PFCD: Are Outcomes Better With Combined Medical-Surgical Tx?

TOPLINE:

Antitumor necrosis factor (TNF) therapy alone yields outcomes comparable with those seen with anti-TNF therapy combined with surgery in patients with perianal fistulizing Crohn’s disease (PFCD), according to a meta-analysis.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis of 13 studies that included 1251 patients who received combination therapy of surgical intervention and anti-TNF therapy (n = 515), surgical intervention alone (n = 330), or anti-TNF therapy alone (n = 406).
• Combination therapy was defined as a local surgical intervention using examination under anesthesia with or without seton placement and anti-TNF therapy (defined as induction and maintenance with infliximab, adalimumab, certolizumab pegol, or golimumab).
• Co-primary outcomes were fistula response (defined as minimal fistula symptoms or a reduced number of draining fistulas, fistula drainage, or fistula discomfort) and fistula healing (defined as the complete closure of fistula tracts).

TAKEAWAY:

• The rates of fistula healing (P = .58) and response (P = .28) were not different among patients treated with combination therapy and those treated with anti-TNF therapy alone.
• Patients receiving combination therapy had a higher likelihood of achieving a fistula response (risk ratio [RR], 1.25; P = .0004) and a seemingly elevated fistula healing rate (RR, 1.17; P = .05) than those treated with surgical intervention alone; however, only three studies made this comparison.
• The rates of fecal diversion were similar between patients receiving combination therapy and those receiving anti-TNF therapy (P = .61) or surgical intervention (P = .86) alone.

IN PRACTICE:

“Perianal fistula response and healing in PFCD occurred more frequently in patients treated with combined surgical intervention and anti-TNF therapy compared with surgical intervention alone but not with anti-TNF therapy alone,” the authors wrote. “While these results suggest that combined modality therapy may not be universally required in all patients with PFCD, prospective controlled studies will be necessary to confirm these findings.”

SOURCE:

This study, led by Moses Fung, MD, Division of Gastroenterology and Hepatology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada, was published online in the Journal of Crohn’s and Colitis.

LIMITATION:

Many studies included in the meta-analysis were observational in nature, with few controlling for confounding factors, potentially introducing bias by indication. The study populations were small, so the generalizability of the findings may be limited. None of the studies used standardized examination under anesthesia protocols.

DISCLOSURES:

The study did not receive any funding. Two of the authors declared receiving research grants, consulting fees, and/or honoraria from various pharmaceutical companies.