Traitement des fistules anales réfractaires à l’Infliximab au cours de la maladie de Crohn : Mise au point
DOI :
https://doi.org/10.62438/tunismed.v102i4.4699Mots-clés :
Maladie de Crohn anopérinéale, fistule, Infliximab, échec, traitementRésumé
Introduction : Le traitement des fistules périanales complexes au cours de la maladie de Crohn (MC) reste un défi notamment après échec de l’Infliximab.
Objectif : Mise au point sur les différentes alternatives thérapeutiques de la fistule anale au cours de la MC réfractaires à l’Infliximab.
Méthodes : Recherche a été effectuée sur PubMed et Google Scholar. Les études de séries de malades, les essais thérapeutiques randomisés en double aveugle et les revues de la littérature ont été retenus. Les études d’observation isolée ou de recherche fondamentale, n’ayant pas encore d’applications pratiques ont été éliminées.
Résultats : Les anti-TNF notamment l’Infliximab restent l'option thérapeutique de choix avec une efficacité estimée à 60% et un taux de perte de réponse non négligeable. De nouvelles stratégies thérapeutiques permettraient d’offrir de nouvelles opportunités : par exemple, l'Ustekinumab pourrait être efficace après l'échec du traitement par les anti-TNF, bien que des études supplémentaires soient nécessaires. Les récentes guidelines suggèrent que l'injection de cellules souches mésenchymateuses est un traitement efficace et sûr pour les fistules complexes. D’autres options chirurgicales ont été proposées comme le lambeau rectal d’avancement, l’obturation du trajet fistuleux par de la colle ou le plug, la ligature intersphinctérienne du trajet fistuleux mais toutes avec une efficacité limitée et discutable. Compte tenu du taux d'échec de toutes ces options, de nouvelles stratégies thérapeutiques sont en cours d’évaluation.
Conclusion : Les fistules anales crohniennes présentent un vrai challenge thérapeutique. De nouvelles thérapeutiques médico-chirurgicales sont en cours d’évaluation avec des résultats prometteurs.
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