BackgroundPerianal Crohn’s disease (pCD) is a debilitating complication affecting up to 30% of Crohn’s disease (CD) population, leading to increased morbidity, mortality and decreased quality of life. Despite the growing armamentarium of medications for luminal CD, their efficacy in pCD remains poorly studied.AimTo determine the efficacy of ustekinumab, a biologic approved for luminal CD, in pCD through a retrospective cohort study and systematic review.MethodsA retrospective cohort study on patients with CD with active perianal fistulae treated with ustekinumab from September 2013 to August 2019 was performed to determine perianal fistula response and remission at 6 and 12 months after ustekinumab induction. A systematic review was performed to further establish rates of fistula response and remission with ustekinumab.ResultsAt 6 months, 48.1% (13/27) patients achieved fistula response with none achieving fistula remission on provider exam, and 59.3% (16/27) achieved patient-reported symptomatic improvement with 3.7% (1/27) achieving symptomatic remission. At 1 year, on provider exam, 55.6% (5/9) had fistula response with none achieving fistula remission, and 100% (9/9) had symptomatic improvement with 22.2% (2/9) achieving symptomatic remission. There were no major safety signals during 1-year follow-up. The systematic review of 25 studies found 44% (92/209) of patients with active perianal fistulas had a clinical response within 6 months of follow-up, and 53.9% (85/152) of patients with 12 months of follow-up achieved clinical response.ConclusionUstekinumab presents a safe and effective therapy for treatment of pCD. Prospective, randomised trials are needed to further elucidate long-term efficacy of ustekinumab for pCD.

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Background: The objective of our systematic review and meta-analysis was to evaluate the effectiveness and safety of tofacitinib in the treatment of moderate-severe ulcerative colitis (UC). Methods: We searched Medline, Embase, Web of Science, and Cochrane Central to identify articles and abstracts reporting efficacy or safety data on tofacitinib use in UC. Primary outcome assessed was remission. Secondary outcomes included clinical response, steroid free remission, and adverse events (AEs). Results: A total of 26 studies were included. The rates of remission were 29.81% [95% confidence interval (CI): 22.37%-37.25%, I 2: 90%] at week 8, 32.27% (95% CI: 27.67%-36.88%, I 2: 42%) at 6 months and 38.03% (95% CI: 33.59%-42.48%, I 2: 0%) at 1-year. Clinical response rates were 59.41% (95% CI: 55.03%-63.94%, I 2: 61%) at week 8, 48.99% (95% CI: 36.92%-61.06%, I 2: 91%) at 6 months and 50.87% (95% CI: 42.16%-59.58%, I 2: 67%) at 1-year. Odds ratio of clinical response at week 8 in biologic naive versus biologic experienced patients was 1.59 (95% CI: 0.54-4.63). Pooled incidence rate for serious infections, major adverse cardiovascular events, and nonmelanotic squamous cell malignancies across all doses was 4.41 per 100-patient years (PYs) (95% CI: 2.32-8.38 per 100-PY, I 2: 78%), 0.91 per 100-PY (95% CI: 0.43-1.93 per 100-PY, I 2: 37%) and 0.91 per 100-PY (95% CI: 0.61-1.34 per 100-PY, I 2: 0%), respectively. Higher dose was associated with an increased frequency of AEs. Conclusions: While the overall efficacy and safety of tofacitinib in moderate-severe UC is consistent with clinical trial data, the dose dependent increase in AEs highlights the significance of early dose de-escalation. Rate of clinical response after tofacitinb induction was similar in biologic naive and biologic experienced patients.

Background: The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastro-jejunal anastomosis (GJA). But there is a paucity of literature pertaining to post-TORe stenosis as an adverse event (AE). Our aim was to determine the rate of stenosis, its potential predictors, and other AEs of the DPSP TORe. Methods: We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019. Results: The adverse event rate (AER) of TORe was 17.1% (n=22), with a 13.2% (n=17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter (GJAD) pre-TORe, procedure duration, GJAD at end-of-TORe, and difference in GJAD between pre-TORe and end-of-TORe, were not predictive of stenosis. Of those that developed stenosis, 10 (58.8%) responded to endoscopic balloon dilation while 7 (41.2%) required stent placement. Conclusion: Due to its high AER, the DPSP technique should not be used as the procedure provides no benefit and increased procedure complexity.