Document Detail


A randomized prospective trial of endoscopic ultrasound to guide combination medical and surgical treatment for Crohn's perianal fistulas.
MedLine Citation:
PMID:  18684178     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
AIMS: To prospectively determine if rectal endoscopic ultrasound (EUS) can guide combination medical and surgical therapy and improve outcomes for patients with perianal fistulizing Crohn's disease. METHODS: Ten patients with perianal Crohn's disease were prospectively enrolled in a randomized prospective pilot study. The patients were randomized to either the EUS cohort or the control group. All patients underwent a rectal EUS to delineate fistula anatomy followed by an examination under anesthesia by a colorectal surgeon with seton placement and/or incision and drainage, as indicated. The surgeon was blinded to the initial EUS results of patients in the control group. Medical treatment was maximized with 6-mercaptopurine (1.0-1.5 mg/kg) or azathioprine (2.0-2.5 mg/kg), ciprofloxacin (1,000 mg a day) or metronidazole (1,500 mg a day), and infliximab (5 mg/kg at 0, 2, and 6 wk and then every 8 wk). For patients in the control group, additional interventions (seton removal and repeat surgery) were at the discretion of the surgeon (without EUS guidance). Patients in the EUS cohort had EUS performed at weeks 22 and 38, with additional surgical interventions based on EUS findings. The primary end point was complete cessation of drainage at week 54. All patients had a repeat EUS performed at week 54 to determine the fistula status on EUS (secondary end point). The need for additional surgery was defined as a treatment failure. RESULTS: Ten patients were enrolled in the study. One of 5 (20%) in the control group and 4 of 5 (80%) in the EUS group had complete cessation of drainage. From the control group, 3 patients failed due to repeat surgery (2 for persistent/recurrent fistula and 1 for abscess), and 1 had a persistent drainage at week 54. In the EUS cohort, 1 patient had a recurrent abscess after his seton fell out prematurely. In the EUS cohort, the median time to cessation of drainage was 99 days, and the time to EUS evidence of fistula inactivity was 229 days. CONCLUSION: This pilot study suggests that using EUS to guide combination medical and surgical therapy for perianal fistulizing Crohn's disease improves the outcomes.
Authors:
Natalie M Spradlin; Paul E Wise; Alan J Herline; Roberta L Muldoon; Michael Rosen; David A Schwartz
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Publication Detail:
Type:  Comparative Study; Journal Article; Randomized Controlled Trial     Date:  2008-08-05
Journal Detail:
Title:  The American journal of gastroenterology     Volume:  103     ISSN:  1572-0241     ISO Abbreviation:  Am. J. Gastroenterol.     Publication Date:  2008 Oct 
Date Detail:
Created Date:  2008-10-15     Completed Date:  2008-10-28     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0421030     Medline TA:  Am J Gastroenterol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  2527-35     Citation Subset:  IM    
Affiliation:
Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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MeSH Terms
Descriptor/Qualifier:
Adult
Aged
Crohn Disease / complications*,  ultrasonography
Drainage / methods
Drug Therapy, Combination
Endosonography / methods*
Female
Follow-Up Studies
Gastrointestinal Agents / therapeutic use*
Humans
Male
Middle Aged
Prospective Studies
Rectal Fistula / etiology,  therapy*,  ultrasonography*
Severity of Illness Index
Treatment Outcome
Wound Healing / physiology
Chemical
Reg. No./Substance:
0/Gastrointestinal Agents

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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