Vuyyuru Sudheer K, Desai Devendra, Kedia Saurabh, Dhoble Pavan, Sahu Pabitra, Kante Bhaskar, Agarwal Samagra, Bopanna Sawan, Dhingra Rajan, Venigalla Pratap Mouli, Sharma Raju, Gupta Siddhartha Datta, Makharia Govind, Sahni Peush, Ahuja Vineet
Department of Gastroenterology All India Institute of Medical Sciences New Delhi India.
Department of Gastroenterology P. D. Hinduja National Hospital & Medical Research Centre Mumbai India.
JGH Open. 2021 Mar 26;5(4):420-427. doi: 10.1002/jgh3.12370. eCollection 2021 Apr.
Unlike perianal fistula, long-term outcomes of nonperianal fistulae (NPF) in Crohn's disease (CD) are not clear. We aimed to compare the outcomes of medical and surgical therapies in patients with NPF.
We retrospectively analyzed the records of patients of CD with NPF who were prospectively followed from January 2005 to December 2018.
Of the 53 patients with NPF [mean age at presentation:29 ± 14 years; 54.7% male; median duration of follow-up: 47 months (interquartile range [IQR]:26-76 months)], enteroenteric fistula (37.8%) was the most common presentation. Of 22 patients treated with anti-tumor necrosis factor (TNF) therapy, complete response was achieved in 40.9% ( = 9). Overall probability of maintaining response was similar between the anti-TNF and surgical groups (95.2% 82.4%; 71% 76%; and 63% 69%% [ = 0.8] at 1, 2, and 3 years, respectively), with only 13.6% of patients treated with biologicals requiring surgery over 56 months. Twenty-one patients required upfront surgery (small bowel or ileocolonic resection with/without diversion; 28.5% emergent), with 47.6% postoperative recurrence over 36 months, of which nine patients required biologicals (77.7% response to anti-TNF therapy). Long-term outcome was comparable between medically and surgically treated patients; 6.4% developed tuberculosis on anti-TNF therapy. Two patients (3.7%) developed malignancy (one - enteroenteric, one - colovesical).
Anti-TNF therapy appears to be as effective as surgery in this retrospective analysis of patients with NPFCD, and it may be indicated in the absence of abscess and other complications. These patients are at higher risk of fistula-associated malignancy, which requires a lower threshold for suspicion, especially over the long term in the presence of nonresponse to medical therapy.
与肛周瘘不同，克罗恩病（CD）中非肛周瘘（NPF）的长期预后尚不清楚。我们旨在比较NPF患者药物治疗和手术治疗的效果。
我们回顾性分析了2005年1月至2018年12月期间前瞻性随访的CD合并NPF患者的记录。
在53例NPF患者中（就诊时平均年龄：29±14岁；54.7%为男性；中位随访时间：47个月（四分位间距[IQR]：26 - 76个月）），肠-肠瘘（37.8%）是最常见的表现形式。在22例接受抗肿瘤坏死因子（TNF）治疗的患者中，40.9%（=9例）达到完全缓解。抗TNF治疗组和手术治疗组维持缓解的总体概率相似（分别在1年、2年和3年时为95.2%对82.4%；71%对76%；63%对69%[P = 0.8]），在56个月内，仅13.6%接受生物制剂治疗的患者需要手术。21例患者需要早期手术（小肠或回结肠切除伴或不伴改道；28.5%为急诊手术），36个月内术后复发率为47.6%，其中9例患者需要使用生物制剂（抗TNF治疗的缓解率为77.7%）。药物治疗和手术治疗患者的长期预后相当；6.4%的患者在抗TNF治疗期间发生结核病。2例患者（3.7%）发生恶性肿瘤（1例为肠-肠瘘，1例为结肠-膀胱瘘）。
在这项对NPF-CD患者的回顾性分析中，抗TNF治疗似乎与手术治疗效果相当，在无脓肿和其他并发症的情况下可考虑使用。这些患者发生瘘管相关恶性肿瘤的风险较高，需要提高怀疑阈值，尤其是在长期药物治疗无效的情况下。
