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White I, Karki C, Geransar P, Leisle L, Junker S, Fleshner P. Impact of Seton Use on Clinical, Patient-Reported, and Healthcare Resource Utilization Outcomes in Complex Crohn's Perianal Fistulas: A Systematic Literature Review. Inflamm Bowel Dis 2024:izae186. [PMID: 39298676 DOI: 10.1093/ibd/izae186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Optimal treatment strategies for seton use in patients with Crohn's perianal fistulas (CPF) remain elusive. This systematic literature review aimed to summarize clinical, patient-reported, and healthcare resource utilization (HCRU) outcomes associated with seton use for symptomatic relief and treatment of complex CPF. METHODS Electronic databases (MEDLINE, Embase, EBM Reviews, EconLit) were searched. Titles, abstracts, and relevant full texts were screened by 2 reviewers for inclusion using prespecified PICOS-T criteria. Articles published in English between January 1, 1980 and September 6, 2021 were included; animal/in vitro studies and case reports with <5 patients were excluded. Outcomes of interest included rates of complete response/remission and fistula recurrence in patients receiving seton with/without infliximab or biologics. Data were summarized using descriptive statistics. RESULTS Overall, 56 studies were included (full texts: n = 43; congress abstracts: n = 13). CPF and clinical outcome definitions were heterogeneous. Rates (range) of complete response/remission varied widely (seton: 13%-75%; seton + infliximab: 23%-100%; seton + biologics: 23%-59%) as did rates for fistula recurrence (seton: 4%-68%; seton + infliximab: 0%-50%; seton + biologics: 0%-17%). Rates of fistula-related reintervention, new fistula or abscess formation, and abscess recurrence were also varied; more consistency was observed regarding the use of patient-reported outcomes. Few studies reported outcomes from pediatric/adolescent patients or HCRU. CONCLUSIONS Optimal use of seton in patients with CPF remains unclear. International standardization of definitions for CPF and related clinical outcomes are required to permit data comparability and identify the most effective treatment strategies involving seton use in CPF.
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Affiliation(s)
- Ian White
- Department of Surgery, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chitra Karki
- Takeda Pharmaceuticals USA, Inc., Cambridge, MA, USA
| | - Parnia Geransar
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Lilia Leisle
- Ingress-Health HWM GmbH, an affiliate of Cytel, Inc., Real World & Advanced Analytics, Berlin, Germany
| | - Sophia Junker
- Ingress-Health HWM GmbH, an affiliate of Cytel, Inc., Real World & Advanced Analytics, Berlin, Germany
| | - Phillip Fleshner
- Cedars-Sinai Medical Center, Division of Colon and Rectal Surgery, Los Angeles, CA, USA
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Shehab M, De Marco D, Lakatos PL, Bessissow T. The potential for medical therapies to address fistulizing Crohn's disease: a state-of-the-art review. Expert Opin Biol Ther 2024; 24:733-746. [PMID: 39045643 DOI: 10.1080/14712598.2024.2383882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/25/2024] [Accepted: 07/20/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic, relapsing immune mediated disease, which is one of the two major types of inflammatory bowel disease (IBD). Fistulizing CD poses a significant clinical challenge for physicians. Effective management of CD requires a multidisciplinary approach, involving a gastroenterologist and a GI surgeon while tailoring treatment to each patient's unique risk factors, clinical representations, and preferences. AREAS COVERED This comprehensive review explores the intricacies of fistulizing CD including its manifestations, types, impact on quality of life, management strategies, and novel therapies under investigation. EXPERT OPINION Antibiotics are often used as first-line therapy to treat symptoms. Biologics that selectively target TNF-α, such infliximab (IFX), have shown high efficacy in randomized controlled trials. However, more than 50% of patients lose response to IFX, prompting them to explore alternative strategies. Current options include adalimumab and certolizumab pegol combination therapies, as well as small-molecule drugs targeting Janus kinases such as Upadacitinib. Furthermore, a promising treatment for complex fistulas is mesenchymal stem cells such as Darvadstrocel (Alofisel), an allogeneic stem cell-based therapy. However, surgical interventions are necessary for complex cases or intra-abdominal complications. Setons and LIFT procedures are the most common surgical options.
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Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Al-Kabeer University Hospital, Kuwait University, Kuwait City, Kuwait
| | - Davide De Marco
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
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Pal P, Reddy DN. Interventional endoscopy in inflammatory bowel disease: a comprehensive review. Gastroenterol Rep (Oxf) 2024; 12:goae075. [PMID: 39055373 PMCID: PMC11272179 DOI: 10.1093/gastro/goae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
Interventional endoscopy can play a key role in the multidisciplinary management of complex inflammatory bowel disease (IBD) as an adjunct to medical and surgical therapy. The primary role of interventional IBD (IIBD) includes the treatment of Crohn's disease-related stricture, fistula, and abscess. Endoscopic balloon dilation (EBD), endoscopic stricturotomy, and placement of endoscopic stents are different forms of endoscopic stricture therapy. EBD is the most widely used therapy whereas endoscopic stricturotomy has higher long-term efficacy than EBD. Fully covered and partially covered self-expanding metal stents are useful in long and refractory strictures whereas lumen-apposing metal stents can be used in short, and anastomotic strictures. Endoscopic fistula/abscess therapy includes endoscopic fistulotomy, seton placement, endoscopic ultrasound-guided drainage of rectal/pelvic abscess, and endoscopic injection of filling agents (fistula plug/glue/stem cell). Endoscopic seton placement and fistulotomy are mainly feasible in short, superficial, single tract fistula and in those with prior surgical seton placement. Similarly, endoscopic fistulotomy is usually feasible in short, superficial, single-tract fistula. Endoscopic closure therapies like over-the-scope clips, suturing, and self-expanding metal stent should be avoided for de novo/bowel to hollow organ fistulas. Other indications include management of postoperative complications in IBD such as management of surgical leaks and complications of pouchitis in ulcerative colitis. Additional indications include endoscopic resection of ulcerative colitis-associated neoplasia (by endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection), retrieval of retained capsule endoscope, and control of bleeding. IIBD therapies can potentially act as a bridge between medical and surgical therapy for properly selected IBD patients.
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Affiliation(s)
- Partha Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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4
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Schaad M, Schoepfer A, Rossel JB, Barry MP, Rogler G, Hahnloser D. Long-Term Outcome of Surgery for Perianal Crohn's Fistula. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1035. [PMID: 39064464 PMCID: PMC11279190 DOI: 10.3390/medicina60071035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Patients with perianal Crohn's (CD) fistula often need repetitive surgeries and none of the established techniques was shown to be superior or preferable. Furthermore, the long-term outcome of fistula Seton drainage is not well described. The aims of this study were to analyze the long-term healing and recurrence rate of CD perianal fistulas in a large patient cohort. Materials and Methods: Database analysis of the Swiss IBD (Inflammatory Bowel Disease) cohort study. Results: 365 perianal fistula patients with 576 surgical interventions and a median follow-up of 7.5 years (0-12.6) were analyzed. 39.7% of patients required more than one procedure. The first surgical interventions were fistulectomies ± mucosal sliding flap (59.2%), Seton drainage (29.6%), fistula plugs or fibrin glue installations (2.5%) and combined procedures (8.8%). Fistulectomy patients required no more surgery in 69%, one additional surgery in 25% and more than one additional surgery in 6%, with closure rates at 7.5 years follow-up of 77.1%, 74.1% and 66.7%, respectively. In patients with Seton drainage as index surgery, 52% required no more surgery, and over 75% achieved fistula closure after 10 years. Conclusions: First-line fistulectomies, when feasible, achieved the highest healing rates, but one-third of patients required additional surgeries, and one-fourth of patients will remain with a fistula at 10 years. Initial Seton drainage and concurrent medical therapy can achieve fistula closure in 75%. However, in 50% of patients, more surgeries are needed, and fistula closure is achieved in only two-thirds of patients.
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Affiliation(s)
- Marie Schaad
- Service of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Bugnon 46, 1005 Lausanne, Switzerland
| | - Alain Schoepfer
- Service of Gastroenterology, Lausanne University Hospital (CHUV), University of Lausanne, Bugnon 46, 1005 Lausanne, Switzerland
| | - Jean-Benoît Rossel
- Unisanté, University Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Mamadou Pathé Barry
- Unisanté, University Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Gerhard Rogler
- Service of Gastroenterology and Hepatology, University Hospital Zürich, University of Zürich, 8091 Zurich, Switzerland
| | - Dieter Hahnloser
- Service of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Bugnon 46, 1005 Lausanne, Switzerland
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Adamina M, Minozzi S, Warusavitarne J, Buskens C, Chaparro M, Verstockt B, Kopylov U, Agrawal M, Allocca M, Atreya R, Battat R, Bettenworth D, Bislenghi G, Brown SR, Burisch J, Casanova MJ, Czuber-Dochan W, de Groof J, El-Hussuna A, Ellul P, Fidalgo C, Fiorino G, Gisbert JP, Sabino JG, Hanzel J, Holubar S, Iacucci M, Iqbal N, Kapizioni C, Karmiris K, Kobayashi T, Kotze PG, Luglio G, Maaser C, Moran G, Noor N, Papamichael K, Peros G, Reenaers C, Sica G, Sigall-Boneh R, Vavricka SR, Yanai H, Raine T, Gordon H, Myrelid P. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2024:jjae089. [PMID: 38878002 DOI: 10.1093/ecco-jcc/jjae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Indexed: 07/28/2024]
Abstract
This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital of Fribourg & Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Visceral and Thoracic Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Christianne Buskens
- Department of Surgery, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Maria Chaparro
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid; Spain
| | - Bram Verstockt
- Department Gastroenterology & Hepatology, University Hospitals Leuven, KU Leuven and Dpt. Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Manasi Agrawal
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva; Faculty of Medicine, Tel Aviv University, Tel Aviv; Israel
| | - Mariangela Allocca
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Raja Atreya
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert Battat
- Department of Surgery, Università Tor Vergata, Roma, Italy
| | | | - Gabriele Bislenghi
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Steven Ross Brown
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Johan Burisch
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - María José Casanova
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham
- Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham. NG7 2UH. United Kingdom
| | | | - Joline de Groof
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Alaa El-Hussuna
- Health Sciences Postgraduate Program, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Pierre Ellul
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Catarina Fidalgo
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - Gionata Fiorino
- Department of Gastroenterology, Attikon University Hospital, Athens, Greece
| | - Javier P Gisbert
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - João Guedelha Sabino
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Jurij Hanzel
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana; Chair of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marietta Iacucci
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Nusrat Iqbal
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Konstantinos Karmiris
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal
| | | | | | - Gaetano Luglio
- Colorectal Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Christian Maaser
- Florence Nightingale Faculty of Nursing- Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Gordon Moran
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid. Spain
| | - Nurulamin Noor
- Gastrounit, Medical Division, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | | | - Georgios Peros
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
| | - Catherine Reenaers
- CED Schwerpunktpraxis, Münster and Medical Faculty of the University of Münster, Münster, NRW, Germany
| | - Giuseppe Sica
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Rotem Sigall-Boneh
- First Department of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan R Vavricka
- IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Gastroenterology and Endoscopy, Milan, Italy
| | - Henit Yanai
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Hannah Gordon
- Translational Gastroenterology and Liver Unit, University of Oxford, Oxford, UK
| | - Pär Myrelid
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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6
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Brochard C, Siproudhis L, Fathallah N, Zerbib P, Sabbagh C, Bouchard D, Etienney I, Cotte E. Allogenic Stem Cells in Anal Fistulas of Crohn's Disease: From Promising Premises to Real Life Experience. Inflamm Bowel Dis 2024:izae065. [PMID: 38862158 DOI: 10.1093/ibd/izae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Indexed: 06/13/2024]
Abstract
BACKGROUND Allogenic adipocyte stem cells represent an unprecedented opportunity for regenerative therapy to treat Crohn anal fistulas. Apart from the results of one 8-year-old trial, scientific evidence remains scarce. METHODS Data from consecutive patients treated with darvadstrocel for Crohn anal fistulas were reviewed at 6 first tertiary reference centers. The judgment criteria combined asymptomatic status plus clinical occlusion of the fistula tract and MRI-confirmed healing of the tract (no inflammation and/or disappearance of the tract). Both clinical and MRI-confirmed healing of the tract defined a deep remission. Clinical remission was defined by an absence of complaint, occlusion of all external openings, and no fistula discharge. RESULTS A total of 116 patients were extracted (median follow-up after cell stem injection: 11 [6-14] months). No severe adverse events were reported after surgery except for subsequent anal surgery in 29 (25%) patients. Fifty-one (44%) patients had clinical remission defined by the absence of complaints, the occlusion of all external openings, and the presence of no fistula discharge. Deep remission was observed in 23 (29%) patients. Patients with clinical remission more often received combined therapy (immunosuppressant antitumor necrosis factors) than those with no improvement (31 of 51 [61%] vs 23 of 65 [35%]; P = .007). Regression analysis showed that high fistulas (odds ratio, 3.8 [1.1-12.5]; P = .03) and younger age (<38 years, odds ratio, 2.3 [1.0-58;4]; P = .02) were associated with a better outcome. CONCLUSIONS Allogeneic stem cell treatment of Crohn's anal fistulas results in complete remission in less than half of patients, with a significant reintervention rate.
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Affiliation(s)
- Charlène Brochard
- Gastroenterology and Physiology Units, University of Rennes 1, Inphy group CIC 1414 CHU-Ponchaillou, 35000 Rennes, France
| | - Laurent Siproudhis
- Gastroenterology and Physiology Units, University of Rennes 1, Inphy group CIC 1414 CHU-Ponchaillou, 35000 Rennes, France
| | - Nadia Fathallah
- Department of Medicosurgical Proctology Groupe Hospitalier Paris Saint Joseph 185, rue Raymond Losserand, 75014, Paris, France
| | | | | | | | - Isabelle Etienney
- Proctology, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125 rue d'Avron, 75020 Paris, France
| | - Eddy Cotte
- Department of Digestive Surgery, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, France
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7
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Yamamoto-Furusho JK, López-Gómez JG, Bosques-Padilla FJ, Martínez-Vázquez MA, De-León-Rendón JL. First Mexican Consensus on Crohn's disease. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:280-311. [PMID: 38762431 DOI: 10.1016/j.rgmxen.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown. OBJECTIVE The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico. MATERIAL AND METHODS Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement. RESULTS The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established. CONCLUSIONS Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - J G López-Gómez
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Centro Médico Nacional 20 de Noviembre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - F J Bosques-Padilla
- Departamento de Gastroenterología, Hospital Universitario de la Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - J L De-León-Rendón
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Coloproctología, Hospital General de México, Mexico City, Mexico
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8
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Sohrabi M, Bahrami S, Mosalli M, Khaleghian M, Obaidinia M. Perianal Fistula; from Etiology to Treatment - A Review. Middle East J Dig Dis 2024; 16:76-85. [PMID: 39131109 PMCID: PMC11316198 DOI: 10.34172/mejdd.2024.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/18/2024] [Indexed: 08/13/2024] Open
Abstract
Anal fistula has been a challenging clinical issue for years due to its complex pathogenesis. The risk of frequent recurrence and incontinence complicates long-term treatment. Recent scientific literature has reviewed new techniques used for anal fistula treatment in recent years, assessing the advantages and disadvantages of each based on clinical outcomes. Although surgery is the main method used to treat anal fistula, there is no simple technique that can completely heal complex anal fistula. The surgical treatment should consider the healing outcome and the protection of anal function comprehensively. Several innovative techniques have emerged in recent years, such as combined techniques based on drainage seton and LIFT-plug, which appear to be relatively effective therapies. However, more multi-center prospective trials with long-term follow-up are needed to validate their effectiveness. In some situations, medical treatment may also be considered.
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Affiliation(s)
- Masoudreza Sohrabi
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Somayeh Bahrami
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mozhdeh Mosalli
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Khaleghian
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of General Surgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mobin Obaidinia
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
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9
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Fathallah N, Akaffou M, Haouari MA, Spindler L, Alam A, Barré A, Pommaret E, Fels A, de Parades V. Deep remission improves the quality of life of patients with Crohn's disease and anoperineal fistula treated with darvadstrocel: results of a French pilot study. Tech Coloproctol 2023; 27:1201-1210. [PMID: 36811811 DOI: 10.1007/s10151-023-02765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The injection of allogeneic adipose tissue-derived mesenchymal stem cells (MSC) into anal fistulas in patients with Crohn's disease has never been evaluated in "real-life" conditions in France. METHODS We prospectively studied the first patients receiving MSC injections at our center and undergoing 12 months of follow-up. The primary endpoint was the clinical and radiological response rate. The secondary endpoints were symptomatic efficacy, safety, anal continence, quality of life (Crohn's anal fistula-quality of life scale, CAF-QoL), and predictive factors of success. RESULTS We included 27 consecutive patients. The complete clinical and radiological response rates at M12 were 51.9% and 50%, respectively. The combined complete clinical-radiological response (deep remission) rate was 34.6%. No major adverse effects or changes in anal continence were reported. The perianal disease activity index decreased from 6.4 to 1.6 (p < 0.001) for all patients. The CAF-QoL score also decreased from 54.0 to 25.5 (p < 0.001). At the end of the study, M12, the CAF-QoL score was significantly lower only in patients with a complete combined clinical-radiological response relative to those without a complete clinical-radiological response (15.0 versus 32.8, p = 0.01). Having a multibranching fistula and infliximab treatment were associated with a combined complete clinical-radiological response. CONCLUSIONS This study confirms reported efficacy data for the injection of MSC for complex anal fistulas in Crohn's disease. It also shows a positive impact on the quality of life of patients, particularly those for whom a combined clinical-radiological response was achieved.
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Affiliation(s)
- N Fathallah
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France.
| | - M Akaffou
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - M A Haouari
- Radiology Department, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - L Spindler
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A Alam
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A Barré
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - E Pommaret
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A Fels
- Clinical Research Centre, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - V de Parades
- Department of MedicoSurgical Proctology, Institut Léopold Bellan, Groupe Hospitalier Paris Saint-Joseph, Paris, France
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10
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Anandabaskaran S, Hanna L, Iqbal N, Constable L, Tozer P, Hart A. Where Are We and Where to Next?-The Future of Perianal Crohn's Disease Management. J Clin Med 2023; 12:6379. [PMID: 37835022 PMCID: PMC10573672 DOI: 10.3390/jcm12196379] [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: 08/26/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Perianal fistulizing Crohn's Disease (pCD) affects about 25% of patients with Crohn's Disease (CD). It remains a difficult entity to manage with a therapeutic ceiling of treatment success despite improving medical and surgical management. The refractory nature of the disease calls for an imminent need to better understand its immunopathogenesis and classification to better streamline our treatment options. In this article, we overview the current state of pCD management and discuss where the future of its management may lie.
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Affiliation(s)
- Sulak Anandabaskaran
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Hammersmith Campus, Imperial College London, London W12 0NN, UK
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Faculty of Medicine, St Vincent’s Clinical School, University of New South Wales, 390 Victoria Street, Darlinghurst, NSW 2010, Australia
| | - Luke Hanna
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Hammersmith Campus, Imperial College London, London W12 0NN, UK
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
| | - Nusrat Iqbal
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Department of Surgery and Cancer, South Kensington Campus, Imperial College London, London SW7 2BX, UK
| | - Laura Constable
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Hammersmith Campus, Imperial College London, London W12 0NN, UK
| | - Phil Tozer
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Department of Surgery and Cancer, South Kensington Campus, Imperial College London, London SW7 2BX, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Department of Surgery and Cancer, South Kensington Campus, Imperial College London, London SW7 2BX, UK
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11
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Rosevics L, Savio MC, Lima Júnior E, Ramos Júnior O. FISTULIZING PERIANAL CROHN'S DISEASE: IS THE PATIENT'S SEX A BURDEN? A SYSTEMATIC REVIEW. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:490-524. [PMID: 38018554 DOI: 10.1590/s0004-2803.230402023-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/31/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Fistulizing perianal Crohn's disease poses a treatment challenge, and researchers postulate that this phenotype in young male patients could have a worst outcome. OBJECTIVE Thus, the aim of this study was to assess whether sex influences the response to treatment for these patients. METHODS This systematic review (PROSPERO CRD42022319629) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. We selected articles published in English, Spanish, Portuguese, and Italian between 2010 and 2020 in the PubMed and Science Direct databases. According to the PICO acronym, prospective studies in patients older than 18 years with the objective of treating fistulizing perianal Crohn's disease were selected. Studies in pediatric populations, retrospective, without treatment objectives, and that included only rectovaginal fistulas or a single sex were excluded. Study quality was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale. RESULTS Of the 1887 articles found, 33 were included. Most studies used anti-TNF drugs as treatment (n=11). Ten studies had subgroup analyses; of them, the two studies reporting sex differences used infliximab and adalimumab as treatment and showed that women had a longer fistula closure time than men. CONCLUSION This systematic review showed that few data corroborate the difference between sexes in the treatment of fistulizing perianal Crohn's disease, possibly having a greater relationship with the phenotype. However, considering the lack of results, further studies with this objective and with standardization of fistulas and response assessment methods are needed.
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12
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Bhat S, Xu W, Varghese C, Dubey N, Wells CI, Harmston C, O'Grady G, Bissett IP, Lin AY. Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis. Tech Coloproctol 2023; 27:827-845. [PMID: 37460830 PMCID: PMC10485107 DOI: 10.1007/s10151-023-02845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. METHODS Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. RESULTS Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients). CONCLUSIONS There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.
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Affiliation(s)
- S Bhat
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - W Xu
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - C Varghese
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - N Dubey
- Department of General Medicine, Tauranga Hospital, Te Whatu Ora, Tauranga, New Zealand
| | - C I Wells
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - C Harmston
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - G O'Grady
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - I P Bissett
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - A Y Lin
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.
- Department of Surgery, Wellington Regional Hospital, Te Whatu Ora, Wellington, New Zealand.
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13
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Chahal JK, Sriranganathan D, Poo S, Lo SW, Kashkooli S, Garg M, Segal JP. Network meta-analysis: efficacy and safety of treatments for fistulising Crohn's disease. Eur J Gastroenterol Hepatol 2023; 35:702-710. [PMID: 37115969 DOI: 10.1097/meg.0000000000002552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION Fistulas are a debilitating complication of Crohn's disease and treatment options remain limited. There is a lack of head-to-head comparisons between treatments. To our knowledge, this is the first network meta-analysis on the efficacy of medical therapies in achieving fistula remission and maintenance of fistula closure in Crohn's disease. METHODS Biomedical databases and the Cochrane Central Registry were searched between 1978 and 2022 for randomized controlled trials (RCTs) reporting on treatments. A network meta-analysis was performed using the frequentist model with pooled relative risks (RRs) and P -scores used to rank treatments. RESULTS Twenty-five RCTs were included for analysis with 2239 patients included. At the 16-24 week time point, infliximab produced the only statistically significant result with the 5 mg/kg dose proving the most effective [RR, 2.30; 95% confidence interval (CI), 1.40-3.77]. At 44 weeks, ustekinumab was found to be most superior with it being 2.38 times (RR, 2.38; 95% CI, 1.24-4.56) more superior to placebo, with adalimumab (RR, 2.06; 95% CI, 1.06-3.99) and infliximab 5 mg/kg (RR, 1.68; 95% CI, 1.03-2.75) also producing a statistically significant result. CONCLUSION Despite infliximab being favoured in international guidelines for the treatment of perianal fistulising Crohn's disease, biologics such as ustekinumab, vedolizumab and adalimumab show promising results.
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Affiliation(s)
- Jacinder K Chahal
- Department of Surgery, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust
| | - Danujan Sriranganathan
- Department of Gastroenterology, Whipps Cross University Hospital, Barts Health NHS Trust, London
| | - Stephanie Poo
- Department of Gastroenterology, The Hillingdon Hospitals NHS Foundation Trust, Middlesex, UK
| | - Sheng Wei Lo
- Department of Gastroenterology, Northern Hospital, Epping
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
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14
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Berinstein JA, Aintabi D, Higgins PD. In-hospital management of inflammatory bowel disease. Curr Opin Gastroenterol 2023; 39:274-286. [PMID: 37265192 PMCID: PMC11227907 DOI: 10.1097/mog.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW The management of hospitalized patients with inflammatory bowel disease (IBD) is complex. Despite considerable therapeutic advancements in outpatient ulcerative colitis and Crohn's disease management, the in-hospital management continues to lag with suboptimal outcomes. The purpose of this review is to provide a brief overview of our approach to managing patients hospitalized with acute severe ulcerative colitis (ASUC) and Crohn's disease-related complications, followed by a summary of emerging evidence for new management approaches. RECENT FINDINGS ASUC has seen the emergence of well validated prognostic models for colectomy as well as the development of novel treatment strategies such as accelerated infliximab dosing, Janus kinase inhibitor therapy, and sequential therapy, yet the rate of colectomy for steroid-refractory ASUC has not meaningfully improved. Crohn's disease has seen the development of better diagnostic tools, early Crohn's disease-related complication stratification and identification, as well as better surgical techniques, yet the rates of hospitalization and development of Crohn's disease-related complications remain high. SUMMARY Significant progress has been made in the in-hospital IBD management; however, both the management of ASUC and hospitalized Crohn's disease remain a challenge with suboptimal outcomes. Critical knowledge gaps still exist, and dedicated studies in hospitalized patients with IBD are needed to address them.
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Affiliation(s)
- Jeffrey A. Berinstein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Daniel Aintabi
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Peter D.R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
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15
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Aho Fält U, Zawadzki A, Starck M, Bohe M, Regnér S, Johnson LB. Postoperative three-dimensional endoanal ultrasound findings and relation to anal fistula plug failure. Scand J Gastroenterol 2023; 58:1200-1206. [PMID: 37203207 DOI: 10.1080/00365521.2023.2212310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/05/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES To explore the utilization of three-dimensional (3D) endoanal ultrasound (EAUS) for the follow-up of the anal fistula plug (AFP), describe morphological findings in postoperative 3D EAUS, and evaluate if postoperative 3D EAUS combined with clinical symptoms can predict AFP failure. MATERIALS AND METHODS A retrospective analysis of 3D EAUS examinations performed during a single-centre study of prospectively included consecutive patients treated with the AFP between May 2006 and October 2009. Postoperative assessment by clinical examination and 3D EAUS was performed at 2 weeks, 3 months and 6-12 months ("late control"). Long-term follow-up was carried out in 2017. The 3D EAUS examinations were blinded and analysed by two observers using a protocol with defined relevant findings for different follow-up time points. RESULTS A total of 95 patients with a total of 151 AFP procedures were included. Long-term follow-up was completed in 90 (95%) patients. Inflammation at 3 months, gas in fistula and visible fistula at 3 months and at late control, were statistically significant 3D EAUS findings for AFP failure. The combination of gas in fistula and clinical finding of fluid discharge through the external fistula opening 3 months postoperatively was statistically significant (p < 0.001) for AFP failure with 91% sensitivity and 79% specificity. The positive predictive value was 91%, while the negative predictive value was 79%. CONCLUSIONS 3D EAUS may be utilized for the follow-up of AFP treatment. Postoperative 3D EAUS at 3 months or later, especially if combined with clinical symptoms, can be used to predict long-term AFP failure.ClinicalTrials.gov identifier NCT03961984.
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Affiliation(s)
- Ursula Aho Fält
- Department of Surgery, Skåne University Hospital - Malmö, Lund University, Sweden
| | - Antoni Zawadzki
- Department of Surgery, Skåne University Hospital - Malmö, Lund University, Sweden
| | - Marianne Starck
- Department of Surgery, Skåne University Hospital - Malmö, Lund University, Sweden
| | - Måns Bohe
- Department of Surgery, Skåne University Hospital - Malmö, Lund University, Sweden
| | - Sara Regnér
- Department of Surgery, Skåne University Hospital - Malmö, Lund University, Sweden
| | - Louis B Johnson
- Department of Surgery, Skåne University Hospital - Malmö, Lund University, Sweden
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16
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Scheurlen KM, MacLeod A, Kavalukas SL, Galandiuk S. State-of-the-art surgery for Crohn's disease: part III-perianal Crohn's disease. Langenbecks Arch Surg 2023; 408:132. [PMID: 36995518 DOI: 10.1007/s00423-023-02856-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/04/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE Diagnosis and treatment of perianal Crohn's disease is challenging and requires its own domain of therapy. Different types of perianal disease require a spectrum of treatment strategies. Treatment options range from conservative therapy, including immunosuppressives, biologics, or stem cell therapy, to surgical treatment with specific indications depending on the underlying lesion. This is part III of the series "state-of-the-art surgery for Crohn's disease," focusing on the management of perianal disease. We discuss the definition and diagnosis of perianal Crohn's disease, the treatment of perianal lesions, and specific surgical indications and techniques. RESULTS AND CONCLUSION Pitfalls and complications play a substantial role in the treatment of perianal Crohn's disease, and surgical therapy may fail. Realistic treatment goals and an individual patient-oriented treatment approach are crucial in the treatment of perianal Crohn's disease.
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Affiliation(s)
- Katharina M Scheurlen
- Price Institute of Surgical Research, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, KY, 40202, USA
| | - Anne MacLeod
- Price Institute of Surgical Research, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, KY, 40202, USA
| | - Sandra L Kavalukas
- Price Institute of Surgical Research, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, KY, 40202, USA
- Division of Colon & Rectal Surgery, Hiram C Polk Jr MD Department of Surgery, University of Louisville, Louisville, KY, 40202, USA
| | - Susan Galandiuk
- Price Institute of Surgical Research, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, KY, 40202, USA.
- Division of Colon & Rectal Surgery, Hiram C Polk Jr MD Department of Surgery, University of Louisville, Louisville, KY, 40202, USA.
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17
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Systematic Review of Endoscopic Management of Stricture, Fistula and Abscess in Inflammatory Bowel Disease. GASTROENTEROLOGY INSIGHTS 2023. [DOI: 10.3390/gastroent14010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background: Interventional inflammatory bowel disease (IIBD) therapies can play a key role in inflammatory bowel disease (IBD) related stricture/fistula/abscess deferring or avoiding invasive surgery. Methods: A total of 112 studies pertaining to IIBD therapy for strictures/fistula/abscess between 2002 and December 2022 were included by searching Pubmed, Medline and Embase with a focus on technical/clinical success, recurrence, re-intervention and complications. Results: IIBD therapy for strictures include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES) and self-expanding metal stent (SEMS) placement. EBD is the primary therapy for short strictures while ES and SEMS can be used for refractory strictures. ES has higher long-term efficacy than EBD. SEMS is inferior to EBD although it can be useful in long, refractory strictures. Fistula therapy includes endoscopic incision and drainage (perianal fistula)/endoscopic seton (simple, low fistula) and endoscopic ultrasound-guided drainage (pelvic abscess). Fistulotomy can be done for short, superficial, single tract, bowel-bowel fistula. Endoscopic injection of filling agents (fistula plug/glue/stem cell) is feasible although durability is unknown. Endoscopic closure therapies like over-the-scope clips (OTSC), suturing and SEMS should be avoided for de-novo/bowel to hollow organ fistulas. Conclusion: IIBD therapies have the potential to act as a bridge between medical and surgical therapy for properly selected IBD-related stricture/fistula/abscess although future controlled studies are warranted.
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18
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García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence. BMC Surg 2023; 23:29. [PMID: 36740680 PMCID: PMC9901165 DOI: 10.1186/s12893-023-01912-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula. METHODS PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network. RESULTS Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips. CONCLUSION New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.
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Affiliation(s)
- D. García-Olmo
- grid.419651.e0000 0000 9538 1950New Therapies Laboratory, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD/UAM), Department of Surgery, Fundación Jiménez Díaz University Hospital (UAM), Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - M. Gómez-Barrera
- grid.512746.3Pharmacoeconomics & Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo, 4 i, 28224 Pozuelo de Alarcón, Madrid Spain
| | - F. de la Portilla
- grid.9224.d0000 0001 2168 1229Coloproctology Unit, Clinical Management Unit of General and Gastrointestinal Surgery, Division Seville, Biomedical Research Institute (IBIS), University Hospital Virgen del Rocio/CSIC University of Seville, Seville, Spain
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Lan N, Shen B. Endoscopic Therapy for Fistulas and Abscesses in Crohn's Disease. Gastrointest Endosc Clin N Am 2022; 32:733-746. [PMID: 36202513 DOI: 10.1016/j.giec.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Crohn disease (CD) patients can develop fistula or abscess from persistent active disease or postsurgical complications. Penetrating CD is traditionally treated with medication and surgery. The role of medication alone in the treatment of fistula is limited, except perianal fistulas or enterocutaneous fistula. Surgery is the standard treatment in those with hollow-organ to hollow-organ fistula, like ileovesicular fistula. Surgery is invasive with a higher risk of postoperative complications. Endoscopic therapy has evolved as a valid option. Fistulotomy, surgical or endoscopic, should be considered first-line therapy when feasible. Incision and drainage of perianal abscesses with an endoscopic device may be attempted.
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Affiliation(s)
- Nan Lan
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, 161 Fort Washington Avenue, HIP Floor 8-843, New York, NY 10032, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, 161 Fort Washington Avenue, HIP Floor 8-843, New York, NY 10032, USA.
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20
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Badla O, Goit R, Saddik SE, Dawood S, Rabih AM, Mohammed A, Raman A, Uprety M, Calero M, Villanueva MRB, Joshaghani N, Villa N, Mohammed L. The Multidisciplinary Management of Perianal Fistulas in Crohn’s Disease: A Systematic Review. Cureus 2022; 14:e29347. [PMID: 36284816 PMCID: PMC9582904 DOI: 10.7759/cureus.29347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/19/2022] [Indexed: 11/05/2022] Open
Abstract
Perianal fistulas in Crohn's disease (CD) are often recurring and challenging to treat. This systematic review aimed to evaluate the medical, surgical, and combination treatment options and provide an overview of their efficacy. We performed this systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Our group searched PubMed, Medline, PubMed Central, Google Scholar, and ScienceDirect for articles within the last ten years using different terms and criteria mentioned in detail in the search strategy and eligibility criteria sections. Initially, 739 records were retrieved, out of which we excluded 731 records for various reasons, such as irrelevant titles and abstracts and low scores on quality assessment tools. The evidence for combination (surgical and medical) therapy is superior to that for medical and surgical treatments individually. In contrast, the studies on medical and surgical treatments individually reported varied evidence and efficacy for their respective options.
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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22
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Queiroz NSF, Garcia KS, Miranda EF, Kotze PG. Patient-Reported Outcomes Measures in Perianal Fistulizing Crohn's Disease. Rev Recent Clin Trials 2022; 17:RRCT-EPUB-122860. [PMID: 35469573 DOI: 10.2174/1574887117666220425125424] [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: 09/04/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
Perianal fistulizing Crohn's disease (PFCD) is a disabling complication of Crohn's disease (CD) that can significantly impact on patients' quality of life (QoL) and often requires multidisciplinary care. Clinical trials assessing the efficacy of medical and surgical interventions for fistulas usually evaluate outcomes such as closure of fistula tracts or radiologic healing. However, these traditional outcome assessments fail in capturing the impact of the disease from patients' perspectives. In this context, regulatory authorities have increasingly encouraged the inclusion of validated patient-reported outcomes (PRO) that assess disease activity and reveal how a patient functions and feels. This recent trend towards patient-centered care aims to ensure that improvements in efficacy outcomes are accompanied by meaningful benefits to patients. The aim of this review is to discuss currently available PRO measures (PROMS) for the assessment of PFCD to provide to physicians appropriate tools aiming to optimize patient care and disseminate the use of these instruments in clinical practice.
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Affiliation(s)
| | - Karoline Soares Garcia
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Eron Fabio Miranda
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
- Health Sciences Postgraduate Program, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
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Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
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Huang H, Ji L, Gu Y, Li Y, Xu S. Efficacy and Safety of Sphincter-Preserving Surgery in the Treatment of Complex Anal Fistula: A Network Meta-Analysis. Front Surg 2022; 9:825166. [PMID: 35211503 PMCID: PMC8861434 DOI: 10.3389/fsurg.2022.825166] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background There are many surgical methods of sphincter preservation in treating complex anal fistula, but the therapeutic effects of each operation are different. Therefore, this study aimed to compare the impact of other treatment methods through a network meta-analysis to evaluate the best sphincter preservation method for treating complex anal fistula. Methods We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Journal Database, and the Wanfang Database to collate randomized controlled trials on sphincter-preserving surgery for complex anal fistula. Results A total of 29 articles were included in this meta-analysis. The cure rates showed no statistically significant differences between any two interventions (P > 0.05). The recurrence rate results showed that the rate of patients after Fistulectomy was higher than others (P < 0.05). The incidence rate of complications showed that the incidence rate after fistulectomy treatment was higher than that of others (P < 0.05). The surface under the cumulative ranking (SUCRA) was used to arrange their advantages and disadvantages, and a larger SUCRA value indicates that the intervention may be more effective. The results showed that TROPIS may have the highest cure rate (SUCRA = 78.6%), stem cell transplantation (SCT) may have the lowest recurrence rate (SUCRA = 85.5%), and imLIFT may have the least complications (SUCRA = 88.2%). Conclusion According to the existing literature data, for patients with complex anal fistula, TROPIS may be the surgical method with the highest cure rate, SCT may be the treatment method with the lowest recurrence rate, and imLIFT may be the surgical method with the lowest incidence of postoperative complications. Systematic Review Registration PROSPERO, identifier: CRD42020221907.
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Affiliation(s)
- Hua Huang
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Lijiang Ji
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
- *Correspondence: Lijiang Ji
| | - Yunfei Gu
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Youran Li
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Shanshan Xu
- Nanjing University of Chinese Medicine, Nanjing, China
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Abramowitz L, Brochard C, Pigot F, Roumeguere P, Pillant H, Vinson Bonnet B, Faucheron JL, Senéjoux A, Bonnaud G, Meurette G, Fayette JM, Train C, Staumont G, Siproudhis L, Bouchard D. Surgical closure, mainly with glue injection and anti-tumour necrosis factor α, in fistulizing perianal Crohn's disease: A multicentre randomized controlled trial. Colorectal Dis 2022; 24:210-219. [PMID: 34623746 DOI: 10.1111/codi.15947] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022]
Abstract
AIM In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab. METHODS This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities. RESULTS Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000). CONCLUSIONS Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution.
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Affiliation(s)
- Laurent Abramowitz
- Service d'Hépato-gastroentérologie et Proctologie, Hôpital Bichat-Claude Bernard, Paris, France.,Ramsay Général de Santé, Clinique Blomet, Paris, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - François Pigot
- Service de Proctologie, Hôpital Bagatelle, Maison de Santé Protestante Bagatelle, Talence, France
| | | | - Hélène Pillant
- Service de Proctologie, Groupe Hospitalier Paris Saint Joseph, Institut Léopold-Bellan, Paris, France
| | - Béatrice Vinson Bonnet
- Service de Chirurgie Viscérale et Digestive, CHI, Poissy-St-Germain-en-Laye, Paris, France
| | - Jean Luc Faucheron
- Unité de Chirurgie Colo-rectale, Service de Chirurgie Digestive et de l'Urgence, Hôpital Michallon, CHUGA, Grenoble, France
| | | | | | - Guillaume Meurette
- Clinique de Chirurgie Digestive et Endocrinienne (CCDE), Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France
| | | | | | | | - Laurent Siproudhis
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Dominique Bouchard
- Service de Proctologie, Hôpital Bagatelle, Maison de Santé Protestante Bagatelle, Talence, France
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Geldof J, Iqbal N, Warusavitarne J, Hart A. The Essential Role of a Multidisciplinary Approach in Inflammatory Bowel Diseases: Combined Medical-Surgical Treatment in Complex Perianal Fistulas in CD. Clin Colon Rectal Surg 2022; 35:21-31. [PMID: 35069027 PMCID: PMC8763455 DOI: 10.1055/s-0041-1740035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Perianal fistulizing Crohn's disease (PFCD) represents a challenging and complex disease phenotype. Patients typically suffer a more severe disease course than those without perianal complications and are often managing debilitating symptoms. Etiology is understood to be multifactorial, with genetic predisposition, microbiological insult, aberrant immunity, and mechanical factors all implicated. As a result, multimodal treatment strategies must be employed to achieve disease control and fistula closure. This requires the complimentary involvement of medical and surgical disciplines in order to ensure thorough assessment and treatment tailored to the individual scenario and patient goals. The aim of this article is to describe an overview of the various treatment strategies available for PFCD, focusing on how a synergistic approach is required to ensure maximal chances of success.
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Affiliation(s)
- Jeroen Geldof
- IBD Unit, St. Mark's Hospital, Harrow, United Kingdom,Gastroenterology Department, University Hospital Ghent, Ghent, Belgium,Address for correspondence Jeroen Geldof, MD IBD Unit, St. Mark's HospitalWatford Road, Harrow HA1 3UJUnited Kingdom
| | - Nusrat Iqbal
- Robin Phillips Fistula Research Unit, St. Mark's Hospital, Harrow, United Kingdom
| | | | - Ailsa Hart
- IBD Unit, St. Mark's Hospital, Harrow, United Kingdom,Robin Phillips Fistula Research Unit, St. Mark's Hospital, Harrow, United Kingdom
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Yzet C, Brazier F, Sabbagh C, Fumery M. Managing complex perianal disease after anti-TNF failure: Where to go next? CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100081. [PMID: 35106477 PMCID: PMC8784625 DOI: 10.1016/j.crphar.2022.100081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 12/05/2022] Open
Abstract
Crohn's disease is a chronic inflammatory bowel disease that affects various intestinal segments and can involve the perianal region. Although anti-tumor necrosis factor (TNF) agents have revolutionized the management of Crohn's disease and improved the prognosis for patients with perianal Crohn's disease (pCD), their long-term effectiveness is limited: over 60% of patients relapse after one year of maintenance therapy. In recent years, significant advances have been made in the treatment of complex perianal fistulas after anti-TNF failure. Concomitant treatment with antibiotics and immunosuppressants improves the effectiveness of anti-TNF agents. Therapeutic drug monitoring and dose adjustment of anti-TNF therapy (targeting a higher trough level) might also improve treatment response. Novel therapeutic strategies might provide new opportunities for pCD management; for example, ustekinumab might be effective after anti-TNF treatment failure, although more studies are needed. As suggested in recent international guidelines, mesenchymal stem cell injection might be an effective, safe treatment for complex pCD.
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Affiliation(s)
- Clare Yzet
- Gastroenterology Unit, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France
| | - Franck Brazier
- Gastroenterology Unit, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France
| | - Charles Sabbagh
- Digestive Surgery Unit, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France
| | - Mathurin Fumery
- Gastroenterology Unit, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France
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An Affordable Approach of Mesenchymal Stem Cell Therapy in Treating Perianal Fistula Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1401:73-95. [DOI: 10.1007/5584_2022_716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Flap-Techniken – heute noch „State of the Art“? COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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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Merten J, Eichelmann AK, Mennigen R, Flammang I, Pascher A, Rijcken E. Minor Sphincter Sparing Surgery for Successful Closure of Perianal Fistulas in Patients with Crohn's Disease. J Clin Med 2021; 10:jcm10204721. [PMID: 34682844 PMCID: PMC8540669 DOI: 10.3390/jcm10204721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study is to demonstrate that repetitive minor surgical procedures allow for a high rate of permanent closure of perianal fistulas in patients with Crohn’s disease (CD). Patients with perianal fistulizing CD (PFCD) who underwent perianal surgery at the University Hospital of Muenster between 2003 and 2018 were assessed for fistula characteristics and surgical procedures. We included 45 patients (m:f = 28:17) with a mean age of 27 years at first fistula appearance. Of these, 49% suffered from a complex fistula. An average of 4.2 (1–14) procedures were performed, abscess incisions and fistula seton drainages included. Draining setons were left in place for 5 (1–54) months, until fistula closure. Final surgical techniques were fistulotomy (31.1%), seton removal with sustained biological therapy (26.7%), Anal Fistula Plug (AFP) (17.8%), Over-The Scope-Clip proctology (OTSC) (11.1%), and mucosa advancement flap (4.4%). In 8.9% of cases, the seton was kept as permanent therapy. The time from first to last surgery was 18 (0–182) months and the median follow-up time after the last surgery was 90 (15–200) months. The recurrence rate was 15.5% after 45 (17–111) months. Recurrent fistulas healed after another 1.86 (1–2) surgical re-interventions. The final success rate was 80%. Despite biological treatment, PFCD management remains challenging. However, by repeating minor surgical interventions over a prolonged period of time, high permanent healing rates can be achieved.
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Affiliation(s)
- Jennifer Merten
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (A.-K.E.); (I.F.); (A.P.)
- Correspondence: (J.M.); (E.R.)
| | - Ann-Kathrin Eichelmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (A.-K.E.); (I.F.); (A.P.)
| | - Rudolf Mennigen
- MVZ Portal 10, Albersloher Weg 10, 48155 Muenster, Germany; (R.M.)
| | - Isabelle Flammang
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (A.-K.E.); (I.F.); (A.P.)
| | - Andreas Pascher
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (A.-K.E.); (I.F.); (A.P.)
| | - Emile Rijcken
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (A.-K.E.); (I.F.); (A.P.)
- Correspondence: (J.M.); (E.R.)
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Buscail E, Le Cosquer G, Gross F, Lebrin M, Bugarel L, Deraison C, Vergnolle N, Bournet B, Gilletta C, Buscail L. Adipose-Derived Stem Cells in the Treatment of Perianal Fistulas in Crohn's Disease: Rationale, Clinical Results and Perspectives. Int J Mol Sci 2021; 22:ijms22189967. [PMID: 34576129 PMCID: PMC8470328 DOI: 10.3390/ijms22189967] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/07/2021] [Accepted: 09/12/2021] [Indexed: 12/16/2022] Open
Abstract
Between 20 to 25% of Crohn’s disease (CD) patients suffer from perianal fistulas, a marker of disease severity. Seton drainage combined with anti-TNFα can result in closure of the fistula in 70 to 75% of patients. For the remaining 25% of patients there is room for in situ injection of autologous or allogenic mesenchymal stem cells such as adipose-derived stem/stromal cells (ADSCs). ADSCs exert their effects on tissues and effector cells through paracrine phenomena, including the secretome and extracellular vesicles. They display anti-inflammatory, anti-apoptotic, pro-angiogenic, proliferative, and immunomodulatory properties, and a homing within the damaged tissue. They also have immuno-evasive properties allowing a clinical allogeneic approach. Numerous clinical trials have been conducted that demonstrate a complete cure rate of anoperineal fistulas in CD ranging from 46 to 90% of cases after in situ injection of autologous or allogenic ADSCs. A pivotal phase III-controlled trial using allogenic ADSCs (Alofisel®) demonstrated that prolonged clinical and radiological remission can be obtained in nearly 60% of cases with a good safety profile. Future studies should be conducted for a better knowledge of the local effect of ADSCs as well as for a standardization in terms of the number of injections and associated procedures.
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Affiliation(s)
- Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France;
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Fabian Gross
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Marine Lebrin
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Laetitia Bugarel
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Céline Deraison
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Nathalie Vergnolle
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
- Correspondence: ; Tel.: +33-561323055
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Caron B, D'Amico F, Danese S, Peyrin-Biroulet L. Endpoints for Perianal Crohn's Disease Trials: Past, Present and Future. J Crohns Colitis 2021; 15:1387-1398. [PMID: 33550374 DOI: 10.1093/ecco-jcc/jjab026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Since the 1980s, many studies have evaluated the efficacy of therapies to improve the outcomes of patients with perianal Crohn's disease. We performed a systematic review to describe the evolution of endpoints in perianal fistulizing Crohn's disease. Efficacy outcomes, definitions and measurement tools were assessed. METHODS Electronic databases were searched up to November 1, 2020. All published randomized placebo-controlled trials enrolling patients with perianal fistula and Crohn's disease were eligible for inclusion. Ongoing randomized clinical trials were also described. RESULTS Nineteen randomized controlled trials were included. Clinical efficacy endpoints were reported in all trials. Clinical response was the most frequent primary endpoint [6/19 studies, 31.6%], followed by clinical remission in four studies [21%]. Clinical response was defined as closure of at least 50% of fistulas, while remission was defined as closure of all fistulas. A combined clinical and radiological primary endpoint was used to assess fistula healing in four studies [21%]. The Perianal Disease Activity Index was a primary endpoint in only one study [5.5%]. In addition, eight ongoing controlled trials were identified. Combined clinical and radiological remission was the most frequent primary endpoint in these studies [4/8, 50%]. CONCLUSION In this systematic review, significant changes in outcomes used in randomized clinical trials of perianal Crohn's disease were observed. Radiological endpoints are increasingly used in perianal fistulizing Crohn's disease trials.
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Affiliation(s)
- Bénédicte Caron
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Gastroenterology, IBD Center, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Gastroenterology, IBD Center, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
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Tyrell S, Coates E, Brown SR, Lee MJ. A systematic review of the quality of reporting of interventions in the surgical treatment of Crohn's anal fistula: an assessment using the TIDiER and Blencowe frameworks. Tech Coloproctol 2021; 25:359-369. [PMID: 33599902 PMCID: PMC8016786 DOI: 10.1007/s10151-020-02359-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in the literature. The aim of this study was to review the quality of reporting of components of surgical interventions for Crohn's anal fistula. METHODS A systematic review was conducted. It was registered with PROSPERO (CRD:42019135157). The Medline and EMBASE databases were searched for studies reporting interventions intended to close fistula in patients with Crohn's disease, published between 1999 and August 2019. Abstracts and full texts were screened for inclusion by two reviewers. Dual extraction of data was performed to compare reporting to the TIDiER and Blencowe frameworks for reporting of interventions. RESULTS Initial searches identified 207 unique studies; 38 full texts were screened for inclusion and 33 were included. The most common study design was retrospective cohort (17/33), and the most frequently reported interventions were anal fistula plug (n = 8) and fibrin glue (n = 6). No studies showed coverage of all domains of TIDieR. Reporting was poor among domains related to who provided an intervention, where it was provided, and how it was tailored. Reporting of domains in the Blencowe framework was poor; the majority of studies did not report the component steps of procedures or efforts to standardise them. CONCLUSIONS This study demonstrates that reporting on technical aspects of interventions for Crohn's anal fistula is poor. Surgeons should aim to improve reporting to allow accurate reproduction of techniques both in clinical practice and in clinical trials.
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Affiliation(s)
- S Tyrell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - E Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steven R Brown
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, S10 2RX, UK.
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Vidon M, Munoz-Bongrand N, Lambert J, Maggiori L, Zeitoun JD, Corte H, Panis Y, Seksik P, Treton X, Abramowitz L, Allez M, Gornet JM. Long-term efficacy of fibrin glue injection for perianal fistulas in patients with Crohn's disease. Colorectal Dis 2021; 23:894-900. [PMID: 33278859 DOI: 10.1111/codi.15477] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/16/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022]
Abstract
AIM The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment. METHODS This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1 year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics. RESULTS In all, 119 patients (median age 33 years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1 year) were analysed with a median follow-up of 18.3 months. The complete clinical remission rate at 1 year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P = 0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years. CONCLUSION An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.
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Affiliation(s)
- Mathias Vidon
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France
| | | | - Jérôme Lambert
- Université Paris-Denis Diderot, Paris, France.,Service de Biostatistiques, Hôpital Saint-Louis, Paris, France
| | - Léon Maggiori
- Université Paris-Denis Diderot, Paris, France.,Service de Chirurgie Digestive, Hôpital Beaujon, Clichy, France
| | - Jean-David Zeitoun
- Service de Proctologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Hélène Corte
- Service de Chirurgie Digestive, Hôpital Saint-Louis, Paris, France
| | - Yves Panis
- Université Paris-Denis Diderot, Paris, France.,Service de Chirurgie Digestive, Hôpital Beaujon, Clichy, France
| | - Philippe Seksik
- Service de Gastroentérologie et Nutrition, APHP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France.,Université Sorbonne-UPMC Paris VI, Paris, France
| | - Xavier Treton
- Université Paris-Denis Diderot, Paris, France.,Service de Gastroentérologie, Hôpital Beaujon, Clichy, France
| | - Laurent Abramowitz
- Proctologie du service de Gastroentérologie, Hôpital Bichat, Clinique Blomet, Groupe Ramsay générale de santé, Paris, France
| | - Matthieu Allez
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Denis Diderot, Paris, France
| | - Jean-Marc Gornet
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France
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36
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Lee JL, Yoon YS, Yu CS. Treatment Strategy for Perianal Fistulas in Crohn Disease Patients: The Surgeon's Point of View. Ann Coloproctol 2021; 37:5-15. [PMID: 33730796 PMCID: PMC7989558 DOI: 10.3393/ac.2021.02.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Perianal fistula is a frequent complication and one of the subclassifications of Crohn disease (CD). It is the most commonly observed symptomatic condition by colorectal surgeons. Accurately classifying a perianal fistula is the initial step in its management in CD patients. Surgical management is selected based on the type of perianal fistula and the presence of rectal inflammation; it includes fistulotomy, fistulectomy, seton procedure, fistula plug insertion, video-assisted ablation of the fistulous tract, stem cell therapy, and proctectomy with stoma creation. Perianal fistulas are also managed medically, such as antibiotics, immunomodulators, and biologics including anti-tumor necrosis factor-alpha agents. The current standard treatment of choice for perianal fistula in CD patients is the multidisciplinary approach combining surgical and medical management; however, the rate of long-term remission is low and is reported to be 50% at most. Therefore, the optimum management strategy for perianal fistulas associated with CD remains controversial. Currently, the goal of management for CD-related perianal fistulas are controlling symptoms and maintaining long-term anal function without proctectomy, while monitoring progression to anorectal carcinoma. This review evaluates perianal fistula in CD patients and determines the optimal surgical management strategy based on recent evidence.
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Affiliation(s)
- Jong Lyul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Aho Fält U, Zawadzki A, Starck M, Bohe M, Johnson LB. Long-term outcome of the Surgisis ® (Biodesign ® ) anal fistula plug for complex cryptoglandular and Crohn's fistulas. Colorectal Dis 2021; 23:178-185. [PMID: 33155391 PMCID: PMC7898619 DOI: 10.1111/codi.15429] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/25/2020] [Accepted: 10/03/2020] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the long-term success rate of treatment with the Surgisis® (Biodesign® ) anal fistula plug for complex anal fistulas, assess fistula plug failure over time and compare success rates for fistula plug between a group of patients with cryptoglandular fistula and another group with Crohn's fistula. METHOD This is a single-centre study of consecutive patients treated with the Surgisis® (Biodesign® ) anal fistula plug between May 2006 and October 2009. All patients had complex anal fistulas in need of surgical treatment. The patients were assessed preoperatively by physical examination and three-dimensional (3D) endoanal ultrasound, and treated with a loose seton. Postoperative assessment by clinical examination and 3D endoanal ultrasound was performed at 2 weeks, 3 months and 6-12 months. Long-term follow-up was carried out in 2017 using a questionnaire, and clinical examination combined with 3D endoanal ultrasound was performed if the questionnaire indicated any signs of fistula recurrence. RESULTS A total of 95 patients were included; 30 had quiescent Crohn's disease. Overall, 151 plug procedures were performed. Long-term follow-up was undertaken in 90 (95%) patients; the results showed that after a median period of 110 months, the overall healing rate after one to five plug procedures was 38%. No statistically significant difference in success rate was found between the cryptoglandular fistula group and the Crohn's fistula group (P = 0.37). No further healing was observed after the use of three plugs. CONCLUSION Considering its low morbidity in a complex disease with high recurrence rates over time, the anal fistula plug may still be considered as one of the first-line treatments for patients with complex anal fistulas.
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Affiliation(s)
- Ursula Aho Fält
- Department of SurgeryPelvic Floor CentreSkåne University Hospital – MalmöLund UniversityMalmöSweden
| | - Antoni Zawadzki
- Department of SurgeryPelvic Floor CentreSkåne University Hospital – MalmöLund UniversityMalmöSweden
| | - Marianne Starck
- Department of SurgeryPelvic Floor CentreSkåne University Hospital – MalmöLund UniversityMalmöSweden
| | - Måns Bohe
- Department of SurgeryPelvic Floor CentreSkåne University Hospital – MalmöLund UniversityMalmöSweden
| | - Louis B. Johnson
- Department of SurgeryPelvic Floor CentreSkåne University Hospital – MalmöLund UniversityMalmöSweden
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38
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Herissay A, Siproudhis L, Le Balc'h E, Merlini L'Heritier A, Dewitte M, Wallenhorst T, Bouguen G, Brochard C. Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors. Colorectal Dis 2021; 23:159-168. [PMID: 32640112 DOI: 10.1111/codi.15241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 06/21/2020] [Indexed: 12/13/2022]
Abstract
AIM The medico-surgical strategy for the treatment of perianal fistulizing Crohn's disease (CD) following surgical drainage remains challenging and debated. Our aims were to describe the failure rate of therapeutic interventions after drainage of the fistula tract and determine the factors associated with failure to optimize medico-surgical strategies. METHOD All consecutive patients with perianal fistulizing CD who underwent surgical drainage with at least a 12-week follow-up were included. Failure was defined as the occurrence of at least one of the following items: abscess recurrence, purulent discharge from the tract, visible external opening and further drainage procedure(s). RESULTS One hundred and sixty-nine patients were included. The median follow-up was 4.0 years. The cumulative failure rates were 20%, 30% and 36% at 1, 3 and 5 years, respectively. The cumulative failure rates in patients who had sphincter-sparing surgeries or seton removal were significantly higher than in those who had a fistulotomy. Anterior fistula [hazard ratio (HR) = 2.52 (1.13-5.61), P = 0.024], supralevator extension [HR = 20.78 (3.38-127.80), P = 0.001] and the absence or discontinuation of immunosuppressants after anal drainage [HR = 3.74 (1.11-12.5), P = 0.032] were significantly associated with failure in the multivariate analysis model. CONCLUSION Combined strategies for perianal fistulizing CD lead to a failure rate of 36% at 5 years. Where advisable, fistulotomy may be preferred because it has a lower rate of recurrence. The benefits of immunosuppressants require a dedicated prospective randomized trial.
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Affiliation(s)
- A Herissay
- CHU Rennes, Universitaire Rennes, Rennes, France
| | - L Siproudhis
- INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), CHU Rennes, Universitaire Rennes, Rennes, France
| | - E Le Balc'h
- CHU Rennes, Universitaire Rennes, Rennes, France
| | | | - M Dewitte
- CHU Rennes, Universitaire Rennes, Rennes, France
| | | | - G Bouguen
- INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), CHU Rennes, Universitaire Rennes, Rennes, France
| | - C Brochard
- INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), CHU Rennes, Universitaire Rennes, Rennes, France
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39
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Zabot GP, Cassol O, Saad-Hossne R, Bemelman W. Modern surgical strategies for perianal Crohn's disease. World J Gastroenterol 2020; 26:6572-6581. [PMID: 33268947 PMCID: PMC7673971 DOI: 10.3748/wjg.v26.i42.6572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/05/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023] Open
Abstract
One of the most challenging phenotypes of Crohn’s disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn’s disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.
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Affiliation(s)
- Gilmara Pandolfo Zabot
- Department of Coloproctology, Hospital Moinhos de Vento, Porto Alegre 90035-902, RS, Brazil
| | - Ornella Cassol
- Department of Surgery, Hospital de Clínicas de Passo Fundo, Passo Fundo 99010-260, RS, Brazil
| | - Rogerio Saad-Hossne
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam 19268, Netherlands
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40
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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41
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Sahnan K, Adegbola SO, Fareleira A, Hart A, Warusavitarne J. Medical-surgical Combined Approach in Perianal Fistulizing Crohn's Disease (CD): Doing it Together. Curr Drug Targets 2020; 20:1373-1383. [PMID: 31109272 DOI: 10.2174/1389450120666190520103454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/13/2019] [Accepted: 04/17/2019] [Indexed: 02/08/2023]
Abstract
Fistulising perianal Crohn's disease (pCD) is an aggressive phenotype, and patients not only suffer from perianal manifestations but also a worsening course for their luminal disease. This article describes the 6 key steps clinicians need to consider when managing patients with pCD which include; (i) ensuring a prompt diagnosis, (ii) multi-disciplinary management, (iii) psychological support, (iv) using multimodal medical and surgical treatment strategies, (v) continually monitoring and optimising therapy and (vi) ensuring that patients have a way of accessing care if required. Patients with fistulising pCD often have an unpredictable disease course and complete remission can be elusive. As such, a considered and nuanced approach is essential keeping the wider multi-disciplinary team and the patient involved in all decision making.
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Affiliation(s)
- Kapil Sahnan
- Robin Phillips' Fistula Research Unit, St. Mark's Hospital, Harrow, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Samuel O Adegbola
- Robin Phillips' Fistula Research Unit, St. Mark's Hospital, Harrow, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Ailsa Hart
- Robin Phillips' Fistula Research Unit, St. Mark's Hospital, Harrow, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Janindra Warusavitarne
- Robin Phillips' Fistula Research Unit, St. Mark's Hospital, Harrow, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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42
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Adegbola SO, Sahnan K, Twum-Barima C, Iqbal N, Reza L, Lung P, Warusavitarne J, Tozer P, Hart A. Current review of the management of fistulising perianal Crohn's disease. Frontline Gastroenterol 2020; 12:515-523. [PMID: 34712470 PMCID: PMC8515276 DOI: 10.1136/flgastro-2020-101489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 02/04/2023] Open
Abstract
Perianal manifestations of Crohn's disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-date surgical and medical management of perianal fistulas, highlighting current consensus management guidelines and the evidence behind them, as well as future directions in management.
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Affiliation(s)
- Samuel O Adegbola
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kapil Sahnan
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Charlene Twum-Barima
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nusrat Iqbal
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lillian Reza
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phillip Lung
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Janindra Warusavitarne
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phil Tozer
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ailsa Hart
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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43
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Spinelli A, Armuzzi A, Ciccocioppo R, Danese S, Gionchetti P, Luglio G, Orlando A, Rispo A, Rizzello F, Sofo L, Solina G, Poggioli G. Management of patients with complex perianal fistulas in Crohn's disease: Optimal patient flow in the Italian clinical reality. Dig Liver Dis 2020; 52:506-515. [PMID: 31901310 DOI: 10.1016/j.dld.2019.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022]
Abstract
Perianal fistulizing Crohn's disease (PFCD) is a common, disabling and aggressive phenotype that negatively impacts on the quality of life of affected patients. Its successful treatment is still a struggle for both physicians and patients. Significant advances in the management of this condition have occurred in the last two decades holding promise for a better future. This culminated into the concept of a collaborative multidisciplinary approach using the latest medical therapies combined with modern surgical and endoscopic techniques. Despite this, PFCD management and treatment have not been standardized yet. Thus the gastroenterologist and surgeon have to be familiar with several approaches and/or techniques. The positioning of each therapeutic option will certainly evolve with new data, but for the time being it should be driven by patient's characteristics, physician's preference and/or experience, costs and availability in local practice. Additionally, patient's perception of benefits and risks of treatment may differ from those of physicians and recognition of this difference is a starting point for difficult clinical decision-making. In this paper, a multidisciplinary group of Italian IBD experts explore and discuss current medical and surgical therapeutic options, highlighting areas of unmet needs in PFCD, with particular focus on the optimal patient flow within the Italian clinical reality.
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Affiliation(s)
- Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
| | | | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, G.B. Rossi University Hospital, Verona, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy; IBD Center, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - Paolo Gionchetti
- Emilia-Romagna IBD Regional Referral Center, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Gaetano Luglio
- Surgery Unit, Department of Public Health, Federico II University Hospital, Naples, Italy
| | | | - Antonio Rispo
- Gastroenterology Unit, Federico II University Hospital, Naples, Italy
| | - Fernando Rizzello
- Emilia-Romagna IBD Regional Referral Center, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Luigi Sofo
- Abdominal SUrgery Unit, Department of Gastroenterology, Endocrine-metabolic and Nephrourological Science, A. Gemelli Hospital, Cattolica University, Rome, Italy
| | - Gaspare Solina
- Unit of General and Oncological Surgery, Department of Surgery, "Villa Sofia-Cervello" Hospital, Palermo, Italy
| | - Gilberto Poggioli
- Digestive Surgery Department, S. Orsola-Malpighi University Hospital, Bologna, Italy
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44
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Flacs M, Collard M, Doblas S, Zappa M, Cazals-Hatem D, Maggiori L, Panis Y, Treton X, Ogier-Denis E. Preclinical Model of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2020; 26:687-696. [PMID: 31774918 DOI: 10.1093/ibd/izz288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fistulizing anoperineal lesions (FAPLs) are common and severe complications of Crohn's disease (CD), exposing patients to the risk of anal sphincter alteration and permanent stoma. Due to the limited efficacy of current treatments, identifying new local therapies is mandatory. However, testing new treatments is currently limited because no relevant preclinical model of Crohn's-like FAPL is available. Thus, a reliable and reproducible experimental model of FAPLs is needed to assess new therapeutic strategies. METHODS Twenty-one rats received a rectal enema of 2,4,6-trinitrobenzensulfonic acid (TNBS) to induce proctitis. Seven days later, a transsphincteric fistula tract was created with a surgical thread, instilled with TNBS twice a week until its removal at day 7 (group 1), day 14 (group 2), or day 28 (group 3). In each rat, pelvic MRI was performed just before and 7 days after thread removal. Rats were sacrificed 7 days after thread removal for pathological assessment of the fistula tract. RESULTS The optimal preclinical model was obtained in group 3. In this group, 7 days after thread removal, all animals (9 of 9) had a persistent fistula tract visible on MRI with T2-hypersignal (normalized T2 signal intensity: 2.36 ± 0.39 arbitrary units [a.u.] [2.08-2.81]) and elevation of the apparent diffusion coefficient (1.33 ± 0.16 10-3 millimeter squared per seconds [1.18-1.49]). The pathological examination of the fistula tract revealed acute and chronic inflammation, granulations, fibrosis, epithelialization, and proctitis in the adjacent rectum. CONCLUSIONS This reproducible preclinical model could be used to assess the effectiveness of innovative treatments in perianal fistulizing CD.
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Affiliation(s)
- Meredith Flacs
- Department of Colorectal Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France.,Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France
| | - Maxime Collard
- Department of Colorectal Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France.,Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France
| | - Sabrina Doblas
- Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Laboratory of Imaging Biomarkers, Paris, France
| | - Magaly Zappa
- Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Laboratory of Imaging Biomarkers, Paris, France.,Department of Radiology, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France
| | - Dominique Cazals-Hatem
- Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France.,Department of Pathology, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France
| | - Léon Maggiori
- Department of Colorectal Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France.,Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France
| | - Yves Panis
- Department of Colorectal Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France.,Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France
| | - Xavier Treton
- Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France.,Department of Gastroenterology, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy la Garenne, Clichy Cedex, France
| | - Eric Ogier-Denis
- Université de Paris, Centre de Recherche sur l'Inflammation, INSERM, CNRS, Team Gut Inflammation, Paris, France
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45
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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: 32] [Impact Index Per Article: 8.0] [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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46
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Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A, Ellul P, Fiorino G, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gisbert JP, Gomollon F, González Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Kucharzik T, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B, Zmora O. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2020; 14:155-168. [PMID: 31742338 DOI: 10.1093/ecco-jcc/jjz187] [Citation(s) in RCA: 307] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Alessandro Armuzzi
- IBD Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS - Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland; Department of Human Medicine, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | | | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa', IIS Aragón, CIBEREHD, Zaragoza, Spain
| | | | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Sub-department of Gastroenterology and Hepatology, University Hospital Bratislava and Faculty of Medicine, Comenius University Bratislava, Slovakia
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal Medicine, Riga Stradiņš University, Riga, Latvia
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Faculty of Medicine, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
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47
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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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48
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Merlini l'Héritier A, Siproudhis L, Bessi G, Le Balc'h E, Wallenhorst T, Bouguen G, Brochard C. Sphincter-sparing surgery for complex anal fistulas: radiofrequency thermocoagulation of the tract is of no help. Colorectal Dis 2019; 21:961-966. [PMID: 30897291 DOI: 10.1111/codi.14618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/12/2019] [Indexed: 02/08/2023]
Abstract
AIM To compare the rate of failure of radiofrequency thermocoagulation for anal fistula with that of rectal advancement flap in a case-matched study. METHOD Patients who underwent radiofrequency treatment were compared with age- and sex-matched patients with Crohn's disease (CD) who underwent a rectal flap procedure. Fistula features, general characteristics and the main clinical events were recorded in a prospective database. Failure was defined by at least one of following: abscess, purulent discharge, visible external opening or further drainage procedure. RESULTS A total of 62 patients [median age 45 (range 36.8-57.5) years; 22 women, 40 men; 22 with CD] were analysed. The failure rate of radiofrequency treatment was higher than that of rectal flap treatment (74.2% vs 32.2%; P = 0.004). The cumulative probabilities of failure of the radiofrequency treatment were 53.8% (38.8-68.3), 71.8% (55.3-84.0) and 87.4% (70.6-95.3) at 3, 6 and 12 months, respectively. Three patients in the radiofrequency group required drainage for an abscess and one had severe thermal ulceration. The Cox proportional hazards regression model (surgical procedure, obesity, CD) showed rectal flap treatment [3.48 (1.60-8.07); P = 0.001] and CD [2.60 (1.16-6.41); P = 0.02] to be the main independent predictors of healing. CONCLUSION Radiofrequency thermocoagulation is a less satisfactory sphincter-sparing treatment for the management of anal fistula than a rectal flap procedure.
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Affiliation(s)
- A Merlini l'Héritier
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - L Siproudhis
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France.,INSERM U1241, University of Rennes 1, Rennes, France.,INPHY CIC 1414, University Hospital of Rennes, Pontchaillou, France
| | - G Bessi
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - E Le Balc'h
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - T Wallenhorst
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - G Bouguen
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France.,INSERM U1241, University of Rennes 1, Rennes, France.,INPHY CIC 1414, University Hospital of Rennes, Pontchaillou, France
| | - C Brochard
- Department of Gastroenterology, University Hospital of Rennes, Pontchaillou, France.,INSERM U1241, University of Rennes 1, Rennes, France.,INPHY CIC 1414, University Hospital of Rennes, Pontchaillou, France
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49
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Advances in Perianal Disease Associated with Crohn's Disease-Evolving Approaches. Gastrointest Endosc Clin N Am 2019; 29:515-530. [PMID: 31078250 DOI: 10.1016/j.giec.2019.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Perianal diseases, common complications of Crohn's disease, are difficult to diagnose/manage. Patients with perianal Crohn's disease suffer from persistent pain and drainage, recurrent perianal sepsis, impaired quality of life, and financial burden. Conventional medical and surgical therapies carry risk of infection, myelosuppression, incontinence, disease recurrence. Although the phenotype of Crohn's disease has been extensively studied, reported outcomes are inconsistent. Endoanal ultrasonography is also becoming popular because of low cost and ability to acquire images in real time. Emerging management strategies for treatment including laser therapy, local injection of agents, use of hyperbaric oxygen, and stem cell therapy, have demonstrated efficacy.
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50
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Lightner AL. The Present State and Future Direction of Regenerative Medicine for Perianal Crohn's Disease. Gastroenterology 2019; 156:2128-2130.e4. [PMID: 31034831 DOI: 10.1053/j.gastro.2019.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio.
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