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Using Stem Cells To Treat Perianal Fistulas

2019 May;23(5):411-427. doi: 10.1007/s10151-019-01994-z. Epub 2019 May 2.
The clinical efficacy of stem cell therapy for complex perianal fistulas: a meta-analysis.
Choi S1, Jeon BG2, Chae G1, Lee SJ3.
Author information

Abstract

BACKGROUND:
Treatment of complex anal fistulas remains difficult. However, treatment with stem cells has had an encouraging success rate when applied to complex perianal fistulas. We systematically reviewed the current evidence through meta-analysis.
METHODS:
We performed an electronic literature search on PubMed, Embase, and the Cochrane Library and identified studies (published between January 1946 and August 2017) that used stem cells to treat patients with complex perianal fistula. Each paper was evaluated for treatment success rate, target patients, types of stem cells used, number of cells used, and criteria for complete healing. Potential publication bias was assessed via visual inspection of a funnel plot and Orwin's fail-safe N. Out of 171 papers, 16 were included in the meta-analysis.
RESULTS:
The overall healing rate of stem cell injection therapy for patients with complex perianal fistulas was 62.8% (95% CI 53.5-71.2, I2 = 54.05%), whereas those for patients with Crohn's perianal fistulas alone and complex anal fistulas not associated with Crohn's disease were 64.1% and 61.5% (p = 0.840), respectively. Healing rates for autologous and allogenic stem cell treatment were 69.4% and 50.7% (p = 0.020), respectively. Four comparative studies out of 16 studies were analyzed separately. Stem cell therapy increased the healing rate compared to the control groups (OR 0.379, 95% CI 0.152-0.947).
CONCLUSIONS:
Stem cell therapy is a good treatment option for complex perianal fistulas, which cannot be healed by conventional operative procedures. However, further research for additional supportive evidence, such as a large-scale randomized controlled trial, is required.



. 2018 Oct 26; 6(12): 493–500.
Published online 2018 Oct 26. doi: 10.12998/wjcc.v6.i12.493
PMCID: PMC6212615
PMID: 30397605
One more chance of fistula healing in inflammatory bowel disease: Stem cell therapy
Erica P Turse, Francis E Dailey, Maliha Naseer, Edward K Partyka, and Veysel Tahan

Abstract
Patients with fistulizing inflammatory bowel disease are traditionally difficult to treat. This patient population often experiences delayed or insufficient healing of fistulas using current standard regimens including antibiotics, immunomodulators, anti-tumor necrosis factor-α drug, placement of setons, and surgical repair. Several studies over the last ten to fifteen years have been conducted using stem cell therapies with promising results in this patient population. These studies show stem cell therapy in fistulizing disease to be successful in healing between 60%-88% compared to currently 50% with infliximab. Moreover, remission was seen 24 wk to 52 wk in these studies. Further research with a multi-approach treatment using medications, stem cell therapy, and surgical interventions will likely be the future of this innovative treatment approach.


. 2018 Aug 9; 8(4): 97–101.
Published online 2018 Aug 9. doi: 10.5500/wjt.v8.i4.97
PMCID: PMC6107517
PMID: 30148075
Review of stem cells as promising therapy for perianal disease in inflammatory bowel disease
Francis E Dailey, Erica P Turse, Maliha Naseer, Jack D Bragg, and Veysel Tahan
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.

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Abstract
Those patients with perianal Crohn’s disease or ulcerative colitis experience a difficult to treat disease process with a delayed state and often inability to heal despite current therapies. The approaches currently used to treat these patients with corticosteroids, antibiotics, immunomodulators, anti-tumor necrosis factor-α drug, and surgical repair are limited in their healing ability. This review presents all current literature since emergence in the early 2000s of stem cell therapy for patients with perianal inflammatory bowel disease and analyzes the efficacy, outcomes and safety within these studies.


2018 May;61(5):629-640. doi: 10.1097/DCR.0000000000001093.
A Systematic Review and Meta-analysis of Mesenchymal Stem Cell Injections for the Treatment of Perianal Crohn's Disease: Progress Made and Future Directions.
Lightner AL1, Wang Z2, Zubair AC3, Dozois EJ1.
Author information

Abstract

BACKGROUND:
There has been a surge in clinical trials studying the safety and efficacy of mesenchymal stem cells for the treatment of perianal Crohn's disease.
OBJECTIVE:
The purpose of this work was to systematically review the literature to determine safety and efficacy of mesenchymal stem cells for the treatment of refractory perianal Crohn's disease.
DATA SOURCES:
Sources included PubMed, Cochrane Library Central Register of Controlled Trials, and Embase.
STUDY SELECTION:
Studies that reported safety and/or efficacy of mesenchymal stem cells for the treatment of perianal Crohn's disease were included. Two independent assessors reviewed eligible articles.
INTERVENTION:
The study intervention was delivery of mesenchymal stem cells to treat perianal Crohn's disease.
MAIN OUTCOMES MEASURES:
Safety and efficacy of mesenchymal stem cells used to treat perianal Crohn's disease were measured.
RESULTS:
Eleven studies met the inclusion criteria and were included in the systematic review. Three trials with a comparison arm were included in the meta-analysis. There were no significant increases in adverse events (OR = 1.07 (95% CI, 0.61-1.89); p = 0.81) or serious adverse events (OR = 0.53 (95% CI, 0.28-0.98); p = 0.04) in patients treated with mesenchymal stem cells. Mesenchymal stem cells were associated with improved healing as compared with control subjects at primary end points of 6 to 24 weeks (OR = 3.06 (95% CI, 1.05-8.90); p = 0.04) and 24 to 52 weeks (OR = 2.37 (95% CI, 0.90-6.25); p = 0.08).
LIMITATIONS:
The study was limited by its multiple centers and heterogeneity in the study inclusion criteria, mesenchymal stem cell origin, dose and frequency of delivery, use of scaffolding, and definition and time point of fistula healing.
CONCLUSIONS:
Although there have been only 3 trials conducted with control arms, existing data demonstrate improved efficacy and no increase in adverse or serious adverse events with mesenchymal stem cells as compared with control subjects for the treatment of perianal Crohn's disease.


2019 Jun;156(8):2208-2216.e1. doi: 10.1053/j.gastro.2019.02.005. Epub 2019 Feb 14.
Efficacy of Injection of Freshly Collected Autologous Adipose Tissue Into Perianal Fistulas in Patients With Crohn's Disease.
Dige A1, Hougaard HT2, Agnholt J3, Pedersen BG4, Tencerova M5, Kassem M5, Krogh K3, Lundby L2.
Author information

Abstract

BACKGROUND & AIMS:
Perianal fistulas are common in patients with Crohn's disease (CD). Injections of cultured autologous and allogeneic adipose tissue-derived stem cells have been shown to heal CD-associated fistulas. Unfortunately, this treatment is time consuming and expensive. We investigated the effects of injecting freshly collected autologous adipose tissue into perianal fistulas in patients with CD.
METHODS:
In a prospective interventional study, freshly collected autologous adipose tissues were injected into complex perianal fistulas of 21 patients with CD, from March 2015 through June 2018. The primary endpoint was complete fistula healing (no symptoms of discharge, no visible external fistula opening in the perineum, and no internal opening detected by rectal digital examination) 6 months after the last injection. We performed pelvic magnetic resonance imaging to confirm fistula resolution in patients with intersphincter and transsphincter fistulas who showed complete healing at clinical examination. Patients without complete fistula healing after 6 weeks and those with later relapse were offered additional injections. No control individuals were included.
RESULTS:
Six months after the last adipose tissue injection, 12 patients (57%) had complete fistula healing. Three patients (14%) had ceased fistula secretion, and 1 patient (5%) reported reduced secretion. Among 10 patients with trans-sphincter or inter-sphincter fistulas, magnetic resonance imaging showed complete fistula resolution in 9 patients and a markedly reduced gracile fistula in the remaining patient. Of the 12 patients with complete fistula healing, 9 (43%) required 1 injection, 2 (10%) required 2 injections, and 1 (5%) required 3 injections. The predominant adverse effect was postprocedure proctalgia lasting a few days. Two patients developed small abscesses, 1 had urinary retention, and 1 had minor bleeding during liposuction.
CONCLUSION:
In a study of 21 patients with CD and perianal fistulas, we found injection of recently collected autologous adipose tissue to be safe and to result in complete fistula healing in 57% of patients. ClinicalTrials.gov, Number: NCT03803917.


Stem Cell Therapy: A Compassionate Use Program in Perianal Fistula
M. D. Herreros,1 D. Garcia-Olmo,1,2,3 H. Guadalajara,1,3,4 T. Georgiev-Hristov,4 L. Brandariz,1 and M. Garcia-Arranz2,3

Received 15 October 2018; Accepted 26 February 2019; Published 5 May 2019

Abstract

Aim. To report our experience in a compassionate use program for complex perianal fistula. Methods. Under controlled circumstances and approved by European and Spanish laws, a compassionate use program allows the use of stem cell therapy for patients with nonhealing diseases, mostly complex fistula-in-ano, who do not meet criteria to be included in a clinical trial. Candidates had previously undergone multiple surgical interventions that had failed. The intervention consisted of surgery (with closure of the internal opening or a surgical flap performance), followed by stem cell injection. Three types of cells were used for implant: stromal vascular fraction, autologous expanded adipose-derived, or allogenic adipose-derived stem cells. Healing was evaluated at 6th month follow-up. Outcome was classified as partial response or healing. Relapse was evaluated 1 year later. Maximum follow-up period was 48 months. Results. 45 patients (24 male) were included; the mean age was 45 years, which ranged from 24 to 69 years. Since some of them received repeated doses, 52 cases were considered (42 fistula-in-ano, 7 rectovaginal fistulas, 1 urethrorectal fistula, 1 sacral fistula, and 1 hidradenitis suppurativa). Regarding fistula-in-ano, there were 18 Crohn’s-associated and 24 cryptoglandular. 49 cases (94.2%) showed partial response starting 6.5 weeks of follow-up. 24 cases (46.2%) healed in a mean time of 5.5 months. A year later, all patients cured remained healed. No adverse effects related to stem cell therapy were reported. Conclusion. Stem cells are safe and useful for treating anal fistulae. Healing can be achieved in severe cases.

. Author manuscript; available in PMC 2018 Jul 1.

Published in final edited form as:
Gastroenterology. 2017 Jul; 153(1): 59–62.e2.
Published online 2017 Apr 9. doi: 10.1053/j.gastro.2017.04.001
PMCID: PMC5484717
NIHMSID: NIHMS867111
PMID: 28400193
Autologous Mesenchymal Stem Cells, Applied in a Bioabsorbable Matrix, for Treatment of Perianal Fistulas in Patients With Crohn’s Disease’
Allan B. Dietz,*,1 Eric J. Dozois,2 Joel G. Fletcher,3 Greg W. Butler,1 Darcie Radel,1 Amy L. Lightner,2 Maneesh Dave,4 Jessica Friton,5 Asha Nair,6 Emily T. Camilleri,7 Amel Dudakovic,7 Andre J van Wijnen,7 and William A. Faubion*,5
Author information Copyright and License information Disclaimer

Abstract
In patients with Crohn’s disease (CD), perianal fistulas frequently recur, causing substantial morbidity. We performed a 12 patient, 6 month phase I trial to determine whether autologous mesenchymal stem cells (MSCs), applied in a bioabsorbable matrix, can heal the fistula. Fistula repair was not associated with any serious adverse events related to MSCs or plug placement. At 6 months, 10/12 patients (83%) had complete clinical healing and radiographic markers of response. We found placement of MSC-coated matrix fistula plugs in 12 patients with chronic perianal fistulas to be safe and lead to clinical healing and radiographic response in 10 patients.


Regeneration
Utilizing the innate potential of the stem cell, or modulating the body’s own regenerative capacity to heal disease, is an exciting and active area of research in many diseases including inflammatory bowel disease. Despite many inherent challenges to this type of therapy, advances are being made at a fast pace. It is likely that regenerative medicine will become a powerful and prominent tool for many disease states including inflammatory bowel disease.

Stem cell therapy (SCT) for inflammatory bowel disease is beginning to emerge as a potentially viable treatment option for some patients. There are numerous clinical trials either published or registered with Clinicaltrials.gov for use of stem cells in CD and UC. Therapies may include stem cells that are hematopoietic, bone marrow-derived, adipose-derived, or mesenchymal. Both autologous and non-autologous stem cells have been studied. The route of administration can be either systemic or locally injected/delivered.

In March of 2018, the European Commision approved Alofisel (formerly Cx601) (Takeda, TiGenix), the allogeneic expanded, adiposederived stem cell therapy for the treatment of complex perianal fistulas in adult patients with Crohn’s disease who have shown inadequate response to at least one conventional or biologic therapy. Approval was based on a randomized, double-blind, parallel-group, placebo-controlled phase III trial (ADMIRE-CD) of Cx601 injection for complex perianal fistulas in adult patients with Crohn’s disease demonstrating safety and efficacy. Display footnote number: 17 In this study 202 patients received a single injection of either Cx601 or placebo (saline solution) into the lesion. The primary endpoint was combined remission, defined as clinical closure of all treated external openings that were draining at baseline, and no collections of greater than 2 cm of treated fistulas on MRI. This was achieved in 50% of the treatment group compared to 34% of the placebo (p = 0.024). This study was also continued for a 52-week period evaluating efficacy endpoints of combined remission (as above), and clinical remission (absence of draining fistulas). At 52 weeks 56.3% of the treatment group achieved combined remission compared to 38.6% in the control group (p = 0.021); and 59.2% of the treatment group compared to 41.6% of the control group achieved clinical remission (p = 0.013). Cx601 also proved to be safe, with similar rates of adverse events in both groups. Display footnote number: 17 A large, multicenter, phase III trial (ADMIRE-CD II) in underway to gain FDA approval (NCT03279081).

Additional promising stem cell therapies in the pipeline include Furestem-CD (Kangstem Biotech) (NCT02000362, NCT02926300) in phase I and II trials for CD, PROCHYMAL (NCT00482092, NCT00543374, NCT01233960) in phase III trials for CD, and MultiStem (NCT01240915) in a phase II trial for UC.

A recent meta-analysis of stem cell therapy (SCT) for CD analyzed 21 studies that included 514 patients. Display footnote number: 18 This study found that systemic infusion of SCT resulted in 56% of patients achieving clinical response using random-effects meta-analysis (95% confidence interval [CI] 33-76, n=150). Efficacy was also demonstrated when evaluating clinical and endoscopic remission, and for patients with perianal CD. This analysis suggests that SCT may be effective, however the rate of severe adverse events (SAEs) was also significant. In this metaanalysis, the overall pooled rate of SAEs was 12%. The pooled rate of SAEs related to SCT was 8%. Severe adverse effects of SCT could be a significant obstacle to the use of these therapies. The use of adipose-derived mesenchymal stem cells as intralesional injection therapy for perianal fistulae in CD is perhaps closest to mainstream clinical use in the US. These studies, combined with the meta-analysis previously discussed, enabled the use of this therapy in Europe, and suggests that intra-fistula injection of adipose-derived stem cells may soon become a readily available treatment options for these patients in the US. In addition to therapies that utilize administration of actual stem cells, several emerging therapies aim to modulate or induce the regenerative capacity of a patient’s own stem cells.

Preliminary evidence suggests that regenerative therapies hold great promise as treatments for IBD. While many barriers to their widespread use remain, this is an area that is likely to occupy a significant role in the treatment of IBD in the future.

Mesenchymal stem cells
Stem cell therapy has not been successful in IBD until the advent of mesenchymal stem cell therapy to treat perianal Crohn’s disease. Cx-601, Alofisel (Tigenix/Takeda) has proven to be efficacious to induce and maintain fistula closure, when applied locally close to the tract in conjunction with surgical preparation of the fistula track [8]. Of note, a high placebo effect was noted in this trial, which could have been due to the background therapies including anti-TNFs and the surgical preparation of the fistula track with closing of the internal orifice in both treatment arms. The drug received approval in Europe and a second phase III trial is being conducted.


General description

Darvadstrocel is an expanded human allogeneic mesenchymal adult stem cells extracted from adipose tissue (expanded adipose stem cells - eASC).

Qualitative and quantitative composition

Each vial contains a suspension of 30 million cells (eASC) in 6 mL solution, corresponding to a concentration of 5 million cells/mL.


The European Commission has approved Alofisel (darvadstrocel), a stem cell therapy to treat complex perianal fistulas — one of the most disabling complications of Crohn’s disease. The cell therapy represents an alternative to multiple surgeries for patients with Crohn’s that have shown an inadequate response to at least one conventional biologic therapy.


This medicine is authorised for use in the European Union.


Gastroenterology. 2018 Apr;154(5):1334-1342.e4. doi: 10.1053/j.gastro.2017.12.020. Epub 2017 Dec 24.
Long-term Efficacy and Safety of Stem Cell Therapy (Cx601) for Complex Perianal Fistulas in Patients With Crohn's Disease.
Panés J1, García-Olmo D2, Van Assche G3, Colombel JF4, Reinisch W5, Baumgart DC6, Dignass A7, Nachury M8, Ferrante M3, Kazemi-Shirazi L9, Grimaud JC10, de la Portilla F11, Goldin E12, Richard MP13, Diez MC13, Tagarro I13, Leselbaum A14, Danese S15; ADMIRE CD Study Group Collaborators.
Collaborators (61)

Author information

Abstract

BACKGROUND & AIMS:
Therapies for perianal fistulas in patients with Crohn's disease are often ineffective in producing long-term healing. We performed a randomized placebo-controlled trial to determine the long-term efficacy and safety of a single local administration of allogeneic expanded adipose-derived stem cells (Cx601) in patients with Crohn's disease and perianal fistulas.
METHODS:
We performed a double-blind study at 49 hospitals in Europe and Israel, comprising 212 patients with Crohn's disease and treatment-refractory, draining, complex perianal fistulas. Patients were randomly assigned (1:1) to groups given a single local injection of 120 million Cx601 cells or placebo (control), in addition to the standard of care. Efficacy endpoints evaluated in the modified intention-to-treat population (randomly assigned, treated, and with 1 or more post-baseline efficacy assessment) at week 52 included combined remission (closure of all treated external openings draining at baseline with absence of collections >2 cm, confirmed by magnetic resonance imaging) and clinical remission (absence of draining fistulas).
RESULTS:
The study's primary endpoint, at week 24, was previously reported (combined remission in 51.5% of patients given Cx601 vs 35.6% of controls, for a difference of 15.8 percentage points; 97.5% confidence interval [CI] 0.5-31.2; P = .021). At week 52, a significantly greater proportion of patients given Cx601 achieved combined remission (56.3%) vs controls (38.6%) (a difference of 17.7 percentage points; 95% CI 4.2-31.2; P = .010), and clinical remission (59.2% vs 41.6% of controls, for a difference of 17.6 percentage points; 95% CI 4.1-31.1; P = .013). Safety was maintained throughout week 52; adverse events occurred in 76.7% of patients in the Cx601 group and 72.5% of patients in the control group.
CONCLUSION:
In a phase 3 trial of patients with Crohn's disease and treatment-refractory complex perianal fistulas, we found Cx601 to be safe and effective in closing external openings, compared with placebo, after 1 year. ClinicalTrials.gov no: NCT01541579.


BioDrugs. 2018 Dec;32(6):627-634. doi: 10.1007/s40259-018-0311-4.
Darvadstrocel: A Review in Treatment-Refractory Complex Perianal Fistulas in Crohn's Disease.
Scott LJ1.
Author information

Abstract

Darvadstrocel (Alofisel®) consists of a suspension of expanded human allogeneic adipose-derived mesenchymal stem cells (eASCs). It is the first mesenchymal stem cell (MSC) advanced therapy approved in the EU for the treatment of complex perianal fistulas in adult patients with non-active/mildly active luminal Crohn's disease, when fistulas have shown an inadequate response to ≥ 1 conventional or biologic therapy. In the pivotal phase 3 ADMIRE-CD trial in this difficult-to-treat patient population, after standard-of-care fistula conditioning, add-on therapy with a single dose of darvadstrocel (120 million eASC) administered into the tissue surrounding complex perianal fistulas was significantly more effective than placebo (saline), with the darvadstrocel group having a higher combined remission rate (i.e. clinically-assessed fistula closure plus MRI-assessed absence of abscesses) at 24 weeks in intent-to-treat (ITT primary analysis), modified ITT and per-protocol analyses. Clinical remission was maintained in > 50% of patients at 52 weeks' follow-up. Given the very limited treatment options available for this difficult-to-treat rare condition, darvadstrocel is a promising, novel, minimally invasive therapy that represents an important advance in the therapeutic options for complex perianal fistulas in adult patients with non-active/mildly active luminal Crohn's disease when fistulas have shown an inadequate response to ≥ 1 conventional or biologic therapy.


Drugs Today (Barc). 2019 Feb;55(2):95-105. doi: 10.1358/dot.2019.55.2.2914336.
Darvadstrocel for the treatment of patients with perianal fistulas in Crohn's disease.
Kotze PG1, Spinelli A2, Warusavitarne J3, Di Candido F4, Sahnan K3, Adegbola SO3, Danese S5.
Author information

Abstract

Despite significant advances in medical and surgical therapy for perianal fistulas in Crohn's disease (CD), treatment results are still modest, and a specific need for more effective therapies is a reality. Darvadstrocel is composed of expanded human allogeneic mesenchymal adult stem cells extracted from adipose tissue and constitutes the first stem cell therapy for perianal fistulizing CD to receive approval from the European Medicines Agency (EMA). This therapy is injected in both internal and external openings, as well as inside the fistula tracks, to induce fistula healing. In this monograph, the authors review the preclinical pharmacology of darvadstrocel, as well as pharmacokinetics and metabolism, and cover the main indications and detailed information on the efficacy and safety profile of the agent. Possible interactions with other agents used to treat CD are also explored. Darvadstrocel is a safe and effective therapy for perianal complex fistulas in CD, and represents the beginning of a new era of mesenchymal stem cell therapy in this difficult phenotype of the disease.
 
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Brandon's Story



In November of 2014, an enormously painful half-dollar sized perianal abscess took me by surprise. At the time, I had no idea what an abscess was, or where the perianal region was, so I went to my internist to learn more. (For readers who don't know, a perianal abscess is when a collection of pus develops near the anus). He directed me to a colorectal surgeon, who insisted that we immediately cut and drain the abscess. After two surgical attempts, he surrendered to the uncontrollable buildup of fluid, and passed me along to another surgeon.

This new surgeon was more tactful in his approach, but he was fighting a harder battle. The abscess had grown into abscesses, that manifested into a intersphincteric fistula. After four more surgical cuts and drain attempts, he could no longer cut because the skin was too raw.

The next option presented was an ileostomy, in which a stoma is opened, and a bag is placed over the stoma to collect waste products that usually pass through the colon. The decision was nuclear, but I had the procedure performed.

The ileostomy failed, causing massive blockages inside of my small bowel. This complication led to many emergency hospital visits and the use of an NG tube. After even more complications, an ileostomy revision was performed in which I was admitted into the hospital for twenty-three nights.

After my discharge, I was introduced to the head GI at the University of Michigan and he put me on two new medications hoping to heal my fistulas. At this point I had also been introduced to a highly regarded GI at The Mayo Clinic in Rochester, MN. I was also introduced to another surgeon who would manage my surgical treatment. For the next eight months I visited Mayo Clinic dozens of times in hopes that my fistulas were healing. Progress was checked through a Pelvic MRI conducted at each visit. The MRI's continued to show no improvement.

After more surgeries for anal fissures and continued pain at the fistula/seton drain sites, I asked "When is this going to end?" The answer I was given changed my life forever.

I was told that complex perianal fistula (cpf) healing isn't measured in days, weeks, or months, but, rather years. Refusing to accept this answer, I went home that evening and went onto clinicaltrials.gov in search of something that could accelerate my healing. I found numerous trials around the world for cpf's and started reading up on the studies.

There were a lot of elements to weigh before making my decision. Some trials were higher risk with a higher reward, and some lower risk with a lower reward. I took into consideration the country and its medical establishments, time of healing, number of treatments, cost, and many other factors.

The trial I found most interesting was a study on the efficacy of a stem cell procedure being performed in Madrid, Spain. The two leading doctors behind the study had excellent credentials. I spoke to several trusted members of my care team to validate the high standing reputation of the institution, and I set out to make contact with the study coordinators.

I emailed them explaining my condition, my research on their trial, and my eagerness to fly to Spain for treatment and almost instantly received a response back. The next steps included formalities, like sending them some of my medical information so they could validate my condition. After a few weeks of back and forth I was accepted as a patient, however, since only European Union citizens technically qualify for the study, I would have to pay cash to receive the treatment.

All that was left to do was to seek final approval from the quarterbacks of my care team, aka my doctors at Mayo. Proving the efficacy of the treatment took two visits to the hospital spread over the course of six months, in which I shared all the trial information with my GI and surgeon.

If they had any reservations about the treatment, I was prepared to follow their advice and forgo participating. They could not have been more open, excited, and encouraging for me to try this option.

When I arrived in Spain, I was to have liposuction performed to extract the adipose tissue to collect cells for replication. This happened first thing in the morning, and I was put under general anesthesia while the plastic surgeon performed the procedure. The surgical room was very sterile, and had all of the modern equipment you would find in US hospitals. I woke up to my stem cell surgeon running over in excitement! He was holding a small vial containing the five million stem cells collected. He was so animated it seemed as if this was the first time he was going to perform the procedure. To see the smartest and most experienced person in the room respond with such enthusiasm elated me. I was relieved that we had been able to culture the cells successfully. It was truly a special moment. A few hours after the liposuction, the surgeons injected four million stem cells into the branch fistula and one million into the main trunk.

Eight weeks later, I was back home in the USA, visiting Mayo Clinic to see the results. My GI and surgeon were anxious to examine me, so they did so together.

With results from my MRI taken earlier in the day, they concluded that the results revealed a closed fistula at the branch -- the stem cell treatment worked!

I went back to Spain in April of 2017 for my second treatment, which consisted of placing about forty-five million cells into the remaining fistula. I did not have liposuction performed this time around, as they were able to culture enough cells from the first procedure to produce the needed amount. After returning to the states, I had a few visits back to Mayo without a clear result, waiting to see if the stem cells worked. Finally in July, it was concluded that my fistulas were officially healed! This result gave me the opportunity to get my ileostomy removed on November 8th and I haven't looked back since.

I owe my successful recovery to my family's unwavering commitment to my health, my team of doctors who never gave up on me no matter how many times I asked them to throw in the towel and make my ostomy permanent, and of course, I must give credit to myself -- the patient.

I fought hard, did my research, asked the right questions, educated myself to question how I was being medically and surgically managed, and I never gave up hope.

If you want to get healthy, you must believe that there is light at the end of the tunnel no matter how dark, cold, and damp that tunnel gets. I am uncertain if my disease will ever resurface, however, if it does…I AM READY!
 
Prevalence of Fistulizing Crohn’s Disease in the United States: Estimate From a Systematic Literature Review Attempt and Population-Based Database Analysis
David A Schwartz, MD, Ignacio Tagarro, PhD, Mary Carmen Díez, MD, William J Sandborn, MD
Inflammatory Bowel Diseases, https://doi.org/10.1093/ibd/izz056
Published: 09 April 2019

Abstract

Background
Fistulas may arise as a relevant complication of Crohn’s disease (CD). Despite their clinical significance and the substantial burden imposed on patients, limited data are available on the epidemiology of fistulizing CD in the United States.

Methods
A systematic literature review was conducted to identify data published between 1970 and 2017 on the epidemiology of fistulas in patients with CD, with the aim to estimate the number of prevalent cases in the United States. Retrieved titles and abstracts were screened by 2 independent researchers for inclusion criteria (US population-based studies reporting data on the epidemiology of fistulizing CD). To validate the literature-based estimate, data from a US claims database (Truven Health MarketScan database) were analyzed. This database has broad geographic coverage, with health care data for >60 million patients during the period of the analysis.

Results
The literature search retrieved 7 articles for full-text review, and only 1 met the criteria for inclusion. This study described the cumulative incidence of fistulas in a CD population from Minnesota over 20 years. From the reported data, the estimated number of prevalent cases with fistulizing CD in the United States was ~76,600 in 2017 (~52,900 anal, ~7400 rectovaginal, ~2300 enterocutaneous, and ~14,100 internal). Analysis from the US health care database resulted in an estimated number of ~75,700 patients, confirming the robustness of the original estimate from the literature.

Conclusions
Based on 2 separate analyses, the estimated number of patients with fistulizing CD in the United States is ~77,000 patients.

 
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