Infliximab as a therapy for non-Crohn’s enterocutaneous fistulae

Persistent enterocutaneous fistulae are associated with high morbidity and mortality and are surgically challenging to repair. Anti-TNF alpha antibody (Infliximab) promotes healing of fistulae associated with active inflammatory bowel disease (IBD). We report three patients with persistent fistulae, not associated with IBD that healed following single infusion of infliximab.

Patient 1 was a 31-year-old woman who had a panproctocolectomy and ileostomy in 1985 for ulcerative colitis. Twelve years after surgery she developed a strangulated parastomal hernia and required extensive resection of the small bowel. Postoperatively, she developed an enterocutaneous fistula within the midline wound. Radiological studies showed no evidence of ongoing active inflammatory bowel disease. The fistula remained patent for 3 years after which a single infusion (5 mg/kg) of Infliximab was administered. The fistula healed within 1 week and remained closed thereafter. Patient 2 was a 48-year-old man who had a polya gastrectomy for a large perforated duodenal ulcer. Four days after surgery a large left subdiaphragmatic collection was drained under CT guidance. A week later a high-output fistula (500- to 1000-ml/day) developed from the midline wound. Six weeks later a single infusion of Infliximab (5 mg/kg) was administered. The output from the fistula was reduced to 50 ml/day on the day 2, and the fistula healed within 3 weeks. It remains closed 2 years later. Patient 3 was a 27-year-old man who had a pancreatic necrosectomy for acute pancreatitis in 1996. Over the next year he had further laparotomies for post-operative complications. As a result, he developed a fistula from the small bowel that was confirmed on sinogram. The fistula continued to discharge intermittently for the next 2 years at which time he was considered for Infliximab therapy. The fistula healed within 10 days of treatment and remains closed 6 months later.

These cases suggest that TNF alpha inhibition can accelerate the healing of chronic enterocutaneous fistulae not associated with IBD. Further studies are required to assess the effectiveness of this treatment formally in this problematic condition.