Timothée Wallenhorst

Long-term Outcome of Perianal Fistulizing Crohn's Disease Treated With Infliximab

BACKGROUND & AIMS Little is known about the long-term efficacy of infliximab for patients with fistulizing perianal Crohns disease. We evaluated outcomes and predictors of outcomes in these patients. METHODS The medical records of 156 patients treated with infliximab for fistulizing perianal Crohns disease at 2 referral centers from 1999 through 2010 were reviewed through September 2011. Cumulative probabilities of fistula closure and recurrence were estimated by using the Kaplan-Meier method. Predictors of outcomes were identified by using a Cox proportional hazards model. RESULTS When infliximab treatment began, only 17.9% of patients had a simple fistula; seton drainage was performed for 97 patients (62%). Concomitant immunosuppressants were given to 90 patients (56%). After a median follow-up period of 250 weeks, 108 patients (69%) had at least 1 fistula closure. Cumulative probabilities of first fistula closure were 40% and 65% at 1 and 5 years, respectively. Factors that predicted fistula closure were ileocolonic disease (hazard ratio [HR] = 1.88), concomitant immunosuppressants (HR = 2.58), duration of seton drainage <34 weeks (HR = 2.31), and long duration of infliximab treatment (HR = 1.76). Of the 108 patients with fistula closure, cumulative probabilities of first fistula recurrence were 16.6% and 40.1% at 1 and 5 years, respectively. Forty-four patients (28.9%) developed an abscess during follow-up. A number of infliximab infusions greater than 19 was associated with less abscess recurrence (HR = 0.33). At the maximal follow-up time, 55% of patients had fistula closure. CONCLUSIONS About two-thirds of patients with fistulizing perianal Crohns disease had fistula closure, and one-third had fistula recurrence after infliximab initiation. Combination therapy, duration of seton drainage less than 34 weeks, and long-term treatment with infliximab were associated with better outcomes.

Anorectal stricture in 102 patients with Crohn's disease: natural history in the era of biologics.

The natural history of nonfistulising perianal Crohns disease (PCD) remains unknown.

Long-term impact of full-thickness rectal prolapse treatment on fecal incontinence

BACKGROUND Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse. OBJECTIVE We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse. DESIGN A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010). MAIN OUTCOME MEASURES Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score. RESULTS Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017). LIMITATIONS Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias. CONCLUSION Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies.

Magnetic resonance imaging and clinical assessments for perianal Crohn's disease: Gain and limits

BACKGROUND Assessment of perianal Crohns disease remains challenging. European Crohns and Colitis Organisation (ECCO) recommend magnetic resonance imaging (MRI) as a gold standard, but both accuracy and advantages remain limited compared to systematic clinical assessment. The aim of this study was to define their actual diagnostic value. METHODS We performed a retrospective analysis of a prospective database of consecutive patients with perianal Crohns disease assessed by magnetic resonance imaging and clinical examination from 2006 to 2012. At each outpatient visit, perianal activity (Perianal Disease Activity Index) and perianal phenotype (Cardiff-Hughes classification) were noted. MRI was interpreted according to Cardiff-Hughes and Van Assche classifications. RESULTS Overall, 122 combined evaluations were assessed in 70 patients. Radiological imaging failed to show superficial ulcerations in 20/21 patients (95%) and severe ulcerations in 13/15 patients (87%). It consistently failed to diagnose anal stenosis (n=21, 100%). For fistulising lesions, the global agreement between the two methods was 71/122 (58%) in assessing complex fistulas. Clinical assessment underestimated 44/68 (65%) of multiple or ramified fistula tracts. Clinical examination failed to diagnose half of the radiological abscesses. CONCLUSIONS Current ECCO guidelines should be applied with some caution because of the low sensitivity of MRI for the diagnosis of non-fistulising perianal disease. Combining clinical and MRI assessments improves diagnostic accuracy.

Small-bowel video capsule endoscopic findings of Cronkhite-Canada syndrome

Cronkhite-Canada syndrome (CCS) is a rare, non-familial disorder characterized by multiple gastrointestinal polyps and ectodermal changes. This article presents the first small-bowel video sequences of CCS using video capsule endoscopy (VCE).

Outcomes of Perianal Fistulising Crohn’s Disease Following Anti-TNFα Treatment Discontinuation

Background Discontinuation of antitumour necrosis factor (TNF)α therapy with perianal fistulising Crohns disease remains controversial due to the risk of severe relapse without any clear evidence. Aim The aim of this study was to assess the rate and type of perianal and luminal relapses following anti-TNFα discontinuation. Methods All patients treated with anti-TNFα for perianal fistulising Crohns disease with subsequent discontinuation of therapy were retrospectively reviewed from a prospective database (1998-2016). Cumulative probabilities of relapse-free survival were estimated by actuarial analysis. Results After a median follow-up of 62 months, 24 of the 45 patients experienced perianal relapse. A new surgical drainage was needed in 19 (79%) patients. The cumulative probabilities of perianal relapse at 1 and 5 years were 24% and 55%, respectively. Ileal localization (L1) at diagnosis, persistence of an external fistula opening, second line anti-TNFα use, or prior dose optimization was associated with perianal relapse, whereas continuation of immunosuppressive agents decreased this risk (HR = 0.3). Luminal relapse occurred in 42% of patients at 5 years. The cumulative probability of global relapse at 5 years was 67%. Retreatment with anti-TNFα allowed further remission in 23 of 24 (96%) patients. Conclusion Half of patients with perianal fistulising Crohns disease relapse within 5 years after anti-TNFα discontinuation. Immunosuppressant continuation may decrease this risk. The high risk of relapse (perianal and luminal) may suggest a benefit in pursuing biologics over a longer period in patients with perianal fistulas.

Advancement flap procedure in Crohn and non-Crohn perineal fistulas: a simple surgical approach

Rectal flap advancement is still a part of therapeutic management of anal fistulas. Data on the outcome of rectal flap advancement in patients with Crohns disease (CD) is scarce. Our objective was to ascertain rates of failure of rectal flap advancement and to determine predictive factors for failure, with a special focus on CD

Anal ulcerations in Crohn's disease: Natural history in the era of biological therapy

BACKGROUND The natural history of anal ulcerations in Crohns disease remains unknown. AIMS To assess the long-term outcomes of anorectal ulcerations. METHODS Data from consecutive patients with perineal Crohns disease were prospectively recorded. The data of patients with anal ulceration were extracted. RESULTS Anal ulcerations were observed in 154 of 282 patients (54.6%), and 77 cases involved cavitating ulcerations. The cumulative healing rates were 47%, 70% and 82% at 1, 2 and 3 years, respectively. Patients with a primary fistula phenotype had a shorter median time to healing of their anal ulceration (28 [13-83] weeks) than those with a stricture (81 [28-135] weeks) or those with isolated ulceration (74 [31-181] weeks) (p=0.004). Among patients with ulcerations but no fistula at referral (n=67), only 4 (6%) developed de novo abscesses and/or fistula during follow-up. There was no benefit associated with introducing or optimising biologics, nor with combining immunosuppressants and biologics. CONCLUSION Anal ulceration in Crohns disease usually requires a long time to achieve sustained healing. Determining the impact of biologics on healing rates will require dedicated randomised trials although it does not show a significant healing benefit in the present study.

Chronic hepatic cytolysis revealing a pheochromocytoma

We report here the first case of chronic cytolysis that led to the diagnosis of pheochromocytoma, in a 48-year-old woman with a recent onset of hypertension. The etiological research ruled out the common causes of raised transaminase levels, and led to the discovery of a left adrenal pheochromocytoma. The sustained normalization of liver function tests after the removal of the tumour strongly suggests that hepatocyte injury was due to catecholamine hyperproduction. The present original clinical case, linking pheochromocytoma and liver dysfunction, raises important mechanistic questions concerning the relationship between catecholamines and liver function. It may also have clinical implications. Indeed, pheochromocytoma should be considered as a possible cause in case of unexplained transaminase increase associated with the recent onset of hypertension.