Treatment of Perianal Fistulas in Crohn´s Disease Patients With Autologous Adipose Tissue Injection: A Randomized and Placebocontrolled Study
Phase: PHASE2
Conditions: Crohn Disease, Perianal Fistulas, Cell- and Tissue-Based Therapy, Treatment
Sponsor: University of Aarhus

English version 1.0, 01042019
Treatment of Perianal Fistulas in Crohn’s Disease with Injection of
Freshly Harvested Autologous Adipose Tissue: A placebocontrolled
and randomized study
Participants
Department of Hepatology and Gastroenterology, Aarhus University Hospital
Ph.d Anders Dige, MD
Prof. Klaus Krogh, MD
Ph.d Jørgen Agnholt, MD
Department of Surgery, Pelvic Floor Unit, Aarhus University Hospital, Aarhus 
Ph.d Lilli Lundby, MD
Helene Tarri Hougaard, MD
Gastrounit, Herlev Hospital
Ph.D Jakob Seidelin, MD
Claus Rønholdt, MD
Department of Abdominal Surgery, Odense University Hospital
Prof. Niels Qvist, MD  
Surgical Department, Køge Hospital
Ph.d Andreas Nordholm-Carstensen, MD
Abdominalcenter K, Bispebjerg Hospital
Kikke Hagen, MD

Aim
To investigate the effects of injection of freshly harvested autologous adipose tissue in 
140 patients with Crohn´s Disease (CD) and complex perianal fistulas. 
 
Primary endpoint
Number of patients who have achieve complete clinical healing 6 months after 
treatment with freshly harvested adipose tissue. Complete clinical healing is defined as 
i) if the patient has no symptoms of discharge; (ii) no visible external fistula opening in 
the perineum; (iii) no internal opening can be palpated with rectal digital examination 
(iiii) no signs of a fluid conducting tract at the location of the former fistula.
Secondary endpoints
a) Number of patients who have achieve complete clinical healing 3 months after 
treatment with freshly harvested adipose tissue.
b) Number of patients with complete or partial healing 6 months after treatment. 
c) Reduction of symptoms evaluated by the Perianal Disease Activity Index (PDAI) 
3 months after treatment.
d) Reduction of symptoms evaluated by the Perianal Disease Activity Index (PDAI) 
6 months after treatment.
e) Changes in fecal inconsistency evaluated by St. Marks score
Background

Perianal fistulas are frequently present in Crohn´s Disease (CD). The cumulative 
incidence of CD patients who develop perianal fistulas is as high as 26% during 20 
years of follow-up, with the greatest risk present in the first 10 years after diagnosis. 
Treatment of perianal fistulas with cultured mesenchymal stem cells derived from 
adipose tissue marrow has shown efficacy in CD patients. The use of cultured 
autologous cells, however, has the disadvantage of being time consuming, as it involves
a harvesting procedure and weeks of in vitro stem cell expansion. 
The injection of freshly harvested autologous adipose tissue is an easily accessible 
alternative to in vitro expanded autologous adipose-derived stem cells. 
Present study investigate the effects of injection of freshly harvested autologous 
adipose tissue in 140 CD patients with complex fistulas. 
Methods
Design
The study is a randomized double-blinded and placebo-controlled interventional study. It
will be conducted as a national multicenter study. Based on a power-calculation 140 
patients will be included. An interim analysis will be performed after the inclusion of 80 
patients.
Patients
Inclusion Criteria
   a) Diagnosed with Crohn´s Disease
  b) Perianal fistula with out branching or cavities with one external and one internal 
opening, which due to the risk for development of incontinence is not suitable for lay-
open procedure, meaning: 1) all anterior interspinchteric and low transpinchteric 
(involving<1/3 of spinchter) in women 2) high interspinchteric fistulas 3) high 

transspinchteric (>1/3 of sphincter), suprasphincteric and ekstrasphincteric fistulas 4) 
intersphincteric or low transsphincteric fistula in patients with fecal incontinence and/or 
fecal urge.
  c) no or minimal luminal disease activity by colonoscopy < 3 months before treatment 
defined by Simple Endoscopic Severity for Crohn´s Disease<3
  d) Prior optimal medical treatment for fistulas (immunmodulators, antibiotics and/or 
anti-TNF-alfa treatment) with out achieving fistula healing
  e) Treatment with seton for a minimum of 6 weeks
  f) Speaks and understand Danish
  
Exclusion Criteria
  a) Pregnancy
  b) Changes in immunmodulator or anti-TNFalfa treatment < 12 weeks
  c) Anovaginal fistulas
  d) Rectal or anal stenosis
  e) Active proctitis
  f) Stoma
  g) Previous surgery for fistulas besides simpel drainage or seton
  h) Smoker
  i) Insulin-dependent diabetes, conditions inducing defective immunity, previous pelvic 
radiation
  j) pelvic MRI contraindicated

Study course
Included patients wilI in the period before treatment with freshly collcted adipose tissue 
or placebo receive standard surgical (regular curettage and seton) and/or medical 
treatment for their fistula(s). When the treating surgeon estimates (reduced secretion 
and fistula shrinkage) that the patients can achieve fistula healing by injection with 
freshly collected adipose tissue patients will be referred to pelvic MRI for exact fistula 
classification. The patient will only be included if pelvic MRI confirms that the fistula is 
applicable for treatment with freshly collected adipose tissue. 
The surgical procedure is performed in general anaestesia. An abdominal liposuction 
will be performed and thereafter patients will be randomized 1:1 to either injection with 
freshly collected adipose tissue or saline (placebo). At least two experienced surgeons 
will be affiliated to the study at each study center. One will perform the surgical 
procedure and the other will be blinded for whether the patient receives active or 
placebo treatment. The blinded surgeon will be responsible for the subsequently clinical 
clinical evaluations of the treatment effects. Clinical evaluation of the treatment 
response will be performed 3 months after the procedure. If healing has not been 
achieved the initial treatment (adipose tissue/placebo) will be repeated and the 
treatment response will be evaluated following another 3 months. Patients with clinical 
healing after 3 months will be evaluated again 6 months after treatment. In case 
patients also present clinical healing 6 months after treatment a pelvic MRI will be 
performed to confirm complete fistula healing. All pelvic MRI scans will be reviewed 
centrally and the evaluating radiologist is blinded to what treatment the patients have 
received. Placebo treated patients who do not achieve healing from 2 placebo 
treatments will subsequently be offered treatment with injection with adipose tissue. 
Patients who achieves fistula healing will be followed for a total of 2 years.
Patients who receive immunomodulators or biological treatment at the time for inclusion 
will continue this treatment in the study period. However, the treatment will be paused 2 
weeks before and 3 weeks after treatment.

Surgical procedure
The surgical procedure will be performed as previously described (Gastroenterology 
2019 Feb 14. pii: S0016-5085(19)30375-0. doi: 10.1053/j.gastro.2019.02.005. [Epub 
ahead of print]
Randomization
A randomizationlist has been generated by use of the webpage randomization.com The 
randomization will be performed en bloc (5 adipose tissue/ 5 placebo)
Statistical considerations
Data analysis will be performed as intention-to-treat. A power-calculation has shown a 
power of 80 % based on the assumptions that 55% of the patients receiving active 
treatment and 30 % of the patients receiving placebo achieves clinical healing 6 months
after treatment with a level of 0.05 for significance, when including 60 patients in each 
group. We have chosen to include  a total of 140 patients who will be randomized 1:1. 
An interim analysis will be performed after 80 included patients. In case this interim 
analysis  demonstrates a clear and statistical significant effect of the treatment 
compared to placebo further inclusion in the study be terminated.