Strategies and advances in the combined surgical management of perianal lesions in Crohn′s disease

doi:10.3969/j.issn.1009-976X.2023.04.013

Abstract

Abstract: Perianal fistulizing Crohn′s disease （PFCD） remains one of the greatest challenges in inflammatory bowel disease. Despite the development of new treatments, such as the introduction of newer biologics, including the most promising field of bone marrow mesenchymal stem cells, the most effective cure is still lacking. Surgery remains the predominant approach to PFCD and each treatment option is individualized according to the different patients. The endoscopic and surgical techniques, experienced surgeons, and multidisciplinary collaboration holds promisea brighter future for patients.

Key words: Crohn′s disease, anal fistula, surgery, progress

摘要： 瘘管型肛周克罗恩病（PFCD）的治疗仍然是炎性肠病中最大的挑战之一。尽管研发了一些新的治疗,例如引入生物疗法,包括最有前景的骨髓间充质干细胞领域,但仍然缺乏最有效的治愈的方法。外科手术仍然是PFCD的最主要方法,且每个治疗方案均根据不同患者采用的个性化治疗。内窥镜治疗技术的应用、经验丰富的外科医生、多学科的合作有望为患者带来更光明的未来。

关键词: 克罗恩病, 肛瘘, 手术治疗, 进展

CLC Number:

R656

YAO Xiao, GAO Jin-bo. Strategies and advances in the combined surgical management of perianal lesions in Crohn′s disease[J]. Lingnan Modern Clinics In Surgery, 2023, 23(04): 360-367.

姚潇, 高金波. 生物治疗联合外科治疗克罗恩病肛周病变的策略和进展[J]. 岭南现代临床外科, 2023, 23(04): 360-367.

References

[1] Feroz SH, Ahmed A, Muralidharan A, et al.Comparison of the efficacy of the various treatment modalities in the management of perianal Crohn′s fistula: a review[J]. Cureus, 2020, 12(12): e11882.
[2] Gecse K, Bemelman W, Kamm M, et al.A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn′s disease[J]. Gut, 2014, 63(9): 1381-1392.
[3] Sahnan K, Adegbola SO, Fareleira A, et al.Medical-surgical Combined Approach in Perianal Fistulizing Crohn′s Disease (CD): Doing it Together[J]. Curr Drug Targets, 2019, 20(13): 1373-1383.
[4] Geldof J, Iqbal N, LeBlanc JF, et al. Classifying perianal fistulising Crohn′s disease: an expert consensus to guide decision-making in daily practice and clinical trials[J]. Lancet Gastroenterol Hepatol, 2022, 7(6): 576-584.
[5] Meima-van Praag EM, van Rijn KL, Monraats MA, Buskens CJ, Stoker J. Magnetic resonance imaging after ligation of the intersphincteric fistula tract for high perianal fistulas in Crohn′s disease: a retrospective cohort study[J]. Colorectal Dis, 2021, 23(1): 169-177.
[6] Santillan CS, Huang C, Eisenstein S, et al.MRI of perianal Crohn disease: technique and interpretation[J]. Top Magn Reson Imaging, 2021, 30(1): 63-76.
[7] Ripollés T, Muñoz F, Martínez-Pérez MJ, et al.Usefulness of intestinal ultrasound in inflammatory bowel disease[J]. Radiologia (Engl Ed), 2021, 63(1): 89-102.
[8] Losco A, Viganò C, Conte D, et al.Assessing the activity of perianal Crohn′s disease: comparison of clinical indices and computer-assisted anal ultrasound[J]. Inflamm Bowel Dis, 2009, 15(5): 742-749.
[9] Bourikas LA, Koutroubakis IE.Anti-TNF and fistulizing perianal Crohn′s disease: use in clinical practice[J]. Curr Drug Targets, 2010, 11(2): 187-197.
[10] Gionchetti P, Dignass A, Danese S, et al.3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn′s Disease 2016: Part 2: Surgical Management and Special Situations[J]. J Crohns Colitis, 2017, 11(2): 135-149.
[11] Sordo-Mejia R, Gaertner WB.Multidisciplinary and evidence-based management of fistulizing perianal Crohn′s disease[J]. World J Gastrointest Pathophysiol, 2014, 5(3): 239-251.
[12] de Groof EJ, Sahami S, Lucas C, et al. Treatment of perianal fistula in Crohn′s disease: a systematic review and meta-analysis comparing seton drainage and anti-tumor necrosis factor treatment[J]. Colorectal Dis, 2016, 18(7): 667-675.
[13] Singh S, Murad MH, Fumery M, et al.Comparative efficacy and safety of biologic therapies for moderate-to-severe Crohn′s disease: a systematic review and network meta-analysis[J]. Lancet Gastroenterol Hepatol, 2021, 6(12): 1002-1014.
[14] Gisbert JP, Chaparro M.Anti-TNF Agents and New Biological Agents (Vedolizumab and Ustekinumab) in the Prevention and Treatment of Postoperative Recurrence After Surgery in Crohn′s Disease[J]. Drugs, 2023, 83(13): 1179-1205.
[15] Beelen EMJ, Nieboer D, Arkenbosch JHC, et al. Risk Prediction and Comparative Efficacy of Anti-TNF vs Thiopurines, for Preventing Postoperative Recurrence in Crohn′s Disease: A Pooled Analysis of 6 Trials [J]. Clin Gastroenterol Hepatol, 2022, 20(12): 2741-2752.e6.
[16] Lamb CA, Kennedy NA, Raine T, et al.British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults[J]. Gut, 2019, 68(Suppl 3): s1-s106.
[17] Cira K, Weber MC, Wilhelm D, et al.The Effect of Anti-Tumor Necrosis Factor-Alpha Therapy within 12 Weeks Prior to Surgery on Postoperative Complications in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis[J]. J Clin Med, 2022, 11(23): 6884.
[18] Moosvi Z, Duong J, Bechtold ML, Nguyen DL.Systematic review and meta-analysis: risks of postoperative complications with preoperative use of anti-tumor necrosis factor-alpha biologics in inflammatory bowel disease patients[J]. Eur J Gastroenterol Hepatol, 2021, 33(6): 799-816.
[19] Law CC, Bell C, Koh D, et al. Risk of postoperative infectious complications from medical therapies in inflammatory bowel disease [J]. Cochrane Database Syst Rev, 2020, 10(10): CD013256.
[20] Duijvestein M, Vos AC, Roelofs H, et al.Autologous bone marrow-derived mesenchymal stromal cell treatment for refractory luminal Crohn′s disease: results of a phase I study[J]. Gut, 2010, 59(12): 1662-1669.
[21] Forbes GM, Sturm MJ, Leong RW, et al.A phase 2 study of allogeneic mesenchymal stromal cells for luminal Crohn′s disease refractory to biologic therapy[J]. Clin Gastroenterol Hepatol, 2014, 12(1): 64-71.
[22] Lan N, Wu X, Shen B. Stem cell therapy: light in the tunnel for penetrating Crohn′s disease [J]. Gastroenterol Rep (Oxf), 2023, 11: goac085.
[23] García-Olmo D, García-Arranz M, Herreros D, et al.A phase I clinical trial of the treatment of Crohn′s fistula by adipose mesenchymal stem cell transplantation[J]. Dis Colon Rectum, 2005, 48: 1416-1423.
[24] Garcia-Olmo D, Herreros D, Pascual I, et al.Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial[J]. Dis Colon Rectum, 2009, 52(1): 79-86.
[25] Ciccocioppo R, Bernardo ME, Sgarella A, et al. Autologous bone marrow-derived mesenchymal stromal cells in the treatment of fistulising Crohn′s disease [J]. Gut.2011 Jun;60(6):788-798
[26] Kotze PG, Shen B, Lightner A, et al.Modern management of perianal fistulas in Crohn′s disease: future directions[J]. Gut, 2018, 67(6): 1181-1194.
[27] Panés J, García-Olmo D, Van Assche G, et al. Long-term Efficacy and Safety of Stem Cell Therapy (Cx601) for Complex Perianal Fistulas in Patients With Crohn′s Disease [J]. Gastroenterology, 2018, 154(5): 1334-1342.e4.
[28] Garcia-Olmo D, Gilaberte I, Binek M, et al.Follow-up Study to Evaluate the Long-term Safety and Efficacy of Darvadstrocel (Mesenchymal Stem Cell Treatment) in Patients With Perianal Fistulizing Crohn′s Disease: ADMIRE-CD Phase 3 Randomized Controlled Trial[J]. Dis Colon Rectum, 2022, 65(5): 713-720.
[29] Carvello M, Lightner A, Yamamoto T, et al.Mesenchymal Stem Cells for Perianal Crohn′s Disease[J]. Cells, 2019, 8(7): 764.
[30] Biancone L, Cretella M, Tosti C, et al.Local injection of infliximab in the postoperative recurrence of Crohn′s disease[J]. Gastrointest Endosc, 2006, 63(3): 486-492.
[31] Lorenzo-Zúñiga V, Boix J, Mañosa M, et al.Local injection of infliximab in symptomatic isolated mucosal lesions: a novel scenario for endoscopic therapy?[J]. Inflamm Bowel Dis, 2013, 19(4): E59-61.
[32] Teich N, Wallstabe I, Schiefke I.Topic infliximab injection for refractory rectal stenosis in Crohn′s disease: long-term follow-up in two patients[J]. Int J Colorectal Dis, 2017, 32(9): 1289-1294.
[33] Gareb B, Otten AT, Frijlink HW, et al.Review: Local Tumor Necrosis Factor-α Inhibition in Inflammatory Bowel Disease[J]. Pharmaceutics, 2020, 12(6): 539.
[34] Mennigen R, Laukötter M, Senninger N, Rijcken E. The OTSC(?) proctology clip system for the closure of refractory anal fistulas[J]. Tech Coloproctol, 2015, 19(4):241-246.
[35] 于飞鸿. 克罗恩病的内镜下治疗[J]. 中国实用儿科杂志, 2023, 38(4): 282-284.
[36] Venezia L, Michielan A, Condino G, et al.Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract[J]. World J Gastrointest Endosc, 2020, 12(2): 60-71.
[37] Lan N, Shen B.Endoscopic Stricturotomy with Needle Knife in the Treatment of Strictures from Inflammatory Bowel Disease[J]. Inflamm Bowel Dis, 2017, 23(4): 502-513.
[38] Feleshtynskiy Y, Mylianovska A, Pirogovsky V, Dyadyk O.Evaluation of the endoscopic treatment with topical prednisolone administration for intestinal strictures in Crohn′s disease[J]. Pol Przegl Chir, 2021, 94(1): 28-33.
[39] Loras C, Pérez-Roldan F, Gornals JB, et al.Endoscopic treatment with self-expanding metal stents for Crohn′s disease strictures[J]. Aliment Pharmacol Ther, 2012, 36(9): 833-839.
[40] Amrani L, Ménard C, Berdah S, et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization”[J]. Gastrointest Endosc, 2009, 69(7): 1282-1287.
[41] Lee MJ, Heywood N, Sagar PM, et al.Surgical management of fistulating perianal Crohn′s disease: a UK survey[J]. Colorectal Dis, 2017; 19(3): 266-273.
[42] Lichtenstein GR, Loftus EV, Isaacs KL, et al.ACG Clinical Guideline: Management of Crohn′s Disease in Adults[J]. Am J Gastroenterol, 2018, 113(4): 481-517.
[43] Bemelman WA, Warusavitarne J, Sampietro GM, et al.ECCO-ESCP Consensus on Surgery for Crohn′s Disease[J]. J Crohns Colitis, 2018, 12(1): 1-16.
[44] Tatli F, Bardakci O, Ozgonul A, et al.A new seton tightening method for anal fistula treatment: sailor′s knot[J]. Ann Ital Chir, 2021, 92: 201-205.
[45] Zhu P, Sun JF, Gu YF, et al.Combined therapy with early initiation of infliximab following drainage of perianal fistulising Crohn′s disease: a retrospective cohort study[J]. BMC Gastroenterol, 2022, 22(1): 15.
[46] Gu B, Venkatesh K, Williams AJ, et al.Higher infliximab and adalimumab trough levels are associated with fistula healing in patients with fistulising perianal Crohn′s disease[J]. World J Gastroenterol, 2022, 28(23): 2597-2608.
[47] Emile SH, Khan SM, Adejumo A, Koroye O.Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure[J]. Surgery, 2020, 167(2): 484-492.
[48] Stellingwerf ME, van Praag EM, Tozer PJ, et al. Systematic review and meta-analysis of endorectal advancement flap and ligation of the intersphincteric fistula tract for cryptoglandular and Crohn′s high perianal fistulas[J]. BJS Open, 2019, 3(3):231-241.
[49] Osterkamp J, Gocht-Jensen P, Hougaard K, Nordentoft T.Long-term outcomes in patients after ligation of the intersphincteric fistula tract[J]. Dan Med J, 2019, 66(4): A5537.
[50] Schwandner O.Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn′s disease[J]. Tech Coloproctol, 2013, 17(2): 221-225.
[51] Chase TJG, Quddus A, Selvakumar D, et al.VAAFT for complex anal fistula: a useful tool, however, cure is unlikely[J]. Tech Coloproctol, 2021, 25(10): 1115-1121.
[52] Cao D, Li W, Ji Y, et al.Efficacy and safety of FiLaC^TM for perianal fistulizing Crohn′s disease: a systematic review and meta-analysis[J]. Tech Coloproctol, 2022, 26(10): 775-781.
[53] Wilhelm A, Fiebig A, Krawczak M.Five years of experience with the FiLaC^TM laser for fistula-in-ano management: long-term follow-up from a single institution[J]. Tech Coloproctol, 2017, 21(4): 269-276.
[54] Yao YB, Xiao CF, Wang QT, et al.VAAFT plus FiLaC^TM: a combined procedure for complex anal fistula[J]. Tech Coloproctol, 2021, 25(8): 977-979.
[55] Yellinek S, Krizzuk D, Moreno Djadou T, et al.Endorectal advancement flap for complex anal fistula: does flap configuration matter?[J]. Colorectal Dis, 2019, 21(5): 581-587.
[56] Gaertner WB, Burgess PL, Davids JS, et al.Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula[J]. Dis Colon Rectum, 2022, 65(8): 964-985.
[57] Emile SH, Garoufalia Z, Aeschbacher P, et al.Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials[J]. Surgery, 2023, 174(2): 172-179.
[58] Vitton V, Gasmi M, Barthet M, et al.Long-term healing of Crohn′s anal fistulas with fibrin glue injection[J]. Aliment Pharmacol Ther, 2005, 21(12): 1453-1457.
[59] Grimaud JC, Munoz-Bongrand N, Siproudhis L, et al. Fibrin glue is effective healing perianal fistulas in patients with Crohn′s disease [J]. Gastroenterology, 2010, 138(7): 2275-2281, 2281.e1.
[60] Nasseri Y, Cassella L, Berns M, et al.The anal fistula plug in Crohn′s disease patients with fistula-in-ano: a systematic review[J]. Colorectal Dis, 2016, 18: 351-356.
[61] O′Riordan JM, Datta I, Johnston C, et al. A systematic review of the anal fistula plug for patients with Crohn′s and non-Crohn′s related fistula-in-ano[J]. Dis Colon Rectum, 2012, 55: 351-358.