Sudheer K Vuyyuru1, Pabitra Sahu1, Saurabh Kedia1, Bhaskar Kante1, Peeyush Kumar1, Mukesh Kumar Ranjan1, Raju Sharma2, Govind Makharia1, S D Gupta3, Peush Sahni4, Vineet Ahuja5. 1. Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India. 2. Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. 3. Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India. 4. Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India. 5. Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India. vineet.aiims@gmail.com.
Abstract
BACKGROUND: Perianal fistula is one of the most challenging complications of Crohn's disease (CD). We aimed to describe treatment response with surgical and medical therapies, and long-term complications. METHODS: We retrospectively analyzed records of patients with perianal fistulizing CD who were prospectively followed from January 2005 to December 2018. RESULTS: Among 807 patients, 81 (10%) had perianal fistula and 65 were included in the final analysis. The mean age of presentation was 27.4 ± 10.3 years, and 78.5% were males with a median duration of follow-up of 45 (IQR, 24-66) months. 75.4% (n = 49) had complex fistulae. 55.4% (n = 36) of patients received multiple courses (> 5 courses) of antibiotics. Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively. The relapse rate was highest after fistula surgery (52.6%). 44.6% of patients received medical (immunomodulators-21 and biologicals-8) whereas 46.1% received surgery as the first-line therapy. The absence of perianal abscess was associated with complete fistula closure. One patient developed malignancy and 4 (6.1%) died at the end of follow-up. Among the patients (n = 28) who received biologicals, TB reactivation occurred in one patient (3.5%). CONCLUSION: Medical therapy should be offered as first-line therapy, and immunomodulators can be considered when patients cannot afford biologicals. Surgery offers temporary improvement and is associated with high relapse rates. Absence of perianal abscess predicts long-term complete fistula closure.
BACKGROUND: Perianal fistula is one of the most challenging complications of Crohn's disease (CD). We aimed to describe treatment response with surgical and medical therapies, and long-term complications. METHODS: We retrospectively analyzed records of patients with perianal fistulizing CD who were prospectively followed from January 2005 to December 2018. RESULTS: Among 807 patients, 81 (10%) had perianal fistula and 65 were included in the final analysis. The mean age of presentation was 27.4 ± 10.3 years, and 78.5% were males with a median duration of follow-up of 45 (IQR, 24-66) months. 75.4% (n = 49) had complex fistulae. 55.4% (n = 36) of patients received multiple courses (> 5 courses) of antibiotics. Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively. The relapse rate was highest after fistula surgery (52.6%). 44.6% of patients received medical (immunomodulators-21 and biologicals-8) whereas 46.1% received surgery as the first-line therapy. The absence of perianal abscess was associated with complete fistula closure. One patient developed malignancy and 4 (6.1%) died at the end of follow-up. Among the patients (n = 28) who received biologicals, TB reactivation occurred in one patient (3.5%). CONCLUSION: Medical therapy should be offered as first-line therapy, and immunomodulators can be considered when patients cannot afford biologicals. Surgery offers temporary improvement and is associated with high relapse rates. Absence of perianal abscess predicts long-term complete fistula closure.
Authors: Wing Yan Mak; Oi Sze Mak; Choon Kin Lee; Whitney Tang; Wai Keung Leung; Marc T L Wong; Alex Shun Fung Sze; Michael Li; Chi Man Leung; Fu Hang Lo; Belsy C Y Lam; Kam Hon Chan; Edwin Hok Shing Shan; Steven Woon Choy Tsang; Aric J Hui; Wai Hung Chow; Francis K L Chan; Joseph J Y Sung; Siew C Ng Journal: J Crohns Colitis Date: 2018-11-28 Impact factor: 9.071