jcoloproctol(rioj).2015;35(4):238–239
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Letter
to
the
Editor
Fistulazing
perianal
Crohn’s
disease
–
update
and
new
ongoing
treatments
DearEditor,
Perianalinvolvementisoneofthemostimportant manifes-tationsofCrohn’sdisease (CD),andit affectsupto30–40% ofthese patients.Usually,CD affectsyoungpatients andit isassociatedtohighmorbidityand negativeimpactinthe qualityoflife.Theclinicaltreatmenthasbeenimprovedin the last decade withthe largeuse ofimmunosuppressant drugsandtheadventofmonoclonalantibodies,suchasthe anti-TNF-␣(anti-tumornecrosisfactoralfa).Thebestresults
inthetreatmentofperianal CDdependontheappropriate drugmanagement and surgicalapproach.1 Theboundaries
betweenmedicaltreatment,whichinvolvesthemanagement ofincreasingly specific drugs, and surgeryare noteasy to establish.Theassociationofbothisbetterthanisolated thera-pies,mainlyforcomplexfistulazingperianalCD.Thisisdueto thefactthatCDisachronic,recurrentdiseasewhoseetiology isnotfullyelucidated.Forthisreason,surgicalindicationsare restrictedtothetreatmentofthedisease’scomplicationsand itsclinicalintractability.
About 70–80%ofpatients willundergo asurgical proce-dureduringtheirfollow-up,andperianalsurgicalprocedures are part ofthose surgeries. Thesurgery does not promote thecureofthediseaseandthereforethedecisiontooperate canbedifficultanddependsonthesurgeon’sexperiencein handlingthistypeofcondition.Bestclinicalmanagementhas influencedthetimingofsurgicalindication,delayingoreven avoidingit.However,itisstillaconflictingissueand more prospectivestudiesarerequired.RelapseofCDaftersurgery may occur in patients considered to be high risk, such as beingyoungattheonsetofthedisease,smokinghabits, fam-ilyhistoryofCD,andfistulizingphenotype.Inthissense,the decisionforsurgerydependsontheaggressivenessofthe peri-analCDandtheconcomitantinvolvementofthecolonand/or smallintestine.Furthermore,itisimportanttoestablishCD phenotypes,whichcanbeinflammatory,stenoticand/or fis-tulizing.Thefistulizingformofthediseaseisrelatedtohigher incidenceofrecurrenceandindicatesitsprogression.
Indicationforsurgery,concerningperianalCD,includesthe presenceofabscesses andfistulasthat remain activeeven withtheuseofimmunosuppressantand/orbiologicaltherapy.
Preoperative imagingstudies, such as magnetic resonance imaging(MRI)oftheanalcanaland/orendoanal ultrasonogra-phy,canhelpidentifyabscesseswhicharesometimessmaller anddeeper,butsymptomatic.Theycanalsodelimitthe loca-tionoftheabscessesinrelationtotheanalsphinctersandthe involvedportionoftheanalcanal.2Additionally,theseexams
allow the identification of the course of perianal fistulas, showingthedegreeofinvolvementofthesphinctermuscles. Endoanalultrasonographyislimitedincasesofsevere steno-sisoftheanalcanal,whichmakesitimpossibletointroduce thedevice.
Perinealexaminationunderanesthesiaandsurgical proce-duresshouldconsistofdrainingabscessesandexplorationof fistulasbyplacingseton,whichcanremainforalongperiod. Fistulotomywithoutrepairsshouldberestrictedtovery shal-low paths that donot compromise the sphincter muscles. Another option toconsider isthe endorectal advancement flap, which hasbeen used inthe treatment ofcomplex or recurrentfistulas,and healingisobservedin60–70%ofCD patients.3
TheuseoffibringlueinthetreatmentofCDperianalfistula showedefficacyinthetreatmentofcomplexfistulas,butno advantagesinthecaseofsimplefistulaswhencomparedto conventionaltreatment.4Fibringlueseemstobelesseffective
inpatientswithCD,butiswelltoleratedandhasaminimal riskprofile,andcouldbeusedtoavoidfurthersurgeryoras analternativetolong-termsetonplacement.Thefistulaplug isanothertreatmentoptionthathasbeenstudiedfor peri-anal fistula.Itis aportionoflyophilized porcineintestinal submucosaandactsasacollagenscaffold,whichisfilledby endogenous cells.Reportedhealingrateswere54.3% inCD patientsatfollow-upbetween3and24months,whichdidnot differfrompatientswithoutCD.Theextrusionoftheplugis themainreasonforsecondaryfailureofthistechnique.5
Mesenchymalstemcell(MSC)therapyforCDrepresentsa promisingstrategyandhasbeenstudiedforluminaldisease.6
jcoloproctol(rioj).2015;35(4):238–239
239
induction of remission in perianal fistulizing CD, and the estimatedprimarycompletiondateisthe beginningofthe nextyearwithpromisingresults.Themainadvantageofthis techniqueisthe sphincterpreservation, avoidingrepairsor fistulotomy.
Not infrequently, perianal fistulas are accompanied by extensive CD involvement of the rectum, which can lead toloss ofthe rectumand anal canal, exhausting eventhe bestinclinicaltherapy,requiringproctectomyandpermanent ostomy.
Insummary,perianalCDisacommonmanifestationofthe diseaseandifitisconcomitanttorectallesions,theclinical andsurgicalmanagementmaybecomecomplex.Despiteall developeddrugsandnewsurgicaltechniques,thereisafailure ratethatisnotnegligible.Somecelltherapies,suchasMSCs, andnewdrugsthatactuponotherspecificimmunetargets maybepromisingtreatmentsforcomplexand/orrecurrent fistulazingCDinthefuture.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1.RegueiroM,MardiniH.Treatmentofperianalfistulizing Crohn’sdiseasewithInfliximabaloneorasanadjuncttoexam underanesthesiawithsetonplacement.InflammBowelDis. 2003;9:98–103.
2.SpinelliA,DeCassanC,SacchiM,BazziP,DaneseS,MalesciA, etal.ImagingmodalitiesforperianalCrohn’sdisease.Curr DrugTargets.2012;13:1287–93.
3.SoltaniA,KaiserAM.Endorectaladvancementflapfor cryptoglandularorCrohn’sfistula-in-ano.DisColonRectum. 2010;53:486–95.
4.LindseyI,Smilgin-HumphiesMM,CunninghamC,Mortensen NJ,GeorgeBD.Arandomizedcontroltrialoffibringlueversus conventionaltreatmentforanalfistula.DisColonRectum. 2002;45:1608–15.
5.O’RiordanJM,DattaI,JohnstonC,BaxterNN.Asystematic reviewoftheanalfistulaplugforpatientswithCrohn’sand non-Crohn’srelatedfistula-in-ano.DisColonRectum. 2012;55:351–8.
6.RicartE,Jauregui-AmezagaA,OrdásI,PinóS,RamírezAM, PanésJ.CelltherapiesforIBD:whatworks?CurrDrugTargets. 2013;14:1453–9.
RaquelF.Leala,∗, MuktaKraneb
aUniversidadeEstadualdeCampinas,SãoPaulo,SP,Brazil
bUniversityofChicago,Chicago,UnitedStates
∗Correspondingauthor.
E-mail:[email protected](R.F.Leal).
Received17August2015 Accepted28August2015
http://dx.doi.org/10.1016/j.jcol.2015.08.001
