Abstract
Background
Persistent enterocutaneous fistulae are associated with high morbidity and mortality and are surgically challenging to repair. Anti-TNF alpha antibody (Infliximab) promotes healing of fistulae associated with active inflammatory bowel disease (IBD). We report three patients with persistent fistulae, not associated with IBD that healed following single infusion of infliximab.
Patients
Patient 1 was a 31-year-old woman who had a panproctocolectomy and ileostomy in 1985 for ulcerative colitis. Twelve years after surgery she developed a strangulated parastomal hernia and required extensive resection of the small bowel. Postoperatively, she developed an enterocutaneous fistula within the midline wound. Radiological studies showed no evidence of ongoing active inflammatory bowel disease. The fistula remained patent for 3 years after which a single infusion (5 mg/kg) of Infliximab was administered. The fistula healed within 1 week and remained closed thereafter. Patient 2 was a 48-year-old man who had a polya gastrectomy for a large perforated duodenal ulcer. Four days after surgery a large left subdiaphragmatic collection was drained under CT guidance. A week later a high-output fistula (500- to 1000-ml/day) developed from the midline wound. Six weeks later a single infusion of Infliximab (5 mg/kg) was administered. The output from the fistula was reduced to 50 ml/day on the day 2, and the fistula healed within 3 weeks. It remains closed 2 years later. Patient 3 was a 27-year-old man who had a pancreatic necrosectomy for acute pancreatitis in 1996. Over the next year he had further laparotomies for post-operative complications. As a result, he developed a fistula from the small bowel that was confirmed on sinogram. The fistula continued to discharge intermittently for the next 2 years at which time he was considered for Infliximab therapy. The fistula healed within 10 days of treatment and remains closed 6 months later.
Conclusion
These cases suggest that TNF alpha inhibition can accelerate the healing of chronic enterocutaneous fistulae not associated with IBD. Further studies are required to assess the effectiveness of this treatment formally in this problematic condition.
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References
Dudrick SJ, Maharaj AR, McKelvey AA (1999) Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg 23:570–576
Present DH, Rutgeerts P, Targan SR, et al (1999) Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398–1405
Rutgeerts P, D’Haens G, Targan S, et al (1999) Efficacy and safety of retreatment with anti-tumor necrosis factor antibody (Infliximab) to maintain remission in Crohn’s disease. Gastroenterology 117:761–769
Targan SR, Hanauer SB, van Deventer SJH, et al (1997) A short term study of chimeric monoclonal antibody cA2 to tumour necrosis factor α for Crohn’s disease. N Engl J Med 337:1029–1035
Meguid MM, Campos ACL (1996) Preface: surgical management of gastrointestinal fistulas. Surg Clin North Am 76:XI
González-Pinto I, Moreno González E (2001) Optimising the treatment of upper gastrointestinal fistulae. Gut 49:iv21–iv28
Li-Ling J, Irving M (2001) Somatostatin and Octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials. Br J Surg 88:190–199
Marone G, Santoro LM, Torre V (1989) Successful endoscopic treatment of GI tract fistulas with a fast hardening amino acid solution. Endoscopy 21:47–49
Alvarez AA, Maxwell GL, Rodriguez GC (2001) Vacuum- assisted closure for cutaneous gastrointestinal fistula management. Gynaecol Oncol 80:413–416
McDermott MF (2001) TNF and TNFR biology in health and disease. Cell Mol Biol 47:619–635
Baldassano RN (2001) Surpassing conventional therapies: the role of biologic therapy. J Pediatr Gastroenterol Nutr 33:S19–S26
Nahar IK (2003) Infliximab treatment of rheumatoid arthritis and Crohn’s disease. Ann Pharmacother 37:1256–1265
Braun J, de Keyser F, Brandt J, Mielants H, Sieper J, Veys E (2001) New treatment options in spondyloarthropathies: increasing evidence for significant efficacy of anti-tumor necrosis factor therapy. Curr Opin Rheumatol 13:245–249
Anonymous (2001) Summaries for patients. A new anti-inflammatory therapy (Infliximab) for complicated sarcoidosis. Ann Intern Med 135:S20
Yee AM, Pochapin MB (2001) Treatment of complicated sarcoidosis with Infliximab anti-tumor necrosis factor-alpha therapy. Ann Intern Med 135:27–31
Sfikakis PP (2001) Theodossiadis PG, Katsiari CG, Kaklamanis P, Markomichelakis NN (2001) Effect of Infliximab on sight-threatening panuveitis in Bechet’s disease. Lancet 358:295–296
Tan MH, Gordon M, Lebwohl O, George J, Lebwohl MG (2001) Improvement of Pyoderma gangrenosum and psoriasis associated with Crohn’s disease with anti-tumor necrosis factor alpha monoclonal antibody. Arch Dermatol 137:930–933
Chaudhari U, Romano P, Mulcahy LD, Dooley LT, Baker DG, Gottlieb AB (2001) Efficacy and safety of Infliximab monotherapy for plaque-type psoriasis: a randomised trial. Lancet 357:1842–1847
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P. Neilly has sadly died since the writing of this paper
Presented at the Annual Scientific Congress of Royal Australasian College of Surgeons with the Royal College of Surgeons of Edinburgh at Adelaide, Australia, on 11 May 2002
Published abstract: PJD Neilly, Aust N Z J Surg 2002; 72[Suppl]:A33–34
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Date, R.S., Panesar, K.J.S. & Neilly, P. Infliximab as a therapy for non-Crohn’s enterocutaneous fistulae. Int J Colorectal Dis 19, 603–606 (2004). https://doi.org/10.1007/s00384-004-0595-3
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DOI: https://doi.org/10.1007/s00384-004-0595-3