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Long-Term Outcome of Enterocutaneous Fistula in Patients With Crohn's Disease Treated With Anti-TNF Therapy: A Cohort Study from the GETAID

Amiot, Aurelien MD1,13; Setakhr, Vida MD2,13; Seksik, Philippe MD, PhD3; Allez, Mathieu MD, PhD4; Treton, Xavier MD, PhD1; De Vos, Martine MD5; Laharie, David MD, PhD6; Colombel, Jean-Frederic MD, PhD7; Abitbol, Vered MD8; Reimund, Jean Marie MD, PhD9; Moreau, Jacques MD10; Veyrac, Michel MD11; Flourié, Bernard MD, PhD12; Cosnes, Jacques MD3; Lemann, Marc MD4; Bouhnik, Yoram MD, PhD1 and the GETAID

American Journal of Gastroenterology: September 2014 - Volume 109 - Issue 9 - p 1443–1449
doi: 10.1038/ajg.2014.183
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OBJECTIVES: Although anti-tumor necrosis factor (TNF) therapy is the treatment of choice for perianal fistulizing Crohn's disease (CD), the efficacy and safety of anti-TNF therapy in enterocutaneous fistula (ECF) remains unclear.

METHODS: Between January 2008 and December 2009, we retrospectively reviewed the outcomes of all CD patients with ECF (excluding perianal fistula) treated with anti-TNF therapy followed up in Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID) centers. ECF closure and tolerance of anti-TNF therapy were studied using univariate and multivariate analyses.

RESULTS: Forty-eight patients (twenty-six women; median age 34.6 (interquartile range=25.0–45.5) years) were included in this study. The median follow-up period was 3.0 (2.0–6.6) years. The fistula was located in the small bowel (n=38), duodenum (n=1), and colon (n=9). The fistula has been developed in ileocolonic anastomosis in 17 (35%) cases. Sixteen patients (33%) had complex fistulas with multiple tracts and eleven patients (23%) had a high ECF output (if wearing an ostomy bag). Complete ECF closure was achieved in 16 (33%) patients, of whom eight relapsed during the follow-up period. In multivariate analysis, complete ECF closure was associated with the absence of multiple ECF tracts and associated stenosis. An abdominal abscess developed in 15 (31%) patients. ECF resection was needed in 26 (54%) patients. One patient died after surgery owing to abdominal sepsis.

CONCLUSIONS: In CD patients with ECF, anti-TNF therapy may be effective in up to one-third of patients, especially in the absence of stenosis and complex fistula. A careful selection of patients is mandatory to prevent treatment failure and improves the safety.

1Department of Gastroenterology, Henri Mondor Hospital, UPEC, Creteil, France

2Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, University Paris 7 Denis Diderot, Clichy, France

3Department of Gastroenterology, Saint-Antoine Hospital, University Paris 6 Pierre and Marie Curie, Paris, France

4Department of Gastroenterology, Saint-Louis Hospital, University Paris 7 Denis Diderot, Paris, France

5Department of Gastroenterology, Gent Hospital, University of Gent, Gent, Belgium

6Department of Gastroenterology, Haut–Leveque Hospital, University of Bordeaux 2, Pessac, France

7Department of Gastroenterology, Claude Huriez Hospital, University of Lille 2, Lille, France

8Department of Gastroenterology, Cochin Hospital, University Paris 5 Descartes, Paris, France

9Department of Gastroenterology, Cote de Nacre Hospital, University of Caen, Caen, France

10Department of Gastroenterology, Rangueil University Hospital, University of Toulouse, Toulouse, France

11Department of Gastroenterology, Montpellier University Hospital, University of Montpellier, Montpellier, France

12Department of Gastroenterology, Edouard Herriot Hospital, University Lyon 1 Claude Bernard, Lyon, France

13These authors contributed equally to this work

Correspondence: Yoram Bouhnik, Department of Gastroenterology, IBD and Nutritional Support, Pôle des maladies de l’appareil digestif (PMAD), Beaujon University Hospital–APHP–Université Paris VII Denis Diderot, 100, Boulevard du général Leclerc, 92110 Clichy, France. E-mail: yoram.bouhnik@bjn.aphp.fr

SUPPLEMENTARY MATERIAL accompanies this paper at http://links.lww.com/AJG/A975

Received 06 January 2014; accepted 12 May 2014

Guarantor of the article: Yoram Bouhnik, MD, PhD.

Specific author contributions: Conception and design of the study: Y.B., M.L., V.S., and A.A.; generation, collection, assembly, and analysis and/or interpretation of data: A.A., V.S., J.C., J.M.R., and Y.B.; drafting or revision of the manuscript: A.A., V.S., J.C., J.M.R., and Y.B.; approval of the final version of the manuscript: A.A., V.S., P.S., M.A., X.T., M.D.V., D.L., J.-F.C., V.A., J.M.R., J.M., M.V., B.F., J.C., and Y.B.

Financial support: None

Potential competing interests: A.A. has received consulting fees from Abbvie and lecture fees and travel accommodation from Abbvie and MSD. P.S. has received consulting fees from Abbvie, MSD and Biocodex. M.A. has received consulting fees from Abbvie, UCB Pharma, and MSD. D.L. has received lecture, consulting and advisory board membership fees from Abbvie and MSD. J.F.C. has received consulting, and lecture fees from AbbVie, MSD, and UCB Pharma, financial support for research from Abbvie and UCB Pharma, and is a shareholder in Intestinal Biotech Development. B.F. has received lecture fees from MSD. J.C. has received consulting fee from Abbvie. Y.B. has received advisory board membership fee from Abbvie, MSD and lecture fee from Abbvie, and is a shareholder in Inception IBD, San Diego, CA, USA.

© The American College of Gastroenterology 2014. All Rights Reserved.
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