Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors.
Perianal fistulizing Crohn's disease
fistulotomy
immunosuppressants
Journal
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland
ISSN: 1463-1318
Titre abrégé: Colorectal Dis
Pays: England
ID NLM: 100883611
Informations de publication
Date de publication:
Jan 2021
Jan 2021
Historique:
received:
21
12
2019
accepted:
21
06
2020
pubmed:
9
7
2020
medline:
19
8
2021
entrez:
9
7
2020
Statut:
ppublish
Résumé
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. 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). 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. 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.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
159-168Subventions
Organisme : MSD Life Science Foundation, Public Interest Incorporated Foundation
Organisme : Takeda Pharmaceutical Company
Informations de copyright
© 2020 Association of Coloproctology of Great Britain and Ireland.
Références
Ingle SB, Loftus EV. The natural history of perianal Crohn’s disease. Dig Liver Dis 2007; 39: 963-9.
Schwartz DA, Loftus EV, Tremaine WJ et al. The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 2002; 122: 875-80.
Mahadev S, Young JM, Selby W, Solomon MJ. Quality of life in perianal Crohn’s disease: what do patients consider important? Dis Colon Rectum 2011; 54: 579-85.
Tang LY, Rawsthorne P, Bernstein CN. Are perineal and luminal fistulas associated in Crohn’s disease? A population-based study. Clin Gastroenterol Hepatol 2006; 4: 1130-4.
Lapidus A. Crohn’s disease in Stockholm County during 1990-2001: an epidemiological update. World J Gastroenterol 2006; 12: 75-81.
Bouguen G, Siproudhis L, Gizard E et al. Long-term outcome of perianal fistulizing Crohn’s disease treated with infliximab. Clin Gastroenterol Hepatol 2013; 11: 975-81.e1-4.
Present DH, Rutgeerts P, Targan S et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999; 340: 1398-405.
Gecse KB, Bemelman W, Kamm MA et al. A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn’s disease. Gut 2014; 63: 1381-92.
Sands BE, Anderson FH, Bernstein CN et al. Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 2004; 350: 876-85.
Bessi G, Siproudhis L, Merlini l'Héritier A et al. Advancement flap procedure in Crohn and non-Crohn perineal fistulas: a simple surgical approach. Colorectal Dis 2019; 21: 66-72.
Senéjoux A, Siproudhis L, Abramowitz L et al. Fistula plug in fistulising ano-perineal Crohn’s disease: a randomised controlled trial. J Crohns Colitis 2016; 10: 141-8.
Panés J, García-Olmo D, Van Assche G et al. Long-term efficacy and safety of stem cell therapy (Cx601) for complex perianal fistulas in patients with Crohn’s disease. Gastroenterology 2018; 154: 1334-42. e4.
Bouchard D, Brochard C, Vinson-Bonnet B et al. How to manage anal ulcerations and anorectal stenosis in Crohn’s disease: algorithm-based decision making: French National Working Group Consensus 2018. Tech Coloproctol 2019; 23: 353-60.
Satsangi J, Silverberg MS, Vermeire S, Colombel J-F. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006; 55: 749-53.
Hughes LE. Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 1992; 35: 928-32.
Harvey RF, Bradshaw JM. A simple index of Crohn’s-disease activity. Lancet 1980; 1: 514.
Irvine EJ. Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 1995; 20: 27-32.
Williams JG, Rothenberger DA, Nemer FD, Goldberg SM. Fistula-in-ano in Crohn’s disease. Results of aggressive surgical treatment. Dis Colon Rectum 1991; 34: 378-84.
Papaconstantinou I, Kontis E, Koutoulidis V, Mantzaris G, Vassiliou I. Surgical management of fistula-in-ano among patients with Crohn’s disease: analysis of outcomes after fistulotomy or seton placement-single-center experience. Scand J Surg 2017; 106: 211-5.
Brochard C, Landemaine A, L’Heritier AM et al. Anal fistulas in severe perineal Crohn’s disease: Mri assessment in the determination of long-term healing rates. Inflamm Bowel Dis 2018; 24: 1612-8.
Schröder O, Blumenstein I, Schulte-Bockholt A, Stein J. Combining infliximab and methotrexate in fistulizing Crohn’s disease resistant or intolerant to azathioprine. Aliment Pharmacol Ther 2004; 19: 295-301.
Roumeguère P, Bouchard D, Pigot F et al. Combined approach with infliximab, surgery, and methotrexate in severe fistulizing anoperineal Crohn’s disease: results from a prospective study. Inflamm Bowel Dis 2011; 17: 69-76.
Topstad DR, Panaccione R, Heine JA, Johnson DRE, MacLean AR, Buie WD. Combined seton placement, infliximab infusion, and maintenance immunosuppressives improve healing rate in fistulizing anorectal Crohn’s disease: a single center experience. Dis Colon Rectum 2003; 46: 577-83.