Division of Colorectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Subrata Ghosh
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Martín Arranz E, Martín Arranz MD, Robredo T, Mancheño-Corvo P, Menta R, Alves FJ, Suárez de Parga JM, Mora Sanz P, de la Rosa O, Büscher D, Lombardo E, de Miguel F. Endoscopic submucosal injection of adipose-derived mesenchymal stem cells ameliorates TNBS-induced colitis in rats and prevents stenosis. Stem Cell Res Ther 2018; 9:95. [PMID: 29631607 PMCID: PMC5892014 DOI: 10.1186/s13287-018-0837-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 02/07/2023] Open
Abstract
Background Mesenchymal stem cells have potential applications in inflammatory bowel disease due to their immunomodulatory properties. Our aim was to evaluate the feasibility, safety and efficacy of endoscopic administration of adipose-derived mesenchymal stem cells (ASCs) in a colitis model in rats. Methods Colitis was induced in rats by rectal trinitrobenzenesulfonic acid (TNBS). After 24 h ASCs (107 cells) or saline vehicle were endoscopically injected into the distal colon. Rats were followed for 11 days. Daily weight, endoscopic score at days 1 and 11, macroscopic appearance at necropsy, colon length and mRNA expression of Foxp3 and IL-10 in mesenteric lymph nodes (MLN) were analyzed. Results Endoscopic injection was successful in all the animals. No significant adverse events or mortality due to the procedure occurred. Weight evolution was significantly better in the ASC group, recovering initial weight by day 11 (− 0.8% ± 10.1%, mean ± SD), whereas the vehicle group remained in weight loss (− 6.7% ± 9.2%, p = 0.024). The endoscopic score improved in the ASC group by 47.1% ± 5.3% vs. 21.8% ± 6.6% in the vehicle group (p < 0.01). Stenosis was less frequent in the ASC group (4.8% vs. 41.2%, p < 0.01). Colon length significantly recovered in the ASC group versus the vehicle group (222.6 ± 17.3 mm vs. 193.6 ± 17.9 mm, p < 0.001). The endoscopic score significantly correlated with weight change, macroscopic necropsy score and colon length. Foxp3 and IL-10 mRNA levels in MLN recovered with ASC treatment. Conclusions ASC submucosal endoscopic injection is feasible, safe and ameliorates TNBS-induced colitis in rats, especially stenosis. Electronic supplementary material The online version of this article (10.1186/s13287-018-0837-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eduardo Martín Arranz
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain.
| | - María Dolores Martín Arranz
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain
| | - Tomás Robredo
- Cell Therapy Laboratory, La Paz Hospital Institute for Health Research, Madrid, Spain
| | | | | | | | - Jose Manuel Suárez de Parga
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain
| | - Pedro Mora Sanz
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain
| | | | - Dirk Büscher
- Grifols SA, Sant Cugat del Vallés, Barcelona, Spain
| | | | - Fernando de Miguel
- Cell Therapy Laboratory, La Paz Hospital Institute for Health Research, Madrid, Spain
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Teich N, Wallstabe I, Schiefke I. Topic infliximab injection for refractory rectal stenosis in Crohn's disease: long-term follow-up in two patients. Int J Colorectal Dis 2017; 32:1289-1294. [PMID: 28725960 DOI: 10.1007/s00384-017-2860-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE TNF blockers are approved for intravenous or subcutaneous systemic therapy of many chronic inflammatory diseases. As it is not possible to achieve a sufficient local clinical improvement through systemic therapy in every patient, diverse approaches of topical therapy using TNF blockers have been investigated in recent years. METHODS In this paper, we report on long-term clinical results of originator infliximab (IFX) injections into symptomatic combined scarring and inflammatory stenoses of the rectum in two patients with Crohn's disease. Aiming at high tissue IFX levels, 25 mg of IFX was injected into each quadrant of the stenosis after endoscopic balloon dilatation. This off-label treatment was repeated as necessary, depending on the clinical success. RESULTS Topic IFX injection after balloon dilation reduced imperative stool pressure, isolated episodes of incontinence and incomplete emptying. Improvement lasted between 4 and 14 weeks in one patient and the treatment was repeated 13 times in the following 6.6 years. In the other patient, the technique was necessary only twice with no symptom recurrence in the subsequent 5.3 years. CONCLUSION Our experience suggests that topic application of a systemically approved anti-TNF substance may be a successful individualized therapy for refractory stenosis of the rectum in patients with Crohn's disease.
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Affiliation(s)
- Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten Leipzig und Schkeuditz, Nordstr. 21, 04105, Leipzig, Germany. .,Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany.
| | - Ingo Wallstabe
- Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany
| | - Ingolf Schiefke
- Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany
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22
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Amil-Dias J, Kolacek S, Turner D, Pærregaard A, Rintala R, Afzal NA, Karolewska-Bochenek K, Bronsky J, Chong S, Fell J, Hojsak I, Hugot JP, Koletzko S, Kumar D, Lazowska-Przeorek I, Lillehei C, Lionetti P, Martin-de-Carpi J, Pakarinen M, Ruemmele FM, Shaoul R, Spray C, Staiano A, Sugarman I, Wilson DC, Winter H, Kolho KL. Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2017; 64:818-835. [PMID: 28267075 DOI: 10.1097/mpg.0000000000001562] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.
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Affiliation(s)
- Jorge Amil-Dias
- *Department of Pediatrics, Centro Hospitalar, S. João, Porto, Portugal †Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia ‡The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel §Department of Pediatrics, Hvidovre University Hospital, Hvidovre, Denmark ||Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland ¶Department of Pediatric Gastroenterology, University Hospital Southampton, Southampton, UK #Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland **Department of Pediatrics, University Hospital Motol, Prague, Czech Republic ††Queen Mary's Hospital for Children, Epsom and St Helier NHS Trust, Surrey ‡‡Chelsea and Westminster Hospital, London, UK §§Paris-Diderot Sorbonne-Paris-Cité University and Robert Debré Hospital, Paris, France ||||Pediatric Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany ¶¶St George's, University of London, London, UK ##Boston Children's Hospital and Harvard Medical School, Boston, MA ***Department NEUROFARBA, University of Florence - Meyer Hospital, Florence, Italy †††Unit for the Comprehensive Care of Pediatric Inflammatory Bowel Disease, Hospital Sant Joan de Déu, Barcelona, Spain ‡‡‡Department of Pediatric Gastroenterology, Necker Enfants Malades University Hospital, Sorbonne Paris Cité University, Paris Descartes University, Institut IMAGINE - INSERM U1163, Paris, France §§§Pediatric Gastroenterology Institute, Ruth Children's Hospital, Rambam Medical Center, Haifa, Israel ||||||Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK ¶¶¶Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy ###Department of Pediatric Surgery, Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK ****Child Life and Health, University of Edinburgh, Scotland, UK ††††MassGeneral Hospital for Children, Harvard Medical School, Boston, MA ‡‡‡‡Children's Hospital, University of Helsinki, Helsinki, Finland
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Abstract
Perianal Crohn’s disease affects a significant number of patients with Crohn’s disease and is associated with poor quality of life. The nature of the disease, compounded by presentation of various disease severities, has made the treatment of perianal Crohn’s disease difficult. The field continues to evolve with the use of both historical and contemporary solutions to address the challenges associated with it. The goal of this article is to review current literature regarding medical and surgical treatment, as well as the future directions of therapy.
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Affiliation(s)
- Katherine A Kelley
- Department of General Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Taranjeet Kaur
- Department of General Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Vassiliki L Tsikitis
- Department of General Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Sciences University, Portland, OR, USA
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Adegbola SO, Sahnan K, Tozer PJ, Phillips RK, Faiz OD, Warusavitarne J, Hart A. Review of local injection of anti-TNF for perianal fistulising Crohn's disease. Int J Colorectal Dis 2017; 32:1539-1544. [PMID: 28900730 PMCID: PMC5635080 DOI: 10.1007/s00384-017-2899-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perianal fistulising Crohn's disease (PFCD) affects a third of Crohn's disease patients and represents a disabling phenotype with poor outcome. The anti-tumour necrosis factor alpha (TNF) therapies have been shown to maintain clinical remission in a third of patients after 1 year of treatment. Maintenance therapy with systematic administration schedules confers greatest benefit, but exposes patients to risks/side effects of continued systemic use and led to consideration of local drug delivery (first described in 2000). In this review, we analyse all published articles on local anti-TNF therapy in the treatment of PFCD. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to systematically search Medline and Embase using the medical subject headings 'fistula', 'anus', 'Crohn disease', 'infliximab' and 'adalimumab'. This was combined with free text searches, e.g. 'local injection' and 'Crohn's perianal disease'. Studies/abstracts describing local injection treatment with anti-TNF were included in this review. RESULTS Six pilot studies including a total of 92 patients were included in this review. Outcomes reported were mostly clinical and included 'complete/partial response' to therapy and short-term results varied between 40 and 100%. There were no significant adverse events and the local injections were well tolerated. CONCLUSIONS There is paucity of data assessing this treatment modality. Local anti-TNF therapy appears safe, but outcome reporting is heterogeneous, subjective and long-term data are unavailable. Our review suggests a potential role may be in those in whom systemic treatment is contraindicated and calls for standardised reporting of outcomes in this field to enable better data interpretation.
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Affiliation(s)
- Samuel O Adegbola
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, HA1 3UJ, UK.
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK.
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK.
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK.
| | - Kapil Sahnan
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
| | - Philip J Tozer
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
| | - Robin Ks Phillips
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
| | - Omar D Faiz
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
| | - Janindra Warusavitarne
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
| | - Ailsa Hart
- Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W2 1NY, UK
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
- Fistula Research Unit, St Mark's Academic Institute, Harrow, Middlesex, HA1 3UJ, UK
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25
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Ileal pouch-anal anastomosis 20 years later: is it still a good surgical option for patients with ulcerative colitis? Int J Colorectal Dis 2016; 31:1835-1843. [PMID: 27682647 DOI: 10.1007/s00384-016-2657-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-term results after ileo-pouch anal anastomosis (IPAA) are well established; data are conflicting in long-standing patients. We retrospectively evaluated long-term complications and functional results after follow-up longer than 20 years. METHODS Two hundred five patients with follow-up longer than 20 years have been identified out of 1112 IPAA performed in our institution; of these, 20 cases were lost at follow-up or decline to take part at the study. We evaluated long-term complications and failure rate also according to changes in histological diagnosis. Changes in functional results and quality of life (QoL) were analyzed at 5 and 20 years after IPAA. RESULTS Pouch failure rate was 10.8 % (35 % due to misdiagnosed Crohn). Incidences of fistulas, anastomotic stenosis, chronic pouchitis, and pre-pouch ileitis were 17.3, 12.9, 28.6, and 7.6 %, respectively. Most of the patients reported good functional outcomes. Day-time evacuations at 5 and after 20 years were 4.3 and 4.8 (p = n.s.) while during night-time were 0.8 and 1.2 (p < 0.05). Urgency was 6 and 9.4 % (p = n.s.), respectively; need of antimotility drugs was 16 and 35 % (p < 0.001). Dietary limitations and work restrictions were similar over time. Only sexuality got worse during follow-up. Satisfaction for surgery was always high and it did not change over time. CONCLUSION IPAA is still an excellent surgical option for UC with a low rate of pouch failure even after more than 20 years. Despite a slight worsening of functional results over time, the QoL remained high and most patients expressed satisfaction with the procedure and were willing to recommend it to others.
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Modern Treatments and Stem Cell Therapies for Perianal Crohn's Fistulas. Can J Gastroenterol Hepatol 2016; 2016:1651570. [PMID: 28053967 PMCID: PMC5174164 DOI: 10.1155/2016/1651570] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 11/03/2016] [Indexed: 12/16/2022] Open
Abstract
Crohn's disease (CD) is a complex disorder with important incidence in North America. Perianal fistulas occur in about 20% of patients with CD and are almost always classified as complex fistulas. Conventional treatment options have shown different success rates, yet there are data indicating that these approaches cannot achieve total cure and may not improve quality of life of these patients. Fibrin glue, fistula plug, topical tacrolimus, local injection of infliximab, and use of hematopoietic stem cells (HSC) and mesenchymal stem cells (MSC) are newly suggested therapies with variable success rates. Here, we aim to review these novel therapies for the treatment of complex fistulizing CD. Although initial results are promising, randomized studies are needed to prove efficacy of these approaches in curing fistulizing perianal CD.
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Treatment of minor dehiscence after endorectal advancement flap in perianal Crohn's fistulas with ozonized oil NOVOX(®). Tech Coloproctol 2015; 20:139-40. [PMID: 26643941 DOI: 10.1007/s10151-015-1404-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/06/2015] [Indexed: 12/18/2022]
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28
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Guidelines for medical treatment of Crohn's perianal fistulas: critical evaluation of therapeutic trials. Inflamm Bowel Dis 2015; 21:737-52. [PMID: 25751068 DOI: 10.1097/mib.0000000000000377] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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29
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Marzo M, Felice C, Pugliese D, Andrisani G, Mocci G, Armuzzi A, Guidi L. Management of perianal fistulas in Crohn’s disease: An up-to-date review. World J Gastroenterol 2015; 21:1394-1403. [PMID: 25663759 PMCID: PMC4316082 DOI: 10.3748/wjg.v21.i5.1394] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/17/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal disease is one of the most disabling manifestations of Crohn’s disease. A multidisciplinary approach of gastroenterologist, colorectal surgeon and radiologist is necessary for its management. A correct diagnosis, based on endoscopy, magnetic resonance imaging, endoanal ultrasound and examination under anesthesia, is crucial for perianal fistula treatment. Available medical and surgical therapies are discussed in this review, including new local treatment modalities that are under investigation.
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30
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Smith RK, Carter Paulson E. Perianal fistulas in patients with inflammatory bowel disease. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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31
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Surgical treatment of perianal fistulizing Crohn's disease: from lay-open to cell-based therapy--an overview. ScientificWorldJournal 2014; 2014:146281. [PMID: 25431776 PMCID: PMC4241327 DOI: 10.1155/2014/146281] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
Background. Perianal Crohn's disease (CD) can be challenging. Despite the high incidence of fistulizing CD, literature lacks clear guidelines. Several medical, surgical, and combined treatment modalities have been proposed, but evidences are scarce. Methods. We searched the literature to assess the facets of perianal CD, with particular focus on complex fistulae. Disease epidemiology, classification, diagnosis, activity scoring systems, and medical-surgical treatments were assessed. Results. Perianal fistulizing CD is common, frequently associated with upper gastrointestinal and colorectal CD. Complex fistulas often require repeated treatments. Continence is a major concern when dealing with repeated procedures. A prudent pathway is to resolve active sepsis and to limit damages, delaying a definitive treatment to the time when acute phase has been controlled. The improved diagnostic techniques allow better preoperative planning and are useful in monitoring the response to treatment. Besides newer devices, cell-based treatments are promising tools which have recently enriched the treatment portfolio. However, the need for proctectomy is still disturbingly high in CD patients with complex perianal fistulae. Conclusions. Perianal CD can impair quality of life and lead to need for proctectomy. A staged approach is reasonable. Treatment success can be improved by multimodal treatment and collaborative management by experienced gastroenterologists and surgeons.
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32
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Buda A, Okolo PI. Endoscopic treatment of Crohn's complications. Expert Rev Gastroenterol Hepatol 2014; 8:887-95. [PMID: 24849124 DOI: 10.1586/17474124.2014.919850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.
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Affiliation(s)
- Andrea Buda
- Department of Surgical, Gastroenterological and Oncological Sciences, Division of Gastroenterology, University of Padova, 35100, Padova, Italy
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33
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Hendel J, Karstensen JG, Vilmann P. Serial intralesional injections of infliximab in small bowel Crohn's strictures are feasible and might lower inflammation. United European Gastroenterol J 2014; 2:406-12. [PMID: 25360319 DOI: 10.1177/2050640614547805] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/07/2014] [Accepted: 07/18/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Crohn's disease can cause strictures throughout the gastrointestinal tract. Endoscopic balloon dilatation is a well-established treatment, but recurrence is seen in up to three out of four cases. Infliximab is playing an increasingly important role in the modern systemic treatment of severe Crohn's disease. Combining the anti-inflammatory effects of infliximab with the proven effect of endoscopic balloon dilatation could possibly improve outcome. In small studies, intralesional injections in perianal fistulas have been effective and endoscopic injection therapy in colonic strictures is feasible. OBJECTIVE We wanted to assess whether serial intralesional injection of infliximab in small bowel strictures is feasible and reduces local inflammation. METHODS We included six patients with Crohn's disease and inflammatory small bowel strictures. They were treated with endoscopic serial balloon dilatation. Subsequent to each dilatation, 40 mg infliximab was injected submucosally. A modified simplified endoscopic score for Crohn's disease was used for the involved area before the initial treatment and at the final follow-up after six months. Complications and development of symptoms were registered. RESULTS Balloon dilatation and serial injection of infliximab were accomplished in five out of six patients. One patient completed the serial balloon dilatations and follow-up but received only one infliximab injection. The modified simplified endoscopic score for Crohn's disease decreased in all patients. There were no adverse events registered and all patients described themselves as feeling well. CONCLUSIONS Combining balloon dilatation of strictures with serial intralesional injection of infliximab in Crohn's disease of the small bowel is feasible and seems successful in reducing inflammation.
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Affiliation(s)
- Jakob Hendel
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
| | | | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
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Sordo-Mejia R, Gaertner WB. Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:239-51. [PMID: 25133026 PMCID: PMC4133523 DOI: 10.4291/wjgp.v5.i3.239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.
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35
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Adenocarcinoma in Crohn’s disease: the pathologist’s experience in a tertiary referral centre of inflammatory bowel disease. Pathology 2014; 46:439-43. [DOI: 10.1097/pat.0000000000000123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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36
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Improving the outcome of fistulising Crohn's disease. Best Pract Res Clin Gastroenterol 2014; 28:505-18. [PMID: 24913389 DOI: 10.1016/j.bpg.2014.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/13/2014] [Accepted: 04/13/2014] [Indexed: 01/31/2023]
Abstract
Fistulas are a frequent manifestation of Crohn's disease (CD) and can result in considerable morbidity. Approximately 35% of all patients with CD will experience one fistula episode during their disease course of which 54% is perianal. The major symptoms of patients with perianal fistulas are constant anal pain, the formation of painful swellings around the anus and continuous discharge of pus and/or blood from the external fistula opening. The exact aetiology of perianal fistulas in CD patients remains unclear, but it is thought that a penetrating ulcer in the rectal mucosa caused by active CD forms an abnormal passage between the epithelial lining of the rectum and the perianal skin. Genetic, microbiological and immunological factors seem to play important roles in this process. Although the incidence of perianal fistulas in patients with CD is quite high, an effective treatment is not yet discovered. In this review all available medical and surgical therapies are discussed and new treatment options and research targets will be highlighted.
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37
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Lopetuso LR, Petito V, Cufino V, Arena V, Stigliano E, Gerardi V, Gaetani E, Poscia A, Amato A, Cammarota G, Papa A, Sgambato A, Gasbarrini A, Scaldaferri F. Locally injected Infliximab ameliorates murine DSS colitis: differences in serum and intestinal levels of drug between healthy and colitic mice. Dig Liver Dis 2013; 45:1017-21. [PMID: 23911613 DOI: 10.1016/j.dld.2013.06.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/03/2013] [Accepted: 06/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infliximab is effective in human and murine IBD, but its pharmacodynamic is still poorly known. The aim of this study was to assess the affinity of infliximab to murine TNF-α, its role in murine colitis when administered intra-rectally and its levels in the blood, gut mucosa and stool of healthy and sick mice. METHODS An ELISA kit was built in order to assess the affinity of infliximab to human or murine-TNF-α. Human IgG were used as controls. DSS model of colitis on C57BL/6 mice was used to assess clinical efficacy of infliximab administered intravenously or by enema. Stool, serum and colon samples were collected to assess infliximab levels and histology for Rachmilewitz score. RESULTS Infliximab showed a good affinity both for human-TNF-α and murine-TNF-α. In DSS colitic mice infliximab ameliorated the severity of colitis, regardless of the administration route. In comparison with colitic mice, healthy mice displayed higher serum and mucosal infliximab levels, while detectable levels of infliximab were found in faeces, particularly in colitic mice. CONCLUSION Our data support murine models to study infliximab pharmacokinetics and dynamics. Measurable levels of infliximab can be found at different concentrations in blood, intestinal mucosa and stool from healthy and sick mice, thus infliximab pharmacokinetics could have a major impact in human IBD.
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Affiliation(s)
- Loris Riccardo Lopetuso
- Department of Internal Medicine, Gastroenterology Division, IBD Unit, Catholic University of the Sacred Heart, Rome, Italy
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38
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Imaging techniques and combined medical and surgical treatment of perianal Crohn's disease. J Ultrasound 2013; 18:19-35. [PMID: 25767636 DOI: 10.1007/s40477-013-0042-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/05/2013] [Indexed: 12/13/2022] Open
Abstract
Crohn's disease is a chronic inflammatory disease which may involve any segment of the gastrointestinal tract, most frequently the terminal ileum, the large intestine, and the perianal region. The symptoms of perianal Crohn's disease include skin disorders, hemorrhoids, anal ulcers, anorectal stenosis, perianal abscesses and fistulas, rectovaginal fistulas and carcinoma of the perianal region. The perianal manifestations of Crohn's disease cause great discomfort to the patient and are among the most difficult aspects to treat. Management of perianal disease requires a combination of different imaging modalities and a close cooperation between gastroenterologists and dedicated surgeons.
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39
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Cabriada JL, Vera I, Domènech E, Barreiro-de Acosta M, Esteve M, Gisbert JP, Panés J, Gomollón F. [Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis on the use of anti-tumor necrosis factor drugs in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:127-46. [PMID: 23433780 DOI: 10.1016/j.gastrohep.2013.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/21/2013] [Indexed: 12/13/2022]
Affiliation(s)
- José Luis Cabriada
- Servicio de Aparato Digestivo, Hospital Galdakao-Usansolo, Galdakao, Vizcaya, España.
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40
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Maggi L, Capone M, Giudici F, Santarlasci V, Querci V, Liotta F, Ficari F, Maggi E, Tonelli F, Annunziato F, Cosmi L. CD4+CD161+ T lymphocytes infiltrate Crohn's disease-associated perianal fistulas and are reduced by anti-TNF-α local therapy. Int Arch Allergy Immunol 2012; 161:81-6. [PMID: 23257766 DOI: 10.1159/000343467] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 09/12/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Crohn's disease (CD) is an idiopathic inflammatory bowel disease (IBD) in the pathogenesis of which both Th1 and Th17 lymphocytes have been described as being involved. The NK-associated molecule CD161 has recently been described as a marker of IL-17-producing lymphocytes. In this work we assessed the presence and the functional features of CD161 T helper lymphocytes infiltrating CD-associated perianal fistulas, both before and after inoculation of anti-TNF-α mAbs along the fistula. METHODS In a group of 9 CD patients with fistulizing perianal disease, we evaluated phenotypic and functional features of T cells recovered from the fistula, comparing them with peripheral blood (PB) T lymphocytes. Moreover, the effects anti-TNF-α mAbs injections along the fistula in terms of ability to reduce the inflammatory infiltrate and to determine fistula disappearance were assessed. RESULTS In CD patients with fistulizing disease there is an accumulation of CD161+ T helper lymphocytes, with higher frequencies of Th1, Th17 and Th17/Th1 cells in the fistula than in PB. Local anti-TNF-α administration is associated with fistula resolution in the majority of patients with disappearance of infiltrating T lymphocytes, without any systemic effect in circulating effector T cells. CONCLUSIONS These findings suggest that CD4+CD161+ T cells with Th17, Th17/Th1 and Th1 phenotype accumulate in CD perianal fistulas, and indicate local anti-TNF-α mAbs administration along the fistula as a promising tool for the treatment of these patients.
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Affiliation(s)
- Laura Maggi
- Center for Research, Transfer and High Education DENOTHE, University of Florence, Florence, Italy
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41
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Abstract
Perianal Crohn’s Disease (CD) is a significant cause of morbidity in CD patients. Accurate identification of perianal involvement requires advanced imaging techniques in addition to physical exam. Treatment of the disease is aimed at improving both the perianal and intestinal manifestations. Proper treatment depends upon the severity of the disease and combines current medical and surgical therapies to maximize response. The ability to improve perianal disease has grown significantly since the introduction of anti-TNF agents which are now a mainstay of treatment along with antibiotics and immunomodulators. New experimental therapies are limited by lack of research to support their use.
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Affiliation(s)
- Dawn M Wiese
- Vanderbilt University Medical Center, Nashville, TN 37232-5283, USA.
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42
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Lorenzo-Zúñiga V, García-Planella E, Moreno De Vega V, Domènech E, Boix J. [Endoscopic management of luminal stenosis in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:404-10. [PMID: 22341673 DOI: 10.1016/j.gastrohep.2011.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 11/27/2022]
Abstract
Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
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Update on anal fistulae: surgical perspectives for the gastroenterologist. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 25:675-80. [PMID: 22175058 DOI: 10.1155/2011/931316] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Anal fistulae are common and debilitating; they are characterized by severe pain and discharge. They arise following infection near the anal canal, or as a primary event from an abscess in the abdomen, fistulating into the vagina or perianal skin. The term 'cryptoglandular' is given to abscesses arising from the anal glands.For many years, the treatment of choice was to lay open the fistula; however, this risks causing incontinence with potentially devastating consequences. Alternative surgical treatments include setons, fibrin glue, collagen plugs and flaps to cover the internal fistula opening. These have achieved varying degrees of success, as will be discussed. The present review also discusses anal fistulae in light of much recently published literature. Currently, anal fistulae remain challenging and require specialist expertise; however, new treatment options are on the horizon.
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Alessandroni L, Kohn A, Cosintino R, Marrollo M, Papi C, Monterubbianesi R, Tersigni R. Local injection of infliximab in severe fistulating perianal Crohn's disease: an open uncontrolled study. Tech Coloproctol 2011; 15:407-12. [PMID: 22011835 DOI: 10.1007/s10151-011-0759-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 09/07/2011] [Indexed: 12/26/2022]
Abstract
BACKGROUND Perianal fistulas are frequent complications of Crohn's disease. Intravenous infliximab can control perianal disease and promote perianal fistula closure. Perifistular infliximab injections have been proposed for patients who are intolerant or unresponsive to intravenous therapy. The aim of this study was to assess the long-term efficacy of surgical treatment combined with local infliximab therapy. METHODS A prospective cohort study was designed. Twelve patients with Crohn's disease and high/complex transphincteric and intrasphincteric perianal fistulas refractory to other treatment were submitted to core-out fistulectomies, plus perifistular injections of infliximab (20-25 mg in 15-20 ml of 5% glucose) every 4-6 weeks. The main outcome measure was the clinical closure of all perianal fistulas. A 95% confidence interval was calculated for short- and long-term fistula closure rates. RESULTS None of the procedures were associated with local or systemic adverse effects. Four patients did not complete treatment, two because of relapse of intestinal symptoms, which required intravenous infliximab. In one case, treatment with intravenous infliximab was complicated by a hypersensitivity reaction. Eight patients continued treatment until all perianal fistulas were closed and setons were removed (median: 5 sessions). Persistent closure was observed in seven (87.5%, 95% CI: 47.4-99.6) of the eight patients 12 months after completion of treatment and in five (62.5%; 95% CI: 24.5-91.5) of eight at the end of follow-up (range: 19-43 months, median: 35 months). CONCLUSIONS The cohort we examined is small, but fistulectomy combined with repeated perifistular injections of infliximab appears to be safe and may help in fistula healing. However, in most patients, permanent closure of all fistulas is not achieved.
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Affiliation(s)
- L Alessandroni
- General and Oncologic Surgery Unit, San Camillo-Forlanini Hospitals, Cir.ne Gianicolense 86, 00152 Rome, Italy.
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Abstract
Crohn’s disease (CD) is a chronic inflammatory disease of the gastrointestinal tract characterized by recurring flares followed by periods of inactive disease and remission. The etiology is unknown, although the common opinion is that the disease arises from a disordered immune response to the gut contents in genetically predisposed individuals. Infliximab (IFX), a chimeric immunoglobulin G1 monoclonal antibody to tumor necrosis factor, has dramatically changed the approach to managing patients with CD and improving their treatment, by achieving treatment goals, such as mucosal healing, and decreasing the need for hospitalizations and surgeries. This review provides an update on existing evidence for the use of IFX in CD, taking into account the safety profile in clinical practice and special situations such as pregnancy. Antitumor necrosis factor therapy has been evaluated as an induction and maintenance therapy in CD in several randomized controlled trials and meta-analyses, showing efficacy in both clinical settings. Early use of biologics may improve patient outcomes in active CD. However, a widespread use of a “top-down” approach in all CD patients cannot be recommended. Clinical factors at diagnosis may predict poor outcome in CD, and should be taken into account when determining the initial therapeutic approach.
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Affiliation(s)
- M Cottone
- Biomedical Department of Internal and Specialist Medicine, Division of Medicine, Villa Sofia-V Cervello Hospital, Palermo University, Palermo, Italy
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Ruffolo C, Citton M, Scarpa M, Angriman I, Massani M, Caratozzolo E, Bassi N. Perianal Crohn’s disease: Is there something new? World J Gastroenterol 2011; 17:1939-46. [PMID: 21528071 PMCID: PMC3082746 DOI: 10.3748/wjg.v17.i15.1939] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/17/2011] [Accepted: 01/24/2011] [Indexed: 02/06/2023] Open
Abstract
Perianal lesions are common in patients with Crohn’s disease, and display aggressive behavior in some cases. An accurate diagnosis is necessary for the optimal management of perianal lesions. Treatment of perianal Crohn’s disease includes medical and/or surgical options. Recent discoveries in the pathogenesis of this disease have led to advances in medical and surgical therapy with good results. Perianal lesions in Crohn’s disease remain a challenging aspect for both gastroenterologists and surgeons and lead to a greatly impaired quality of life for all patients affected by this disease. A multidisciplinary approach is mandatory to obtain the best results.
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Immunopathological characteristics of cryptoglandular and Crohn's anorectal fistulas. Folia Med (Plovdiv) 2011; 52:5-12. [PMID: 21462886 DOI: 10.2478/v10153-010-011-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Anorectal fistulas are quite common proctologic disorders. They can be either of cryptoglandular origin or can be associated with Crohn's disease and chronic ileocolitis. Mechanical obstruction and local infections are prime causes of this pathological condition. Genetic predisposition and inadequate immune response with overproduction of pro-inflammatory cytokines appear prominently in the course of Crohn's disease. Interferon-gamma, a Th1 type cytokine, reflecting the engagement of cellular immune mechanisms, is the first to be produced in the intestinal mucosa. The inflammatory process in the colon mucosa induced by the abundant microbial flora is sustained and turned chronic by the gradual elevation of the local TNF-a and regulatory cytokines levels (interleukin-10, transforming growth factor-beta). The number of activated local memory T cells CD4+CD45RBl0 increases significantly. The regulatory CD4+CD25+ T lymphocytes producing interleukin-10 increase also trying to counterbalance the cytokine reaction. The chronic inflammatory infiltrates of the colon mucosa are represented by lymphocytes, plasma cells, macrophages. The long-term activation of macrophages by the released interferon-gamma leads to tissue damage and potentiation of angiogenesis--a risk factor for carcinoma development. Management of anorectal abscesses and fistulas is complex aiming to alleviate the symptoms, prevent relapses, reduce the risk of sphincter damage and improve quality of life. The main approach (surgery) should be combined with antimicrobial infection control and immunomodulation by intravenous or local administration of anti-TNF-alpha antibodies.
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Tozer PJ, Burling D, Gupta A, Phillips RKS, Hart AL. Review article: medical, surgical and radiological management of perianal Crohn's fistulas. Aliment Pharmacol Ther 2011; 33:5-22. [PMID: 21083581 DOI: 10.1111/j.1365-2036.2010.04486.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with frequent recurrence and complications. AIM To examine medical treatments previously and currently used, surgical techniques and the important role of optimal imaging. METHODS We conducted a literature search in the Pub Med database using Crohn's, Anal Fistula, Surgery, Imaging and Medical Treatment as search terms. RESULTS Antibiotics and immunosuppressants have a role, but slow initial response, side effects and relatively low remission rates of up to around a third with frequent recurrence limit their value. Long-term infliximab produces clinical remission in 36-58% of patients with combined medical and surgical management achieving optimal outcomes. Traditional and newer surgical procedures often have a high rate of recurrence with a significant risk of temporary or, in up to 10% of cases, permanent stomas, incontinence and unhealed or slowly healing wounds in 30%. CONCLUSIONS Management of Crohn's anal fistulas remains challenging. Established principles are to drain infection, use setons as required, aggressively manage active proctitis, give antibiotics, immunosuppressants and employ anti-TNFα therapy, and they demand significant co-operation between gastroenterologists and surgeons.
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Affiliation(s)
- P J Tozer
- St Mark's Hospital, Imperial College London, UK
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Poggioli G, Laureti S, Pierangeli F, Bazzi P, Coscia M, Gentilini L, Gionchetti P, Rizzello F. Local injection of adalimumab for perianal Crohn's disease: better than infliximab? Inflamm Bowel Dis 2010; 16:1631. [PMID: 20848458 DOI: 10.1002/ibd.21210] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Keshaw H, Foong KS, Forbes A, Day RM. Perianal fistulae in Crohn's Disease: current and future approaches to treatment. Inflamm Bowel Dis 2010; 16:870-80. [PMID: 19834976 DOI: 10.1002/ibd.21137] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
: affecting sphincter integrity and continence. Traditional surgical and medical approaches are not without their limitations and may result in either comorbidity, such as fecal incontinence, or incomplete healing of the fistulae. Over the last 2 decades these limitations have led to a paradigm shift toward the use of biomaterials, and more recently cell-based therapies, which have met with variable degrees of success. This review discusses the traditional and current methods of treatment, as well as emerging and possible alternative approaches that may improve fistula healing.
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Affiliation(s)
- Hussila Keshaw
- Biomaterials and Tissue Engineering Group, Centre for Gastroenterology & Nutrition, University College London, UK
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