André da Luz Moreira

Combined Therapy With Surgery and Anti-TNF Therapy for Perianal Crohnʼs Disease: Seton Withdrawal Timing Data From a Brazilian Case Series: P-111

BACKGROUND: Perianal fistulizing Crohn’s disease (CD) is one of the most severe phenotypes of inflammatory bowel diseases (IBD). Combined therapy with examination under anesthesia, seton placement and anti-TNF therapy is the most common strategy for the management of this condition. There is still lack of data regarding the proper timing of seton withdrawal after induction therapy with anti-TNF agents, and the criteria for its determination is undefined. The aim of this study was to analyze the timing of seton withdrawal in a Brazilian case series of perianal fistulizing CD patients. METHODS: This was a retrospective observational study that included Brazilian patients with perianal fistulizing CD submitted to combined therapy with examination under anesthesia and seton placement followed by anti-TNF therapy, from 4 IBD referral centres, from January 2009 to June 2012. Electronic chart review was performed and data were inputted in a specific protocol. We analyzed patients’ demographic characteristics, Montreal classification, concomitant medication, type of biological agent, classification of the fistulae, occurrence of perianal complete remission, number of setons placed and timing of seton withdrawal. Complete perianal remission was defined as absence of drainage from the fistula tracks without after seton removal. RESULTS: A total of 78 patients were included, 44 females (55.8%) with a mean age of 33.8 (615) years. Medium time of CD diagnosis was 88.9 (676.8) months. Montreal Classification: age at diagnosis (A1 1⁄4 21.8%, A2 1⁄4 50% e A3 1⁄4 28.2%); disease location (L1 1⁄4 0%, L2 1⁄4 7.7%, L3 1⁄4 78.2% e L4 1⁄4 14.1%); disease phenotype (B3 in 100% of the cases). Azathioprine was used in combination with the anti-TNF agents in 76.6% of the cases, 66.2% of the patients were treated with Infliximab (IFX) and 33.8% with Adalimumab (ADA). Complex fistulae were found in 52/78 patients (66.7%). Medium follow-up period was 48.2 months, and 52,6% of the patients had complete perianal remission. The average number of setons placed was 2 (61.4) per patient, ranging from 1 to 7. Seton withdrawal occurred in 51 patients (65.3%), performed in an average period of 7.3 (66,4; 1 to 36) months. CONCLUSION(S): After combined surgery with seton placement and anti-TNF therapy, approximately 2/3 of the patients had their setons removed in this study, and the average period for the withdrawal was 7.3 months. There is still unclear criteria for the definition of the proper timing for seton withdrawal with the aim of perianal complete remission, and an individualized approach is recommended.