Long-term outcomes of perianal fistulizing Crohn's disease in the biologic era.

Tanya Lee,Chamara Basnayake,Rodney Woods,William Connell,Steve Brown,Nik Sheng Ding,Mark Lust,Basil D'Souza,Shu Chen Wei,Michael A Kamm,Emily Wright,Sally Bell,Alexander Thompson,Ola Niewiadomski,Eric Yong

doi:10.1002/jgh3.12475

Abstract

Background and AimWhile the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn's disease (pfCD), loss of response is common. Previous studies suggest that patients who achieve radiological healing (with healing of underlying tracts on magnetic resonance imaging [MRI]) have a longer duration of response. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long‐term clinical outcomes between patients achieving MRI and clinical healing.MethodsA retrospective analysis of perianal fistulizing Crohn's patients treated at one specialist IBD unit was performed. Records were reviewed for patient demographics, disease history, clinical assessments, investigation results, and disease flares. Clinical remission was defined as closure of all baseline fistula openings. Radiological healing was defined as the absence of any T2‐hyperintense sinuses, tracts, or collections. The primary end‐point was rate of MRI healing. The secondary outcome was defined as flare‐free period (time between clinical or radiological healing and patients' first signs/symptoms requiring therapy escalation).ResultsA total of 93 patients were included, with a median follow‐up of 4.8 years (interquartile range, 2.4–6 years). Of 44 patients, 22 (50%) achieved clinical remission, while 15 of 93 (16%) achieved radiological healing. Of 22 patients, 10 (45%) with clinical remission had a subsequent disease flare (median time of 7 months) compared with 3 of 15 (20%) patients with MRI healing (median time of 3.6 years). Radiological healing was associated with a significantly longer flare‐free period (P = 0.01).ConclusionRadiological healing occurs less commonly but represents a deeper form of healing, associated with improved long‐term clinical outcomes.

Highlights

Perianal fistulizing Crohn’s disease remains a significant clinical challenge due to its prevalence,[1] debilitating symptoms, and effect on patient quality of life,[2] as well as relative treatment resistance.[3]
Current treatment regimens may result in clinical remission and, to a lesser degree, radiological healing in a smaller subset of patients
This study demonstrates that radiological healing is associated with a longer duration of response to biologics and may represent a more clinically accurate and meaningful end-point than clinical remission

Summary

Introduction

Perianal fistulizing Crohn’s disease (pfCD) remains a significant clinical challenge due to its prevalence,[1] debilitating symptoms, and effect on patient quality of life,[2] as well as relative treatment resistance.[3]. While the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn’s disease (pfCD), loss of response is common. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long-term clinical outcomes between patients achieving MRI and clinical healing. The secondary outcome was defined as flare-free period (time between clinical or radiological healing and patients’ first signs/symptoms requiring therapy escalation). Of 22 patients, 10 (45%) with clinical remission had a subsequent disease flare (median time of 7 months) compared with 3 of 15 (20%) patients with MRI healing (median time of 3.6 years). Conclusion: Radiological healing occurs less commonly but represents a deeper form of healing, associated with improved long-term clinical outcomes

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