title: Infliximab and/or azathioprine in the treatment of Crohn's disease-like complications after IPAA.
abstract: OBJECTIVE
  Ileal pouch-anal anastomosis continues to be confounded by Crohn's disease-like complications after surgery. Such patients experience significant morbidity and often require either pouch excision or diversion. This study evaluated the effectiveness in our hands of infliximab and/or azathioprine/6-mercaptopurine in treating this patient population.
  
  
  METHODS
  We conducted a retrospective chart review of all patients who underwent IPAA who experienced Crohn's disease-like complications (pouch fistulas, stricturing small-bowel disease, or pouchitis unresponsive to antibiotics) after ileostomy closure. Patients were segregated according to treatment (azathioprine/6-mercaptopurine only, infliximab only, or both azathioprine/6-mercaptopurine and infliximab) and evaluated for clinical response defined by significant symptomatic improvement and avoidance of stoma.
  
  
  RESULTS
  Of 382 IPAAs, 32 (8.4%) patients developed Crohn's disease-like complications a mean of 17 months after stoma closure. Of these, 22 were treated with azathioprine/6-mercaptopurine and/or infliximab with one lost to follow-up. Overall mean follow-up was 97 ± 11.8 months. Failure rate (requiring stomas) was highest in the fistula group treated with infliximab and azathioprine/6-mercaptopurine (6/13, 46%). Patients with stricturing disease (6) or severe pouchitis (2) were all effectively treated with azathioprine/6-mercaptopurine (5/6) or infliximab (1 patient allergic to azathioprine/6-mercaptopurine) and none of these patients required stomas. In the group not receiving stomas, bowel frequency improved from 8.3 ± 1 to 5.7 ± 0.5 per day (P < .05).
  
  
  CONCLUSIONS
  Fistulizing disease after IPAA has the highest failure/stoma rate (46%) despite treatment with infliximab and/or azathioprine/6-mercaptopurine. IPAA patients with stricturing disease and/or antibiotic resistant pouchitis were successfully treated without stomas and all had resolution of symptoms, which suggests that fistulous disease after IPAA should be treated with infliximab, but stricturing disease and antibiotic resistant pouchitis may be effectively treated with azathioprine/6-mercaptopurine only. Such a protocol will potentially minimize the risks associated with infliximab in this difficult group of patients.
authors.affiliation: Division of Colon and Rectal Surgery, Penn State Hershey/Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
authors.forename: Liam A
authors.initials: LA
authors.lastname: Haveran
authors.forename: Rishabh
authors.initials: R
authors.lastname: Sehgal
authors.forename: Lisa S
authors.initials: LS
authors.lastname: Poritz
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: McKenna
authors.forename: David B
authors.initials: DB
authors.lastname: Stewart
authors.forename: Walter A
authors.initials: WA
authors.lastname: Koltun
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D001379:Azathioprine / Q000627:therapeutic use*; D003093:Colitis, Ulcerative / Q000601:surgery*; D039021:Colonic Pouches; D003424:Crohn Disease / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology; D005260:Female; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D000069285:Infliximab; D008297:Male; D015122:Mercaptopurine / Q000627:therapeutic use; D011183:Postoperative Complications / Q000188:drug therapy* / Q000453:epidemiology; D016737:Proctocolectomy, Restorative; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D005765:Gastrointestinal Agents; D007166:Immunosuppressive Agents; D000069285:Infliximab; D015122:Mercaptopurine; D001379:Azathioprine