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Combined medical, surgical care plan improves outcomes in septic perianal Crohn's disease
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Researchers at Penn State have developed a combined medical and surgical care paradigm to guide the management of septic perianal Crohn’s disease and found that this protocol resulted in a 60% healing rate lasting at least 6 months.
“What we did with this study is look at a combined medical and surgical protocol for managing this problem, recognizing that there’s a role for the medicines and there’s a role for the surgery,” Walter A. Koltun, MD, FACS, FASCRS, professor of surgery at Penn State College of Medicine, said in a press release. “Although this is acknowledged by most surgeons and gastroenterologists, no one had written down a protocol to follow that is predictable in its outcome.”
Septic perianal Crohn’s disease was usually treated surgically before Remicade (infliximab, Janssen) was introduced in 1998, and while early studies showed up to a 60% response rate to the drug, only 25% of patients had continued healing after 1 year, according to the press release.
“What was thought to be a silver bullet of sorts for this problem really is not,” Koltun said.
He and colleagues therefore developed a decision tree describing surgical options for fistulas that do not respond to medical treatment and their chances for healing. Then they performed a retrospective chart review of 114 patients who had 135 episodes of septic perianal Crohn’s disease treated between 1990 and 2015 using this combined medical and surgical protocol (mean follow-up, 77 months).
Complete healing lasting at least 6 months occurred in 59.3% of the episodes, with comparable healing rates between patients on and off anti-TNFs (60.4% vs. 56.8%). Women were especially likely to experience healing among patients on anti-TNFs (63.6% vs. 25%; P = .0005).
Among the patients who did not achieve complete healing, 19.3% required a total proctocolectomy or completion proctectomy, and the remainder experienced some improvement but did not have complete healing.
Koltun hopes this care plan will improve treatment consistency “in a way that then allows the physician and the patient some confidence in regard to the outcome,” he said in the press release. “Our protocol provides a paradigm for when you perhaps should stop the drug and when to consider surgery with or without medication.”
The researchers also performed a genetic analysis of 185 single-nucleotide polymorphisms (SNPs) associated with Crohn’s disease in 78 of the patients, aiming to determine if any were predictive of healing. No SNPs were significantly associated with healing, but multivariate analyses suggested several SNPs identified in previous studies may have possible associations with healing in septic perianal Crohn’s disease.
“We’re gaining some sense of confidence that there are a certain number of genes that, if adversely affected, predispose patients toward having this problem and possibly not healing well,” Koltun said in the press release. – by Adam Leitenberger
Disclosures: The researchers report no relevant financial disclosures.
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