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AIM Low anterior resection syndrome (LARS) following sphincter-preserving surgery for rectal cancer has a high prevalence, with an impact on long-term bowel dysfunction and quality of life. We designed the bowel rehabilitation programme (BOREAL) as a proactive strategy to assess and treat patients with LARS. The BOREAL programme consists of a stepwise approach of escalating treatments: medical management (steps 0-1), pelvic floor physiotherapy, biofeedback and transanal irrigation (step 2), sacral nerve neuromodulation (step 3), percutaneous endoscopic caecostomy and anterograde enema (step 4) and definitive colostomy (step 5). METHODS A pilot study was undertaken to assess the feasibility of collecting LARS data routinely with the parallel implementation of the BOREAL programme. All patients who underwent total mesorectal excision for rectal cancer between February 2017 and March 2019 were included. LARS was assessed using the LARS score and the Wexner Faecal Incontinence score at 30 days and 3, 6, 9 and 12 months postoperatively. A good functional result was considered to be a combined LARS score

Background and Aim: Anti-tumour necrosis factor [TNF] agents have dramatically improved the prognosis of inflammatory bowel disease [IBD]. However, despite their good safety profile, use of these agents may lead to paradoxical manifestations involving skin or joints. Pathogenesis of such side effects is poorly understood and may involve anti-TNF pharmacokinetics. The aim of the present study was to look for an association between infliximab trough levels [ITL] and cutaneous [CPM] or rheumatological [RPM] paradoxical manifestations. Methods: IBD patients receiving infliximab as maintenance therapy were included in a cross-sectional prospective monocentre study. At inclusion, patients had an ITL measurement [LISA-TRACKER®, Biomedical Diagnostics BMD] and were assessed for paradoxical manifestations: a CPM was defined by new onset or exacerbation of pre-existing psoriasis lesions during IFX therapy, and an RPM by new onset of severe poly-arthralgia during IFX therapy. Results: Among the 121 patients included [69 female; median age: 38.9 years; 92 with Crohn’s disease], 7% had CPM and 8% RPM. Median ITL values were 5.87 [range: 0.52–19.53] µg/ml in patients with CPM and 1.90 [0.00–13.5] µg/ml in those with RPM, as compared respectively with 5.12 [0.00–49.12] µg/ml in patients without CPM [ p = 0.56] and 5.57 [0.00–49.12] µg/ml in those without RPM [ p = 0.058]. No prognostic factor was associated with CPM. The single factor associated with RPM was elevated antinuclear antibodies. Conclusion: ITL were not elevated in IBD patients developing cutaneous or rheumatological paradoxical manifestations when receiving IFX as maintenance therapy. As suggested by the high level of antinuclear antibodies, RPM could be related to an induced autoimmune disorder.

BACKGROUND Urogenital dysfunctions after rectal cancer treatment are well recognized, although incidence and evolution over time are less well known. OBJECTIVE We aimed to assess the evolution of urogenital functions over time after the treatment for rectal cancer. DESIGN This is a prospective, longitudinal cohort study. SETTINGS This study was conducted at a quaternary referral center for colorectal surgery. PATIENTS A total of 250 consecutive patients treated for rectal cancer were prospectively enrolled for urogenital assessment. MAIN OUTCOME MEASURES End points were the International Prostatic Symptom Score, the International Index of Erectile Function, and the Female Sexual Index obtained by questionnaires before (baseline status) and after preoperative radiotherapy and 3, 6, and 12 months after surgery. RESULTS Overall, 169 patients (68%) responded to the questionnaires. The urinary function decreased temporary after irradiation in men (International Prostatic Symptom Score: 7.8 vs 4.9; p < 0.001). Sexual activity decreased significantly in women after radiotherapy (p = 0.02), and in all patients after surgery (p < 0.001). At 12 months, sexual activity in women declined from 59% before treatment to 36% (p = 0.02). In men, sexual activity (82% vs 57%), erectile function (71% vs 24%), and ejaculatory function (78% vs 32%) decreased from baseline (p < 0.001). Stage T3T4 tumors (OR = 5.72 (95% CI, 1.24-26.36)) and low rectal tumors (OR = 17.86 (95% CI, 1.58-20.00)) were independent factors of worse sexual function. LIMITATIONS This study was limited by the proportion of uncompleted questionnaires, especially in women, and by its monocentric feature. CONCLUSIONS Most patients experienced sexual dysfunction at 12 months after surgery for rectal cancer, and predictive factors for this dysfunction were related to characteristics of the tumor.

Introduction Cyclosporine (CsA) is an effective agent for treating patients with acute steroid-refractory ulcerative colitis (UC). The aim was to assess endoscopic and histologic responses to CsA and to determine their predictive value on UC outcome. Patients and methods Consecutive UC patients who received intravenous CsA for an acute refractory UC were included when they had endoscopic assessments with biopsies at entry and, at CsA interruption in responders. Mucosal healing (MH) was defined by Mayo endoscopic subscore ≤1 and, histologic response (HR) by the absence of basal plasmocytosis or a Geboes score Results Among 21 patients who responded to CsA, MH was achieved in 81%. Survival rates without relapse at 2 years were 79% and 25% in patients with MH and without MH, respectively (p = 0.04). HR was observed in 84% of patients according to basal plasmocytosis and in 68% according to Geboes score. Multivariate analysis revealed that a Mayo endoscopic subscore of 0 was the only prognostic factor associated with absence of relapse (RR = 12; 95%CI: 1.05–136.79). Conclusion CsA provides MH and HR in most of UC patients responding to this drug. As suggested with other UC treatments, a complete MH with CsA has a good prognostic value.

Objective Approximately 30% of patients with gastro-oesophageal reflux disease (GORD) do not achieve adequate symptom control with proton pump inhibitors (PPIs). The aim of this study was to determine whether any symptom profile or reflux pattern was associated with refractoriness to PPI therapy. Design Patients with typical GORD symptoms (heartburn and/or regurgitation) were included and had 24 h pH-impedance monitoring off therapy. Patients were considered to be responders if they had fewer than 2 days of mild symptoms per week while receiving a standard or double dose of PPI treatment for at least 4 weeks. Both clinical and reflux parameters were taken into account for multivariate analysis (logistic regression). Results One hundred patients were included (median age 50 years, 42 male), 43 responders and 57 non-responders. Overall, multivariate analysis showed that the factors associated with the absence of response were absence of oesophagitis (p=0.050), body mass index (BMI) ≤25 kg/m 2 (p=0.002) and functional dyspepsia (FD) (p=0.001). In patients who reported symptoms during the recording (n=85), the factors associated with PPI failure were BMI ≤25 kg/m 2 (p=0.004), FD (p=0.009) and irritable bowel syndrome (p=0.045). In patients with documented GORD (n=67), the factors associated with PPI failure were absence of oesophagitis (p=0.040), FD (p=0.003), irritable bowel syndrome (p=0.012) and BMI ≤25 kg/m 2 (p=0.029). Conclusion No reflux pattern demonstrated by 24 h pH-impedance monitoring is associated with response to PPIs in patients with GORD symptoms. In contrast, absence of oesophagitis, presence of functional digestive disorders and BMI ≤25 kg/m 2 are strongly associated with PPI failure.

Restoration of bowel continuity is a major goal after surgical treatment of rectal cancer. Intersphincteric resection allows sphincter preservation in low rectal cancer but may have poor functional results, including frequent bowel movements, urgency, and incontinence.This study aimed to evaluate long-term functional outcome after intersphincteric resection to identify factors predictive of good continence.Descriptive observational study.Follow-up of surgery in tertiary care university hospital.Eligible patients were without recurrence 1 year or more after surgery for low rectal cancer.Intersphincteric resection.: Bowel function was assessed with a standardized questionnaire sent to patients. Functional outcome was considered as good if the Wexner score was 10 or less. Univariable and multivariable regression analyses were used to evaluate impact of age, gender, body mass index, tumor stage, tumor location, distance of the tumor from the anal verge and from the anal ring, type of surgery, colonic pouch, height of the anastomosis, pelvic sepsis, and preoperative radiotherapy on functional outcome.Of 125 eligible patients, 101 responded to the questionnaire. Median follow-up was 51 (range, 13-167) months. In multivariate analyses, the only independent predictors of good continence were distance of the tumor greater than 1 cm from the anal ring (OR, 5.88; 95% CI, 1.75-19.80; P = .004) and anastomoses higher than 2 cm above the anal verge (OR, 6.59; 95% CI, 1.12-38.67; P = .037).The study is limited by its retrospective, observational design and potential bias due to possible differences between those who responded to the questionnaire and those who did not.Patient characteristics do not appear to influence functional outcome at long-term follow-up after intersphincteric resection. The risk of fecal incontinence depends mainly on tumor level and height of the anastomosis.

Aliment Pharmacol Ther 2011; 34: 462–469 Summary Background Faecal calprotectin is a reliable tool for predicting Crohn’s disease (CD) relapse in patients with sustained remission. Prediction of relapse with faecal calprotectin has been less studied in patients with severe CD treated with anti-TNF. Aim To identify an association between faecal calprotectin concentration and CD clinical relapse in patients achieving remission with infliximab (IFX). Methods From February 2007 to October 2008, consecutive patients with refractory luminal CD were prospectively included when they received three IFX infusions (5 mg/kg at weeks 0, 2 and 6) followed by maintenance with an immunomodulator alone. Faecal calprotectin and C-reactive protein (CRP) were measured at entry and at week 14 (w14). Results Sixty-five patients (43W; median age: 30.4 years) were included, and 50 (77%) were in clinical remission off steroids at w14; twenty-three of fifty (46%) experienced CD clinical relapse during the first year of follow-up. Median faecal calprotectin level at w14 was similar in patients with and without CD clinical relapse (200 and 150 μg/g respectively). When considering two suggested faecal calprotectin cut-offs to predict CD relapse, sensitivities and specificities were 61% and 48% for 130 μg/g, respectively, and 43% and 57% for 250 μg/g. Neither faecal calprotectin nor CRP at baseline and at w14 could predict relapse even when CD location subgroup analysis was considered. Conclusion In patients responding to an infliximab induction regimen, faecal calprotectin measurement at w14 cannot predict Crohn’s disease clinical relapse at 1 year.

Aliment Pharmacol Ther 2011; 33: 714–721 Summary Background Mucosal healing has become a new therapeutic goal in Crohn’s disease and can be achieved with azathioprine (AZA) or biologics. Methotrexate (MTX) is an effective drug for both the induction and maintenance of remission in Crohn’s disease. However, mucosal healing with MTX has been poorly investigated. Aim To assess the mucosal healing rate in patients with Crohn’s disease with clinical response to MTX as compared with AZA or infliximab (IFX). Methods From October 2007 to May 2009, consecutive patients with Crohn’s disease were prospectively enrolled into a single-centre study when they met the following criteria: previous identification of mucosal ulcerations with ileo-colonoscopy, clinical remission within at least 3 months with MTX, AZA or IFX monotherapy, usual indication for colonoscopy in Crohn’s disease (dysplasia/cancer screening, suspected stenosis) excluding assessment for mucosal healing. Mucosal healing was defined as absence of mucosal ulceration in all segments. Results Fifty-one patients with Crohn’s disease (38 female; median age: 42 years) were included: 18 receiving MTX, 18 AZA and 15 IFX. Mucosal healing was achieved in 2/18 (11%) with MTX, in 9/18 (50%) with AZA (P = 0.011 vs. MTX) and in 9/15 (60%) with IFX (P = 0.008 vs. MTX). Conclusion In patients with Crohn’s disease in sustained clinical remission, mucosal healing is less frequently achieved with MTX as compared with AZA or IFX.

Background: Infliximab is the only medical therapy that has been proven to be effective in fistulizing Crohn's disease (CD), but the recurrence rate of fistulas is high despite maintenance therapy. The aim of this prospective study was to evaluate the short- and long-term efficacy of a combined schedule with infliximab, methotrexate, and sphincter-sparing surgery in patients with severe fistulizing anoperineal CD. Methods: From January 2006 to November 2007, all consecutive patients in three referral centers with severe fistulizing anoperineal CD were prospectively included after primary drainage. At inclusion, patients received three infliximab infusions at weeks 0, 2, and 6, and maintenance therapy with methotrexate. A second optimized surgical step consisting of at least removal of setons was performed between the second and the third infliximab infusions. Results: Thirty-four CD patients (26 women; median age 38.5 years) with complex anoperineal fistula were enrolled (including 9 with recto-vaginal fistulas, and 10 with anorectal stenosis). At week 14 the response rate was 85% with 74% complete responders. At 1 year, 50% were still responders; luminal CD worsening was the major cause of relapse. Median Perineal Disease Activity Index (PDAI) and magnetic resonance imaging (MRI) scores significantly decreased from baseline to week 50. Conclusions: A combined approach with infliximab induction, two surgical sphincter-sparing steps and methotrexate is effective in achieving short-term response in severe fistulizing anoperineal CD. The best maintenance regimen remains to be determined. (Inflamm Bowel Dis 2011;)

Approximately 20% of patients have persistent symptoms of gastro-oesophageal reflux despite proton pump inhibitor (PPI) therapy. The aim of this study was to assess the determinants of reflux perception in patients on PPI therapy.20 patients with typical gastro-oesophageal reflux symptoms (heartburn and/or regurgitation) despite double-dose PPIs (twice daily) were included in this study. Ambulatory 24 h pH-impedance studies were performed in all patients. The characteristics of symptomatic and asymptomatic reflux episodes were compared. Symptoms were considered globally and separately for heartburn and regurgitation.A total of 1273 reflux episodes were detected including 243 (19.1%) acidic, 1018 (80.0%) weakly acidic and 12 (0.9%) weakly alkaline reflux episodes. Overall, 312 (24.5%) reflux episodes were symptomatic. The only factor associated with reflux perception was high proximal extent (p = 0.037). Compared with regurgitation, reflux episodes associated with heartburn were more frequently pure liquid (p = 0.009) and acidic (p = 0.027), had a lower nadir pH (p0.001), were more frequently preceded by acid reflux episodes (p0.001) and had a longer reflux bolus clearance time (p0.001).High proximal extent of the refluxate is the only factor associated with reflux perception in patients on double-dose PPI. However, compared with regurgitation, composition of the refluxate, sensitisation of the oesophagus by preceding acid exposure and delayed bolus clearance appear to play a role in heartburn perception.

Background The incidence of hepatocellular carcinoma (HCC) in cirrhotic and noncirrhotic liver is increasing in the world, probably because of the high prevalence of infections by hepatitis B and C viruses. Despite numerous publications on hepatic resection, prognostic factors for intrahepatic recurrence and survival are not well known for patients with HCC without cirrhosis. Study design One hundred eight consecutive patients with HCC in noncirrhotic liver have been treated by hepatic resection in the past 18 years in our center. Clinical, biologic, and histopathologic parameters of these patients were collected. Risk factors for intrahepatic recurrence and prognostic factors for survival were evaluated by univariate and multivariate analyses. Results Postoperative morbidity and mortality rates were 23% and 6.5%, respectively. The 3- and 5-year disease-free and overall survival rates were 55% and 43%, and 43% and 29%, respectively. Blood transfusion, absence of tumor capsule, and daughter nodules were independently associated with overall survival. But the only risk factors for recurrence were blood transfusion, absence of tumor capsule, daughter nodules, and margin resection Conclusions In the treatment of HCC without cirrhosis, hepatectomy remains a safe and legitimate treatment, but longterm results are impaired by a high rate of early recurrence likely related to metastatic dissemination. Only histopathologic factors related to the tumor are predictive of recurrence and overall survival.

Controlled attenuation parameter (CAP) evaluated with transient elastography (FibroScan®) is a recent method for non-invasive assessment of steatosis. Its usefulness in clinical practice is unknown. We prospectively investigated the determinants of CAP failure and the relationships between CAP and clinical or biological parameters in a large cohort of consecutive patients.All CAP examinations performed in adult patients with suspected chronic liver disease were included. CAP failure was defined as zero valid shot. The following factors were analyzed for their influence on CAP value and the relationships between CAP and clinico-biological parameters: age, gender, body mass index, waist circumference, hypertension, diabetes, metabolic syndrome, alcohol use, liver stiffness measurement, indication, and different biological parameters.CAP failure occurred in 7.7% of 5323 examinations. By multivariate analysis, factors independently associated with CAP measurement failure were female gender, BMI, and metabolic syndrome. By multivariate analysis, factors significantly associated with elevated CAP were BMI [25-30]kg/m(2), BMI30kg/m(2), metabolic syndrome, alcohol14 drink/week and liver stiffness6kPa. CAP increased with the number of parameters of metabolic syndrome, BMI, waist circumference, the presence of diabetes or hypertension, and the cause of the disease. In the 440 patients with liver biopsy, for the diagnosis of steatosis10%, steatosis33%, and steatosis66%, AUROCs of CAP were 0.79 (95% CI 0.74-0.84, p0.001), 0.84 (95% CI 0.80-0.88, p0.001), 0.84 (95% CI 0.80-0.88, p0.001), respectively.CAP provides an immediate assessment of steatosis simultaneously with liver stiffness measurement. The strong association of CAP with the metabolic syndrome and alcohol use could be of interest for the follow-up of NAFLD or alcoholic patients.

Summary Background Mucosal healing can be achieved with infliximab (IFX). Aim To assess the impact of mucosal healing on long-term outcomes in patients with ulcerative colitis (UC) when treated with infliximab (IFX) beyond 1 year. Methods All consecutive adult patients with refractory UC receiving maintenance treatment with IFX in five French referral centres were analysed retrospectively. Only patients who had endoscopic evaluation between 6 and 52 weeks following IFX initiation were included. According to their Mayo endoscopic sub-score, patients were categorised into mucosal healing (sub-score: 0–1) and no mucosal healing (2–3). Outcome measures were colectomy and IFX failure defined by drug withdrawal due to secondary failure among primary responders. Results Of the 63 patients (30 women; median age: 38 years), 30 (48%) achieved mucosal healing. The median follow-up duration was 27 (3–79) months. Colectomy-free survival rates at 12, 24 and 36 months were, respectively, 100%, 96% and 96% in patients with mucosal healing. The corresponding figures were, respectively, 80%, 65% and 65% in patients without mucosal healing (P = 0.004). By multivariate analysis, mucosal healing was the only factor associated with colectomy-free survival, with an odds ratio of 18.01 (95%CI: 1.58–204.92). IFX failure-free survival rates at 12, 24 and 36 months were, respectively, 76%, 69% and 64% in patients with mucosal healing, and 44%, 25% and 21% in those without mucosal healing (P = 0.003). Conclusion Patients with refractory UC who achieved mucosal healing after IFX initiation had better long-term outcomes, with significantly less colectomy and less IFX failure.

Objectives The aim of this study was to assess oncological outcomes in patients treated with pancreaticoduodenectomy for advanced pancreatic head adenocarcinoma after preoperative chemoradiotherapy and to compare these with outcomes in patients treated with surgery alone. Methods From 2004 to 2009, patients treated with pancreaticoduodenectomy for pancreatic head adenocarcinoma were included in a retrospective comparative study. Patients with locally advanced adenocarcinoma were treated with preoperative chemoradiotherapy (CRT group) and were compared with those treated with surgery alone (SURG group). Results A total of 111 patients were included; these comprised 72 patients in the SURG group and 39 patients in the CRT group. The median follow‐up was 21 months. Patients in the CRT group presented with a more advanced tumoral status. Microscopic resection rates were similar in both groups, but nodal status and vascular or lymphatic emboli were lower in the CRT group. At 3 years, the SURG and CRT groups exhibited similar overall (36% and 51%, respectively) and disease‐free (35% and 37%, respectively) survival ( P = 0.10). Conclusions In patients with advanced pancreatic head adenocarcinoma, a good response after preoperative chemoradiotherapy results in a survival rate similar to that in patients treated with surgery alone in whom the initial prognosis is better.

To determine the presence of Helicobacter species DNA in the liver of chronic hepatitis C (CHC) patients with and without cirrhosis as compared to controls, and to identify the bacterial species involved.Seventy-nine consecutive patients (HBV and HIV negative) with a liver sample obtained after liver biopsy or hepatic resection were studied: 41 with CHC without cirrhosis, 12 with CHC and cirrhosis, and 26 controls (HCV negative). Polymerase chain reactions (PCRs) targeting Helicobacter 16S rDNA and species-specific were performed on DNA extracted from the liver. A gastric infection with H pylori was determined by serology and confirmed by 13C-urea breath test.Overall, Helicobacter 16S rDNA was found in 16 patients (20.2%). Although positive cases tended to be higher in CHC patients with cirrhosis (41.6%) than in those without cirrhosis (17.0%) or in controls (15.4%), the difference was not statistically significant (P = 0.08). H pylori-like DNA was identified in 12 cases and H. pullorum DNA in 2, while 2 cases remained unidentified. Gastric infection with H pylori was found in only 2 of these patients.Our results do not confirm the association of Helicobacter species DNA in the liver of CHC patients with advanced liver disease. The lack of correlation between positive H pylori serology and the presence of H pylori-like DNA in the liver may indicate the presence of a variant of this species.

of calcium homeostasis and inflammatory parameters in subjects with either active or inactive IBD. In the linear regression model, calprotectin was the strongest predictor of the disease activity, as expected [beta coefficient 0.75 (P< 0.001) in men and 0.42 (P< 0.05) in women, respectively], when adjusted for age and TNF-alpha inhibitor treatment. Ionized calcium and serum PTH did not demonstrate any significant associations with disease activity in the same regression model. Conclusions: IBD patients have an altered calcium homeostasis and ionized calcium levels are significantly lower in the active disease state. That may indicate that IBD patients with frequent relapses may suffer from underestimated calcium losses and could be at higher risk of osteoporosis.

Background: The natural history of CD of the pouch has not been characterized. Methods: All eligible patients with CD of the pouch were identified and included from our subspecialty Pouchitis Clinic between 2002 and 2009. Demographic & clinical variables were collected from a prospectively maintained database. Results: 206 pts with CD of the pouch consisted of 49 inflammatory, 40 fibrostenotic, and 117 fistulizing types. Pts with fistulizing CD were younger than those with fibrostenotic CD. The interval from IBD diagnosis and pouch construction was shorter in the fistulizing CD group. More pts with fistulizing CD had postoperative use of biologics (25.6% vs. 10.2% and 12.5%, p=0.028). More patients with fistulizing CD were hospitalized for pouch-related condition (21.4% vs. 15.0% and 2.0%, p=0.007). Progression of phenotypes and pouch survival are shown in Figures. Conclusions: Clinical phenotypes of Crohn's pouch can change over time. These phenotypes of CD were associated with different natural history and risk for pouch failure.

But L’infliximab est le traitement de reference des fistules ano-perineales de la maladie de Crohn (MC) [1,2]. Cependant, son effet semble suspensif et les trajets fistuleux persistent en IRM. Le but de cette etude prospective etait d’evaluer, au cours des fistules ano-perineales complexes de MC, l’efficacite a court et a long terme d’un traitement associant infliximab en induction, methotrexate en traitement de fond, et chirurgie proctologique optimale. Patients et Methodes Entre janvier 2006 et novembre 2007, tous les malades avec fistules ano-perineales complexes de MC ont ete inclus prospectivement et consecutivement apres le drainage initial de la suppuration. A l’inclusion, tous recevaient un traitement par methotrexate (25 mg/semaine pendant toute la duree de l’etude) et trois perfusions d’infliximab (5 mg/kg aux semaines 0, 2 et 6). Lors du deuxieme temps chirurgical proctologique, realise a la semaine 4, les setons etaient retires et une procedure optimale etait realisee. L’infliximab etait interrompu apres l’induction et le methotrexate etait poursuivi en entretien. La reponse clinique initiale etait definie par une diminution d’au moins 50 % du nombre des ecoulements fistuleux lors d’au moins deux visites consecutives. L’objectif principal de l’etude etait la reponse clinique a la semaine 14. Les objectifs secondaires etudies etaient : 1) le delai median de perte de reponse chez les repondeurs a la semaine 14 ; 2) l’evolution du Perineal Disease Activity Index (PDAI) et du score IRM de Van Assche ; 3) la tolerance du traitement. Resultats Trente-quatre malades (26 femmes, âge median : 38,5 ans) atteints de fistules ano-perineales fistules complexes ont ete inclus : 29 % avaient une stenose ano-rectale et 26 % une fistule recto-vaginale ; 62 % etaient cortico-dependants ou cortico-resistants, 62 % avaient deja recu de l’azathioprine et 26 % de l’infliximab. Le deuxieme temps chirurgical proctologique a consiste en une ablation simple de seton (n = 7), une fistulotomie (4), une application de colle biologique (10), un lambeau (11), une intervention de Musset (2). A la semaine 14, 85 % des malades etaient repondeurs dont 73,5 % de reponse complete. Le delai median de perte de reponse etait de 69 semaines. Aux semaines 0, 14 et 50, le PDAI median etait respectivement de 11, 3 puis 0 (p Conclusion Un traitement associant infliximab en induction et chirurgie proctologique optimisee permet d’obtenir une reponse clinique rapide en cas de fistules ano-perineales complexes de MC. Le traitement d’entretien par le methotrexate en monotherapie permet ensuite de maintenir cette reponse clinique et anatomique (IRM) pendant plus d’un an. Le methotrexate pourrait etre compare a l’infliximab en traitement d’entretien de la MC ano-perineale fistulisante.

Background: Treatment with infliximab (IFX) can result in immunogenicity through the formation of human anti-chimeric antibodies (HACAs). These antibodies are associated with a decreased duration of response, whereas therapeutic levels of IFX are associated with durable clinical response. We evaluated the clinical utility of measuring serum IFX and HACA levels. Methods: We retrospectively reviewed charts of patients with inflammatory bowel disease who had IFX drug and HACA levels measured over a three-year period from 2005-2008. The clinical utility of these tests was assessed by determining whether the result affected clinical management. The management and subsequent clinical response to therapeutic changes based on test results was evaluated. Fisher's exact test and log-rank test for discontinuation were used for statistical analysis. Results: One hundred and fifty-five patients underwent IFX level and HACA status testing. The median time to initial testing after IFX initiation was 50 weeks (IQR: 22.7-120). The main indications for testing were: loss of response to IFX (50.3%), partial response after initiation of IFX (22.6%) and possible autoimmune/delayed hypersensitivity reaction (14.8%). HACAs were identified in 35 patients (22.6%) and therapeutic IFX levels were found in 51 (32.9%). Of 177 total tests assessed, the results impacted treatment decisions in 73.4% (95% CI: 66-80%). In those with positive HACAs, change to another anti-TNF was associated with a complete or partial response in 91.6% of patients whereas increasing the dose had a response of 16.7% (p