Department of General Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain.
J Crohns Colitis. 2011 Dec;5(6):598-607. doi: 10.1016/j.crohns.2011.06.004. Epub 2011 Jul 1.
Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies.
Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures.
Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation.
Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.
由于担心并发症、病情恶化和最终进行直肠切除术的风险，传统上，外科医生试图避免对患有复杂肛周疾病的克罗恩病患者进行任何复杂的手术。生物治疗的引入改变了克罗恩病的治疗方法。本研究评估了在接受抗 TNF-α 抗体治疗的患者中，针对肛门括约肌缺陷和复杂瘘管进行治疗的长期效果。
连续 10 例患者前瞻性地计划接受 5mg/kg 英夫利昔单抗诱导治疗，第 0、2 和 6 周，以及每 8 周维持治疗联合硫唑嘌呤。选择性手术采用同时处理括约肌缺陷和瘘管的方法。结果通过 Wexner 评分和补充问卷评估长期控便能力、并发症。采用重复测量的一般线性模型进行统计学分析。
3 例患者出现与手术相关的并发症：2 例脓肿和低位括约肌间瘘，1 例直肠狭窄导致粪便急迫。无缝合裂开。Wexner 评分在 12 个月时（10.0±2.4 比 18.0±2.6；p=0.003）和随时间推移时（48 个月时 9.5±2.8；p=0.001）改善。在治疗前有急迫症状的患者中，这些评分明显更差（12.8±1.2 比 9.5±2.8；p=0.03），而在急迫症状出现后则没有差异。没有患者对固体粪便失禁。3 例患者偶尔对液体粪便失禁，与疾病复发有关。
对于涉及括约肌缺陷和严重或难治性瘘管的克罗恩病失禁患者，手术修复和英夫利昔单抗免疫调节剂治疗可能是一种选择。
