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P304. Anti-TNF based treatment regimens (triple: anti-TNF, azathioprine, antibiotic vs double: anti-TNF, azathioprine or anti-TNF, antibiotic) on complex perianal fistula healing in Crohn's disease patients: a retrospective clinical data assessment

Y. Erzin1, I. Hatemi1, K. Ercaliskan1, D. Eyice1, B. Baca2, A.F. Celik1, 1Istanbul University Cerrahpasa Medical Faculty, Gastroenterology, Istanbul, Turkey, 2Istanbul University Cerrahpasa Medical Faculty, Surgery, Istanbul, Turkey

Background

CD patients with complex perianal fistulas who are not responsive and/or intolerant to solo or combined use of antibiotics (ABx) and azathioprine (AZA) so need addition of anti-TNFs in a step-up approach.

Methods

CD patients' charts between 1999–12 were reviewed. 53/638 (8%) CD patients with complex perianal fistulas were identified being treated with anti-TNFs that were not responsive and/or intolerant to solo or combined use of ABx and AZA. 14 patients were excluded for anti-TNF intolerance, insufficient data or being lost to follow-up. According to the patients' clinical response anti-TNF+AZA+ABx (triple Tx), or anti-TNF+AZA or ABx (double Tx) was applied. In case of medical Tx failure surgery was applied. At least 3 months under each Tx was the prerequisite condition for evaluating Tx success. Cessation of discharge, closure of external orifice was a partial, and additionally radiological disappearance of the fistula tract assessed by MRI between 3–6 months was the definite closure. Age, sex, disease duration, location, behaviour, rectal involvement, number of fistula, smoking, duration of Tx, type of surgery was noted. Each patient's last fistula status was determined as the primary endpoint and luminal activity was noted when available at that point of time.

Results

The mean age±SD at the last visit was 37±11 yr., and 15 of 39 (39%) being female, with a disease duration of 8.4±6.7 yr., and the mean follow-up time for fistulae being 31±27 months. 14/39 (36%) patients had one fistulae the remaining multiple, with maximum four. 24 patients (62%) were complicated by abscesses and loose seton placement was applied to 22 (56%), four of them had permanent setons for repeating abscesses. Ileostomy was performed in seven (18%) patients and fistula closure was achieved in only 3/7 (42%) between 2–5 months. 29 out of 39 (75%) had triple and the remaining 10 double Tx. 14/29 (48%) under triple and 7/10 (70%) under double Tx had a clinical fistula response, so 21/39 (54%) patients were in clinical remission but only four (10%) with radiological closure. No correlation was identified between disease location, duration, number of fistulas, and Tx modality and fistulae response.

Conclusion

This study stresses on anti-TNFs necessity for even small success of complex fistula closure. Clinical response was just 54%, and only 10% had radiological tract closure reaching our ultimate aim. Even in patients with an ileostomy on top of this Tx regimens only a minority could achieve this goal.