Anti-TNF, surgical closure induces long-term healing in Crohn’s fistulas
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Short-term anti-tumor necrosis factor treatment combined with surgical closure induced long-term MRI healing in patients with Crohn’s perianal fistulas more frequently than anti-TNF therapy alone, according to research.
“Management [for Crohn's perianal fistulas] remains challenging and the most optimal treatment for Crohn’s high perianal fistulas with a single internal opening is still undetermined,” Elisa M. Meima-van Praag, MD, of the department of surgery at Amsterdam University Medical Center, and colleagues wrote in The Lancet Gastroenterology & Hepatology. “Guidelines on Crohn’s perianal fistulas recommend anti-TNF treatment and suggest considering surgical closure in patients with surgically amenable disease. However, long-term outcomes of these treatments have not been directly compared.”
Meima-van Praag and colleagues conducted a multicenter, patient-preference study in hospitals in the Netherlands and Italy to compare rates of radiological healing among 94 patients with CD and active high perianal fistula (median age, 33 years; 60% women). Participants received either anti-TNF therapy combined with surgical closure or anti-TNF treatment alone. Following physician counseling, 66% of patients chose a specific treatment pathway and 34% of patients underwent randomization between groups; 60% of patients entered the anti-TNF arm and 40% of patients entered the surgical closure arm.
The primary outcome was MRI-assessed radiological healing at 18 months; additional outcomes included clinical closure, reintervention rate, recurrence rate and quality of life impact as measured by the Perianal Disease Activity Index (PDAI). At the 18-month mark, 91% of patients in the anti-TNF arm underwent MRI, as did 84% of patients in the surgery arm.
Study results showed a higher percentage of patients who underwent surgery achieved radiological healing at 18 months compared with patients who received anti-TNF alone (32% vs. 9%; P = .005); there was no significant difference between groups for clinical closure rates (68% vs. 52%).
Further, fewer patients in the surgery group required reintervention compared with the anti-TNF group (13% vs. 43%; P = .005). Anti-TNF combined with surgical closure also yielded decreased PDAI score (1 vs. 4; P = .031).
“Short-term anti-TNF therapy combined with surgical closure induces radiological healing, assessed by MRI, more frequently than anti-TNF therapy,” Meima-van Praag and colleagues concluded. “On the basis of these data, we believe that patients with Crohn’s perianal fistula amenable for surgical closure should be counseled for this therapeutic approach.”
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Meima-van Praag E, et al. Lancet Gastroenterol Hepatol. 2022;doi:10.1016/S2468-1253(22)00088-7.
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