Abstract
During infliximab treatment of perianal Crohn’s disease (CD), the healing of the skin opening precedes fistula tract healing and this contributes to abscess formation and fistula recurrence. The aims of this study were to evaluate the efficacy of combined treatment with infliximab and setons for complex perianal fistulas in CD and to define the optimal time for seton removal by anal endosonography (AE). Nine consecutive patients with CD were studied. Perianal sepsis was eradicated when necessary and setons were placed before infliximab therapy. Setons were removed after AE evidence of fistulous tracts healing. Patients received a mean of 10±2.3 infliximab infusions. At week 6 all patients showed a reduction in mean CD activity index (p<0.005) and perianal disease activity index (p<0.0001). Complete fistula response was achieved in eight of nine patients. In six patients after a mean of 9.2 infusions, infliximab treatment was discontinued. Clinical and AE response persisted at 19.4±8.8 months (range 3–28 months) in five of these patients. One patient had fistula recurrence 20 weeks after infliximab discontinuation and responded rapidly to retreatment. At the time of this report, two patients were still on infliximab and in remission after a mean follow-up of 25±5 months. Combined therapy with infliximab and setons with AE monitoring of the response showed high efficacy in the management of patients with CD with complex perianal fistulas.
References
Schwartz DA, Loftus EV, Tremaine WJ et al (2002) The natural history of fistulizing Crohn’s disease in Olmsted Country, Minnesota. Gastroenterology 122:875-80
Ardizzone S, Bianchi Porro G (2007) Perianal Crohn’s disease: overview. Dig Liver Dis 39:957-58
Ingle SB, Loftus EV Jr (2007) The natural history of perianal Crohn’s disease. Dig Liver Dis 39:963-69
Singh B, George BD, Mortensen NJ (2007) Surgical therapy of perianal Crohn’s disease. Dig Liver Dis 39:988-92
Sandborn WJ, Fazio VW, Feagan BG et al (2003) AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508-530
Griggs L, Schwartz DA (2007) Medical options for treating perianal Crohn’s disease. Dig Liver Dis 39:979-87
Present DH, Rutgeerts P, Targan S et al (1999) Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398-405
Sands BE, Anderson FH, Bernstein CN et al (2004) Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 350:876-85
Rutgeerts P, Feagan BG, Lichtenstein GR et al (2004) Comparison of scheduled and episodic treatment strategies of infliximab in Crohn’s disease. Gastroenterology 126:402-13
Van der Hagen SJ, Baeten CG, Soeters PB et al (2005) Anti-TNF-alpha (infliximab) used as induction treatment of active proctitis in a multistep strategy followed by definitive surgery of complex anal fistulas in Crohn’s disease: a preliminary report. Dis Colon Rectum 48:758-67
Poggioli G, Laureti S, Pierangeli F et al (2005) Local injection of infliximab for the treatment of perianal Crohn’s disease. Dis Colon Rectum 48:768-74
Schroder O, Blumenstein I, Schulte-Bockholt A et al (2004) Combining infliximab and methotrexate in fistulizing Crohn’s disease resistant or intolerant to azathioprine. Aliment Pharmacol Ther 19:295-01
Ochsenkuhn T, Goke B, Sackmann M (2002) Combining infliximab with 6-mercaptopurine/azathioprine for fistula therapy in Crohn’s disease. Am J Gastroenterol 97:2022-025
Baert F, Noman M, Vermeire S et al (2003) Influence of immunogenicity on the long-term efficacy of infliximab in Crohn’s disease. N Engl J Med 348:601-08
Bell SJ, Halligan S, Windsor AC et al (2003) Response of fistulating Crohn’s disease to infliximab treatment assessed by magnetic resonance imaging. Aliment Pharmacol Ther 17:387-93
Ardizzone S, Maconi G, Colombo E et al (2004) Perianal fistulae following infliximab treatment: clinical and endosonographic outcome. Inflamm Bowel Dis 10:91-6
Regueiro M, Mardini H (2003) Treatment of perianal fistulizing Crohn’s disease with infliximab alone or as an adjunct to exam under anesthesia with seton placement. Inflamm Bowel Dis 9:98-03
Talbot C, Sagar PM, Johnston MJ et al (2005) Infliximab in the surgical management of complex fistulating anal Crohn’s disease. Colorectal Dis 7:164-68
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula in ano. Br J Surg 63:1-2
Cho DY (1999) Endosonographic criteria for an internal opening of fistula-in-ano. Dis Colon Rectum 42:515-18
Best WR, Becktel JM, Singleton JW et al (1976) Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology 70:439-44
Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 20:27-2
Schwartz DA, Wiersema MJ, Dudiak KM et al (2001) A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology 121:1064-072
Felt-Bersma RJ (2006) Endoanal ultrasound in perianal fistulas and abscesses. Dig Liver Dis 38:537-43
Ardizzone S, Maconi G, Cassinotti A (2007) Imaging of perianal Crohn’s disease. Dig Liver Dis 39:970-78
van Bodegraven AA, Sloots CE, Felt-Bersma RJ et al (2002) Endosonographic evidence of persistence of Crohn’s disease-associated fistulas after infliximab treatment, irrespective of clinical response. Dis Colon Rectum 45:39-5
Rasul I, Wilson SR, MacRae H et al (2004) Clinical and radiological responses after infliximab treatment for perianal fistulizing Crohn’s disease. Am J Gastroenterol 99:82-8
Van Assche G, Vanbeckevoort D, Bielen D et al (2003) Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn’s disease. Am J Gastroenterol 98:332-39
Topstad DR, Panaccione R, Heine JA et al (2003) Combined seton placement, infliximab infusion, and maintenance immuno-suppressives improve healing rate in fistulizing anorectal Crohn’s disease: a single center experience. Dis Colon Rectum 46:577-83
Schwartz DA, White CM, Wise PE et al (2005) Use of endoscopic ultrasound to guide combination medical and surgical therapy for patients with Crohn’s perianal fistulas. Inflamm Bowel Dis 11:727-32
Hyder SA, Travis SP, Jewell DP et al (2006) Fistulating anal Crohn’s disease: results of combined surgical and infliximab treatment. Dis Colon Rectum 49:1837-841
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Guidi, L., Ratto, C., Semeraro, S. et al. Combined therapy with infliximab and seton drainage for perianal fistulizing Crohn’s disease with anal endosonographic monitoring: a single-centre experience. Tech Coloproctol 12, 111–117 (2008). https://doi.org/10.1007/s10151-008-0411-0
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DOI: https://doi.org/10.1007/s10151-008-0411-0