Effecacy of the Immunoregulatory Agent with Cyclosporine for the Treatment of Inflammatory Bowel Disease with Emphasis on Ulcerative Colitis and Crohn's Disease

Patients with inflammatory bowel disease who fail to respond to first-line agents such as 5-ASA compounds and corticosteroids can benefit from immunomodulating medications. In past years, the short-term effectiveness of CsA in Inflammatory bowel disease(IBD) has been reported, but the long-term efficacy, benefit, and safety of this therapy have not been fully established yet. This study was conducted using a total of 60 IBD patients with long-term follow-up from among the 82 patients who visited the IBD Clinic, Song Do Hospital, Seoul, ROK, from Jan. 1994 to Dec. 1996. The effectiveness of CsA was analyzed with respect to induction and maintenance of the remission in the 43 patients with ulcerative colitis(UC) and 17 the patients with Crohn's disease(CD). Treatment on admission was with intravenous CsA (4mg/kg/day) for 7-10 days in 15 patients with UC and in 13 patients with CD. These 28 patients were unresponsive to conventional treatment and had a recurrence of symptoms on refractory to first-line agents. Following the intravenous induction of cyclosporine, the patients continued to receive oral CsA (2.0-5.0mg/Bd.wt/day). In another group, 28 patients with UC and 4 patients with CD who were nonresponsive to or had recurrence of symptoms with first-line agents were treated with oral CsA. The mean period of treatment with CsA was an average of 10 months for CD and 7.5 months for UC. The CsA blood levels were measured by whole blood monoclonal radioimmunoassay, and levels of 200-400 ng per milliliter were obtained. Among the 43 patients with UC, 33 patients had remission (77%) within a mean induction time of 3.2 months and maintained remission for a mean of 7.1 months. Of the 15 patients with UC who had been admitted for CsA IV therapy, all the patients had remission within a mean of 2.8 months and maintained remission for 6.5 months. Among the 17 patients with CD, 9 patients had remission (52.1%) within a mean of 2.7 months and remained in remission for a mean of 8.6 months. Of the 13 patients with CD who had been admitted for CsA IV therapy, 7 patients (53.8%) had remission within a mean of 2.6 months and maintained remission for a mean of 8.0 months. During the management with an average medium dosage of CsA, no serious side effects or toxicity was observed. In this study, initial cyclosporine IV (4mg/kg/day) therapy, followed by PO (2-5mg/kg/day) therapy was effective in achieving remission in ulcerative colitis but not in Crohn's disease, and the initial continuous intravenous infusion of CsA induced a more rapid and prolonged remission than oral CsA. During the induction and maintenance of remission, serious side effects were not found during the period of this study. In cases of acute or severe and refractory inflammatory bowel disease or of recurrence after conventional therapy, the continuous intravenous infusion of CsA for 7-10 days will induce a more rapid and prolonged remission than the oral administration of CsA.

The Effect of Fistulectomy with Seton in Intersphincteric Fistula

Intersphincteric fistulas are the most prevalent fistulas encountered by a surgeon. In general, there are two surgical methods for treating intersphincteric fistulas: fistulotomy and fistulectomy. The advantage of a fistulotomy is less sphincter muscle destruction; the disadvantage is a higher recurrence rate. The advantage of a fistulectomy is a lower recurrence rate; the disadvantage is more sphincter muscle destruction and a higher flatus incontinence rate. Because of the disadvantages with both surgical methods, the authors have developed a new method for treating intersphincteric fistulas. The new method is a fistulectomy with seton. A fistulectomy with seton is a seton tightening of the remaining internal sphincter and subcutaneous external sphincter after coring out of the fistula tract. The advantages of this method are a lower recurrence rate due to complete removal of the fistula and a lower flatus incontinence rate due to the seton slowly cutting the remaining sphincter muscle. For that reason, the authors submit that fistulectomy with seton is the most effective operation method for treating intersphincteric fistulas, especially because fistulectomy with seton has many advantages such as a lower recurrence rate, a lower flatus incontinence rate, and less anal deformity.