- Email: [email protected]
P415 Perianal complete remission after combined therapy with seton placement and anti-TNF therapy for Crohn's disease: results of a Brazilian multicenter observational study
S176 were described without sign of malignancy. Patient received local excision of vaginal and transsphinktar fistulas, abscess draining. The rectoscopy did not show any signs of inflammation or malignancy. In 07/2010 she was admitted again because of painful defecation and fistulas. The peritoneal adhaesiolysis, vaginal and omental plasty had to be performed this time. Histopathology showed the mucinous adenocarcinoma in the anal stenosis. pT4b pN0 L0 V0 Pn0 G2R1. Upon diagnosis, a second intervention was performed including the radical lymphadenectomy, rectum and sphincter extirpation. The radiation and chemotherapy followed. Following MRI-Scans did not display any signs of carcinoma recurrence as of today.
Figure 1. Adenocarcinoma.
Figure 2. Poorly differentiated adenocarcinoma.
Conclusions: We present a case of mucinous adenocarcinoma of a fistula tract thus to make surgeons and gastroenterologists aware of the cancer risk in patients with perianal CD. Reference(s) [1] Mpofu C, Watson AJ, Rhodes JM, (2004), Strategies for detecting colon cancer and/or dysplasia in patients with inflammatory bowel disease. Cochrane Database Syst Rev. [2] Moore-Maxwell CA, Robboy SJ, (2004), Mucinous adenocarcinoma arising in rectovaginal fistulas associated with Crohn’s disease. Gynecologic Oncology. [3] Sjodahl RI, Myrelid P, Soderholm JD, (2003), Anal and rectal cancer in Crohn’s disease, Colorectal Dis 5:490 495.
Poster presentations P415 Perianal complete remission after combined therapy with seton placement and anti-TNF therapy for Crohn’s disease: results of a Brazilian multicenter observational study P.G. Kotze1 *, I.C. Albuquerque2 , A.d.L. Moreira3 , C.R. Coy4 , W.B. Tonini1 , G.S. Formiga2 , R.F. Leal4 , M.d.L.S. Ayrizono4 , A.T.P. Carvalho5 , M. Olandoski6 , L.M.S. Kotze7 . 1 Catholic University of Parana, Colorectal Surgery Unit, Curitiba PR, Brazil, 2 Heli´ opolis Hospital, IBD clinics, S˜ ao Paulo SP, Brazil, 3 UERJ, Colorectal Surgery Unit, Rio de Janeiro RJ, Brazil, 4 Unicamp, Colorectal Surgery Unit, Campinas SP, Brazil, 5 UERJ, Gastroenterology Unit, Rio de Janeiro RJ, Brazil, 6 Catholic University of Parana, Statistics, Curitiba PR, Brazil, 7 Catholic University of Parana, Gastroenterology unit, Curitiba PR, Brazil Background: Perianal fistulizing Crohn’s disease (CD) is one of the most severe phenotypes of inflammatory bowel diseases (IBD). Combined therapy with examination under anesthesia, seton placement and anti-TNF therapy is the most common strategy for the management of this condition. There is scarce data regarding complete “healing” of the fistulae in these patients. The aim of this study was to analyze the rates of complete perianal remission after combined therapy for perianal fistulizing CD, as well as epidemiological characteristics of these patients. Methods: This was a retrospective observational study that included Brazilian patients with perianal fistulizing CD submitted to combined therapy with examination under anesthesia and seton placement followed by anti-TNF therapy, from 4 IBD referral centers, from January 2009 to June 2012. Electronic chart review was performed and data were inputed in a specific protocol. We analyzed patients’ demographic characteristics, Montreal classification, concomitant medication, type of biological agent, classification of the fistulae, occurrence of perianal complete remission, number of setons placed, timing of seton withdrawal and recurrence after remission. Complete perianal remission was defined as abscense of drainage from the fistula tracks associated with seton removal. Remission and recurrence rates were analyzed with confidence intervals (CI) of 95% and the timing of recurrence was analyzed in a Kaplan Meier curve. Results: A total of 78 patients were included, 44 females (55.8%) with a mean age of 33.8 (±15) years. Medium time of CD diagnosis was 88.9 (±76.8) months. Montreal Classification: age at diagnosis (A1 = 21.8%, A2 = 50% and A3 = 28.2%); disease location (L1 = 0%, L2 = 7.7%, L3 = 78.2% and L4 = 14.1%); disease phenotype (B3 in 100% of the cases). Azathioprine was used in combination with the anti-TNF agents in 76.6% of the cases, 66.2% of the patients were treated with Infliximab (IFX) and 33.8% with Adalimumab (ADA). Complex fistulae were found in 52/78 patients (66.7%). After a medium follow-up period of 48.2 months, 41/78 patients (52.6%) had complete perianal remission (95% CI: 43.5 63.6%). Recurrence occurred in 4 (9.8%) patients (95% CI: 0.7 18.8%) in an average period of 74.8 months. Conclusions: After combined surgery with seton placement and anti-TNF therapy, 52.6% of the patients had complete perianal remission an only 9.8% had recurrence. These results demonstrate the clear benefits of this approach in perianal fistulizing CD.
Figure 1. Adenocarcinoma.
Figure 2. Poorly differentiated adenocarcinoma.
Conclusions: We present a case of mucinous adenocarcinoma of a fistula tract thus to make surgeons and gastroenterologists aware of the cancer risk in patients with perianal CD. Reference(s) [1] Mpofu C, Watson AJ, Rhodes JM, (2004), Strategies for detecting colon cancer and/or dysplasia in patients with inflammatory bowel disease. Cochrane Database Syst Rev. [2] Moore-Maxwell CA, Robboy SJ, (2004), Mucinous adenocarcinoma arising in rectovaginal fistulas associated with Crohn’s disease. Gynecologic Oncology. [3] Sjodahl RI, Myrelid P, Soderholm JD, (2003), Anal and rectal cancer in Crohn’s disease, Colorectal Dis 5:490 495.
Poster presentations P415 Perianal complete remission after combined therapy with seton placement and anti-TNF therapy for Crohn’s disease: results of a Brazilian multicenter observational study P.G. Kotze1 *, I.C. Albuquerque2 , A.d.L. Moreira3 , C.R. Coy4 , W.B. Tonini1 , G.S. Formiga2 , R.F. Leal4 , M.d.L.S. Ayrizono4 , A.T.P. Carvalho5 , M. Olandoski6 , L.M.S. Kotze7 . 1 Catholic University of Parana, Colorectal Surgery Unit, Curitiba PR, Brazil, 2 Heli´ opolis Hospital, IBD clinics, S˜ ao Paulo SP, Brazil, 3 UERJ, Colorectal Surgery Unit, Rio de Janeiro RJ, Brazil, 4 Unicamp, Colorectal Surgery Unit, Campinas SP, Brazil, 5 UERJ, Gastroenterology Unit, Rio de Janeiro RJ, Brazil, 6 Catholic University of Parana, Statistics, Curitiba PR, Brazil, 7 Catholic University of Parana, Gastroenterology unit, Curitiba PR, Brazil Background: Perianal fistulizing Crohn’s disease (CD) is one of the most severe phenotypes of inflammatory bowel diseases (IBD). Combined therapy with examination under anesthesia, seton placement and anti-TNF therapy is the most common strategy for the management of this condition. There is scarce data regarding complete “healing” of the fistulae in these patients. The aim of this study was to analyze the rates of complete perianal remission after combined therapy for perianal fistulizing CD, as well as epidemiological characteristics of these patients. Methods: This was a retrospective observational study that included Brazilian patients with perianal fistulizing CD submitted to combined therapy with examination under anesthesia and seton placement followed by anti-TNF therapy, from 4 IBD referral centers, from January 2009 to June 2012. Electronic chart review was performed and data were inputed in a specific protocol. We analyzed patients’ demographic characteristics, Montreal classification, concomitant medication, type of biological agent, classification of the fistulae, occurrence of perianal complete remission, number of setons placed, timing of seton withdrawal and recurrence after remission. Complete perianal remission was defined as abscense of drainage from the fistula tracks associated with seton removal. Remission and recurrence rates were analyzed with confidence intervals (CI) of 95% and the timing of recurrence was analyzed in a Kaplan Meier curve. Results: A total of 78 patients were included, 44 females (55.8%) with a mean age of 33.8 (±15) years. Medium time of CD diagnosis was 88.9 (±76.8) months. Montreal Classification: age at diagnosis (A1 = 21.8%, A2 = 50% and A3 = 28.2%); disease location (L1 = 0%, L2 = 7.7%, L3 = 78.2% and L4 = 14.1%); disease phenotype (B3 in 100% of the cases). Azathioprine was used in combination with the anti-TNF agents in 76.6% of the cases, 66.2% of the patients were treated with Infliximab (IFX) and 33.8% with Adalimumab (ADA). Complex fistulae were found in 52/78 patients (66.7%). After a medium follow-up period of 48.2 months, 41/78 patients (52.6%) had complete perianal remission (95% CI: 43.5 63.6%). Recurrence occurred in 4 (9.8%) patients (95% CI: 0.7 18.8%) in an average period of 74.8 months. Conclusions: After combined surgery with seton placement and anti-TNF therapy, 52.6% of the patients had complete perianal remission an only 9.8% had recurrence. These results demonstrate the clear benefits of this approach in perianal fistulizing CD.