Published online Mar 26, 2024. doi: 10.4252/wjsc.v16.i3.257
Peer-review started: October 13, 2023
First decision: December 11, 2023
Revised: December 25, 2023
Accepted: February 18, 2024
Article in press: February 18, 2024
Published online: March 26, 2024
Perianal fistulas are a common complication in Crohn’s disease, with a higher incidence in East Asia. Stem cell transplantation, specifically using autologous adipose tissue-derived stem cells (ASCs), has been explored as a potential effective and safe therapeutic approach, with favorable results reported in South Korean studies.
While the combination of medication and surgery has shown promise, the effectiveness of combining biologics such as anti-tumor necrosis factor (TNF) agents with stem cell transplantation remains an unproven area in improving fistula closure outcomes.
The study focused on assessing the long-term outcomes of stem cell transplantation, comparing closure rates with and without anti-TNF therapy, and evaluating risk factors for therapeutic failure and recurrence in Crohn’s perianal fistula (CPF) after stem cell transplantation.
This retrospective study, conducted at Asan Medical Center in Seoul, Korea, aimed to evaluate the long-term outcomes of stem cell transplantation in patients with CPF. Data from patients who underwent stem cell transplantation from June 2014 to December 2022 were reviewed, considering clinical variables such as age, sex, smoking status, and Montreal classification subclass. Autologous ASCs were used, and the study also included information on surgical procedures, anti-TNF agents (infliximab and adalimumab) used, and postoperative management. The study focused on comparing closure rates between patients who underwent stem cell transplantation with and without biologics, defining closure as the absence of discharge, swelling, or pain, and recurrence as the relapse of symptoms after the closure of the fistulous tract. Statistical analyses were performed to assess differences in outcomes.
Between June 2014 and December 2022, a total of 65 patients underwent stem cell transplantation for the treatment of CPF, with 26 receiving preoperative anti-TNF agents. The mean follow-up duration was 66.09 ± 32.37 months. Among all patients, 76.9% achieved complete closure of perianal fistula, and the recurrence rate after closure was 14.0%. The closure rates at 1 and 2 years for patients with anti-TNF treatment were 63.0% and 66.7%, respectively, while for those without anti-TNF treatment, the rates were 68.4%, 78.9%, and 81.6% at 1, 2, and 3 years, respectively. Fistula closure was less likely in patients with longer fistulas (> 7 cm), proctitis, and rectal stricture. The cumulative closure rate, excluding those with recurrence, was approximately 66.1%. The use of anti-TNF agents did not significantly impact closure and recurrence rates.
In conclusion, stem cell transplantation emerges as a viable treatment option for CPF, with favorable outcomes expected in appropriate patients regardless of the use of anti-TNF agents. This study suggests that selecting patients based on clinical features such as proctitis or stricture, along with considering the length of the fistulous tract, plays an important role in influencing the prognosis of fistula closure.
The study, conducted at a single center with a limited number of patients, underscores the need for further research involving a larger multi-center cohort to thoroughly investigate the long-term outcomes and prognostic factors associated with stem cell transplantation in patients with CPF.