Combined Therapy With Surgery and Anti-TNF Therapy for Perianal Crohnʼs Disease: Seton Withdrawal Timing Data From a Brazilian Case Series
Bibliographic record
Abstract
Perianal fistulizing Crohn's disease (CD) is one of the most severe phenotypes of inflammatory bowel diseases (IBD). Combined therapy with examination under anesthesia, seton placement and anti-TNF therapy is the most common strategy for the management of this condition. There is still lack of data regarding the proper timing of seton withdrawal after induction therapy with anti-TNF agents, and the criteria for its determination is undefined. The aim of this study was to analyze the timing of seton withdrawal in a Brazilian case series of perianal fistulizing CD patients. This was a retrospective observational study that included Brazilian patients with perianal fistulizing CD submitted to combined therapy with examination under anesthesia and seton placement followed by anti-TNF therapy, from 4 IBD referral centres, from January 2009 to June 2012. Electronic chart review was performed and data were inputted in a specific protocol. We analyzed patients' demographic characteristics, Montreal classification, concomitant medication, type of biological agent, classification of the fistulae, occurrence of perianal complete remission, number of setons placed and timing of seton withdrawal. Complete perianal remission was defined as absence of drainage from the fistula tracks without after seton removal. A total of 78 patients were included, 44 females (55.8%) with a mean age of 33.8 (±15) years. Medium time of CD diagnosis was 88.9 (±76.8) months. Montreal Classification: age at diagnosis (A1 = 21.8%, A2 = 50% e A3 = 28.2%); disease location (L1 = 0%, L2 = 7.7%, L3 = 78.2% e L4 = 14.1%); disease phenotype (B3 in 100% of the cases). Azathioprine was used in combination with the anti-TNF agents in 76.6% of the cases, 66.2% of the patients were treated with Infliximab (IFX) and 33.8% with Adalimumab (ADA). Complex fistulae were found in 52/78 patients (66.7%). Medium follow-up period was 48.2 months, and 52,6% of the patients had complete perianal remission. The average number of setons placed was 2 (±1.4) per patient, ranging from 1 to 7. Seton withdrawal occurred in 51 patients (±5.3%), performed in an average period of 7.3 (±6,4; 1 to 36) months. After combined surgery with seton placement and anti-TNF therapy, approximately 2/3 of the patients had their setons removed in this study, and the average period for the withdrawal was 7.3 months. There is still unclear criteria for the definition of the proper timing for seton withdrawal with the aim of perianal complete remission, and an individualized approach is recommended.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".