COMBINED SETON PLACEMENT, INFLIXIMAB INFUSION AND MAINTENANCE IMMUNOSUPPRESSIVES IMPROVES HEALING RATE IN FISTULIZING ANORECTAL CROHN'S DISEASE: A SINGLE CENTRE EXPERIENCE

D Topstad, R Panaccione, J Heine, D Johnson, A MacLean, D Buie

Departments of Medicine and Surgery, University of Calgary, Calgary, Alberta

PURPOSE: Infliximab (anti TNF a) has been used for the treatment of fistulizing Crohn's disease with variable efficacy. The aim of this study was to evaluate the efficacy of infliximab combined with selective seton drainage in the healing of fistulizing anorectal Crohn's disease.
METHODS: Retrospective chart review of all patients with fistulizing Crohn's disease treated with infliximab between 03/00-02/02.
RESULTS: 29 patients (12 males, mean age 31yr) received a mean of 3 (range 1-5) doses of infliximab 5mg/kg. 21 patients had perianal fistulas (PAF), 8 had rectovaginal fistulas (RVF), 4 with concomitant PAF. 14 of 21 patients (67%) with PAF had a complete response (mean follow-up 9 months), 4 of the 14 relapsed (mean 9 months) but all had a complete response to retreatment (mean 9 months). A partial response occurred in 4 patients (19%), defined by decreased drainage (2 patients) or infliximab dependence (2 patients) requiring repeated dosing every 6-8 weeks. 3 patients (14%) had no response. Seton drainage was used prior to infusion in 13 PAF patients for perianal infection and 17 were treated with maintenance azathioprine or methotrexate. Of 8 patients with RVF, complete response occurred in 1, partial response in 5 and 2 had no response. Two partial responders became infliximab dependent. A complete response was observed in 1 patient with isolated RVF, a partial response in 5. No patient with a combined RVF/PAF had a complete response. Five RVF patients were on maintenance immunosuppressive agents and 2 had Seton drainage prior to infusion.
CONCLUSIONS: Selective seton placement combined with infliximab infusion and maintenance immunosuppressives resulted in complete healing in 67% of Crohn's patients with PAF and partial healing in 19%. Relapse was successfully treated with repeat infusion. Concomitant RVF was a poor prognostic indicator for successful infliximab therapy.