title: Surgical repair and biological therapy for fecal incontinence in Crohn's disease involving both sphincter defects and complex fistulas.
abstract: OBJECTIVE
  Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies.
  
  
  METHODS
  Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures.
  
  
  RESULTS
  Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation.
  
  
  CONCLUSIONS
  Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.
authors: Department of General Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain. jesus.alvarezs@salud.madrid.org
authors: J A
authors: JA
authors: Alvarez
authors: F
authors: F
authors: Bermejo
authors: A
authors: A
authors: Algaba
authors: M P
authors: MP
authors: Hernandez
authors: M
authors: M
authors: Grau
mesh_terms: D000038:Abscess / Q000601:surgery; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D001004:Anus Diseases / Q000209:etiology / Q000601:surgery*; D001379:Azathioprine / Q000627:therapeutic use; D003424:Crohn Disease / Q000150:complications / Q000628:therapy*; D017577:Cutaneous Fistula / Q000209:etiology / Q000601:surgery*; D005242:Fecal Incontinence / Q000209:etiology / Q000601:surgery*; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D000069285:Infliximab; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery; D011788:Quality of Life; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D012720:Severity of Illness Index; D055815:Young Adult
chemical_list: D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D007166:Immunosuppressive Agents; D000069285:Infliximab; D001379:Azathioprine