Perineal Crohn Research Articles

TOpClass Class 4 Perineal Crohn's Disease: A Systematic Review and Meta-analysis of Perineal Wound Complication After Proctectomy in Crohn's Patients.

Nonhealing perineal wounds have been reported to be common after proctectomy for Crohn's disease (CD). We performed a systematic review and meta-analysis of perineal wound healing after proctectomy for CD and assessed the risk factors for nonhealing. A comprehensive literature search was conducted in PubMed, Embase, and Scopus databases from 2010 to 2023, and articles reporting perineal wound healing rates after proctectomy for CD were included. Data on study characteristics and proportion of healed wounds, and risk factors, were extracted. Random-effects meta-analysis was performed to estimate the pooled proportion and 95% CIs using the "meta" package in R. Heterogeneity was assessed using the I2 statistic. We identified 501 articles, of which 252 remained after de-duplication. After screening, 4 retrospective cohort studies involving 333 patients were included. Across the 4 studies, the pooled proportion of completely healed perineal wounds at 6 months was 65% (95% CI 52%-80%), and 70% (95% CI 60%-83%) at 12 months. Significant heterogeneity was found between studies (I2 = 86% at 6 months). Three studies examined risk factors for impaired healing after proctectomy. One study identified preoperative perineal sepsis as the only independent factor associated with impaired healing (P = .001) on multivariable analysis. In 1 study, male sex, shorter time from diversion to proctectomy, and higher preoperative C-reactive protein levels were all associated with delayed healing in univariate analysis. Another study found that close rectal dissection was associated with significantly lower healing rates than total mesorectal excision (P = .01). Prior use of tumor necrosis factor inhibitors was not associated with wound healing outcomes. This meta-analysis revealed complete perineal healing in only 70% of patients 12 months after proctectomy for CD. This highlights knowledge gaps, including the identification of modifiable risk factors and methods for preventing or as rescue therapy, such as vacuum-assisted closure and flap reconstruction, for nonhealing perineal wounds after proctectomy for CD. Poor perineal wound healing outcomes are likely related to imperfectly understood underlying inflammatory dysregulation and systemically impaired wound healing in patients with CD.

Effectiveness of Immunomodulators in Perineal Crohn's Disease: Moroccan Experience and Literature Review

We describe the evolution of patients with perineal Crohn's disease (PCD) treated with immunomodulators (IM): the purine anti-metabolites or methotrexate (MTX) in the absence of biotherapy. This was a retrospective descriptive study including all patients with (PCD) treated with (IM) and who cannot get biotherapy. The evaluation of the response was based on clinical response and / or morphology. Overall, 62 patient were under (IM). a good result was observed in 63% with complete healing in 79.2% and a partial response in 20.8%. The response time was variable with a median of 4 [2-24] months. Our study shows that despite the progress of biotherapy, the purine anti-metabolites retain their place in the treatment of Crohn's disease in general and in (PCD) more specifically.

Indications and Results of Endoanal Ultrasonography in Anal Pathology

Anal disease encompasses a diverse array of disorders, including conditions such as sphincter defects, anorectal fistulas and abscesses, unexplained chronic anal pain. The objective of this study is to assess the diagnostic value of endoscopic ultrasound (EUS) in the context of anal diseases. A total of 58 patients who benefited from an EUS, over a period between January 2018 and april 2023. Mean age was 43,4 years with a sex ratio (M: F) of 0.4. The main indication for EUS is dominated by fecal incontinence (FI) in 53% of patients, followed by the anoperineal manifestations of Crohn's disease in 22%. Among patients with perineal Crohn's disease (CD), fistulas were observed in 47% of CD cases. anovaginal or rectovaginal fistulas (ARVFs) were visualized in 9% of all cases. In patients presenting with fecal incontinence (FI), EUS identified defects in the internal and external anal sphincters. EUS is a highly sensitive technique for assessing anal anatomy and diagnosing of anal diseases.

Regenerative Therapy with Autologous Stromal Vascular Fraction Derived Mesenchymal Stem Cells and Platelet-Rich Plasma to Treat Complex Perianal Diseases

Abstract Background The high recurrence rate of surgically treated anal fistula remains a concern in proctology. Aims This study investigated the healing rate of complex anal fistula procedures supplemented by regenerative therapy with autologous stromal vascular fraction derived mesenchymal stem cells and platelet-rich plasma (SVF-PRP). Methods Consecutive patients with complex anal fistula were prospectively assessed by a validated incontinence questionnaire and MRI 4 and 12 months after surgery. Fistula were drained with setons prior to definitive surgery. SVF was harvested from subcutaneous abdominal fat and PRP from peripheral blood. Distal fistulectomy to the sphincter was performed and the wound left open, while the internal orifice was closed. SVF-PRP was injected around the fistula. Patients showered their excision wound until dry. Outcomes were reported as median & interquartile range (IQR). Results 40 patients (23 males : 17 females) were included from December 2019 to December 2022. Age was 40 years (IQR 30-53). Five patients (12.5%) suffered from perineal Crohn's disease and 3 had a rectovaginal fistula (7.5%). Patients had 2 prior fistula surgeries (IQR 1-3) and SVF-PRP fistula repair was performed 8 months (IQR 5-22.5) after initial diagnosis. Operation time was 82 minutes (IQR 73-95). Five patients were discharged on the day of surgery, 32 on postoperative day 1, and 3 on postoperative day 2. Follow up was 12 months (IQR 6-16). There was no deterioration in fecal continence. Two out of 40 patients (5%) experienced an early failure within 2 months of SVF PRP. All other patients were back to work and leisure. At 4 months of follow-up, 34/40 (85%) patients were clinically well with no active fistula. Of 30 patients who reached 12 months follow-up, 5 had an active fistula in MRI (16%) or on clinical ground. Conclusions SVF-PRP is a safe and promising addition to the broad armentarium of treatments for complex perianal fistula.

Predictive Factors of a New Episode of Suppuration after Remission of Fistulizing Ano Perineal Crohn's Disease: A Moroccan Series

Fistulizing ano-perineal lesions occur in more than 20% of patients with Crohn's disease (CD). Although many medical and surgical treatments are now available, the relapse rate of such lesions remains high at nearly 30%. The objective of this study was to identify factors predictive of a new episode of anal suppuration in patients with fistulizing ano-perineal CD initially put into remission. This was a retrospective single-center study that included between 2018 and 2022 all patients with CD complicated by ano-perineal fistula put into remission. Achievement of remission was defined by the absence of new suppuration within 3 months of the last drainage surgery. Fifty-seven patients (57% female; median age at drainage 31 years) with multiple episodes of suppuration were included consecutively during the period. The rate of new ano-perineal suppuration was 22%, which occurred within a median of 1.8 years. Actuarially, survival without new suppuration was 96.7% at 1 year, 78.4% at 3 years, and 74.4% at 5 years. In the 38 (66.6%) patients receiving anti-TNF therapy after drainage, colonic (OR 1.25, p = 0.015) or ileocolic (OR 5.16, p = 0.015) location of CD, stenosing luminal phenotype (OR 5. 32, p = 0.013) and discontinuation of anti-TNF therapy during follow-up (OR 3.37, p = 0.049) were associated with an increased risk of a new suppurative episode in multivariate analysis. Conversely, discontinuation of conventional immunosuppressive therapy was associated with a reduced risk of a new episode of suppuration (OR 0.22, p = 0.29).

Three-dimensional modelling as a novel interactive tool for preoperative planning for complex perianal fistulas in Crohn's disease.

The aim of this study is to demonstrate the added value of three-dimensional (3D) reconstruction models and artificial intelligence for preoperative planning in complex perianal Crohn's disease. MRI is the gold standard for diagnosis of complex perianal fistulas and abscess due to its high sensitivity, but it lacks high specificity values. This creates the need for better diagnostic models such as 3D image processing and reconstruction (3D-IPR) with artificial intelligence (AI) algorithms. This is a prospective study evaluating the utility of 3D reconstruction models from MRI in four patients with perineal Crohn's disease (pCD). Four pCD patients had 3D reconstruction models made from pelvic MRI. This provided a more visual representation of perianal disease and made possible location of the internal fistula orifice, seton placement in fistula tracts and abscess drainage. Three-dimensional reconstruction in CD-associated complex perianal fistulas can facilitate disease interpretation, anatomy and surgical strategy, potentially improving preoperative planning as well as intraoperative assistance. This could probably result in better surgical outcomes to control perianal sepsis and reduce the number of surgical procedures required in these patients.

Impact on Quality of Life of Seton Placing in Perianal Crohn's Disease

IntroductionOften, in perineal Crohn's disease (CD), a seton is placed to guarantee a constant drainage and prevent septic complication while biologic therapy is ongoing. This study aimed to assess the long-term quality of life after surgery for perineal CD in relation to seton placing.Patients and MethodsData of 65 consecutive patients with CD and non-CD operated on from 2014 to 2019 for perianal fistula or abscess were retrieved. Forty-three had CD and 14 of them had a seton placed during surgery and they kept it on while they had anti-TNF-alpha therapy. Patients were interviewed with the Cleveland Global Quality of Life (CGQL) and SF-12 quality of life questionnaires. Disease activity was defined as Harvey-Bradshaw Index (HBI) and Perianal Disease Activity Index (PDAI). Comparisons between groups were carried out with the nonparametric tests, and multiple regression models were used to assess predictors of quality of life.ResultsThe total CGQL score and SF-12 mental component score (MCS) were significantly higher (and thus better) in the seton group than in patients treated without seton. On the contrary, SF-12 physical component score (PCS) was not different between the two groups. HBI was significantly better in patients in the seton group. At multivariate analysis, seton placement and HBI were confirmed to be independent predictors of long-term SF-12 MCS whereas only HBI confirmed to be a predictor of total CGQL score.ConclusionsSeton placing during anti-TNF-alpha therapy is independently associated with a better MCS. Unexpectedly, this device, instead of to cause psychological distress, seems to assure patients during their biologic therapy providing psychological benefit beyond the mere medical effect.

P245 Evaluation of quality of life in patients with perineal Crohn’s disease: a monocentric Tunisien study

Abstract Background Perianal manifestations of Crohn’s disease considerably affects the life quality of patients. This study aims to assess the quality of life of patients with perineal Crohn’s disease by using the SIBDQ (Short Inflammatory Bowel Disease Questionnaire) and to evaluate its correlation with the Perineal Disease Activity Index (PDAI). Methods We retrospectively reviewed the medical records of patients with perineal Crohn’s disease between January 2018 and December 2020. Patients with active luminal disease were not included in this study (Crohn’s Disease Activity Index (CDAI) > 150). All participants answered the SIBDQ. Active perineal disease was defined as a PDAI > 7. We studied the correlation between SIBDQ and PDAI. Patients were divided into 2 groups according to the duration of the disease greater or less than 5 years. SIBDQ and PDAI were compared between the 2 groups. Results We included 52 patients with a mean age of 37 years (range: 17–62 years). There were 34 males (65.4%) and 18 females (34.6%). Crohn’s disease has been diagnosed for 7.6 years in average (range 2–19 years). The PDAI varied from 1 to 15 (average=7) and the SIBDQ ranged from 11 to 66 (average= 41). The SIBDQ was inversely correlated to the PDAI with a Pearson’s correlation coefficient equal to -0.885 (p=0.01). Indeed, the SIBDQ score for patients with an active perineal disease was significantly lower than those with inactive one (28.3 ± 11.6 vs. 50.1 ± 7.7; p< 0.0001), which indicates a worse life quality. Comparing the 2 groups, there were no significant differences in terms of age, gender and PDAI. The SIBDQ was lower in patients who had the disease for more than 5 years compared to the other ones (38.3 ±15.6 vs.48.2 ± 7.5; p=0.003). Conclusion The quality of life for patients with perineal Crohn’s disease seems to be altered by both activeness and duration of the disease. The SIBDQ is a simple tool that helps physicians detect patients with poor life quality. Other studies are necessary to validate this questionnaire for the evaluation of the quality of life in patients with perineal Crohn’s disease.

Differential Diagnosis Between Perianal Crohn's Disease and Hidradenitis Suppurativa: A Challenging Teamwork.

Hidradenitis suppurativa (HS) is a rare, debilitating skin disease characterized by the presence of recurrent tender subcutaneous nodules that develop into abscesses and fistulae. Isolated perineal Crohn's disease (CD) is unusual, diagnosis can be difficult, and distinction from HS is a challenge for the gastroenterologist. The aim of this work was to determine the criteria that distinguish perineal CD from perineal HS. Four patients with isolated perineal CD and three with perineal HS were included. Rectal or skin biopsies of all CD patients showed granulomas. No granulomas were found for HS. Fistulae were present in 4/4 CD, extended to the anal canal. All patients with HS had gluteal abscesses. They were bilateral in all cases, superficial. Perineal lesions management should involve a multidisciplinary approach in order to make an accurate diagnosis and ultimately to give the best and most effective treatment.

Predictors of Perianal Fistula Relapse in Crohn’s Disease

Despite an optimal medico-surgical management of perineal Crohn's disease (PCD), fistula relapse still occurs in 30% of patients. Our aim was to determine predictors of fistula relapse in patients in remission after treatment of a PCD lesion. Consecutive patients treated for fistulizing PCD have been included in a retrospective study when they achieved fistula remission within 3 months after the surgery. Remission was defined as the absence of any draining fistula at clinical examination. Primary outcome was the occurrence of a fistula relapse, defined as a subsequent perianal draining fistula or an abscess confirmed clinically and/or by pelvic MRI. One hundred and thirty-seven patients (57% female, median age: 35 years) corresponding to 157 abscess events, including 120 (76.4%) treated by anti-TNF after drainage, achieved fistula remission after surgery. During the follow-up period (median duration: 43 months [interquartile range 26 to 64]), 34 (22%) patients experienced a fistula relapse within a median time of 1.8 years. Survival without fistula was 96.7% at 1 year, 78.4% at 3 years, and 74.4% at 5 years. Fistula relapse rates were not different in patients receiving infliximab or adalimumab (P = 0.66). In patients treated by anti-TNF at inclusion, discontinuation of anti-TNF therapy (odds ratio 3.49, P = 0.04), colonic location (OR 6.25, P = 0.01), and stricturing phenotype (odds ratio 4.39, P = 0.01) were independently associated with fistula relapse in multivariate analysis. In patients achieving fistula remission of PCD, relapse rates are low and are not different between infliximab and adalimumab. Discontinuation of anti-TNF therapy is associated with increased relapse rate.

P316 Transanal minimal invasive proctectomy (TaMIP) for perineal Crohn’s disease; a multi-centre prospective cohort study

P316 Transanal minimal invasive proctectomy (TaMIP) for perineal Crohn’s disease; a multi-centre prospective cohort study

Issue Highlights

Issue Highlights

Anal Fistulas in Severe Perineal Crohn's Disease: Mri Assessment in the Determination of Long-Term Healing Rates.

The European Crohn's and Colitis Organization recommends magnetic resonance imaging (MRI) of anal fistulas to decide on the drug/surgery strategy. No evidence is available on the long-term impact of MRI features on fistula healing. The aim of this study was to evaluate the benefit of combined drug/surgery strategies for the treatment of perianal Crohn's fistulas based on MRI factors at referral. The clinical event (anal abscess, new fistula tract, cellulitis), therapeutic intervention (introduction/optimization of immunosuppressant/biologics, anal surgery, intestinal resection, stoma), and MRI data were prospectively recorded for patients with Crohn's disease (CD) and anal fistulas. Healing was defined by fulfilment of all the following conditions: no discharge or pain, closure of the external opening of the fistula, no visible internal opening, no abscess, and no subsequent draining seton or drainage procedure performed during at least 1 year of follow-up. Seventy CD patients with anal fistulas and MRI evaluations were followed for 70 months. The cumulative rates of fistula healing were 25%, 40%, 50%, and 70% at 12, 24, 36, and 72 months, respectively. Severe, complex, branched, and high fistulas were associated with a less favorable outcome. Surgical closure of the tract improved the healing rates better than treatment with biologics or thiopurines. Male sex, A1 luminal phenotype, and anal ulceration at referral were independently associated with a higher healing rate. Therapeutic strategies for perianal fistulizing CD require robust anatomical and healing evaluations. Combined strategies using biologics to improve both drainage and secondary closure of the fistula tracts merit further study.

Stem Cell Therapy in Refractory Perineal Crohn's Disease: Long-term Follow-up.

To describe the long-term outcomes of adipose-mesenchymal stem cells, platelet-rich plasma, and endorectal advancement flaps in patients with Perineal Crohn's Disease. This was a single-center, prospective, observational pilot study performed between March 2013 and December 2016. The study included adult patients diagnosed with Perianal Crohn's Disease (with complex perianal fistulas) refractory to previous surgical and/or biological treatment. Patients underwent surgical treatment in two stages. Stage 1: Fistula mapping, drainage, seton placement and lipoaspiration to obtain adipose-mesenchymal stem cells were performed. Stage 2: The setons were removed, and the fistula tract was debrided. A small endorectal advancement flap was created, with closure of the previous internal fistula opening. Then, 100-120 million adipose-mesenchymal stem cells mixed with platelet-rich plasma were injected into the internal fistula opening and fistula tract. The study included nine patients (seven females), with a median age of 36 years (r = 23-57). Eleven fistula tracks were treated, of which, two were pouch-vaginal fistulas. The median follow-up period was 31 months (r=21-37). At the end of the follow-up period, 10/11 (91%) fistulas were completely healed and 1/11 (9%) was partially healed. At the end of this period, there was no evidence of fistula relapse or adverse reactions in any patients. The Perianal Disease Activity Index and Inflammatory Bowel Disease Questionnaire scores significantly improved after the procedure. Combined therapy with adipose-mesenchymal stem cells, platelet-rich plasma and endorectal advancement flaps yielded good results in patients with refractory Perineal Crohn's Disease. This article is protected by copyright. All rights reserved.

High Risk of Anal and Rectal Cancer in Patients With Anal and/or Perianal Crohn’s Disease

Little is known about the magnitude of the risk of anal and rectal cancer in patients with anal and/or perineal Crohn's disease. We aimed to assess the risk of anal and rectal cancer in patients with Crohn's perianal disease followed up in the Cancers Et Surrisque Associé aux Maladies Inflammatoires Intestinales En France (CESAME) cohort. We collected data from 19,486 patients with inflammatory bowel disease (IBD) enrolled in the observational CESAME study in France, from May 2004 through June 2005; 14.9% of participants had past or current anal and/or perianal Crohn's disease. Subjects were followed up for a median time of 35 months (interquartile range, 29-40 mo). To identify risk factors for anal cancer in the total CESAME population, we performed a case-control study in which participants were matched for age and sex. Among the total IBD population, 8 patients developed anal cancer and 14 patients developed rectal cancer. In the subgroup of 2911 patients with past or current anal and/or perianal Crohn's lesions at cohort entry, 2 developed anal squamous-cell carcinoma, 3 developed perianal fistula-related adenocarcinoma, and 6 developed rectal cancer. The corresponding incidence rates were 0.26 per 1000 patient-years for anal squamous-cell carcinoma, 0.38 per 1000 patient-years for perianal fistula-related adenocarcinoma, and 0.77 per 1000 patient-years for rectal cancer. Among the 16,575 patients with ulcerative colitis or Crohn's disease without anal or perianal lesions, the incidence rate of anal cancer was 0.08 per 1000 patient-years and of rectal cancer was 0.21 per 1000 patient-years. Among factors tested by univariate conditional regression (IBD subtype, disease duration, exposure to immune-suppressive therapy, presence of past or current anal and/or perianal lesions), the presence of past or current anal and/or perianal lesions at cohort entry was the only factor significantly associated with development of anal cancer (odds ratio, 11.2; 95% CI, 1.18-551.51; P= .03). In an analysis of data from the CESAME cohort in France, patients with anal and/or perianal Crohn's disease have a high risk of anal cancer, including perianal fistula-related cancer, and a high risk of rectal cancer.

Anal ulcerations in Crohn’s disease: Natural history in the era of biological therapy

BackgroundThe natural history of anal ulcerations in Crohn’s disease remains unknown. AimsTo assess the long-term outcomes of anorectal ulcerations. MethodsData from consecutive patients with perineal Crohn’s disease were prospectively recorded. The data of patients with anal ulceration were extracted. ResultsAnal ulcerations were observed in 154 of 282 patients (54.6%), and 77 cases involved cavitating ulcerations. The cumulative healing rates were 47%, 70% and 82% at 1, 2 and 3 years, respectively. Patients with a primary fistula phenotype had a shorter median time to healing of their anal ulceration (28 [13–83] weeks) than those with a stricture (81 [28–135] weeks) or those with isolated ulceration (74 [31–181] weeks) (p=0.004). Among patients with ulcerations but no fistula at referral (n=67), only 4 (6%) developed de novo abscesses and/or fistula during follow-up. There was no benefit associated with introducing or optimising biologics, nor with combining immunosuppressants and biologics. ConclusionAnal ulceration in Crohn’s disease usually requires a long time to achieve sustained healing. Determining the impact of biologics on healing rates will require dedicated randomised trials although it does not show a significant healing benefit in the present study.

Postoperative mortality in inflammatory bowel disease patients

IntroductionSince the 1960s, mortality in Crohn's disease and Ulcerative Colitis patients had a significant decrease due to advances in medical and surgical therapy. An important proportion of these patients are submitted to surgical procedures during their disease course, with postoperative mortality between 4 and 10%. Methods157 inflammatory bowel disease patients submitted to surgical therapy were retrospectively identified and allocated in 2 groups (Crohn's and colitis). Deaths were individually discriminated in detail. Results281 surgical procedures were performed. In the colitis group, 43 operations were performed in 24 patients; in the abdominal Crohn's subgroup, 127 procedures in 90 patients and in the perineal Crohn's subgroup, 115 in 64 patients, respectively. Nine postoperative deaths were observed (3 in the colitis and 6 in the Crohn's groups). Overall postoperative mortality was 5.7% (4.5% for Crohn's; 6.6% in abdominal Crohn's and 12.5% for Colitis). Most of deaths were related to emergency procedures and previous use of corticosteroids. The cause of death in all patients was sepsis. ConclusionsOverall postoperative mortality in inflammatory bowel disease was 5.7%, and it was attributed to the severity of the cases referred.

Adjunctive Hyperbaric Oxygen Therapy promotes successful healing in patients with refractory Crohn's disease.

To investigate de adjunctive effect of Hyperbaric Oxygen Therapy in a group of patients with refractory Crohn's disease. A total of 29 subjects with refractory Crohn's disease were submitted to daily sessions of Hyperbaric Oxygen Therapy, in a 2800 Sechrist Monoplace Hyperbaric Chamber (Sechrist, USA) pressurized to 2.4 ATA. Each session lasted 2 hours. The endpoint was closure of enterocutaneous fistulas and complete healing of Pyoderma Gangrenosum and perineal Crohn's disease. A total of 829 HBOT sessions were performed and no complications were noted. Overall success rate was 76% (22 cases). Pyoderma Gangrenosum and enterocutaneous fistulas had the highest successful healing rates (100% and 91%, respectively). Perineal Crohn's disease healing rate was 65%. Adjunctive Hyperbaric Oxygen Therapy promoted satisfactory healing in a group of patients with refractory Crohn's disease.

Impact of perineal Crohn's disease on utilization of care in the absence of modifiable predictors of treatment failure.

The burden of perineal Crohn's disease (PCD) remains poorly characterized, and many patients ultimately require fecal diversion or proctectomy. Our goal was to characterize the clinical course of patients presenting with perineal Crohn's disease, focusing on the cohort of patients ultimately requiring fecal diversion, and identify modifiable predictors for this unfortunate outcome. We performed a retrospective review of 81 consecutive patients who underwent 172 operations to address complications of PCD. Diverted patients were compared to those who did not require diversion in regard to demographics, surgical procedure, postoperative infliximab, and presence of proctitis (chi square, t tests). Logistic regression was utilized to predict the need for fecal diversion. The number of visits needed to undergo care for this condition was quantified. Eight-one patients underwent a total of 172 surgical procedures and had a total of 2713 outpatient visits (range 1-118) to address symptoms of perineal Crohn's disease. Following first intervention, only 57.1 % healed at 3 months. These rates were highest in patients treated with fistulotomies and were not impacted by whether patients received postoperative infliximab (p = 0.703). Patients (23.5 %) underwent three or more surgical procedures to control their PCD and ultimately only 60 % healed without diversion, which was performed in 19 (23.5 %) patients. Patients undergoing more than three operations (OR = 10.9, p = 0.006) and women with rectovaginal fistula (OR = 3.88, p < 0.01) were at a high risk for diversion. Modifiable factors such as infliximab, smoking, proctitis, and surgery aimed at closing the internal anal opening did not alter outcome. In the patients with perineal Crohn's, complex fistulas healing rates appear to be independent of postoperative infliximab or procedures aimed at closing the internal anal opening. Those who do not heal require numerous specialist visits.

Successful Treatment of Refractory Perineal Metastatic Crohn’s Disease Using a Combination Therapy of Certolizumab, Surgical Debridement, and Hyperbaric Oxygen

Successful Treatment of Refractory Perineal Metastatic Crohn’s Disease Using a Combination Therapy of Certolizumab, Surgical Debridement, and Hyperbaric Oxygen