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La Tunisie Medicale Apr 2024Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab. (Review)
Review
INTRODUCTION
Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab.
AIM
Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab.
METHODS
A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded.
RESULTS
Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated.
CONCLUSION
Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.
Topics: Humans; Crohn Disease; Rectal Fistula; Infliximab; Treatment Failure; Gastrointestinal Agents
PubMed: 38746955
DOI: 10.62438/tunismed.v102i4.4699 -
Journal of Gastrointestinal Surgery :... Jan 2021
Topics: Cell Transformation, Neoplastic; Crohn Disease; Humans; Rectal Fistula
PubMed: 32378091
DOI: 10.1007/s11605-020-04631-5 -
Lancet (London, England) Sep 2016Complex perianal fistulas in Crohn's disease are challenging to treat. Allogeneic, expanded, adipose-derived stem cells (Cx601) are a promising new therapeutic approach.... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Complex perianal fistulas in Crohn's disease are challenging to treat. Allogeneic, expanded, adipose-derived stem cells (Cx601) are a promising new therapeutic approach. We aimed to assess the safety and efficacy of Cx601 for treatment-refractory complex perianal fistulas in patients with Crohn's disease.
METHODS
We did this randomised, double-blind, parallel-group, placebo-controlled study at 49 hospitals in seven European countries and Israel from July 6, 2012, to July 27, 2015. Adult patients (≥18 years) with Crohn's disease and treatment-refractory, draining complex perianal fistulas were randomly assigned (1:1) using a pre-established randomisation list to a single intralesional injection of 120 million Cx601 cells or 24 mL saline solution (placebo), with stratification according to concomitant baseline treatment. Treatment was administered by an unmasked surgeon, with a masked gastroenterologist and radiologist assessing the therapeutic effect. The primary endpoint was combined remission at week 24 (ie, clinical assessment of closure of all treated external openings that were draining at baseline, and absence of collections >2 cm of the treated perianal fistulas confirmed by masked central MRI). Efficacy was assessed in the intention-to-treat (ITT) and modified ITT populations; safety was assessed in the safety population. This study is registered with ClinicalTrials.gov, number NCT01541579.
FINDINGS
212 patients were randomly assigned: 107 to Cx601 and 105 to placebo. A significantly greater proportion of patients treated with Cx601 versus placebo achieved combined remission in the ITT (53 of 107 [50%] vs 36 of 105 [34%]; difference 15·2%, 97·5% CI 0·2-30·3; p=0·024) and modified ITT populations (53 of 103 [51%] vs 36 of 101 [36%]; 15·8%, 0·5-31·2; p=0·021). 18 (17%) of 103 patients in the Cx601 group versus 30 (29%) of 103 in the placebo group experienced treatment-related adverse events, the most common of which were anal abscess (six in the Cx601 group vs nine in the placebo group) and proctalgia (five vs nine).
INTERPRETATION
Cx601 is an effective and safe treatment for complex perianal fistulas in patients with Crohn's disease who did not respond to conventional or biological treatments, or both.
FUNDING
TiGenix.
Topics: Adipose Tissue; Adult; Aged; Combined Modality Therapy; Crohn Disease; Double-Blind Method; Europe; Evidence-Based Medicine; Female; Humans; Israel; Male; Mesenchymal Stem Cell Transplantation; Mesenchymal Stem Cells; Middle Aged; Rectal Fistula; Transplantation, Homologous; Treatment Outcome
PubMed: 27477896
DOI: 10.1016/S0140-6736(16)31203-X -
European Journal of Radiology Aug 2003Accurate preoperative assessment of fistula-in-ano is mandatory if the fistula is not to recur. In recent years, MRI has become pre-eminent for fistula assessment and... (Review)
Review
Accurate preoperative assessment of fistula-in-ano is mandatory if the fistula is not to recur. In recent years, MRI has become pre-eminent for fistula assessment and recent studies have shown that not only is MRI more accurate than surgical assessment, but that surgery based on MRI can reduce further disease recurrence by approximately 75%. The main role of MRI is to alert the surgeon to fistula tracks and extensions that would otherwise have gone undetected and, thus, untreated at the time of surgical assessment under general anaesthetic.
Topics: Anal Canal; Humans; Magnetic Resonance Imaging; Preoperative Care; Rectal Fistula
PubMed: 12880990
DOI: 10.1016/s0720-048x(03)00162-1 -
Radiology Apr 2006Fistula in ano is a common condition that often recurs despite seemingly adequate surgery, usually because of infection that was missed at surgery. It is now... (Review)
Review
Fistula in ano is a common condition that often recurs despite seemingly adequate surgery, usually because of infection that was missed at surgery. It is now increasingly recognized that preoperative imaging can help identify infection that would have otherwise gone unidentified. In particular, magnetic resonance (MR) imaging findings have been shown to influence surgery and markedly diminish the chance of recurrence; thus, preoperative imaging will become increasingly routine in the future. In this article, the authors describe the pathogenesis, classification, and imaging of fistula in ano, with an emphasis on MR imaging. Most important, the authors describe how the radiologist is well placed to answer the surgical riddles that must be solved for treatment to be effective.
Topics: Humans; Magnetic Resonance Imaging; Rectal Fistula; Ultrasonography
PubMed: 16567481
DOI: 10.1148/radiol.2391041043 -
Radiologic Clinics of North America Mar 2003The management of fistula-in-ano has been based on digital examination and operative findings. MR imaging has shown significant limitations to this approach,... (Review)
Review
The management of fistula-in-ano has been based on digital examination and operative findings. MR imaging has shown significant limitations to this approach, particularly in the management of recurrent fistula. The most cost-effective approach may be using a combination of endosonography and MR imaging. Preoperative confirmation of fistula complexity facilitates surgery planning of sphincter saving techniques and prevents sepsis being missed, which has been shown to reduce recurrence. Imaging has a significant role to play in this condition to improve patient outcome.
Topics: Anus Diseases; Endosonography; Humans; Magnetic Resonance Imaging; Radiography; Rectal Fistula
PubMed: 12659348
DOI: 10.1016/s0033-8389(02)00122-7 -
FP Essentials Apr 2014Anal fissures are linear splits in the anal mucosa. Acute fissures typically resolve within a few weeks; chronic fissures persist longer than 8 to 12 weeks. Most... (Review)
Review
Anal fissures are linear splits in the anal mucosa. Acute fissures typically resolve within a few weeks; chronic fissures persist longer than 8 to 12 weeks. Most fissures are posterior and midline and are related to constipation or anal trauma. Painful defecation and rectal bleeding are common symptoms. The diagnosis typically is clinical. High-fiber diet, stool softeners, and medicated ointments relieve symptoms and speed healing of acute fissures but offer limited benefit in chronic fissures. Lateral internal sphincterotomy is the surgical management of choice for chronic and refractory acute fissures. Anorectal fistula is an abnormal tract connecting the anorectal mucosa to the exterior skin. Fistulas typically develop after rupture or drainage of a perianal abscess. Fistulas are classified as simple or complex; low or high; and intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric. Inspection of the perianal area identifies the skin opening, and anoscopy visualizes internal openings. The goal of management is to obliterate the tract and openings with negligible sphincter disruption to minimize incontinence. Fistulotomy is effective for simple fistulas; patients with complex fistulas may require fistulectomy. Other procedures that are used include injection of fibrin glue or insertion of a bioprosthetic plug into the fistula opening.
Topics: Family Practice; Fissure in Ano; Humans; Laxatives; Rectal Fistula; Risk Factors
PubMed: 24742084
DOI: No ID Found -
Saudi Medical Journal Sep 2012To evaluate the recurrence and fecal incontinence of anal fistula plug versus conventional surgical treatment for anal fistulas. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the recurrence and fecal incontinence of anal fistula plug versus conventional surgical treatment for anal fistulas.
METHODS
This meta-analysis was carried out in the General Surgery Department of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China. We searched the Medline, EMBASE, and Cochrane Library from June 2011 to April 2012. The literature searches were carried out using medical subject headings and free-text word: anal fistula, fibrin adhesive, fibrin sealant, and fistula plug.
RESULTS
Two randomized controlled trials and 3 retrospective controlled studies were included. A total of 428 patients were included in our study. The recurrence rate was higher in those patients who accept fistula plug treatment (62.1% versus 47%) (p=0.004).
CONCLUSION
Anal fistula plug has a moderate probability of success with little risk of incontinence, but the recurrence rate is significantly higher than the conventional surgical treatment. This treatment is minimally invasive, repeatable, and sphincter-sparing. This meta-analysis failed to find a statistically significant difference in incontinence rate between conservative treatment and conventional surgical treatment.
Topics: China; Fecal Incontinence; Humans; Rectal Fistula
PubMed: 22964807
DOI: No ID Found -
Journal of Medical Imaging and... Aug 2011This essay illustrates the usefulness of MRI in evaluating perianal fistulas, a common disease, notorious for recurrence if not assessed and treated adequately. MRI... (Review)
Review
This essay illustrates the usefulness of MRI in evaluating perianal fistulas, a common disease, notorious for recurrence if not assessed and treated adequately. MRI exquisitely depicts the perianal anatomy and shows the fistulous tracks and their associated ramifications and abscesses. It thus provides an excellent preoperative understanding of the disease, enabling selection of the most appropriate surgical treatment and therefore minimising all chances of recurrence.
Topics: Humans; Magnetic Resonance Imaging; Rectal Fistula
PubMed: 21843174
DOI: 10.1111/j.1754-9485.2011.02268.x -
The Surgical Clinics of North America Jun 1978
Review
Topics: Abscess; Anus Diseases; Humans; Methods; Rectal Diseases; Rectal Fistula
PubMed: 354053
DOI: 10.1016/s0039-6109(16)41532-x