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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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Wei J, Zhang Y, Chen C, Feng X, Yang Z, Feng J, Jiang Q, Fu J, Xuan J, Gao H, Liao L, Wang F. Efficacy and safety of allogeneic umbilical cord-derived mesenchymal stem cells for the treatment of complex perianal fistula in Crohn's disease: a pilot study. Stem Cell Res Ther 2023; 14:311. [PMID: 37904247 PMCID: PMC10617053 DOI: 10.1186/s13287-023-03531-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 10/10/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVES The aim of the study was to evaluate the efficacy and safety of allogeneic umbilical cord-derived mesenchymal stem cells (TH-SC01) for complex perianal fistula in patients with Crohn's disease (CD). METHODS This was an open-label, single-arm clinical trial conducted at Jinling Hospital. Adult patients with complex treatment-refractory CD perianal fistulas (pfCD) were enrolled and received a single intralesional injection of 120 million TH-SC01 cells. Combined remission was defined as an absence of suppuration through an external orifice, complete re-epithelization, and absence of collections larger than 2 cm measured by magnetic resonance imaging (MRI) at 24 weeks after cell administration. RESULTS A total of 10 patients were enrolled. Six patients (60.0%) achieved combined remission at 24 weeks. The number of draining fistulas decreased in 9 (90.0%) and 7 (70.0%) patients at weeks 12 and 24, respectively. Significant improvement in Perianal Crohn Disease Activity Index, Pelvic MRI-Based Score, Crohn Disease Activity Index, and quality of life score were observed at 24 weeks. No serious adverse events occurred. The probability of remaining recurrence-free was 70% at week 52. CONCLUSION The study demonstrated that local injection of TH-SC01 cells might be an effective and safe treatment for complex treatment-refractory pfCD after conventional and/or biological treatments fail (ClinicalTrials.gov ID, NCT04939337). TRIAL REGISTRATION The study was retrospectively registered on www. CLINICALTRIALS gov (NCT04939337) on June 25, 2021.
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Affiliation(s)
- Juan Wei
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Yufei Zhang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Chunyan Chen
- Department of Gastroenterology and Hepatology, The First School of Clinical Medicine, Southern Medical University, Guangzhou Da Dao Bei 1838, Guangzhou, China
| | - Xiaoyue Feng
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Zhao Yang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Jing Feng
- Department of Gastroenterology and Hepatology, The First School of Clinical Medicine, Southern Medical University, Guangzhou Da Dao Bei 1838, Guangzhou, China
| | - Qiong Jiang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Jinjin Fu
- Department of Gastroenterology and Hepatology, The Affiliated Changzhou No. 2 People's Hospital, Nanjing Medical University, Changzhou, China
| | - Ji Xuan
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Hong Gao
- Department of Radiology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Lianming Liao
- Center of Laboratory Medicine, Union Hospital of Fujian Medical University, No. 29, Xinquan Road, Fuzhou, 350001, People's Republic of China.
| | - Fangyu Wang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, People's Republic of China.
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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [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: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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Barreiro-de Acosta M, Riestra S, Calafat M, Soto MP, Calvo M, Sánchez Rodríguez E, Caballol B, Vela M, Rivero M, Muñoz F, de Castro L, Calvet X, García-Alonso FJ, Utrilla Fornals A, Ferreiro-Iglesias R, González-Muñoza C, Chaparro M, Bujanda L, Sicilia B, Alfambra E, Rodríguez A, Pérez Fernández R, Rodríguez C, Almela P, Argüelles F, Busquets D, Tamarit-Sebastián S, Reygosa Castro C, Jiménez L, Marín-Jiménez I, Alcaide N, Fernández-Salgado E, Iglesias Á, Ponferrada Á, Pajares R, Roncero Ó, Morales-Alvarado VJ, Ispízua-Madariaga N, Sáinz E, Merino O, Márquez-Mosquera L, García-Sepulcre M, Elorza A, Estrecha S, Surís G, Van Domselaar M, Brotons A, de Francisco R, Cañete F, Iglesias E, Vera MI, Mesonero F, Lorente R, Zabana Y, Cabriada JL, Domènech E, Rodríguez-Lago I. Management and Long-term Outcomes of Crohn's Disease Complicated with Enterocutaneous Fistula: ECUFIT Study from GETECCU. J Crohns Colitis 2022; 16:1049-1058. [PMID: 35104314 DOI: 10.1093/ecco-jcc/jjac016] [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: 12/01/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Crohn's disease [CD] can develop penetrating complications at any time during the disease course. Enterocutaneous fistulae [ECF] are disease-related complications with an important impact on quality of life. Our aim was to describe the outcomes of this complication, including its medical and/or surgical management and their temporal trends. The primary endpoint was fistula closure, defined as the absence of drainage, with no new abscess or surgery, over the preceding 6 months. METHODS Clinical information from all adult patients with CD and at least one ECF-excluding perianal fistulae-were identified from the prospectively-maintained ENEIDA registry. All additional information regarding treatment for this complication was retrospectively reviewed. RESULTS A total of 301 ECF in 286 patients [January 1970-September 2020] were analysed out of 30 088 records. These lesions were mostly located in the ileum [67%] and they had a median of one external opening [range 1-10]. After a median follow-up of 146 months (interquartile range [IQR], 69-233), 69% of patients underwent surgery. Fistula closure was achieved in 84%, mostly after surgery, and fistula recurrence was uncommon [13%]. Spontaneous and low-output fistulae were associated with higher closure rates (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.17-1.93, p = 0.001, and HR 1.49, 95% CI 1.07-2.06, p = 0.03, respectively); this was obtained more frequently with medical therapy since biologics have been available. CONCLUSIONS ECF complicating CD are rare but entail a high burden of medical and surgical resources. Closure rates are high, usually after surgery, and fistula recurrence is uncommon. A significant proportion of patients receiving medical therapy can achieve fistula closure.
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Affiliation(s)
- Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Sabino Riestra
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - María Pilar Soto
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Marta Calvo
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Berta Caballol
- Gastroenterology Department, Hospital Clinic, Barcelona, Spain
| | - Milagros Vela
- Gastroenterology Department, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Montserrat Rivero
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla and IDIVAL, Santander, Spain
| | - Fernando Muñoz
- Gastroenterology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Luisa de Castro
- Gastroenterology Department, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Xavier Calvet
- Gastroenterology Department, Corporació Parc Taulí, Sabadell, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | | | | | - Rocío Ferreiro-Iglesias
- Gastroenterology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - María Chaparro
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa IIS-IP, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Luis Bujanda
- Gastroenterology Department, Biodonostia Health Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], and Universidad del País Vasco [UPV/EHU], San Sebastián, Spain
| | - Beatriz Sicilia
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Erika Alfambra
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Andrés Rodríguez
- Gastroenterology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Rubén Pérez Fernández
- Gastroenterology Department, Complejo Asistencial Universitario de León, León, Spain
| | - Cristina Rodríguez
- Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Pedro Almela
- Gastroenterology Department, Hospital General Universitari de Castelló, Castelló, Spain
| | - Federico Argüelles
- Gastroenterology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - David Busquets
- Gastroenterology Department, Hospital Universitari Girona Dr. Josep Trueta, Girona, Spain
| | | | - Cristina Reygosa Castro
- Gastroenterology Department, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Spain
| | - Laura Jiménez
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Ignacio Marín-Jiménez
- Gastroenterology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Noelia Alcaide
- Gastroenterology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Estela Fernández-Salgado
- Gastroenterology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Águeda Iglesias
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Ángel Ponferrada
- Gastroenterology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ramón Pajares
- Gastroenterology Department, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Óscar Roncero
- Gastroenterology Department, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | | | | | - Empar Sáinz
- Gastroenterology Department, Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Olga Merino
- Gastroenterology Department, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - Ainara Elorza
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | - Sandra Estrecha
- Gastroenterology Department, Hospital Universitario Araba, Vitoria, Spain
| | - Gerard Surís
- Gastroenterology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Manuel Van Domselaar
- Gastroenterology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Alicia Brotons
- Gastroenterology Department, Hospital Vega Baja, Orihuela, Spain
| | - Ruth de Francisco
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Eva Iglesias
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María Isabel Vera
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Francisco Mesonero
- Gastroenterology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Rufo Lorente
- Gastroenterology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Yamile Zabana
- Gastroenterology Department, Hospital Universitari Mútua Terrassa, Terrassa, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - José Luis Cabriada
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Iago Rodríguez-Lago
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
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Deng F, Xia P, Wu Z, Zhou H, Wang X. Perianal and Luminal Relapse Following Perianal Surgical Intervention in Crohn's Disease. Int J Gen Med 2021; 14:3387-3396. [PMID: 34285563 PMCID: PMC8286149 DOI: 10.2147/ijgm.s315505] [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: 04/16/2021] [Accepted: 07/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Aims Fistula relapse occurs in 20–30% of patients with perianal Crohn’s disease (PCD) despite optimal medico-surgical management. We aimed in this study to assess the rate of perianal and luminal relapse after surgically induced remission and to determine factors associated with fistula relapse. Methods Consecutive perianal CD patients who achieved clinical remission after surgery for fistulising PCD from January 2013 to January 2019 were included. The cumulative probabilities of relapse-free survival were estimated using the Kaplan–Meier method. Results A total of 130 patients were included. Sixty-six of 130 patients received infliximab (IFX) therapy after perianal surgery. After a median follow-up of 62 months (interquartile range [IQR]: 28–117 months), perianal relapse occurred in 30 of 64 (46.9%) nonbiological medication-treated cases and in 14 of 66 (21.1%) cases in the IFX therapy group. The cumulative probabilities of perianal relapse-free survival in patients with nonbiological treatment were 77.1% at 1 year, 54.6% at 3 years, and 30% at 5 years. The rates of survival without perianal fistula relapse in the IFX-treated group were 91.6%, 69.2%, and 59.3% at 1, 3 and 5 years, respectively. In patients treated with IFX after perianal surgery, discontinuation of IFX therapy (odds ratio [OR]=2.43, p=0.036), a penetrating CD phenotype (OR=4.324, p=0.019), and a complex perianal fistula (OR=3.392, p=0.026) were independently associated with perianal relapse in multivariate analysis. Conclusion Infliximab therapy reduced the risk of perianal relapse after surgical remission in PCD patients compared with nonbiological treatment. However, approximately 40% of patients using infliximab experienced perianal relapse at 5 years, and patients who discontinued use of IFX or experienced a penetrating phenotype or a complex perianal fistula were associated with increased relapse rate.
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Affiliation(s)
- Feihong Deng
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People's Republic of China.,Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People's Republic of China
| | - Pianpian Xia
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People's Republic of China.,Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People's Republic of China
| | - Zengrong Wu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People's Republic of China.,Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People's Republic of China
| | - Hejun Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People's Republic of China.,Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People's Republic of China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People's Republic of China.,Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People's Republic of China
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Papamichael K, Cheifetz AS. Defining and predicting deep remission in patients with perianal fistulizing Crohn’s disease on anti-tumor necrosis factor therapy. World J Gastroenterol 2017; 23:6197-6200. [PMID: 28974885 PMCID: PMC5603485 DOI: 10.3748/wjg.v23.i34.6197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
Perianal fistulas can occur to up to one-third of patients with Crohn’s disease (CD) leading to significant disabling disease and morbidity. Fistulising perianal CD treatment often necessitates a combined pharmacological and surgical approach. Anti-tumor necrosis factor (anti-TNF) therapy, particularly infliximab, has been shown to be very effective for both perianal and internal fistulising CD. Nevertheless, current data suggest that sustained remission and long-term complete fistula healing can be achieved in only 30% to 50% of patients. Moreover, these percentages refer mostly to clinical rather than deep remission, defined as endoscopic and radiologic remission, which is quickly emerging as the preferred goal of therapy. Unfortunately, the therapeutic options for perianal fistulising CD are still limited. As such, it would be of great value to be able to predict, and more importantly, prevent treatment failure in these patients by early and continued optimization of anti-TNF therapy. Similar to ulcerative colitis and luminal CD, recent data demonstrate that higher infliximab concentrations are associated with better clinical outcomes in patients with perianal fistulising CD. This suggests that therapeutic drug monitoring and a treat-to-trough therapeutic approach may emerge as the new standard of care for optimizing anti-TNF therapy in patients with perianal fistulising CD.
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Affiliation(s)
- Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Squamous Cell Carcinoma Originating from a Crohn's Enterocutaneous Fistula. Case Rep Surg 2017; 2017:1929182. [PMID: 28487805 PMCID: PMC5401721 DOI: 10.1155/2017/1929182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/03/2017] [Accepted: 03/28/2017] [Indexed: 01/29/2023] Open
Abstract
Purpose. Squamous cell carcinoma (SCC) developing within fistulae and chronic wounds in patients with Crohn's disease is a rare phenomenon with few reported studies in the literature. Clinical suspicion for SCC in Crohn's disease patients with chronic painful fistulae is low, leading to delayed diagnosis and treatment. We present a patient with long-standing Crohn's disease complicated by malignant degeneration of an enterocutaneous fistula tract. Methods. Workup with MRI, CT, and fistulogram revealed a 7 × 3 cm fistulous connection between a loop of small intestine and the patient's perineum. Biopsies of the fistula tract confirmed the diagnosis of SCC. Results. The patient underwent an abdominoperineal resection with positive margins and is currently awaiting radiation therapy. Conclusions. This is the second case reported within the English literature of SCC arising from an enterocutaneous fistula in the setting of Crohn's disease. Based on the findings in this case report and others presented in the literature, a high degree of suspicion of malignancy should be present in patients with chronic painful, poor-healing fistulae, especially in the absence of infection.
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Gribovskaja-Rupp I, Melton GB. Enterocutaneous Fistula: Proven Strategies and Updates. Clin Colon Rectal Surg 2016; 29:130-7. [PMID: 27247538 DOI: 10.1055/s-0036-1580732] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Management of enterocutaneous fistula represents one of the most protracted and difficult problems in colorectal surgery with substantial morbidity and mortality rates. This article summarizes the current classification systems and successful management protocols, provides an in-depth review of fluid resuscitation, sepsis control, nutrition management, medication management of output quantity, wound care, nonoperative intervention measures, operative timeline, and considerations, and discusses special considerations such as inflammatory bowel disease and enteroatmospheric fistula.
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Affiliation(s)
| | - Genevieve B Melton
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
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