Original article
Alimentary tract
Long-term Outcome of Perianal Fistulizing Crohn's Disease Treated With Infliximab

https://doi.org/10.1016/j.cgh.2012.12.042Get rights and content

Background & Aims

Little is known about the long-term efficacy of infliximab for patients with fistulizing perianal Crohn's disease. We evaluated outcomes and predictors of outcomes in these patients.

Methods

The medical records of 156 patients treated with infliximab for fistulizing perianal Crohn's disease at 2 referral centers from 1999 through 2010 were reviewed through September 2011. Cumulative probabilities of fistula closure and recurrence were estimated by using the Kaplan–Meier method. Predictors of outcomes were identified by using a Cox proportional hazards model.

Results

When infliximab treatment began, only 17.9% of patients had a simple fistula; seton drainage was performed for 97 patients (62%). Concomitant immunosuppressants were given to 90 patients (56%). After a median follow-up period of 250 weeks, 108 patients (69%) had at least 1 fistula closure. Cumulative probabilities of first fistula closure were 40% and 65% at 1 and 5 years, respectively. Factors that predicted fistula closure were ileocolonic disease (hazard ratio [HR] = 1.88), concomitant immunosuppressants (HR = 2.58), duration of seton drainage <34 weeks (HR = 2.31), and long duration of infliximab treatment (HR = 1.76). Of the 108 patients with fistula closure, cumulative probabilities of first fistula recurrence were 16.6% and 40.1% at 1 and 5 years, respectively. Forty-four patients (28.9%) developed an abscess during follow-up. A number of infliximab infusions greater than 19 was associated with less abscess recurrence (HR = 0.33). At the maximal follow-up time, 55% of patients had fistula closure.

Conclusions

About two-thirds of patients with fistulizing perianal Crohn's disease had fistula closure, and one-third had fistula recurrence after infliximab initiation. Combination therapy, duration of seton drainage less than 34 weeks, and long-term treatment with infliximab were associated with better outcomes.

Section snippets

Study Population

All hospital records of consecutive adult patients (age >18 years) treated with IFX for CD in 2 French referral centers (University Hospitals of Rennes and Nancy, France) between January 1998 and September 2011 were reviewed. A centralized diagnostic index was used to identify all patients with diagnosis of CD. The database of these patients with CD was then compared with the pharmacy records of all patients treated with IFX at these 2 hospitals. All adult patients with documented PCD at first

Characteristics of the Population at Infliximab Initiation

A total of 156 CD patients were included. The baseline characteristics at first IFX infusion are listed in Table 1. Of these patients, 61 (39%) were male (Table 1). The median age at CD diagnosis was 24 years (IQR, 13–84), and the median duration of CD before IFX was 3.8 years (IQR, 1–8). According to the Montreal classification,24 15% of the patients were diagnosed with a penetrating complication (B3), and 45% of the patients had ileocolitis involvement (L3) at the time of diagnosis.

Baseline

Discussion

This is the largest study specifically investigating the long-term outcome of perianal fistulizing CD treated with IFX, with a median follow-up of 5 years. All patients were managed by 2 experienced proctologists (L.S., M.A.B.) according to international guidelines.14, 15

We found that the cumulative probability of first fistula closure was 33% at 1 year. These results are in line with those of the ACCENT II trial that evaluated maintenance IFX treatment until 1 year in fistulizing CD.12 In this

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    Conflicts of interest These authors disclose the following: Guillaume Bouguen has received lecture fees from Abbott Laboratories, Ferring, and MSD Pharma. Laurent Peyrin-Biroulet has received consulting and/or lecture fees from Merck, Abbott Laboratories, and UCB Pharma. Laurent Siproudhis has received lecture fees from Abbott Laboratories and MSD Pharma. Jean-François Bretagne has received lecture fees from Abbott Laboratories. The remaining authors disclose no conflicts.

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