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Long-term outcomes in perianal fistulizing Crohn's disease in a resource-limited setting: A cohort analysis
Sudheer K Vuyyuru1, Pabitra Sahu1, Saurabh Kedia1
1Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
Insights
For Crohn's disease (CD) patients with perianal fistulas, medical therapies like immunomodulators and biologics offer better long-term outcomes than surgery. Absence of abscesses predicts successful fistula closure.
Area of Science:
- Gastroenterology
- Surgical Gastroenterology
- Inflammatory Bowel Disease Research
Background:
- Perianal fistula is a complex complication of Crohn's disease (CD).
- Treatment and long-term outcomes for fistulizing CD remain challenging.
- Understanding treatment responses is crucial for patient management.
Purpose of the Study:
- To evaluate treatment response rates for surgical and medical therapies in perianal fistulizing CD.
- To identify factors associated with long-term fistula closure.
- To describe complications and outcomes of various treatment modalities.
Main Methods:
- Retrospective analysis of prospectively followed patients with perianal fistulizing CD (2005-2018).
- Inclusion of 65 patients from an initial cohort of 807.
- Assessment of complete response rates for immunomodulators, fistula surgery, biologics, and diversion.
Main Results:
- Complete response rates varied: immunomodulators (25%), surgery (42.8%), biologics (39.5%), and diversion (45.4%).
- Fistula surgery had the highest relapse rate (52.6%).
- Absence of perianal abscess was linked to complete fistula closure; 4 patients died, and 1 developed malignancy.
Conclusions:
- Medical therapy, including immunomodulators and biologics, should be prioritized as first-line treatment for perianal fistulizing CD.
- Surgery provides temporary improvement but is associated with high relapse rates.
- Absence of perianal abscess is a significant predictor of long-term 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.
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