On-line version ISSN 1678-2674
Acta Cir. Bras. vol.26 supl.2 São Paulo 2011
24 - ORIGINAL ARTICLE ALIMENTARY TRACT
Crohn's disease and hyperbaric oxygen therapy1
Doença de Crohn e oxigenoterapia hiperbárica
Leonardo Estenio IezziI; Marley Ribeiro FeitosaII; Bruno Amaral MedeirosIII; Jussara C. AquinoIV; Ana Luiza Normanha Ribeiro de AlmeidaV; Rogerio Serafim ParraV; José Joaquim Ribeiro da RochaVI; Omar FéresVII
IMD, Resident, Division of Coloproctology, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition, interpretation of data, collection of study information, manuscript preparation
IIMD, Resident, Division of Coloproctology, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Interpretation of data, manuscript preparation and responsible for English language
IIIMD, Resident, Division of Coloproctology, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition and interpretation of data
IVNurse from Hyperbaric Medicine Center of São Paulo Hospital, Ribeirao Preto-SP, Brazil. Acquisition of data
VFellow PhD degree, Division of Coloproctology, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Interpretation of data and manuscript preparation
VIPhD, Head of the Division of Coloproctology, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Responsible for intellectual and scientific content of the study, critical revision, provide guidelines for the surgical interventions
VIIPhD, Assistant Professor, Division of Coloproctology, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil Responsible for manuscript preparation, manuscript writing, responsible for intellectual and scientific content of the study, supervised all phases of the study, provided guidelines for the surgical interventions
PURPOSE: Evaluate the application of Hyperbaric Oxygen Therapy (HBO) in patients with Crohn's disease (CD) refractory to pharmacologic therapy, who developed abdominal, anorectal or skin complications.
METHODS: Fourteen selected patients with refractory CD and treated at the School of Medicine of Ribeirao Preto, University of Sao Paulo (FMRP-USP) and at the Center of Hyperbaric Medicine, São Paulo Hospital (CEMEHI) were submitted to HBO.
RESULTS: Of the 14 patients evaluated, 11 had a satisfactory response.
CONCLUSION: HBO has shown benefits in patients with CD refractory to pharmacologic therapy.
Key words: Crohn Disease. Hyperbaric Oxygenation. Complications.
OBJETIVOS: Avaliar a aplicação da Oxigenoterapia Hiperbárica (HBO) nos pacientes com doença de Crohn (CD), refratários a terapia farmacológica, que evoluíram com complicações abdominais, orificiais ou dermatológicas.
MÉTODOS: Catorze pacientes selecionados no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo e no Centro de Medicina Hiperbárica do Hospital São Paulo de Ribeirão Preto eram portadores de Doença de Crohn refratária ao tratamento farmacológico e foram submetidos a sessões de HBO.
RESULTADOS: Dos 14 pacientes avaliados, 11 apresentaram resposta satisfatória.
CONCLUSÃO: A HBO tem demonstrado benefício nos pacientes com Doença de Crohn refratários ao tratamento farmacológico.
Descritores: Doença de Crohn. Oxigenação Hiperbárica. Complicações.
Crohn's disease (CD) is an idiopathic, chronic, transmural, inflammatory disorder that can affect the whole gastrointestinal tract1. Studies demonstrate a dysfunctional relationship between genetic, immunological and environmental factors resulting in an imbalance between proinflammatory and anti-inflammatory mediators2-4. Its incidence has increased in recent decades, especially in developed countries; and this has stimulated the interest in novel pharmacological and surgical therapies.
The "Biological therapy" is the most advanced weapon against the disease and it targets the TNF-alpha. TNF is a naturally occurring cytokine involved in inflammatory and immune responses. Several studies have demonstrated the benefits of these medications as they provide a longer-lasting remission, corticosteroids independence and prevention of complications such as fistulas and stenosis5-8.
With the advent of new drugs for CD there has been a remarkable clinical improvement as these medications seek to control the inflammatory cascade9-13. However, even with the anti-TNF therapy associated or not to other immunosuppressive drugs, there are still challenging cases refractory to medical and surgical treatment and tissue destruction is the ultimate result14,15.
Poor healing of the mucosa, fistulae persistence, infectious processes and progressive stenosis are some of the complications that can cause nutritional depletion and immunosuppression of the patients. These factors lead to prolonged hospitalization, systemic infections and significant increase in morbidity and mortality16-19.
Drug optimization tends to be ineffective and surgical intervention may be necessary20. There is a higher risk of complication in patients with CD and it is known that correct healing in the areas of resection is impaired by bacterial colonization21.
Several authors advocate the use of Hyperbaric Oxygen Therapy (HBO) as an adjuvant option in patients with refractory disease and the results are favorable22-24. Is consists in expose the patient in a chamber with 100% oxygen with higher pressure (2ATA). HBO promotes increments in plasmatic partial pressures of O2, thus enhancing tissue levels of oxygenation. It´s know that HBO promotes healing in chronic wounds24.
The purpose of this study is to report the experience of the authors with the utilization of HBO as adjuvant therapy in selected cases.
Fourteen patients prospectively selected were followed at the Division of Coloproctology in FMRP-USP and in the CEMEHI with chronic abdominal wounds (enteric-cutaneous fistula), perineal disease (fistulas or chronic perineal wounds) or pyoderma gangrenosum were considered refractory to pharmacological therapy.
The number of sessions ranged from 10-50 according to patient's evolution. We used a Sechrist monoplace chamber pressurized to 2.4 ATA. The sessions lasted 2 hours and were performed daily.
Of the 14 patients studied, 6 had abdominal injuries due to enteric-cutaneous fistula, 10 had perineal disease and 2 presented with pyoderma gangrenosum. Eleven patients (78,5%) had a satisfactory improvement, healing and good local control of inflammation. Three patients (21,5%) maintained injuries and required surgical approaches (Table 1).
Even with all pharmacological advances in the treatment of CD, many patients still present a relapsing course. Some cases are impressively aggressive and mutilating. This situation usually requires surgical intervention and other measures to improve wound healing20.
Utilization of HBO in patients with CD has increased in recent years. HBO promotes increments in plasmatic partial pressures of O2, thus enhancing tissue levels of oxygenation. Tissue hyperoxia increases the healing processes as it leads to vasoconstriction and decreased edema and also stimulates angiogenesis and proliferation of fibroblasts and collagen. There are also some reports of increased bacteriostatic and bactericidal effects17-23.
HBO acts directly in the inflammatory cascade and the effect of such therapy can be explained by reduced activity of nitric oxide synthase and inhibition of inflammatory cytokines. It is effective in suppressing the activity of COX-2 and the stimuli for the THF-alpha production. Vascular endothelial growth factor (VGEF) is significantly increased with HBO25.
The understanding of the pathophysiology of CD has increased in recent years as our genetic and molecular knowledge progresses, resulting in more effective therapies. Nevertheless, the response is not uniform among patients and progression to complications such as extensive perineal disease may be inevitable. HBO was initially indicated only for complex perineal disease. Our report, as many other in the literature, expands the traditional HBO applications and shows its efficacy in controlling both systemic and local inflammatory activity. The benefits become evident as the healing process advances.
1. Podolsky DK. Inflammatory bowel disease. N Engl J Med. 2002;347:417-29 [ Links ]
2. Yap LM, Ahmad T, Jewell DP. The contribution of HLA genes to IBD susceptibility and phenotype. Best Pract Res Clin Gastroenterol. 2004;18:577-96. [ Links ]
3. Gibson PR. Increased gut permeability in Crohn's disease: is TNF the link? Gut. 2001;53:1724-5. [ Links ]
4. Tursi A. Clinical implications of delayed orocecal transit time and bacterial overgrowth in adult patients with Crohn's disease. J Clin Gastroenterol. 2001;32:274-5. [ Links ]
5. Kaplan GG, Hur C, Korzenik J, Sands BE. Infliximab dose escalation vs. initiation of adalimumab for loss of response in Crohn's disease: a cost-effectiveness analysis. Aliment Pharmacol Ther. 2007;26:1509-20. [ Links ]
6. Hanauer SB, Sandborn WJ, Rutgeerts P, Fedorak RN, Lukas M, Macintosh D, Panaccione R, Wolf D, Pollack P. Human anti-tumor necrosis factor monoclonal antibody (Adalimumab) in Crohn's disease: the CLASSIC-I trial. Gastroenterology. 2006;130:323-33. [ Links ]
7. Colombel JF, Sandborn WJ, Rutgeerts P, Enns R, Hanauer SB, Panaccione R, Schreiber S, Byczkowski D, Li J, Kent JD, Pollack PF. Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology. 2007;132:52-65. [ Links ]
8. Lichtenstein GR, Yan S, Bala M, Blank M, Sands BE. Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulizing Crohn's disease. Gastroenterology. 2005;128:862-9. [ Links ]
9. Greenberg GR, Feagan BG, Martin F, Sutherland LR, Thomson AB, Williams CN, Nilsson LG, Persson T. Oral budesonide for active Crohn's disease. Canadian Inflammatory Bowel Disease Study Group. N Engl J Med. 1994;29;331:836-41. [ Links ]
10. Sandborn W, Sutherland L, Pearson D, May G, Modigliani R, Prantera C. Azathioprine or 6-mercaptopurine for inducing remission of Crohn's disease. Cochrane Database Syst Rev. 2000:CD000545. [ Links ]
11. Feagan BG, Fedorak RN, Irvine EJ, Wild G, Sutherland L, Steinhart AH, Greenberg GR, Koval J, Wong CJ, Hopkins M, Hanauer SB, McDonald JW. A comparison of methotrexate with placebo for the maintenance of remission in Crohn's disease. North American Crohn's Study Group Investigators. N Engl J Med. 2000;342:1627-32. [ Links ]
12. Hanauer SB, Feagan BG, Lichtenstein GR, Mayer LF, Schreiber S, Colombel JF, Rachmilewitz D, Wolf DC, Olson A, Bao W, Rutgeerts P, ACCENT I Study Group. Maintenance infliximab for Crohn's disease: the ACCENT I randomised trial. Lancet. 2002;359:1541-9. [ Links ]
13. Fraser AG, Orchard TR, Jewell DP. The efficacy of azathioprine for the treatment of inflammatory bowel disease: a 30 year review. Gut. 2002;50:485-9. [ Links ]
14. Malchow H, Ewe K, Brandes JW, Goebell H, Ehms H, Sommer H, Jesdinsky H. European Cooperative Crohn's Disease Study (ECCDS): results of drug treatment. Gastroenterology. 1984;86:249-66. [ Links ]
15. Atienza P. Refractory perineal fistulas in Crohn's disease. Gastroenterol Clin Biol. 2007;31:404-11. [ Links ]
16. Altomare DF, Serio G, Pannarale OC, Lupo C, Palasciano N, Memeo V, Rubino M. Prediction of mortality by logistic regression analysis in patients with postoperative enterocutaneousfístula. Br J Surg. 1990;77:450-3. [ Links ]
17. Athanassiades S, Notis P, Toutans C. Fistulas of the gastrointestinal tract: Experience with eighty-one cases. Am J Surg. 1975;130:26-8. [ Links ]
18. Bengmark S, Gianotti L. Nutritional support to prevent and treat multiple organ failure. World J Surg. 1996;20:474-81 [ Links ]
19. Berry SM, Fischer JE. Enterocutaneous fistulas. Curr Probl Surg. 1994;31:469-566. [ Links ]
20. Hancock L, Windsor AC, Mortensen NJ. Inflammatory bowel disease: the view of the surgeon. Colorectal Dis. 2006;1:10-4. [ Links ]
21. Farmer RG, Whelan G, Fazio VW. Long-term follow-up of patients with Crohn's disease: Relationship between the clinical pattern and prognosis. Gastroenterology. 1985;88:1818-25. [ Links ]
22. Colombel JF, Mathieu D, Bouault JM, Lesage X. Hyperbaric oxygenation in severe perineal Crohn's disease. Dis Colon Rectum. 1995;38:609-14. [ Links ]
23. Takeshima F, Makiyama K, Doi T. Hyperbaric oxygen as adjunct therapy for crohn's intractable enteric ulcer. Am J Gastroenterol. 1999;94:3374-5. [ Links ]
24. Lavy A, Weisz G, Adir Y, Ramon Y, Melamed Y, Eidelman S; Hyperbaric oxygen for perianal Crohn's disease. J Clin Gastroenterol. 1994;19:202-5. [ Links ]
25. Ercin CN, Yesilova Z, Korkmaz A, Ozcan A, Oktenli C, Uygun A. The effect of iNOS inhibitors and hyperbaric oxygen treatment in a rat model of experimental colitis. Dig Dis Sci. 2009;54:75-9. [ Links ]
Faculdade de Medicina de Ribeirão Preto
Departamento de Cirurgia e Anatomia
Divisão de Coloproctologia
Av. Bandeirantes, 3900
Campus Universitário Monte Alegre
14048-900 Ribeirão Preto - SP Brasil
Tel.: (55 16)3621-1122/3602-2509
Conflict of interest: none
Financial source: none
Presented at the XII National Congress on Experimental Surgery of the Brazilian Society for Development of Research in Surgery-SOBRADPEC, 2011 October 26-29 Ribeirao Preto - SP, Brazil.
1 Research performed at the Division of Coloproctology, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirao Preto of University of Sao Paulo (FMRP-USP), Ribeirao Preto-SP, Brazil.