Retrospective Cohort Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 21, 2016; 22(47): 10380-10387
Published online Dec 21, 2016. doi: 10.3748/wjg.v22.i47.10380
Factors associated with surgery in patients with intra-abdominal fistulizing Crohn's disease
Shaul Yaari, Ariel Benson, Eyal Aviran, Naama Lev Cohain, Ran Oren, Jacob Sosna, Eran Israeli
Shaul Yaari, Ariel Benson, Eyal Aviran, Ran Oren, Eran Israeli, IBD Unit, Institute of Gastroenterology and Liver Diseases, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
Naama Lev Cohain, Jacob Sosna, Department of Radiology and Medical Imaging, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
Author contributions: Yaari S, Sosna J and Israeli E designed the research; Yaari S, Benson A, Aviran E, Lev Cohain N and Sosna J performed the research; Yaari S, Benson A, Lev Cohain N and Israeli E analyzed the data; Yaari S, Benson A, Oren R, Sosna J and Israeli E wrote the paper; Oren R and Israeli E critically revised the manuscript for important intellectual content.
Institutional review board statement: This study was reviewed and approved by the Hadassah- Hebrew University Helsinki committee.
Informed consent statement: Informed consent was waived by the Hadassah-Hebrew University Helsinki committee due to the fact that this was a retrospective observational study, and the identity of all subjects participating in the study remained anonymous.
Conflict-of-interest statement: None for all authors.
Data sharing statement: Clinical dataset available from the corresponding author at email: erani@hadassah.org.il. Participant consent was not obtained but the presented data are anonymized and risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Eran Israeli, MD, MHA, Head, IBD Unit, Institute of Gastroenterology and Liver Diseases, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel. erani@hadassah.org.il
Telephone: +972-2-6776848 Fax: +972-2-6437492
Received: August 27, 2016
Peer-review started: August 28, 2016
First decision: September 21, 2016
Revised: October 3, 2016
Accepted: October 31, 2016
Article in press: October 31, 2016
Published online: December 21, 2016
Processing time: 114 Days and 4.7 Hours
Abstract
AIM

To characterize radiological and clinical factors associated with subsequent surgical intervention in Crohn’s disease (CD) patients with intra-abdominal fistulae.

METHODS

From a cohort of 1244 CD patients seen over an eight year period (2006 to 2014), 126 patients were identified as having intra-abdominal fistulae, and included in the study. Baseline patient information was collected from the medical records. Imaging studies were assessed for: anatomic type and number of fistulae; diameter of the inflammatory conglomerate; length of diseased bowel; presence of a stricture with pre-stenotic dilatation; presence of an abscess; lymphadenopathy; and the degree of bowel enhancement. Multivariate analysis for the prediction of abdominal surgery was calculated via Generalized Linear Models.

RESULTS

In total, there were 193 fistulae in 132 patients, the majority (52%) being entero-enteric. Fifty-nine (47%) patients underwent surgery within one year of the imaging study, of which 36 (29%) underwent surgery within one month. Radiologic features that were associated with subsequent surgery included: multiple fistulae (P = 0.009), presence of stricture (P = 0.02), and an entero-vesical fistula (P = 0.01). Evidence of an abscess, lymphadenopathy, or intense bowel enhancement as well as C-reactive protein levels was not associated with an increased rate of surgery. Patients who were treated after the imaging study with combination immunomodulatory and anti-TNF therapy had significantly lower rates of surgery (P = 0.01). In the multivariate analysis, presence of a stricture [RR 4.5 (1.23-16.3), P = 0.02] was the only factor that increased surgery rate.

CONCLUSION

A bowel stricture is the only factor predicting an increased rate of surgery. Radiological parameters may guide in selecting treatment options in patients with fistulizing CD.

Keywords: Crohn’s disease; Fistula; Cross-sectional imaging; Intra-abdominal surgery; Magnetic resonance imaging; Computed tomography-scan

Core tip: We performed a longitudinal cohort study to identify radiological and clinical parameters that are associated with surgery within one-year of diagnosis of fistulae by cross-sectional imaging. We retrospectively reviewed 126 Crohn’s disease (CD) patients with intra-abdominal fistulae. Radiologic features that were associated with subsequent surgery included: multiple fistulae, presence of stricture, and an entero-vesical fistula. Evidence of an abscess, lymphadenopathy, or intense bowel enhancement was not associated with an increased rate of surgery. In multivariate analysis only the presence of a stricture was independently associated with an increased rate of surgery. These findings should be taken in to account when making therapeutic decisions for patients with fistulizing CD.