Combined Therapy With Early Initiation of Infliximab After Surgery for Perianal Fistulising Crohn’s Disease : A Retrospective Cohort Study

Abstract

Background: Recent studies have recognized that combined surgery and anti-TNF therapy could improve clinical outcomes in patients with perianal fistulising Crohn’s disease (PFCD). However, the optimal timing for infliximab infusion after surgical intervention is uncertain. We aimed to determine the long-term efficacy of early initiation of infliximab after surgery among patients who received combination therapy for PFCD.Methods: We performed a retrospective cohort study of PFCD patients who received combined infliximab and surgical treatment between 2010 and 2018 at a tertiary referral hospital. Patients were grouped according to the time interval between surgery and infliximab infusion, with < 6 weeks into early combination group and > 6 weeks into conventional combination group. The primary outcome was to compare fistula closure and surgical re-intervention between early and conventional combination groups. The secondary outcomes were predictors associated with these outcomes of early combination approach.Results: One hundred and seventeen patients were included (73 in early combination, 44 in conventional combination). The median interval between surgery and initial infliximab infusion was 9.0 (IQR 5.5-17.0) days in early combination group and 188.0 (IQR 102.25-455.75) days in conventional combination group. After followed-up for a median of 36 months, 61.6% of patients in early combination group and 65.9% patients in conventional combination group derived fistula closure (p=0.643). The cumulative re-intervention rate was 23%, 32%, 35% in early combination group and 16%, 24%, 24% in conventional combination group, at 1, 2, and 3 years respectively (P=0.235). Presence of abscess (HR = 5.283; 95% CI, 1.61-17.335; p = 0.006) and maintenance infliximab therapy > 3 times (HR = 3.691; 95% CI, 1.233-11.051; p = 0.02) were associated with re-intervention in early combination group. Presence of abscess also negatively influences fistula closure (HR = 3.429, 95% CI, 1.216-9.668; p = 0.02).Conclusion: Combined therapy with early initiation of infliximab after surgery could achieve promising results for PFCD patients. Durable drainage should be established for patients with concomitant abscess or requiring infliximab maintenance before infliximab initiation.