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Herreros MD, Ramirez JM, Otero-Piñeiro AM, Martí-Gallostra M, Badiola I, Enríquez-Navascues JM, Millan M, Barreiro E, de la Portilla de Juan F, Suárez Alecha J, Garcia-Olmo D. Use of Darvadstrocel (Allogenic Stem Cell Therapy) for Crohn's Fistulas in Real Clinical Practice: The National Project to Implement Mesenchymal Stem Cell for the Treatment of Perianal Crohn's Fistula (the PRIME Study). Dis Colon Rectum 2024:00003453-990000000-00616. [PMID: 38603800 DOI: 10.1097/dcr.0000000000003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BACKGROUND Perianal fistulas may affect 15-50% of patients with Crohn's disease. Treatment is complex, requiring a multidisciplinary approach. Darvadstrocel (allogenic mesenchymal cells obtained from lipoaspirates) was approved in 2018 by the European and Spanish Agencies of Medicines and Medical Products as a treatment for fistulas in Crohn's disease. Recent European Crohn's and Colitis Organisation and Spanish Working Group on Crohn's Disease and Ulcerative Colitis guidelines state that darvadstrocel is effective with a favorable safety profile and a strong level of evidence (2). OBJECTIVE Presenting real-world effectiveness data for darvadstrocel in a Spanish population. DESIGN Observational retrospective cohort study with prospective data gathering. SETTINGS Fourteen institutions. PATIENTS From November 2019-April 2022, all patients (73) treated with darvadstrocel in these institutions were included, fulfilling the following criteria: 1) complex fistula/s in a patient with Crohn's disease; 2) failure of conventional and antitumor necrosis factor treatment; 3) absence of collections >2 cm confirmed by pelvic MRI scan at the time of surgery. INTERVENTIONS Darvadstrocel treatment. MAIN OUTCOME MEASURES Clinical response (closure of ≥50% of external openings), complete clinical closure (100% of external openings) and radiological closure (no fluid collection >2 cm, no edema or inflammation) evaluated 6 months after treatment. RESULTS Clinical response was observed in 63 patients (86.3%), complete clinical closure in 50 patients (68.5%) and radiological closure in 45 patients (69.2%). Combined clinical and radiological response was observed in 41 patients (63.1%). Not all clinically healed patients had radiological closure and vice versa. No serious adverse events were reported. LIMITATIONS Retrospective. CONCLUSIONS Study results were consistent with those reported in previous clinical trials, real-world efficacy findings from the INSPIRE study (assessing darvadstrocel effectiveness in Europe, Israel, Switzerland, UK, and Japan) and previously published literature. Darvadstrocel was effective and demonstrated a favorable safety profile when used in normal clinical practice for treatment of fistulas in Crohn's disease. See Video Abstract.
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Affiliation(s)
- Maria Dolores Herreros
- Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
- New Therapy Laboratory, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, Madrid, Spain
| | - Jose-Manuel Ramirez
- Department of Surgery, University of Zaragoza, Zaragoza, Spain
- Spanish Multimodal Rehabilitation Group (GERM), Zaragoza, Spain
| | | | | | - Izaskun Badiola
- Department of Surgery University Hospital Galdakao-Usansolo, Vizcaya, Pais Vasco, Spain
| | | | - Monica Millan
- Department of Surgery, University Hospital la Fe, Valencia, Spain
| | - Erica Barreiro
- Department of Surgery, University Hospital of Pontevedra, Galicia, Spain
| | | | | | - Damian Garcia-Olmo
- Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
- New Therapy Laboratory, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, Madrid, Spain
- Surgery Department, Universidad Autonoma de Madrid, Madrid, Spain
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Loras C, Mañosa M, Andújar X, Sánchiz V, Martí-Gallostra M, Zabana Y, Gutiérrez A, Barreiro-de Acosta M. Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease. Gastroenterol Hepatol 2022; 45:315-334. [PMID: 34274357 DOI: 10.1016/j.gastrohep.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Abstract
Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.
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Affiliation(s)
- Carme Loras
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España.
| | - Miriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Departamento de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Xavier Andújar
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Vicente Sánchiz
- Servicio de Medicina Digestiva. Hospital Clínico Universitario. Valencia, España
| | - Marc Martí-Gallostra
- Departamento de Cirugía Colorectal, General y Digestiva. Hospital Universitari de la Vall d'Hebron. Barcelona, España
| | - Yamile Zabana
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Hospital General Universitario de Alicante, Alicante, España
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Gómez-Jurado MJ, Martí-Gallostra M, Pellino G, Galvez A, Kreisler E, Biondo S, Espín-Basany E. Long-term outcomes of an acellular dermal matrix for the treatment of complex cryptoglandular anal fistula: a pilot study. Tech Coloproctol 2022; 26:453-459. [PMID: 35212835 PMCID: PMC9072521 DOI: 10.1007/s10151-022-02593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022]
Abstract
Backgound Effective, standardized treatments for complex anal fistula (CAF) still represent a clinical challenge. Emerging procedures attempted to achieve the healing rates of fistulotomy whilst preserving sphincter function. Acellular dermal matrix (ADM) used as a plug inserted through the fistulous tract is among newer treatment options. Varying success rates have been reported, most with short-term follow-up. The aim of this study was to report the long-term results of ADM-plug for CAF. Methods Retrospective analysis of a prospective database of patients treated with CAF. All consecutive patients presenting at two tertiary centers (Vall d’Hebron University Hospital and Bellvitge University Hospital, Barcelona, Spain) between November 2015 and March 2019 with a single, cryptoglandular CAF were evaluated for treatment with an ADM-plug were included. The primary endpoint was absence of discharge at clinical examination at 12 month follow-up. Results Twenty-two patients were included [7 women and 15 men, median age 56 (33–74) years]. Most patients had high transsphincteric fistulas (63.6%). The median follow-up was 42 (21–53) months. The 12 month success rate was 68.2%, with an overall healing rate of 59.1%. 77.8% of recurrences occurred within 12 months from surgery. One plug extrusion was observed. No major complications or mortality occurred during the follow-up. Patients did not report any worsening of fecal continence. Conclusions This pilot study showed that more than half of patients with CAF could benefit from ADM-plug placement, preserving continence. A minimum follow-up of 12 months is recommended, because most recurrences occur during the first year. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02593-1.
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Affiliation(s)
- M. J. Gómez-Jurado
- Department of Advanced Medical and Surgical Sciences, Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
| | - M. Martí-Gallostra
- Department of Advanced Medical and Surgical Sciences, Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
| | - G. Pellino
- Department of Advanced Medical and Surgical Sciences, Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania “Luigi Vanvitelli”, Naples, Italy
| | - A. Galvez
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), Barcelona, Spain
| | - E. Kreisler
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), Barcelona, Spain
| | - S. Biondo
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), Barcelona, Spain
| | - E. Espín-Basany
- Department of Advanced Medical and Surgical Sciences, Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
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Jimenez-Gomez LM, Espin-Basany E, Trenti L, Martí-Gallostra M, Sánchez-García JL, Vallribera-Valls F, Kreisler E, Biondo S, Armengol-Carrasco M. Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer. Colorectal Dis 2017; 20:195-200. [PMID: 28963744 DOI: 10.1111/codi.13901] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 08/14/2017] [Indexed: 12/13/2022]
Abstract
AIM To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer. METHOD Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses. RESULTS The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS. CONCLUSIONS In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Luis Miguel Jimenez-Gomez
- Colorectal Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Unit of Coloproctology, Service of General Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Eloy Espin-Basany
- Colorectal Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Loris Trenti
- Department of Surgery-Colorectal Unit, Hospital Universitari de Bellvitge, University of Barcelona and Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marc Martí-Gallostra
- Colorectal Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Luis Sánchez-García
- Colorectal Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Vallribera-Valls
- Colorectal Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Esther Kreisler
- Department of Surgery-Colorectal Unit, Hospital Universitari de Bellvitge, University of Barcelona and Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sebastiano Biondo
- Department of Surgery-Colorectal Unit, Hospital Universitari de Bellvitge, University of Barcelona and Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Armengol-Carrasco
- Colorectal Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Martí-Gallostra M, Myrelid P, Mortensen N, Keshav S, Travis SPL, George B. The role of a defunctioning stoma for colonic and perianal Crohn's disease in the biological era. Scand J Gastroenterol 2017; 52:251-256. [PMID: 27855530 DOI: 10.1080/00365521.2016.1205127] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A defunctioning stoma is a therapeutic option for colonic or perianal Crohn's disease. In the pre-biologic era the response rate to defunctioning in our unit was high (86%), but intestinal continuity was only restored in 11-20%. Few data exist on the outcome of defunctioning since the widespread introduction of biologicals. MATERIAL AND METHODS All patients undergoing a defunctioning stoma for colonic/perianal Crohn's disease since 2003-2011 were identified from a prospective database. Indications for surgery, medical therapy, response to defunctioning and long-term clinical outcome were recorded. Successful restoration of continuity was defined as no stoma at last follow up. RESULTS Seventy-six patients were defunctioned (57 with biologicals) and at last follow up, 20 (27%) had continuity restored. Early clinical response rate (<3 months) was 15/76 (20%) and overall response 31/76 (41%). Complex anal fistulae/stenosis were associated with a very low chance of restoring continuity (10% and 0%, respectively), while colitis was associated with a higher chance of restoring continuity (48%). Endoscopic or histological improvement in colitis after defunctioning was associated with a higher rate of restoring continuity (10/16, 63%) compared to no such improvement (4/15, 27%, p = 0.05). Those failing biologics had similar chance of restoration as those not receiving biologics, 15/57 (26%) and 5/19 (26%), respectively. CONCLUSION Overall response to colonic defunctioning was 41%. Successful restoration of continuity occurred in 27%, but 48% in the absence of perianal disease. Response is appreciably less in the pre-biologic era, so patient and physician expectations need to be managed appropriately.
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Affiliation(s)
- M Martí-Gallostra
- a Unit of Colorectal Surgery, Department of General Surgery , Hospital Universitari Vall Hebrón , Barcelona , Spain.,b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK
| | - P Myrelid
- b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK.,c Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences , Linköping University , Linköping , Sweden.,d Department of Surgery , County Council of Östergötland , Linköping , Sweden
| | - N Mortensen
- b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK
| | - S Keshav
- e Translational Gastroenterology Unit , Oxford University Hospitals , Oxford , UK
| | - S P L Travis
- e Translational Gastroenterology Unit , Oxford University Hospitals , Oxford , UK
| | - B George
- b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK
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