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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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Tozer P, Borowski DW, Gupta A, Yassin N, Phillips R, Hart A. Managing perianal Crohn's fistula in the anti-TNFα era. Tech Coloproctol 2015; 19:673-8. [PMID: 26264168 DOI: 10.1007/s10151-015-1332-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 06/22/2015] [Indexed: 12/18/2022]
Abstract
Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.
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Affiliation(s)
- P Tozer
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK.
| | - D W Borowski
- University Hospital North Tees, Stockton on Tees, Cleveland, UK
| | - A Gupta
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
| | - N Yassin
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
| | - R Phillips
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
| | - A Hart
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
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Chhaya V, Pollok R. The impact of thiopurines on surgical outcomes in inflammatory bowel disease: do they make a difference? F1000PRIME REPORTS 2013; 5:50. [PMID: 24273651 PMCID: PMC3816845 DOI: 10.12703/p5-50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Ulcerative colitis and Crohn's disease together are known as inflammatory bowel disease (IBD). Surgery is considered for more severe disease and is a dreaded consequence for patients. Thiopurines have proven efficacy in the induction and maintenance of remission of IBD, but the long-term need for surgery remains uncertain with conflicting results from the available studies. The timing and duration of thiopurines also appears to play a pivotal role in the management of these conditions and may also affect the need for surgery. Data from Denmark, Canada, Hungary and the UK appear to suggest a reduction in surgery rates prior to the introduction of anti-tumor necrosis factor (TNF) therapy. The authors aim to review the more recent literature evaluating the surgery rates in IBD and changes in disease trends over time. We ask whether increasing thiopurine prescribing has had an effect on the surgery rates in the era of biologic therapy and whether more aggressive treatment approaches have altered the natural history of IBD.
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Garrick V, Stenhouse E, Haddock G, Russell RK. A multidisciplinary team model of caring for patients with perianal Crohn's disease incorporating a literature review, topical therapy and personal practice. Frontline Gastroenterol 2013; 4:152-160. [PMID: 28839719 PMCID: PMC5369793 DOI: 10.1136/flgastro-2012-100160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 10/29/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn's disease (CD) is characterised by periods of relapse and remission. Over time the disease leads almost inevitably to the complications of stricturing, penetration and fistulisation. Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation. This can be a particularly challenging and complex problem to manage, and a range of potential treatment modalities exist. METHODS This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT), including the use of wound management products and relevant clinical images. RESULTS Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery. These therapies are used individually or in combination. The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes. However, this treatment regime can be debilitating for the patient and compliance can be difficult. Published work on the use of topical therapy in the management of perianal CD focuses specifically on topical drug therapy; it does not, however, address the basic guiding principles of chronic wound management-in particular, optimal moisture control and the management of bacterial burden on the wound surface. Honey and silver-containing wound management products act as topical antimicrobial agents and therefore address these principles. CONCLUSIONS Perianal CD is the archetypal condition that exemplifies the need for an MDT approach in caring for patients with inflammatory bowel disease. A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes.
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Affiliation(s)
- Vikki Garrick
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
| | - Emily Stenhouse
- Department of Paediatric Radiology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
| | - Graham Haddock
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
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Hernández Z, Almeida P, Borrego L, Hernández J. Infiltrated perianal plaques. Perianal Crohn's disease. Int J Dermatol 2013; 52:23-4. [PMID: 23278605 DOI: 10.1111/j.1365-4632.2012.05540.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Zaida Hernández
- Department of Dermatology, Complejo Hospitalario Universitario Insular Materno Infantil, Gran Canaria, Spain.
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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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Benevento G, Avellini C, Terrosu G, Geraci M, Lodolo I, Sorrentino D. Diagnosis and assessment of Crohn's disease: the present and the future. Expert Rev Gastroenterol Hepatol 2010; 4:757-66. [PMID: 21108595 DOI: 10.1586/egh.10.70] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diagnosis of Crohn's disease (CD) is often challenging and requires the utmost precision and perseverance in defining location, extent, severity and type of disease (inflammatory vs stricturing/penetrating), as well as in excluding septic complications and extraintestinal manifestations. Endoscopy and histology remain, as of today, the best tests for initial diagnosis of CD. Increasingly important roles are played by imaging techniques (small bowel MRI, computed tomographic enterography and intestinal ultrasound) and noninvasive markers of disease such as fecal calprotectin and specific autoantibodies. Here, we will review the main tools presently available to make the initial diagnosis of intestinal and perianal CD, to evaluate the response to treatment and to diagnose disease recurrence after surgery. Finally, we will discuss some of the future diagnostic challenges in CD.
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Affiliation(s)
- Gianluca Benevento
- Department of Clinical and Experimental Pathology, University of Udine School of Medicine, 33100 Udine, Italy
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Cellini C, Safar B, Fleshman J. Surgical management of pyogenic complications of Crohn's disease. Inflamm Bowel Dis 2010; 16:512-7. [PMID: 20049952 DOI: 10.1002/ibd.20984] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with Crohn's disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohn's disease.
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Infliximab therapy in children with concurrent perianal Crohn disease: observations from REACH. J Pediatr Gastroenterol Nutr 2009; 49:183-90. [PMID: 19561542 DOI: 10.1097/mpg.0b013e3181a70f21] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Post hoc analyses evaluated the effect of infliximab upon concurrent perianal Crohn disease (CD) in a subpopulation of 31 patients from REACH, a randomized trial of 112 children with moderately to severely active luminal CD. MATERIALS AND METHODS The Pediatric Crohn Disease Activity Index perirectal subscore was used to assess perianal symptom activity and therapeutic response. Patients with no symptoms or asymptomatic tags received a score of 0; those with "1-2 indolent fistula, scant drainage, no tenderness" received a score of 5; and those with "active fistula, drainage, tenderness or abscess" received a score of 10. Initial perirectal subscores of 10 or 5 decreasing to 0 were considered complete response. Subscores of 10 decreasing to 5 were considered partial response. All patients were followed for efficacy and safety through week 54. RESULTS Twenty-two patients with baseline perianal disease were randomized at week 10 following a 3-dose infliximab induction regimen. At week 2, 40.9% (9/22) of patients with signs and symptoms of perianal disease at baseline attained response (4 partial and 5 complete). At week 54, 72.7% (16/22) of patients with signs and symptoms of perianal disease attained response (1 partial and 15 complete). Nine patients developed perianal signs and symptoms during treatment; 7 had complete response and 2 had no response at week 54. The incidence of adverse events for patients with perianal symptoms at baseline and for those in the overall REACH population was similar (95.7% vs 94.6%). CONCLUSIONS Infliximab rapidly reduced concurrent perianal disease signs and symptoms in this REACH cohort.
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Thia KT, Mahadevan U, Feagan BG, Wong C, Cockeram A, Bitton A, Bernstein CN, Sandborn WJ. Ciprofloxacin or metronidazole for the treatment of perianal fistulas in patients with Crohn's disease: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis 2009; 15:17-24. [PMID: 18668682 DOI: 10.1002/ibd.20608] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although metronidazole and ciprofloxacin are used to treat perianal Crohn's disease (CD), no placebo-controlled trials have been performed. METHODS We performed a placebo-controlled pilot trial to evaluate the efficacy and safety of metronidazole and ciprofloxacin in patients with perianal CD. Twenty-five patients with CD and actively draining perianal fistulas were randomized to receive ciprofloxacin 500 mg, metronidazole 500 mg, or placebo twice daily for 10 weeks. Remission and response of perianal fistulas were defined as closure of all fistulas and closure of at least 50% of fistulas that were draining at baseline, respectively. The primary endpoint was remission at 10 weeks. RESULTS Ten patients were randomized to ciprofloxacin, 7 to metronidazole, and 8 to placebo. Remission at week 10 occurred in 3 patients (30%) treated with ciprofloxacin, no patients (0%) treated with metronidazole, and 1 patient (12.5%) treated with placebo (P = 0.41). Response at week 10 occurred in 4 patients (40%) treated with ciprofloxacin, 1 patient (14.3%) treated with metronidazole, and 1 patient (12.5%) treated with placebo (P = 0.43). Termination of the trial prior to week 10 occurred in 1 patient (10%) treated with ciprofloxacin, 5 patients (71.4%) treated with metronidazole, and 1 patient (12.5%) treated with placebo (P < 0.02). No serious adverse events occurred. CONCLUSION Remission and response occurred more frequently in patients treated with ciprofloxacin but the differences were not significant in this pilot study. Ciprofloxacin was well tolerated.
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Affiliation(s)
- Kelvin T Thia
- Miles & Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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Guidi L, Ratto C, Semeraro S, Roberto I, De Vitis I, Papa A, Marzo M, Parello A, Foglietto G, Doglietto GB, Gasbarrini GB, Fedeli G. Combined therapy with infliximab and seton drainage for perianal fistulizing Crohn's disease with anal endosonographic monitoring: a single-centre experience. Tech Coloproctol 2008; 12:111-7. [PMID: 18545878 DOI: 10.1007/s10151-008-0411-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 04/10/2008] [Indexed: 02/07/2023]
Abstract
During infliximab treatment of perianal Crohn's disease (CD), the healing of the skin opening precedes fistula tract healing and this contributes to abscess formation and fistula recurrence. The aims of this study were to evaluate the efficacy of combined treatment with infliximab and setons for complex perianal fistulas in CD and to define the optimal time for seton removal by anal endosonography (AE). Nine consecutive patients with CD were studied. Perianal sepsis was eradicated when necessary and setons were placed before infliximab therapy. Setons were removed after AE evidence of fistulous tracts healing. Patients received a mean of 10+/-2.3 infliximab infusions. At week 6 all patients showed a reduction in mean CD activity index (p<0.005) and perianal disease activity index (p<0.0001). Complete fistula response was achieved in eight of nine patients. In six patients after a mean of 9.2 infusions, infliximab treatment was discontinued. Clinical and AE response persisted at 19.4+/-8.8 months (range 3-28 months) in five of these patients. One patient had fistula recurrence 20 weeks after infliximab discontinuation and responded rapidly to retreatment. At the time of this report, two patients were still on infliximab and in remission after a mean follow-up of 25+/-5 months. Combined therapy with infliximab and setons with AE monitoring of the response showed high efficacy in the management of patients with CD with complex perianal fistulas.
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Affiliation(s)
- L Guidi
- Dipartimento di Medicina Interna Scienze Specialistiche e Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy.
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Abstract
Patients who have inflammatory bowel disease occasionally develop severe complications or emergency situations that require expert and expedited medical care, including toxic colitis, fistulas, abdominal abscesses, malignancy, primary sclerosing cholangitis, and pouchitis. Morbidity and mortality rates of Crohn's disease and ulcerative colitis are increased over the expected rates in the unaffected population. Knowledge of the presenting features, natural history, and treatment of these complications should to lead to early and effective therapy and better outcomes.
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Affiliation(s)
- Francisco Marrero
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH 44195, USA
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