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El-Hussuna A, Myrelid P, Holubar SD, Kotze PG, Mackenzie G, Pellino G, Winter D, Davies J, Negoi I, Grewal P, Gallo G, Sahnan K, Rubio-Perez I, Clerc D, Demartines N, Glasbey J, Regueiro M, Sherif AE, Neary P, Pata F, Silverberg M, Clermont S, Chadi SA, Emile S, Buchs N, Millan M, Minaya-Bravo A, Elfeki H, De Simone V, Shalaby M, Gutierrez C, Ozen C, Yalçınkaya A, Rivadeneira D, Sturiale A, Yassin N, Spinelli A, Warusavitarne J, Ioannidis A, Wexner S, Mayol J. Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives. CROHN'S & COLITIS 360 2019; 1. [DOI: 10.1093/crocol/otz021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
AbstractBackgroundThere is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).AimWe aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.MethodThis is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.ResultsForty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.ConclusionAlthough a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.
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Affiliation(s)
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Stefan D Holubar
- Director of Research, Department of Colon & Rectal Surgery, Cleveland, OH
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | | | - Gianluca Pellino
- Department of Surgery, Università della Campania Luigi Vanvitelli, Aversa, Italy
| | - Des Winter
- Centre for Colorectal Disease, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, Romania
| | - Perbinder Grewal
- Department of Cardiovascular, University Hospital Southampton, UK
| | - Gaetano Gallo
- Department of General Surgery, “Magna Graecia” University, Catanzaro, Italy
| | - Kapil Sahnan
- Imperial College Faculty of Medicine, Department of Surgery and St Marks Hospital, London, UK
| | - Ines Rubio-Perez
- General and Digestive Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Daniel Clerc
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - James Glasbey
- Academic Department of Surgery, University of Birmingham Heritage Building, UK
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH
| | - Ahmed E Sherif
- Department of Clinical Surgery, University of Edinburgh, UK
| | - Peter Neary
- South East Cancer Governance Lead, University Hospital Waterford/Cork, Ireland
| | - Francesco Pata
- Department of Surgery, Sant’Antonio Abate Hospital, Gallarate, Italy
| | - Mark Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, ON, Canada
| | | | - Sami A Chadi
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sameh Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Nicolas Buchs
- Department of Surgery, University Hospitals of Geneva, Switzerland
| | - Monica Millan
- Department of Surgery, Joan XXIII University Hospital, Tarragona, Spain
| | | | - Hossam Elfeki
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Veronica De Simone
- Proctology Unit, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mostafa Shalaby
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Celestino Gutierrez
- Department of Suregry, Centre Hospitalier de Redon Ille-et-Vilaine Bretagne-France
| | - Cihan Ozen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - David Rivadeneira
- Colorectal Surgery & Surgical Services, Northwell Health in Huntington, NY, USA
| | - Alssandro Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Pisa, Italy
| | - Nuha Yassin
- Department of surgery, Royal Wolverhampton Hoaspital, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
| | | | - Argyrios Ioannidis
- Department of General, Laparoscopic and Robotic Surgery, Athens Medical Center
| | - Steven Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
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Abstract
OBJECTIVE To investigate differences in surgical approach and postoperative outcomes for patients with ulcerative colitis (UC) before and after the introduction of biologic therapy. BACKGROUND Biologic use has dramatically increased since Food and Drug Administration approval of infliximab. Studies conflict as to the effect of these agents on surgical outcomes with some demonstrating worse surgical outcomes whereas others have found no difference. METHODS We used an administrative, all-payer, all-age group database located in New York State. Patients were included if they had a diagnosis of UC and underwent surgery for their disease from 1995 to 2013. Outcomes were compared for the index admission, at 90-day, and 1-year follow up. RESULTS A total of 7070 patients were included for analysis; 54% patients underwent surgery between 1995 and 2005 and the remaining 46% patients underwent surgery between 2005 and 2013. There was a significant increase in the proportion of patients who underwent at least 3 procedures after 2005(14% vs 9%, P < 0.01). On adjusted analysis, patients undergoing surgery after 2005 had higher likelihood of major events (odd s ratio, OR = 1.42; 95% confidence interval, CI = 1.13-1.78), procedural complications (OR = 1.42; 95% CI = 1.20-1.68), and nonroutine discharge (OR = 3.17; 95% CI = 2.79-3.60) during the index admission. Similar trends for worse adjusted outcomes in patients initially undergoing surgery after 2005 were seen at 90-day and 1-year follow up. CONCLUSIONS Since the introduction of biologic agents in 2005, surgery for patients with UC is more likely to require multiple procedures. Despite robust adjustments, patients having surgery recently have worse postoperative morbidity during the index hospitalization, at 90-day and 1-year follow up. More work is necessary to improve outcomes in these higher risk patients that undergo surgery.
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Dalal RS, Osterman MT, Buchner AM, Praestgaard A, Lewis JD, Lichtenstein GR. A User-Friendly Prediction Tool to Identify Colectomy Risk in Patients With Ulcerative Colitis. Inflamm Bowel Dis 2019; 25:1550-1558. [PMID: 30753443 DOI: 10.1093/ibd/izz014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/04/2019] [Accepted: 01/18/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Many patients with ulcerative colitis (UC) fear the potential side effects of immunosuppressive therapies. However, those with medically refractory disease often require total proctocolectomy (TPC) with a permanent ostomy or pouch, which may reduce quality of life. Prior studies have identified TPC predictors; however, no clinically useful prognostic tools exist to guide shared therapeutic decision-making. We therefore sought to develop a prediction tool of future TPC risk in UC patients. METHODS In this retrospective study, clinic charts of UC patients were reviewed from January 1, 2017, to December 31, 2017. Cases had TPC performed for refractory UC after January 1, 2008. Controls had no prior UC surgery. Clinical data were assessed 1-12 months preceding TPC or clinic visit for cases and controls, respectively. We randomly selected two-thirds of patients to develop a TPC prediction model using multivariable logistic regression. One-third was reserved for model validation. RESULTS We identified 115 cases and 325 controls. TPC predictors included albumin, 9-point Mayo score >5, Mayo endoscopic subscore >1, and corticosteroid use within 6 months. The areas under the receiver operating characteristic curve for the multivariable model were 0.94 (95% confidence interval [CI], 0.92-0.95) and 0.92 (95% CI, 0.89-0.95) for the test and validation cohorts, respectively. The validation cohort demonstrated a significant difference in calculated probability distributions between patients who did and did not have TPC (P < 0.01). We incorporated our model into a web-based application to allow convenient calculation of a patient's TPC risk. CONCLUSIONS We created a user-friendly tool to assess TPC risk in UC. Prospective assessment will determine its utility for shared therapeutic decision-making.
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Affiliation(s)
- Rahul S Dalal
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark T Osterman
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anna M Buchner
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Praestgaard
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary R Lichtenstein
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Rajan R, Trinder MW, Lo J, Theophilus M. Assessing the efficacy of TNF-alpha inhibitors in preventing emergency and emergent colectomies. JGH OPEN 2019; 4:140-144. [PMID: 32280756 PMCID: PMC7144788 DOI: 10.1002/jgh3.12229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/08/2019] [Indexed: 12/12/2022]
Abstract
Background and Aim Severe ulcerative colitis (UC) is potentially life threatening and is associated with significant morbidity. TNF‐∝ inhibitors (Infliximab) were introduced in Australia for the management of medically resistant, acute, severe flares of UC in 2008. The aim of this study is to assess the efficacy of Infliximab in preventing emergent and emergency colectomies for patients with moderate to severe UC by comparing colectomy rates before and after its introduction at our institution. Methods This was a retrospective cohort study of all patients who were admitted to the Royal Perth Hospital with a flare of UC between 2002 and 2017. Patients were divided into two cohorts: those admitted prior to the introduction of Infliximab (pre‐2008) and those admitted after. We compared data between these two groups, including age, gender, length of admission, use of Infliximab, colectomy, and complications of surgery. We defined emergency surgery as requiring surgery during the index admission and emergent surgery as an operation within 54 weeks. Results A total of 313 UC cases from 2002 to 2017 were analyzed. There was a decrease in emergency and emergent colectomies from 19.4 to 8% in the post‐2008 cohort (P = 0.008). Furthermore, there was a decrease in the proportion of operations performed as emergencies, from 36 to 20%. This resulted in a significantly reduced length of stay (13.4–9.7 days, P < 0.05) and complication rate (36 to 20%, P < 0.05). Conclusion Overall, the need for emergency and emergent operations has drastically reduced at our institution with the introduction of Infliximab. This study has confirmed the efficacy of Infliximab in reducing colectomy rates at our institution.
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Affiliation(s)
- Ruben Rajan
- Department of General Surgery Royal Perth Hospital Perth Western Australia Australia
| | - Matthew W Trinder
- Department of General Surgery Royal Perth Hospital Perth Western Australia Australia
| | - Johnny Lo
- School of Science Edith Cowan University Perth Western Australia Australia
| | - Mary Theophilus
- Department of General Surgery Royal Perth Hospital Perth Western Australia Australia
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Lissel M, Omidy S, Myrelid P, Block M, Angenete E. The Handling of the Rectal Stump Does Not Affect Severe Morbidity After Subtotal Colectomy For Ulcerative Colitis: A Retrospective Cohort Study. Scand J Surg 2019; 109:238-243. [DOI: 10.1177/1457496919857269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Aims: Colectomy due to ulcerative colitis is associated with complications. One severe complication is the risk for blow-out of the remaining rectal remnant. The aim of this study was to compare the frequency and severity of complications in patients with the rectal remnant left subcutaneously versus patients with the rectal remnant left intra-abdominally. A secondary aim was to identify risk factors for complications. Materials and Methods: Consecutive patients at two tertiary centers in Sweden were retrospectively reviewed regarding surgical procedures; complications classified according to Clavien–Dindo; and possible risk factors for complications such as preoperative medication, emergency surgery, and body mass index. Results: 307 patients were identified. Minor complications were more common than previously reported (85%–89%). Severe surgical complications were not related to the handling of the rectal remnant. Leaving the rectal remnant subcutaneously was associated with local wound problems. Risk factors for severe complications were emergency surgery and preoperative medication with 5-aminosalicylic acid. Conclusion: Minor complications after colectomy for ulcerative colitis are very common and need to be addressed. Leaving the rectal stump intra-abdominally seems safe and may be advantageous to reduce local wound morbidity.
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Affiliation(s)
- M. Lissel
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S. Omidy
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - P. Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - M. Block
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital/Östra, Department of Surgery, Gothenburg, Sweden
| | - E. Angenete
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital/Östra, Department of Surgery, Gothenburg, Sweden
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Abstract
Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.
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Vasudevan A, Arachchi A, Scanlon C, Greenhalgh J, Van Langenberg DR. A comparison of long-term healthcare utilization and costs in patients with acute severe ulcerative colitis receiving infliximab versus early colectomy. Ther Adv Chronic Dis 2019; 10:2040622319825595. [PMID: 30728932 PMCID: PMC6354298 DOI: 10.1177/2040622319825595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 12/28/2018] [Indexed: 12/16/2022] Open
Abstract
Background Early intervention for acute severe ulcerative colitis (ASUC) improves outcomes. Outcomes and healthcare costs for an infliximab-first and colectomy-first approach were compared. Methods This single-center retrospective cohort study of inpatients with steroid-refractory ASUC who received infliximab 5 mg/kg (1-3 doses without maintenance) or initial colectomy between 2004 and 2014 assessed long-term healthcare utilization and direct costs following infliximab or colectomy, using admission coding data until 31 December 2016. Results A total of 118 patients received either infliximab (n = 85, 72%) or colectomy (n = 33, 28%) as initial therapy, with 35(41%) patients eventually requiring colectomy post-infliximab (median 213 days, range [6, 3739]). Median follow up was 7 years [0, 14]. Following infliximab for ASUC, 44% of patients then received antitumor necrosis factor maintenance. After ASUC therapy, length of stay and number of admissions did not significantly differ between groups but higher numbers of complications prompting readmission occurred in the colectomy group (median 4 versus 1, p < 0.001). There were no differences in admissions or total length of stay for patients who had received infliximab first then colectomy versus those treated with colectomy first (median 7.0 versus 4.0, 41.5 days versus 29 days, respectively, each p > 0.05). Total costs were lower at 6 months (mean AUD17,662 versus AUD24,852, p = 0.003), yet were similar at 7 years following an infliximab compared with colectomy approach (AUD72,834 versus AUD59,557, p = 0.23). After infliximab, costs were significantly higher at 7 years with biologic rather than immunomodulator-only maintenance therapy (AUD109,365 versus AUD47,842, p < 0.01). Conclusions In support of current practice, infliximab salvage in steroid-refractory ASUC achieved reduced short-term healthcare costs compared with initial colectomy, though long-term costs were not significantly different.
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Level 2, 5 Arnold Street, Box Hill Hospital, Box Hill, Victoria, 3128, Australia
| | - Asiri Arachchi
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Australia
| | - Cian Scanlon
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Australia
| | - Jarrod Greenhalgh
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Australia
| | - Daniel R Van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Australia Monash University, Eastern Health Clinical School, Victoria, Australia
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Dulai PS, Buckey JC, Raffals LE, Swoger JM, Claus PL, OʼToole K, Ptak JA, Gleeson MW, Widjaja CE, Chang JT, Adler JM, Patel N, Skinner LA, Haren SP, Goldby-Reffner K, Thompson KD, Siegel CA. Hyperbaric oxygen therapy is well tolerated and effective for ulcerative colitis patients hospitalized for moderate-severe flares: a phase 2A pilot multi-center, randomized, double-blind, sham-controlled trial. Am J Gastroenterol 2018; 113:1516-1523. [PMID: 29453383 DOI: 10.1038/s41395-018-0005-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/25/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hyperbaric oxygen therapy (HBOT) markedly increases tissue oxygen delivery. Case series suggest it may have a potential therapeutic benefit in ulcerative colitis (UC). We investigated the therapeutic potential of HBOT as an adjunct to steroids for UC flares requiring hospitalization. METHODS The study was terminated early due to poor recruitment with 18 of the planned 70 patients enrolled. UC patients hospitalized for moderate-severe flares (Mayo score ≥6, endoscopic sub-score ≥2) were block randomized to steroids + daily HBOT (n = 10) or steroids + daily sham hyperbaric air (n = 8). Patients were blinded to study assignment, and assessments were performed by a blinded gastroenterologist. Primary outcome was the clinical remission rate at study day 5 (partial Mayo score ≤2 with no sub-score >1). Key secondary outcomes were: clinical response (reduction in partial Mayo score ≥2, rectal bleeding sub-score of 0-1) and progression to second-line therapy (colectomy or biologic therapy) during the hospitalization. RESULTS A significantly higher proportion of HBOT-treated patients achieved clinical remission at study day 5 and 10 (50 vs. 0%, p = 0.04). HBOT-treated patients less often required progression to second-line therapy during the hospitalization (10 vs. 63%, p = 0.04). The proportion requiring in-hospital colectomy specifically as second-line therapy for medically refractory UC was lower in the HBOT group compared to sham (0 vs. 38%, p = 0.07). There were no serious adverse events. CONCLUSION In this small, proof-of-concept, phase 2A trial, the use of HBOT as an adjunctive therapy to steroids for UC patients hospitalized for moderate-severe flares resulted in higher rates of clinical remission, and a reduction in rates of progression to second-line therapy during the hospitalization. Larger well-powered trials are needed, however, to provided definitive evidence of therapeutic benefit.
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Affiliation(s)
- Parambir S Dulai
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jay C Buckey
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura E Raffals
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jason M Swoger
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul L Claus
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin OʼToole
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Judy A Ptak
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael W Gleeson
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christella E Widjaja
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John T Chang
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffery M Adler
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nihal Patel
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laurie A Skinner
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shawn P Haren
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kimberly Goldby-Reffner
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kimberly D Thompson
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Corey A Siegel
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Athayde J, Davies SC, Parker CE, Guizzetti L, Ma C, Khanna R, Feagan BG, Jairath V. Placebo Rates in Randomized Controlled Trials of Pouchitis Therapy. Dig Dis Sci 2018; 63:2519-2528. [PMID: 29995184 DOI: 10.1007/s10620-018-5199-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/05/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Approximately half of the patients with ulcerative colitis (UC) who undergo restorative proctocolectomy develop pouchitis within 10 years of surgery. Currently, there are no approved pouchitis treatments. It is important to quantify, and ultimately minimize, placebo rates to design and conduct efficient pouchitis trials. AIMS To quantify the placebo rate observed in pouchitis randomized controlled trials (RCTs) in meta-analysis. METHODS Embase, MEDLINE, and the Cochrane Library were searched from inception to November 3, 2017, for placebo-controlled RCTs enrolling adult UC patients with, or at risk for developing, pouchitis. A fixed-effect binomial-normal model was used to pool placebo rates on the log-odds (logit) scale. Proportions and 95% confidence intervals were reported. Outcomes of interest included development of pouchitis, induction of remission/response, and maintenance of remission/response. The Cochrane risk of bias tool was used to evaluate study quality. RESULTS Twelve trials (five prevention, five induction, and two maintenance) enrolling a total of 229 placebo patients were eligible for inclusion. The pooled placebo rates for development of pouchitis and induction of response were 47% (95% CI 39-56%) and 24% (95% CI 14-37%), respectively. An insufficient number of trials prevented additional data pooling and meta-regression analysis and no consistent definitions of outcome were identified. CONCLUSIONS No consistent methods for measuring pouchitis disease activity or defining response and remission were identified, highlighting the need for standardized definitions of outcomes for use in pouchitis trials. Additional high-quality trials are required to evaluate existing and novel therapies in this area.
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Affiliation(s)
- Jonathan Athayde
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Sarah C Davies
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Claire E Parker
- Robarts Clinical Trials Inc., 100 Dundas St. #200, London, ON, N6A 5B6, Canada
| | - Leonardo Guizzetti
- Robarts Clinical Trials Inc., 100 Dundas St. #200, London, ON, N6A 5B6, Canada
| | - Christopher Ma
- Robarts Clinical Trials Inc., 100 Dundas St. #200, London, ON, N6A 5B6, Canada
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, ON, Canada
- Robarts Clinical Trials Inc., 100 Dundas St. #200, London, ON, N6A 5B6, Canada
| | - Brian G Feagan
- Department of Medicine, University of Western Ontario, London, ON, Canada
- Robarts Clinical Trials Inc., 100 Dundas St. #200, London, ON, N6A 5B6, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5B6, Canada
| | - Vipul Jairath
- Robarts Clinical Trials Inc., 100 Dundas St. #200, London, ON, N6A 5B6, Canada.
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5B6, Canada.
- Division of Gastroenterology, Departments of Medicine, University of Western Ontario, London, ON, N6A 5B6, Canada.
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Jairath V. Hyperbaric Oxygen for Hospitalized patients with Ulcerative Colitis. Am J Gastroenterol 2018; 113:1432-1434. [PMID: 30158711 DOI: 10.1038/s41395-018-0224-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/17/2018] [Indexed: 12/11/2022]
Abstract
One quarter of patients with ulcerative colitis will develop a severe acute exacerbation of disease during their lifetime. Despite high dose corticosteroids, half of these patients will fail subsequent medical rescue therapy, and half will require colectomy within 5 years. Dulai and colleagues report the results of a fascinating, double blind, sham controlled, proof of concept trial which demonstrated that administration of short term hyperbaric oxygen therapy (HBOT) at the point of presentation with severe UC was able to rapidly induce short term remission and avoid the need for urgent second line medical rescue therapy. Further dose finding studies are underway.
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Affiliation(s)
- Vipul Jairath
- Division of Gastroenterology, Department Medicine, Schulich School of Medicine, Western University, London, ON, Canada. Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Gastroenterology, Department Medicine, Schulich School of Medicine, Western University, London, ON, Canada. Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Chohno T, Uchino M, Sasaki H, Bando T, Takesue Y, Ikeuchi H. Associations Between the Prognostic Nutritional Index and Morbidity/Mortality During Intestinal Resection in Patients with Ulcerative Colitis. World J Surg 2018; 42:1949-1959. [PMID: 29270654 DOI: 10.1007/s00268-017-4411-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Onodera's prognostic nutritional index (O-PNI) is a well-known predictor of the prognosis of several surgeries. The aim of this study was to evaluate the association between O-PNI and surgical outcome during surgery for ulcerative colitis (UC). METHODS This was a single-institution retrospective cohort study conducted in the Department of Inflammatory Bowel Disease at Hyogo College of Medicine, Japan. The preoperative predictive factors associated with mortality, morbidity, and pouch-related complications (PRCs) were examined separately from surgical procedure. RESULTS A total of 1151 patients with UC who underwent surgery between January 2000 and December 2015 were included. Total colectomy (TC) alone, ileal pouch-anal anastomosis (IPAA) with ileostomy, and IPAA without ileostomy were performed in 254 patients, 736 patients, and 161 patients, respectively. Mortality and morbidity were found in nine (0.8%) and 320 (27.8%) patients, respectively. The median O-PNI score was 22.6 in patients with mortality and 35.6 in patients without mortality among TC alone (p < 0.01). The significant predictive factors for mortality among TC alone were older age [p = 0.03, odds ratio (OR) 6.8], higher C-reactive protein (p = 0.02, OR 14.5), and O-PNI < 24.9 (p = 0.04, OR 5.6). Among IPAA with ileostomy, an American Society of Anesthesiologists score ≥3 (p = 0.01, OR 2.3), prednisolone (PSL) dosage just before surgery ≥14 mg/day (p = 0.04, OR 1.8), and O-PNI < 35.5 (p < 0.01, OR 2.1) were predictors of PRCs. O-PNI did not predict PRCs among IPAA without ileostomy. CONCLUSION Lower O-PNI may predict the prognosis in patients with UC. O-PNI may be a useful indicator for decision-making regarding surgical timing and procedure.
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Affiliation(s)
- Teruhiro Chohno
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hirofumi Sasaki
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Toshihiro Bando
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshio Takesue
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Sobotka LA, Husain SG, Krishna SG, Hinton A, Pavurula R, Conwell DL, Zhang C. A risk score model of 30-day readmission in ulcerative colitis after colectomy or proctectomy. Clin Transl Gastroenterol 2018; 9:175. [PMID: 30108206 PMCID: PMC6092348 DOI: 10.1038/s41424-018-0039-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 05/07/2018] [Accepted: 06/08/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION The Center for Medicare and Medicaid Services established 30-day readmission rate as a key metric in measuring high-value, cost-conscious care; therefore, our aim is to develop a risk score for 30-day readmission in ulcerative colitis (UC) patients undergoing colectomy or proctectomy. METHODS This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file (2011-2015). Patients with UC undergoing colectomy or proctectomy were identified using ICD-9, 10, and CPT codes. Stepwise multivariate analyses were used to determine risk factors associated with readmission including pre-operative conditions, laboratory results, operative variables, and post-operative complications. For readmission risk score assessment, a weighted logistic regression model was built and validated using ACS NSQIP 2011-2014 and 2015 data, respectively. RESULTS A total of 4797 patients were included with 963 (20%) patients readmitted within 30 days. Potentially modifiable risk factors included deep vein thrombosis, pulmonary embolism, renal insufficiency, wound infection, urinary tract infection, sepsis/septic shock, and pre-existing congestive heart failure. Ten percent of patients with a risk score between 0 and 9 were readmitted, 18.5% with a score between 10 and 19, 52.2% with a score between 20 and 29, and 59.6% in patients with a risk score >29. CONCLUSIONS Multiple potentially preventable risk factors are associated with 30-day readmission following colectomy or proctectomy in UC patients. Higher risk scores are associated with increased risk of unplanned readmission.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Syed G Husain
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Ravi Pavurula
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cheng Zhang
- Department of Gastroenterology, Springfield Regional Medical Center, Mercy Health, Springfield, OH, USA.
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Kochar B, Barnes EL, Peery AF, Cools KS, Galanko J, Koruda M, Herfarth HH. Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program. Inflamm Bowel Dis 2018; 24:1833-1839. [PMID: 29697787 PMCID: PMC6703434 DOI: 10.1093/ibd/izy082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC). METHODS Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities. RESULTS Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC. CONCLUSIONS Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.
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Affiliation(s)
- Bharati Kochar
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Center for Gastrointestinal Biology and Disease, North Carolina
| | - Edward L Barnes
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Center for Gastrointestinal Biology and Disease, North Carolina
| | - Anne F Peery
- Center for Gastrointestinal Biology and Disease, North Carolina
| | - Katherine S Cools
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Joseph Galanko
- Center for Gastrointestinal Biology and Disease, North Carolina
| | - Mark Koruda
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Center for Gastrointestinal Biology and Disease, North Carolina,Address correspondence to: Hans H. Herfarth, MD, PhD, Division of Gastroenterology and Hepatology, University of North Carolina, Bioinformatics Building, CB#7080, Chapel Hill, NC, 27599 ()
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Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29609882 PMCID: PMC9391696 DOI: 10.1016/j.bjane.2018.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Methods Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. Results There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p = 0.009); and severe complications (15.5% vs. 5.3%; p < 0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p = 0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p = 0.154), or readmission (6.39% vs. 4.39%; p = 0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. Conclusions The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.
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Post-operative morbidity and mortality of a cohort of steroid refractory acute severe ulcerative colitis: Nationwide multicenter study of the GETECCU ENEIDA Registry. Am J Gastroenterol 2018; 113:1009-1016. [PMID: 29713028 DOI: 10.1038/s41395-018-0057-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 02/13/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the increased use of rescue medical therapies for steroid refractory acute severe ulcerative colitis, mortality related to this entity still remains high. We aimed to assess the mortality and morbidity related to colectomy and their predictive factors in steroid refractory acute severe ulcerative colitis, and to evaluate the changes in mortality rates, complications, indications of colectomy, and the use of rescue therapy over time. METHODS We performed a multicenter observational study of patients with steroid refractory acute severe ulcerative colitis requiring colectomy, admitted to 23 Spanish hospitals included in the ENEIDA registry (GETECCU) from 1989 to 2014. Independent predictive factors of mortality were assessed by binary logistic regression analysis. Mortality along the study was calculated using the age-standardized rate. RESULTS During the study period, 429 patients underwent colectomy, presenting an overall mortality rate of 6.3% (range, 0-30%). The main causes of death were infections and post-operative complications. Independent predictive factors of mortality were: age ≥50 years (OR 23.34; 95% CI: 6.46-84.311; p < 0.0001), undergoing surgery in a secondary care hospital (OR 3.07; 95% CI: 1.01-9.35; p = 0.047), and in an emergency setting (OR 10.47; 95% CI: 1.26-86.55; p = 0.029). Neither the use of rescue medical treatment nor the type of surgical technique used (laparoscopy vs. open laparotomy) influenced mortality. The proportion of patients undergoing surgery in an emergency setting decreased over time (p < 0.0001), whereas the use of rescue medical therapy prior to colectomy progressively increased (p > 0.001). CONCLUSIONS The mortality rate related to colectomy in steroid refractory acute severe ulcerative colitis varies greatly among hospitals, reinforcing the need for a continuous audit to achieve quality standards. The increasing use of rescue therapy is not associated with a worse outcome and may contribute to reducing emergency surgical interventions and improve outcomes.
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Ward ST, Mytton J, Henderson L, Amin V, Tanner JR, Evison F, Radley S. Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study. Colorectal Dis 2018; 20:416-423. [PMID: 29059479 DOI: 10.1111/codi.13937] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/03/2017] [Indexed: 01/11/2023]
Abstract
AIM Previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population-based approach to investigate whether there is an association between anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. METHOD Hospital Episode Statistics (HES) data and procedural coding were used to identify all patients in England between April 2006 and March 2015 undergoing subtotal colectomy for UC. Patients were grouped into those who received anti-TNF therapy within 12 or 4 weeks of surgery and those who did not. The incidence of postoperative complications was evaluated by HES coding and compared between groups. RESULTS In all, 6225 UC patients underwent subtotal colectomy. 753 patients received anti-TNF therapy within 12 weeks prior to surgery (418 within 4 weeks). There was no difference in postoperative complications between groups although groups were not comparable for age and comorbidities. Logistic regression with complications as the outcome variable did not show any significant association between anti-TNF therapy and complications. Colectomy performed during an unplanned admission (vs planned admission) and smoking were associated with complications. CONCLUSION This large population-based study does not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.
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Affiliation(s)
- S T Ward
- Department of Colorectal Surgery, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - J Mytton
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - L Henderson
- Department of Colorectal Surgery, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - V Amin
- Department of Colorectal Surgery, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - J R Tanner
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - F Evison
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Radley
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Ripollés-Melchor J, Fuenmayor-Varela MLD, Camargo SC, Fernández PJ, Barrio ÁCD, Martínez-Hurtado E, Casans-Francés R, Abad-Gurumeta A, Ramírez-Rodríguez JM, Calvo-Vecino JM. [Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study]. Rev Bras Anestesiol 2018; 68:358-368. [PMID: 29609882 DOI: 10.1016/j.bjan.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/21/2017] [Accepted: 01/03/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. METHODS Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. RESULTS There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p=0.009); and severe complications (15.5% vs. 5.3%; p<0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p=0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p=0.154), or readmission (6.39% vs. 4.39%; p=0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. CONCLUSIONS The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.
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Affiliation(s)
- Javier Ripollés-Melchor
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha.
| | | | - Susana Criado Camargo
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Madri, Espanha
| | - Pablo Jerez Fernández
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Madri, Espanha
| | | | - Eugenio Martínez-Hurtado
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha
| | - Rubén Casans-Francés
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Hospital Clínico Universitario Lozano Blesa, Departamento de Anestesia, Zaragoza, Espanha
| | - Alfredo Abad-Gurumeta
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha
| | - José Manuel Ramírez-Rodríguez
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Hospital Clínico Universitario Lozano Blesa, Departamento de Cirugía, Zaragoza, Espanha
| | - José María Calvo-Vecino
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Universidad de Salamanca, Salamanca, Espanha; Complejo Hospitalario de Salamanca, Departamento de Anestesia, Salamanca, Espanha
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Feuerstein JD, Curran T, Alosilla M, Cataldo T, Falchuk KR, Poylin V. Mortality Is Rare Following Elective and Non-elective Surgery for Ulcerative Colitis, but Mild Postoperative Complications Are Common. Dig Dis Sci 2018; 63:713-722. [PMID: 29353444 DOI: 10.1007/s10620-018-4922-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 01/07/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND DATA Currently, data regarding the rates of morbidity and mortality following non-elective colectomy for ulcerative colitis (UC) are variable. We sought to determine the rates and predictors of 90-day mortality and complications following colectomy for UC. METHODS Patients undergoing an initial surgery for UC at a tertiary care center between January 2002 and January 2014 were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for mortality and complications within 90 days of surgery. Complications were classified using the Clavien-Dindo classification system. Univariate and multivariate analyses were performed using IBM SPSS Statistics, version 23.0. RESULTS Two hundred and fifty-eight patients underwent surgery for UC. 69% were elective, and 31% were urgent/emergent. There were no deaths reported within 30 days of surgery. At 90 days, there were 2 deaths in the elective group and 1 death in the urgent/emergent group. The death in the urgent/emergent group was likely related to the initial surgery, while the elective group death was not directly related to the initial surgery for UC. Complications occurred in 47% of patients. There were no significant differences in rates of complications in either surgical cohort. Majority (62%) of the complications were Clavien-Dindo grade 1 or 2 with no difference in the elective or urgent/emergent group. Unplanned readmissions occurred in 24% of cases. CONCLUSION Surgery for UC is not associated with any mortality at 30 days and very low mortality at 90 days. However, surgery is associated with an increased rate of minor postoperative complications and readmissions.
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Affiliation(s)
- Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street 8E Gastroenterology, Boston, MA, 02215, USA.
| | - Thomas Curran
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Alosilla
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Thomas Cataldo
- Department of Surgery and Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kenneth R Falchuk
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street 8E Gastroenterology, Boston, MA, 02215, USA
| | - Vitaliy Poylin
- Department of Surgery and Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, Kato J, Kobayashi K, Kobayashi K, Koganei K, Kunisaki R, Motoya S, Nagahori M, Nakase H, Omata F, Saruta M, Watanabe T, Tanaka T, Kanai T, Noguchi Y, Takahashi KI, Watanabe K, Hibi T, Suzuki Y, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol 2018; 53:305-353. [PMID: 29429045 PMCID: PMC5847182 DOI: 10.1007/s00535-018-1439-1] [Citation(s) in RCA: 330] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.
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Affiliation(s)
- Katsuyoshi Matsuoka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Taku Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumiaki Ueno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
- Ofuna Central Hospital, 6-2-24 Ofuna, Kamakura-shi, Kanagawa, 247-0056, Japan.
| | - Toshiyuki Matsui
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumihito Hirai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Nagamu Inoue
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Jun Kato
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kiyonori Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazutaka Koganei
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Reiko Kunisaki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Satoshi Motoya
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masakazu Nagahori
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroshi Nakase
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumio Omata
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masayuki Saruta
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Tanaka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takanori Kanai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshinori Noguchi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Ken-Ichi Takahashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshifumi Hibi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yasuo Suzuki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kentaro Sugano
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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Rescue Diverting Loop Ileostomy: An Alternative to Emergent Colectomy in the Setting of Severe Acute Refractory IBD-Colitis. Dis Colon Rectum 2018; 61:214-220. [PMID: 29337777 DOI: 10.1097/dcr.0000000000000985] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Severe acute refractory colitis has traditionally been an indication for emergent colectomy in IBD, yet under these circumstances patients are at elevated risk for complications because of their heightened inflammatory state, nutritional deficiencies, and immunocompromised state. OBJECTIVE We hypothesized that rescue diverting loop ileostomy may be a viable alternative to emergent colectomy, providing the opportunity for colonic healing and patient optimization before more definitive surgery. DESIGN This was a retrospective case series. SETTINGS The study was conducted at a single academic center. PATIENTS Patients with severe acute medically refractory IBD-related colitis were included. INTERVENTION Rescue diverting loop ileostomy was the intervening procedure. MAIN OUTCOME MEASURES The primary outcome was avoidance of urgent/emergent colectomy. The secondary outcome was efficacy, defined by 3 clinical aims: 1) reduced steroid dependence or opportunity for bridge to medical rescue, 2) improved nutritional status, and 3) ability to undergo an elective laparoscopic definitive procedure or ileostomy reversal with colon salvage. RESULTS Among 33 patients, 14 had Crohn's disease and 19 had ulcerative colitis. Three patients required urgent/emergent colectomy, 2 with ulcerative colitis and 1 with Crohn's disease. Across both disease cohorts, >80% of patients achieved each clinical aim for efficacy: 88% reduced their steroid dependence or were able to bridge to medical rescue, 87% improved their nutritional status, and 82% underwent an elective laparoscopic definitive procedure or ileostomy reversal. A total of 4 patients (11.7%) experienced a postoperative complication following diversion, including 3 surgical site infections and 1 episode of acute kidney injury. LIMITATIONS The study was limited by being a single-center, retrospective series. CONCLUSIONS Rescue diverting loop ileostomy in the setting of severe, refractory IBD-colitis is a safe and effective alternative to emergent colectomy. This procedure has acceptably low complication rates and affords patients time for medical and nutritional optimization before definitive surgical intervention. See Video Abstract at http://links.lww.com/DCR/A520.
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Zhao C, Ding C, Xie T, Zhang T, Dai X, Wei Y, Li Y, Gong J, Zhu W. Validation and optimization of the Systemic Inflammation-Based modified Glasgow Prognostic Score in predicting postoperative outcome of inflammatory bowel disease: preliminary data. Sci Rep 2018; 8:747. [PMID: 29335491 PMCID: PMC5768763 DOI: 10.1038/s41598-017-18771-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/12/2017] [Indexed: 12/18/2022] Open
Abstract
Systemic Inflammation-Based modified Glasgow Prognostic Score (mGPS) was developed as an objective tool to grade state of inflammation. However, the association between mGPS and postoperative complications for inflammatory bowel disease (IBD) patients was still unknown. In our study, 270 IBD patients [Crohn’s disease (CD), n = 186; Ulcerative colitis (UC), n = 84] from January 2013 and January 2016 who underwent elective bowel resection were retrospectively analyzed, and, the levels of preoperative C-reactive protein (CRP) and albumin were included as parameters of mGPS. The incidence of overall postoperative complications was 44.81% (121/270), including 46.77% (87/186) of CD and 40.48% (34/84) of UC. According to multivariate analysis, mGPS (CD: OR = 3.47, p = 0.003; UC: OR = 3.28, p = 0.019) was independently associated with an increased risk of postoperative complications. Patients with a higher mGPS also suffered longer postoperative stay and increased SSIs (both p < 0.05). Combining mGPS with neutrophil ratio improved its prognostic value with a better area under the curve (AUC), using receiver operating characteristic (ROC) method. Then we confirmed that mGPS was associated with postoperative complications in IBD patients undergoing elective bowel resection and the addition of neutrophil ratio enhanced its prognostic value.
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Affiliation(s)
- Chenyan Zhao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chao Ding
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tingbin Xie
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xujie Dai
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yao Wei
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
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72
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Saha SK, Panwar R, Kumar A, Pal S, Ahuja V, Dash NR, Makharia G, Sahni P. Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome. Int J Colorectal Dis 2018; 33:79-82. [PMID: 28920181 DOI: 10.1007/s00384-017-2903-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy. We implemented this policy and report the results of our experience. METHODS The clinical records of all patients with ASUC who underwent emergency colectomy after failure of medical therapy between January 2005 and July 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery, in-hospital mortality and post-operative complications. RESULTS Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these, 75 (85.2%) were operated within 7 days of initiation of intensive medical therapy [n = 51 (58%) were operated < 5 days]. One patient who was operated on day 8 following steroid therapy died postoperatively. The current post-operative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series [8/51 (15.6%); p = 0.001]. In addition, the incidence of overall (9/13 vs. 23/75; p = 0.012) and clinically significant (12/75 vs. 6/13; p = 0.022) complications was significantly higher in patients operated after 7 days as compared to those operated within 7 days. CONCLUSION The policy of early colectomy, within 7 days, in patients with ASUC who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality and morbidity.
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Affiliation(s)
- Sujeet Kumar Saha
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India
| | - Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India
| | - Ameet Kumar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India.
| | - Vineet Ahuja
- Department of Gastroenterology & Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India
| | - Govind Makharia
- Department of Gastroenterology & Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India
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Dulai PS, Jairath V. Acute severe ulcerative colitis: latest evidence and therapeutic implications. Ther Adv Chronic Dis 2017; 9:65-72. [PMID: 29387331 DOI: 10.1177/2040622317742095] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 10/24/2017] [Indexed: 12/16/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease of the colorectum which results from a complex interplay between environmental, genetic and microbial factors. One-fifth of patients with UC will experience an acute flare requiring hospitalization. This is a medical emergency and requires prompt recognition and multidisciplinary management. In patients who fail first-line therapy after approximately 3-5 days of intravenous steroids, medical rescue therapy is indicated with either infliximab (IFX) or cyclosporine (CsA). Optimal dosing strategies for IFX are uncertain, with several retrospective studies suggesting an association between an intensified or accelerated IFX induction regimen and lower colectomy rates, although prospective studies are warranted. In patients not responding to medical rescue therapy, or in those with fulminant colitis, urgent colectomy is indicated. Longer prognosis is suboptimal, with half of patients requiring colectomy within 5 years of presentation with acute severe UC (ASUC).
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Vipul Jairath
- Division of Gastroenterology, Division of Epidemiology and Biostatistics, Department of Medicine, Western University, London, Ontario, OX3 9DU, Canada
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The Impact of Preoperative Serum Anti-TNFα Therapy Levels on Early Postoperative Outcomes in Inflammatory Bowel Disease Surgery. Ann Surg 2017; 266:e61-e62. [PMID: 29136975 DOI: 10.1097/sla.0000000000001502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES Data describing the incidence and risk factors for colectomy in pediatric ulcerative colitis (UC) is inconsistent. Our aim was to describe the colectomy rate and to identify risk factors associated with colectomy in a large cohort of children with UC with long-term follow-up. MATERIALS AND METHODS We performed a retrospective chart review of pediatric UC cases that were diagnosed at Schneider Children's Medical Center of Israel between 1981 and 2013. Potential predictors for colectomy including age at diagnosis, sex, disease extent, severity indices, and different therapeutic regimens during disease course were assessed. RESULTS Of 188 patients with pediatric onset UC, 34 (18%) underwent colectomy. Median follow-up was 6.9 years (range, 1-30). Kaplan-Meier survival estimates of the cumulative probability for colectomy were 4% at 1 year and 17% at 10 years from diagnosis. Multivariate Cox models showed that male sex (hazard ratio 4.2, P = 0.001) and severe disease at diagnosis reflected by Pediatric Ulcerative Colitis Activity Index score ≥65 (hazard ratio 8.9, P < 0.001) were associated with increased risk for colectomy. Age, disease extent, ethnicity, family history of inflammatory bowel disease, early introduction of immunomodulators, or treatment with antitumor necrosis factor α agent did not affect the risk of colectomy. CONCLUSIONS Male sex and higher Pediatric Ulcerative Colitis Activity Index score at diagnosis are independent risk factors for colectomy.
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Clinical Predictors of the Risk of Early Colectomy in Ulcerative Colitis: A Population-based Study. Inflamm Bowel Dis 2017; 23:1272-1277. [PMID: 28719540 DOI: 10.1097/mib.0000000000001211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A subset of patients with ulcerative colitis (UC) will require colectomy within a few years of diagnosis. Thus, our aim was to determine the clinical predictors of early colectomy among patients with UC who are hospitalized with an acute flare. METHODS Using population-based surveillance (1996-2009), all adults (≥18 years) hospitalized for UC within 3 years of diagnosis (n = 489) were identified. The primary outcome was a colectomy within 3 years of diagnosis. All medical charts were reviewed. A logistic regression model evaluated clinical variables that predicted colectomy within 3 years of diagnosis, and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. RESULTS Among patients admitted to hospital with UC within 3 years of diagnosis, 57.7% underwent colectomy, with the odds of colectomy decreasing by 12% per year. Early colectomy was more likely among patients aged 35 to 64 years versus 18 to 34 years (OR 2.18 [95% CI, 1.27-3.74]), males (OR 2.03 [95% CI, 1.24-3.34]), those with pancolitis (OR 5.38 [95% CI, 3.20-9.06]), and living in rural areas (OR 2.81 [95% CI, 1.49-5.29]). Prescription of infliximab before hospitalization increased odds of surgery (OR 5.12 [95% CI, 1.36-19.30]). CONCLUSIONS Patients hospitalized for UC have a high risk of early colectomy. This is particularly true in middle-aged men, those living in rural areas, and those without response to infliximab.
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Michailidou M, Nfonsam VN. Preoperative anemia and outcomes in patients undergoing surgery for inflammatory bowel disease. Am J Surg 2017; 215:78-81. [PMID: 28359559 DOI: 10.1016/j.amjsurg.2017.02.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/01/2017] [Accepted: 02/25/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anemia is the most common extraintestinal manifestation in patients with inflammatory bowel disease (IBD), and has been linked to severity of the disease. The aim of the study was to assess the impact of anemia on postoperative outcomes in patients with IBD. METHODS We retrospectively reviewed patients with IBD from the NSQIP database over an 8-year period. Patients were grouped based on the presence of anemia. The impact of anemia on postoperative morbidity, mortality and length of stay was assessed. RESULTS A total of 15,761 patients met our criteria. Half of the patients were anemic upon presentation. Anemic patients were more likely to have a history of steroid use, present with sepsis and require an emergency operation. In multivariate analysis, anemia was a significant predictor of overall morbidity, serious morbidity and increased length of stay. CONCLUSIONS Anemic patients with IBD present more often with sepsis and require emergency surgery compared to their peers. In addition, anemia serves as an independent predictor of overall complications, serious morbidity and increased length of stay following abdominal operations.
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Affiliation(s)
- M Michailidou
- Department of Surgery, Division of Surgical Oncology, University of Arizona, Tucson, AZ, USA
| | - V N Nfonsam
- Department of Surgery, Division of Surgical Oncology, University of Arizona, Tucson, AZ, USA.
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Li J, Lyu H, Yang H, Li Y, Tan B, Wei MM, Sun XY, Li JN, Wu B, Qian JM. Preoperative Corticosteroid Usage and Hypoalbuminemia Increase Occurrence of Short-term Postoperative Complications in Chinese Patients with Ulcerative Colitis. Chin Med J (Engl) 2017; 129:435-41. [PMID: 26879017 PMCID: PMC4800844 DOI: 10.4103/0366-6999.176072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Clarifying the risk factors for postoperative complications and taking measures to minimize these complications will improve the outcomes in patients with ulcerative colitis (UC). This study aimed to systemically explore the risk factors for short-term postoperative complications in Chinese UC patients undergoing ileocolorectal surgery. Methods: Forty-nine UC patients undergoing proctocolectomy or ileostomy were retrospectively enrolled. Univariate and multivariate logistic regression analyses were conducted to reveal the risk factors among the clinical, laboratory, and surgical variables as well as preoperative medications. Results: Twenty-two (44.9%) patients who suffered from at least one short-term postoperative event had more severe hypoalbuminemia (P = 0.007) and an increased prevalence of preoperative corticosteroid usage (prednisone more than 20 mg daily or equivalent) for more than 6 weeks (59.1% vs. 25.9%, P = 0.023) compared with patients without short-term postoperative complications. Based on the multivariate logistic regression analysis, the odds ratio (95% confidence interval) values of these two risk factors were 1.756 (0.889–3.470, P = 0.105) and 3.233 (0.916–11.406, P = 0.068), respectively. In 32 severe UC patients, prolonged preoperative hospital stay worsened the short-term postoperative outcomes. Conclusions: Preoperative corticosteroids usage and hypoalbuminemia worsened the short-term outcomes following ileocolorectal surgery in Chinese UC patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jia-Ming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Kisiel JB, Konijeti GG, Piscitello AJ, Chandra T, Goss TF, Ahlquist DA, Farraye FA, Ananthakrishnan AN. Stool DNA Analysis is Cost-Effective for Colorectal Cancer Surveillance in Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2016; 14:1778-1787.e8. [PMID: 27464589 PMCID: PMC5108686 DOI: 10.1016/j.cgh.2016.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/17/2016] [Accepted: 07/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective. METHODS We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000. RESULTS All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%. CONCLUSIONS Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.
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Affiliation(s)
- John B. Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN
| | - Gauree G. Konijeti
- Division of Gastroenterology, Scripps Clinic, La Jolla CA,Scripps Translational Science Institute, La Jolla, CA
| | | | | | | | - David A. Ahlquist
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN
| | - Francis A. Farraye
- Center for Digestive Disorders, Boston Medical Center, Section of Gastroenterology, Boston University School of Medicine, Boston MA
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital and Harvard Medical School, Boston MA
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Feld SI, Tevis SE, Cobian AG, Craven MW, Kennedy GD. Multiple postoperative complications: Making sense of the trajectories. Surgery 2016; 160:1666-1674. [PMID: 27769659 DOI: 10.1016/j.surg.2016.08.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/05/2016] [Accepted: 08/16/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many studies have evaluated predictors of postoperative complications, yet little is known about the development of multiple complications. The goal of this study was to assess complication timing in cascades of multiple complications and the risk of future complications given a patient's first complication. METHODS This study includes 30-day, postoperative complications from the American College of Surgeons National Surgical Quality Improvement Program for all patients who underwent major inpatient and outpatient operative procedures from 2005-2013. The timing and sequencing of complications were evaluated using χ2 analysis and pairwise comparisons. RESULTS More severe postoperative complications (cardiac arrest or myocardial infarction, renal insufficiency or failure, stroke, intubation, septic shock, coma) had the greatest impact on the risk for developing further complications, increasing the relative risk of developing future, specific, severe complications by more than 40-fold. These more severe complications occur within a few days of other complications (whether as a preceding factor or an outcome), while less severe complications, such as surgical site infection and urinary tract infection, are linked less tightly to complication cascades. CONCLUSION This analysis highlights both the risk for secondary complications after an initial complication and when those future complications are likely to occur. Physicians can use this information to target interventions to prevent high-risk complications.
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Affiliation(s)
- Shara I Feld
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Sarah E Tevis
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Alexander G Cobian
- Department of Computer Sciences, University of Wisconsin-Madison, Madison, WI; Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Mark W Craven
- Department of Computer Sciences, University of Wisconsin-Madison, Madison, WI; Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Gregory D Kennedy
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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81
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Ananthakrishnan AN, Shi HY, Tang W, Law CCY, Sung JJY, Chan FKL, Ng SC. Systematic Review and Meta-analysis: Phenotype and Clinical Outcomes of Older-onset Inflammatory Bowel Disease. J Crohns Colitis 2016; 10:1224-36. [PMID: 26928965 PMCID: PMC6082591 DOI: 10.1093/ecco-jcc/jjw054] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known of the clinical outcome of patients with older-onset inflammatory bowel disease [IBD]. We performed a systematic review to determine phenotype and outcomes of older-onset IBD compared with younger-onset subjects. METHODS A systematic search of Embase and Medline up to June 2015 identified studies investigating phenotype and outcomes of older-onset [diagnosed at age ≥ 50 years] Crohn's disease [CD] and ulcerative colitis [UC] subjects. Pooled analyses of disease phenotype, medication use, and disease-related surgery were calculated. RESULTS We analysed findings from 43 studies comprising 8274 older-onset and 34641 younger-onset IBD subjects. Compared with younger-onset patients, older-onset CD patients were more likely to have colonic disease (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.88 - 3.48) and inflammatory behaviour [OR 1.19, 95% CI 1.07 - 1.33], and less likely to have penetrating disease or perianal involvement. More older-onset UC patients had left-sided colitis [OR 1.49, 95% CI 1.18 - 1.88]. Although fewer older-onset IBD patients received immunomodulators [CD: OR 0.44; UC: OR 0.60] or biologicals [CD: OR 0.34; UC: OR 0.41], older-onset CD was similar in the need for surgery [OR 0.70, 95% CI 0.40 - 1.22] whereas more older-onset UC patients underwent surgery [OR 1.36, 95% CI 1.18 - 1.57]. CONCLUSIONS Elderly IBD patients present with less complicated disease, but have similar or higher rates of surgery than non-elderly patients. Whether this reflects a non-benign disease course, physicians' reluctance to employ immunomodulators, or both, merits further study which is essential for improving the care of IBD in the elderly.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hai Yun Shi
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong
| | - Whitney Tang
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong
| | - Cindy C Y Law
- University of Ottawa School of Medicine, Ottawa, ON, Canada
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong
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Bollegala N, Jackson TD, Nguyen GC. Increased Postoperative Mortality and Complications Among Elderly Patients With Inflammatory Bowel Diseases: An Analysis of the National Surgical Quality Improvement Program Cohort. Clin Gastroenterol Hepatol 2016; 14:1274-81. [PMID: 26656299 DOI: 10.1016/j.cgh.2015.11.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 10/29/2015] [Accepted: 11/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Elderly patients may be at increased risk for poor outcomes after surgery for inflammatory bowel disease (IBD). We investigated postoperative mortality and the incidence of complications in elderly patients with IBD. METHODS We identified patients who underwent major IBD-related abdominal surgery using the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, from 2005 through 2012. We compared mortality and postoperative complications between elderly patients (≥65 years old) and nonelderly patients (<65 years old). RESULTS We identified 15,495 IBD patients who underwent surgery; of these, 1707 (11%) were elderly. Postoperative 30-day mortality was higher among elderly patients with Crohn's disease (CD) (4.2% vs 0.3% in nonelderly patients; P < .001) or ulcerative colitis (UC) (6.1% vs 0.7%; P < .001). After accounting for potential confounders, the adjusted odds ratio (aOR) of postoperative mortality in patients with CD was 11.67 (95% confidence interval [CI], 5.99-22.74), and in patients with UC was 4.39 (95% CI, 2.49-7.72). Postoperative complications were more common among elderly patients with CD (28.0% vs 19.4% in nonelderly patients; P < .001) or UC (39.3% vs 23.6% in elderly patients; P < .001). The aOR for any postoperative complication (excluding death) was 1.40 (95% CI, 1.16-1.69) in patients with CD and 1.74 for patients with UC (95% CI, 1.49-2.05). Elderly patients with UC were at increased risk for infectious complications, compared with nonelderly patients (aOR, 1.52; 95% CI, 1.27-1.82). The risk of postoperative venous thromboembolism was higher in elderly patients with CD (aOR, 1.68; 95% CI, 1.04-2.73). A higher proportion of elderly patients was still in the hospital more than 30 days after surgery (5.0% vs 1.8% for nonelderly patients; P < .001). CONCLUSIONS Elderly patients with IBD have substantially higher postoperative mortality and more complications than nonelderly patients with IBD. These increased risks should be considered when comparing risks of surgical vs medical therapy in this population.
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Affiliation(s)
- Natasha Bollegala
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada
| | - Timothy D Jackson
- University Health Network, Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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83
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Tevis SE, Kennedy GD. Postoperative Complications: Looking Forward to a Safer Future. Clin Colon Rectal Surg 2016; 29:246-52. [PMID: 27582650 DOI: 10.1055/s-0036-1584501] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colorectal surgery patients frequently suffer from postoperative complications. Patients with complications have been shown to be at higher risk for mortality, poor oncologic outcomes, additional complications, and worse quality of life. Complications are increasingly recognized as markers of quality of care with more use of risk-adjusted national surgical databases and increasing transparency in health care. Quality improvement work in colorectal surgery has identified methods to decrease complication rates and improve outcomes in this patient population. Future work will continue to identify best practices and standardized ways to measure quality of care.
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Affiliation(s)
- Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Gregory D Kennedy
- Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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Ozrazgat-Baslanti T, Blanc P, Thottakkara P, Ruppert M, Rashidi P, Momcilovic P, Hobson C, Efron PA, Moore FA, Bihorac A. Preoperative assessment of the risk for multiple complications after surgery. Surgery 2016; 160:463-72. [PMID: 27238354 PMCID: PMC5114020 DOI: 10.1016/j.surg.2016.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/15/2016] [Accepted: 04/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The association between preoperative patient characteristics and the number of major postoperative complications after a major operation is not well defined. METHODS In a retrospective, single-center cohort of 50,314 adult surgical patients, we used readily available preoperative clinical data to model the number of major postoperative complications from none to ≥3. We included acute kidney injury; prolonged stay (>48 hours) in an intensive care unit; need for prolonged (>48 hours) mechanical ventilation; severe sepsis; and cardiovascular, wound, and neurologic complications. Risk probability scores generated from the multinomial logistic models were used to develop an online calculator. We stratified patients based on their risk of having ≥3 postoperative complications. RESULTS Patients older than 65 years (odds ratio 1.5, 95% confidence interval, 1.4-1.6), males (odds ratio 1.2, 95% confidence interval, 1.2-1.3), patients with a greater Charlson comorbidity index (odds ratio 3.9, 95% confidence interval, 3.6-4.2), patients requiring emergency operation (odds ratio 3.5, 95% confidence interval, 3.3.-3.7), and patients admitted on a weekend (odds ratio 1.4, 95% confidence interval, 1.3-1.5) were more likely to have ≥3 postoperative complications than they were to have none. Patients in the medium- and high-risk categories were 3.7 and 6.3 times more likely to have ≥3 postoperative complications, respectively. High-risk patients were 5.8 and 4.4 times more likely to die within 30 and 90 days of admission, respectively. CONCLUSION Readily available, preoperative clinical and sociodemographic factors are associated with a greater number of postoperative complications and adverse surgical outcomes. We developed an online calculator that predicts probability of developing each number of complications after a major operation.
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Affiliation(s)
| | - Paulette Blanc
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Paul Thottakkara
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Matthew Ruppert
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Parisa Rashidi
- Biomedical Engineering Department, University of Florida, Gainesville, FL
| | - Petar Momcilovic
- Industrial and Systems Engineering, University of Florida, Gainesville, FL
| | - Charles Hobson
- Department of Health Services Research, University of Florida, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL
| | | | - Azra Bihorac
- Department of Anesthesiology, University of Florida, Gainesville, FL
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85
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Lin CC, Wei SC, Lin BR, Tsai WS, Chen JS, Hsu TC, Lin WC, Huang TY, Chao TH, Lin HH, Wong JM, Lin JK. A retrospective analysis of 20-year data of the surgical management of ulcerative colitis patients in Taiwan: a study of Taiwan Society of Inflammatory Bowel Disease. Intest Res 2016; 14:248-57. [PMID: 27433147 PMCID: PMC4945529 DOI: 10.5217/ir.2016.14.3.248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/25/2016] [Accepted: 05/09/2016] [Indexed: 12/19/2022] Open
Abstract
Background/Aims With the recent progress in medical treatment, surgery still plays a necessary and important role in treating ulcerative colitis (UC) patients. In this study, we analyzed the surgical results and outcomes of UC in Taiwan in the recent 20 years, via a multi-center study through the collaboration of Taiwan Society of IBD. Methods A retrospective analysis of surgery data of UC patients from January 1, 1995, through December 31, 2014, in 6 Taiwan major medical centers was conducted. The patients' demographic data, indications for surgery, and outcome details were recorded and analyzed. Results The data of 87 UC patients who received surgical treatment were recorded. The median post-operative follow-up duration was 51.1 months and ranged from 0.4 to 300 months. The mean age at UC diagnosis was 45.3±16.0 years and that at operation was 48.5±15.2 years. The 3 leading indications for surgical intervention were uncontrolled bleeding (16.1%), perforation (13.8%), and intractability (12.6%). In total, 27.6% of surgeries were performed in an emergency setting. Total or subtotal colectomy with rectal preservation (41.4%) was the most common operation. There were 6 mortalities, all due to sepsis. Emergency operation and low pre-operative albumin level were significantly associated with poor survival (P=0.013 and 0.034, respectively). Conclusions In the past 20 years, there was no significant change in the indications for surgery in UC patients. Emergency surgeries and low pre-operative albumin level were associated with poor survival. Therefore, an optimal timing of elective surgery for people with poorly controlled UC is paramount.
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Affiliation(s)
- Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital and Department of Surgery, National Yang-Ming University, Taipei, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Been-Ren Lin
- Division of Colon and Rectal Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Sy Tsai
- Division of Colorectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jinn-Shiun Chen
- Division of Colorectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Wei-Chen Lin
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hung-Hsin Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital and Department of Surgery, National Yang-Ming University, Taipei, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital and Department of Surgery, National Yang-Ming University, Taipei, Taiwan
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86
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Tevis SE, Cobian AG, Truong HP, Craven MW, Kennedy GD. Implications of Multiple Complications on the Postoperative Recovery of General Surgery Patients. Ann Surg 2016; 263:1213-8. [PMID: 27167563 PMCID: PMC6214627 DOI: 10.1097/sla.0000000000001390] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the association between multiple complications and postoperative outcomes and to assess which complications occur together in patients with multiple complications. BACKGROUND Patients who suffer multiple complications have increased risk of prolonged hospital stay and mortality. However, little is known about what places patients at risk for multiple complications or which complications tend to occur in these patients. METHODS Surgical patients were identified from the American College of Surgeons National Quality Improvement Program (ACS NSQIP) database from 2005 to 2011. The frequency of postoperative complications was assessed. Patients with less than two complications were compared with patients who had multiple complications using χ and logistic regression analysis. Relationships among postoperative complications were explored by learning a Bayesian network model. RESULTS The study population consisted of 470,108 general surgery patients. The overall complication rate was 15% with multiple complications in 27,032 (6%) patients. Patients with multiple complications had worse postoperative outcomes (P < 0.001). The strongest predictors for developing multiple complications were admission from chronic care facility or nursing home, dependent functional status, and higher American Society of Anesthesiologist Physical Status classification. In patients with multiple complications, the most common complication was sepsis (42%), followed by failure to wean ventilator (31%), and organ space surgical site infection (27%). We found that severe complications were most strongly associated with development of multiple complications. Using a Bayesian network, we were able to identify how strongly associated specific complications were in patients who developed multiple complications. CONCLUSIONS Almost half (40%) of patients with complications suffer multiple complications. Patient factors such as frailty and comorbidity strongly predict the development of multiple complications. The results of our Bayesian analysis identify targets for interventions aimed at disrupting the cascade of multiple complications in high-risk patients.
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Affiliation(s)
- Sarah E Tevis
- *Department of Surgery, University of Wisconsin, Madison, WI †Departments of Computer Sciences and Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI ‡Department of Surgery, University of California, Berkeley, CA
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87
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Wanderås MH, Moum BA, Høivik ML, Hovde &O. Predictive factors for a severe clinical course in ulcerative colitis: Results from population-based studies. World J Gastrointest Pharmacol Ther 2016; 7:235-241. [PMID: 27158539 PMCID: PMC4848246 DOI: 10.4292/wjgpt.v7.i2.235] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/27/2015] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is characterized by chronic inflammation of the large bowel in genetically susceptible individuals exposed to environmental risk factors. The disease course can be difficult to predict, with symptoms ranging from mild to severe. There is no generally accepted definition of severe UC, and no single outcome is sufficient to classify a disease course as severe. There are several outcomes indicating a severe disease course, including progression of the disease’s extension, a high relapse rate, the development of acute severe colitis, colectomy, the occurrence of colorectal cancer and UC-related mortality. When evaluating a patient’s prognosis, it is helpful to do so in relation to these outcomes. Using these outcomes also makes it easier to isolate factors predictive of severe disease. The aims of this article are to evaluate different disease outcomes and to present predictive factors for these outcomes.
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88
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Ulcerative Colitis Patients With Clostridium difficile are at Increased Risk of Death, Colectomy, and Postoperative Complications: A Population-Based Inception Cohort Study. Am J Gastroenterol 2016; 111:691-704. [PMID: 27091322 DOI: 10.1038/ajg.2016.106] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Clostridium difficile (C. difficile) may worsen the prognosis of ulcerative colitis (UC). The objectives of this study were to: (i) validate the International Classification of Diseases-10 (ICD-10) code for C. difficile; (ii) determine the risk of C. difficile infection after diagnosis of UC; (iii) evaluate the effect of C. difficile infection on the risk of colectomy; and (iv) assess the association between C. difficile and postoperative complications. METHODS The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated by comparing ICD-10 codes for C. difficile with stool toxin tests. A population-based surveillance cohort of newly diagnosed UC patients living in Alberta, Canada were identified from 2003 to 2009 (n=1,754). The effect of a C. difficile infection on colectomy was modeled using competing risk survival regression after adjusting for covariates. The effect of a C. difficile infection on postoperative complications was assessed using a mixed effects logistic regression model. RESULTS The sensitivity, specificity, PPV, and NPV of the ICD-10 code for C. difficile were 82.1%, 99.4%, 88.4%, and 99.1%, respectively. The risk of C. difficile infection within 5 years of diagnosis with UC was 3.4% (95% confidence interval (CI): 2.5-4.6%). The risk of colectomy was higher among UC patients diagnosed with C. difficile (sub-hazard ratio (sHR)=2.36; 95% CI: 1.47-3.80). C. difficile increased the risk of postoperative complications (odds ratio=4.84; 95% CI: 1.28-18.35). C. difficile was associated with mortality (sHR=2.56 times; 95% CI: 1.28-5.10). CONCLUSIONS C. difficile diagnosis worsens the prognosis of newly diagnosed patients with UC by increasing the risk of colectomy, postoperative complications, and death.
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89
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Feuerstein JD, Akbari M, Tapper EB, Cheifetz AS. Systematic review and meta-analysis of third-line salvage therapy with infliximab or cyclosporine in severe ulcerative colitis. Ann Gastroenterol 2016; 29:341-7. [PMID: 27366036 PMCID: PMC4923821 DOI: 10.20524/aog.2016.0032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/22/2016] [Indexed: 12/18/2022] Open
Abstract
Background In patients with ulcerative colitis who fail corticosteroids and are treated with rescue therapy (e.g. infliximab or cyclosporine) but fail to respond, salvage therapy with infliximab or cyclosporine can be considered. We sought to assess the efficacy and safety of this third-line salvage therapy. Methods We performed a meta-analysis of trials published in PubMed up to January 2015 relating to the use of third-line salvage therapy following failure of intravenous corticosteroids and infliximab or cyclosporine. Pooled outcome rates for each salvage strategy and pooled odds ratio comparing the two strategies were calculated using the random effects model. Heterogeneity was assessed by the Q and I2 statistics. Results The search strategy yielded 40 articles of which 4 were eligible for inclusion. Four articles assessed patients who were treated with infliximab after failure of cyclosporine and 2 articles assessed the use of cyclosporine after failure of infliximab. There were 138 patients using infliximab as a third-line salvage therapy and 30 patients using cyclosporine. When comparing these two strategies, there was no significant difference in clinical response (RR 1.03, 95%CI 0.7-1.46 P=0.87), clinical remission (RR 0.69, 95%CI 0.30-1.57 P=0.37), or colectomy at 12 months (RR 1.14, 95%CI 0.79-1.67 P=0.48). Similarly, there was no significant difference in total (RR 1.91, 95% CI0.38-9.64 p=0.43) or serious adverse events (RR 1.18, 95%CI 0.34-4.07 P=0.80). Conclusion While third-line salvage therapy may be efficacious in achieving short-term clinical response/remission, there remains a significant risk of colectomy and adverse events.
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Affiliation(s)
- Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Mona Akbari
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Elliot B Tapper
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Adam S Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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90
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Prediction of surgical site infection after colorectal surgery. Am J Infect Control 2016; 44:450-4. [PMID: 27038393 DOI: 10.1016/j.ajic.2015.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/16/2015] [Accepted: 10/20/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Surgical site infection (SSI) after colorectal surgery is a frequent complication associated with substantial morbidity. Our objective was to identify surgical predictors of SSI in patients undergoing colorectal surgery using a retrospective case-control design. MATERIAL AND METHODS Randomly selected patients from all those undergoing colorectal surgery (2007-2013). Cases were patients who developed SSI within 30 days. Controls were patients who did not develop SSI within 30 days. Patients undergoing multiple procedures during a single surgical intervention were excluded. SSI was diagnosed according to Centers for Disease Control and Prevention definitions. The main outcome measures were SSI, surgical variables, and cumulative survival (Kaplan-Meier method). Variables considered predictors were compared using log-rank test. RESULTS Of 911 patients undergoing colorectal surgery, 221 developed SSI (24.3%; 95% confidence interval, 24.0-24.6). On univariate analysis, significant risk factors for SSI were: female sex (P = .02), >72 hours preoperative stay (P = .04), open surgery (P = .08), incision class: contaminated and dirty (P = .001), and emergency procedures (P = .006). On multivariate analysis, significant independent predictors of SSI and survival were dirty surgery (hazard ratio [HR], 2.12; P = .015), contaminated surgery (HR, 1.74; P = .009), female sex (HR, 1.58; P = .003), open surgery, (HR, 1.51; P = .015) and >72 hours preoperative stay (HR, 1.48; P = .024). CONCLUSIONS Dirty or contaminated surgery, female sex, open surgery, and >72 hours preoperative stay were significant predictors of SSI.
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Shi HY, Chan FKL, Leung WK, Li MKK, Leung CM, Sze SF, Ching JYL, Lo FH, Tsang SWC, Shan EHS, Mak LY, Lam BCY, Hui AJ, Wong SH, Wong MTL, Hung IFN, Hui YT, Chan YK, Chan KH, Loo CK, Tong RWH, Chow WH, Ng CKM, Lao WC, Harbord M, Wu JCY, Sung JJY, Ng SC. Natural History of Elderly-onset Ulcerative Colitis: Results from a Territory-wide Inflammatory Bowel Disease Registry. J Crohns Colitis 2016; 10:176-85. [PMID: 26512132 DOI: 10.1093/ecco-jcc/jjv194] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/07/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Data on the natural history of elderly-onset ulcerative colitis [UC] are limited. We aimed to investigate clinical features and outcomes of patients with elderly-onset UC. METHODS Patients with a confirmed diagnosis of UC between 1981 and 2013, from 13 hospitals within a territory-wide Hong Kong Inflammatory Bowel Disease Registry, were included. Clinical features and outcomes of elderly-onset patients, defined as age ≥ 60 years at diagnosis, were compared with those of non-elderly-onset disease [< 60 years at diagnosis]. RESULTS We identified 1225 patients, of whom 12.8% [157/1225; 56.1% male] had elderly-onset UC. Median duration of follow-up was 11 years [interquartile range, 6-16 years]. Age-specific incidence of elderly-onset UC increased from 0.1 per 100000 persons before 1991 to 1.3 per 100000 persons after 2010. There were more ex-smokers [32.2% vs. 12.2%, p < 0.001] and higher proportion of comorbidities [p < 0.001] in elderly-onset than non-elderly-onset patients. Disease extent, corticosteroids, immunosuppressants use, and colectomy rates were similar between the two groups. Elderly-onset disease was an independent risk factor for cytomegalovirus infection [odds ratio 2.9, 95% confidence interval 1.6-5.2, p < 0.001]. More elderly-onset patients had Clostridium difficile infection [11.0% vs. 5.4%, p = 0.007], hospitalisation for UC exacerbation [50.6% vs. 41.8%, p = 0.037], colorectal cancer [3.2% vs. 0.9%, p = 0.033], all-cause mortality [7.0% vs. 1.0%, p < 0.001], and UC-related mortality [1.9% vs. 0.2%, p = 0.017] than non-elderly-onset patients. CONCLUSIONS Elderly-onset UC patients are increasing in number. These patients have higher risk of opportunistic infections, hospitalisation, colorectal cancer, and mortality than non-elderly-onset patients. Management and therapeutic strategies in this special group need careful attention.
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Affiliation(s)
- Hai Yun Shi
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Wai Keung Leung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Michael K K Li
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong
| | - Chi Man Leung
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Shun Fung Sze
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Jessica Y L Ching
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Fu Hang Lo
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
| | | | - Edwin H S Shan
- Department of Medicine and Geriatrics, Caritas Medical Center, Hong Kong
| | - Lai Yee Mak
- Department of Medicine, North District Hospital, Hong Kong
| | - Belsy C Y Lam
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Aric J Hui
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Sai Ho Wong
- Department of Medicine, Yan Chai Hospital, Hong Kong
| | - Marc T L Wong
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Ivan F N Hung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Yee Tak Hui
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Yiu Kay Chan
- Department of Medicine and Geriatrics, Caritas Medical Center, Hong Kong
| | - Kam Hon Chan
- Department of Medicine, North District Hospital, Hong Kong
| | - Ching Kong Loo
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Raymond W H Tong
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Wai Hung Chow
- Department of Medicine, Yan Chai Hospital, Hong Kong
| | - Carmen K M Ng
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Wai Cheung Lao
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Marcus Harbord
- Department of Gastroenterology, Chelsea and Westminster Hospital, London, UK
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
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Similar Clinical and Surgical Outcomes Achieved with Early Compared to Late Anti-TNF Induction in Mild-to-Moderate Ulcerative Colitis: A Retrospective Cohort Study. Can J Gastroenterol Hepatol 2016; 2016:2079582. [PMID: 27478817 PMCID: PMC4958475 DOI: 10.1155/2016/2079582] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/11/2016] [Accepted: 06/19/2016] [Indexed: 02/08/2023] Open
Abstract
Background. Biologic agents targeting tumor necrosis factor alpha are effective in the management of ulcerative colitis (UC), but their use is often postponed until after failure of other treatment modalities. Objectives. We aim to determine if earlier treatment with infliximab or adalimumab alters clinical and surgical outcomes in UC patients. Methods. A retrospective cohort study was conducted evaluating UC outpatients treated with infliximab or adalimumab from 2003 to 2014. Patients were stratified by time to first anti-TNF exposure; early initiation was defined as starting treatment within three years of diagnosis. Primary outcomes were colectomy, UC-related hospitalization, and clinical secondary loss of response. Kaplan-Meier analysis was used to assess time to the primary outcomes. Results. 115 patients were included (78 infliximab, 37 adalimumab). Median follow-up was 175.6 weeks (IQR 72.4-228.4 weeks). Fifty-seven (49.6%) patients received early anti-TNF therapy; median time to treatment in this group was 38.1 (23.3-91.0) weeks compared to 414.0 (254.0-561.3) weeks in the late initiator cohort (p < 0.0001). Patients treated with early anti-TNF therapy had more severe endoscopic disease at induction (mean Mayo endoscopy subscore 2.46 (SD ± 0.66) versus 1.86 (±0.67), p < 0.001) and trended towards increased risk of colectomy (17.5% versus 8.6%, p = 0.16) and UC-related hospitalization (43.9% versus 27.6%, p = 0.07). In multivariate regression analysis, early anti-TNF induction was not associated with colectomy (HR 2.02 [95% CI: 0.57-7.20]), hospitalization (HR 1.66 [0.84-3.30]), or secondary loss of response (HR 0.86 [0.52-1.42]). Conclusions. Anti-TNF therapy is initiated earlier in patients with severe UC but earlier treatment does not prevent hospitalization, colectomy, or secondary loss of response.
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93
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Anti-Tumor Necrosis Factor-α Antibody Therapy Management Before and After Intestinal Surgery for Inflammatory Bowel Disease: A CCFA Position Paper. Inflamm Bowel Dis 2015; 21:2658-72. [PMID: 26422516 PMCID: PMC4623843 DOI: 10.1097/mib.0000000000000603] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Biologic therapy with anti-tumor necrosis factor (TNF)-α antibody medications has become part of the standard of care for medical therapy for patients with inflammatory bowel disease and may help to avoid surgery in some. However, many of these patients will still require surgical intervention in the form of bowel resection and anastomosis or ostomy formation for the treatment of their disease. Postsurgical studies suggest up to 30% of patients with inflammatory bowel disease may be on or have used anti-TNF-α antibody medications for disease management preoperatively. Significant controversy exists regarding the potential deleterious impact of these medications on the outcomes of surgery, specifically overall and/or infectious complications. In this position statement, we systematically reviewed the literature regarding the potential risk of anti-TNF-α antibody use in the perioperative period, offer recommendations based both on the best-available evidence and expert opinion on the use and timing of anti-TNF-α antibody therapy in the perioperative period, and discuss whether or not the presence of these medications should lead to an alteration in surgical technique such as temporary stoma formation.
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94
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Brown C, Gibson PR, Hart A, Kaplan GG, Kachroo S, Ding Q, Hautamaki E, Fan T, Black CM, Hu X, Beusterien K. Long-term outcomes of colectomy surgery among patients with ulcerative colitis. SPRINGERPLUS 2015; 4:573. [PMID: 26543708 PMCID: PMC4628015 DOI: 10.1186/s40064-015-1350-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/16/2015] [Indexed: 12/12/2022]
Abstract
The objective of this study was to evaluate long-term health-related quality of life outcomes among patients who had a colectomy within the previous 10 years. A cross-sectional survey was administered to consecutive patients ≥18 years of age with ulcerative colitis who had a colectomy within the last 10 years from centers in Canada, Australia, and the United Kingdom. Data were extracted from medical chart reviews to confirm selected self-reported patient characteristics. Of 351 survey respondents, 49 % were male and the median age was 40 years (interquartile range 30-52). Respondents were diagnosed with UC a median of 9.2 (5.7-15.1) years prior to the survey and first surgery occurred a median of 3.7 (2.1-5.8) years ago. Although most respondents (84 %) reported improved quality of life compared to the status before surgery, 81 % experienced problems in at least one of the following areas: depression, work productivity, restrictions in diet, body image, and sexual function. According to HADS scores, 30 and 17 % of survey respondents experienced anxiety and depression, respectively. Among moderate to severe UC patients pre-colectomy, 27 % of men and 28 % of women reported that their sexual life was worse now than before surgery. The mean EQ-5D utility index score overall was 0.79 (95 % confidence interval 0.77-0.81). Quality of life after colectomy for UC is generally good, but there are persistent quality of life issues that impact multiple domains, including psychological and sexual functioning.
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Affiliation(s)
- Carl Brown
- />Division of General Surgery, Providence Health Care, St. Paul’s Hospital, Room C310, St Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Peter R. Gibson
- />Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, VIC 3004 Australia
| | - Ailsa Hart
- />IBD Unit, St. Mark’s Hospital NWLH NHS Trust, Northwick Park, Harrow, London HA1 3UJ UK
| | - Gilaad G. Kaplan
- />Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB T2N 4N1 Canada
| | | | - Qian Ding
- />Merck & Co. Inc., Rahway, 07065 NJ USA
- />Ferris University, Big Rapids, 49307 MI USA
| | - Emily Hautamaki
- />Oxford Outcomes Inc., an ICON plc company, Bethesda, 20814 MD USA
| | - Tao Fan
- />Merck & Co. Inc., Rahway, 07065 NJ USA
- />Sanofi US and Center for Clinical Epidemiology and Biostatistics, Bridgewater, 08807 NJ USA
- />University of Pennsylvania School of Medicine, Philadelphia, 19104 NJ USA
| | | | - Xiaohan Hu
- />Merck & Co. Inc., Rahway, 07065 NJ USA
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Abstract
BACKGROUND Hospitalization costs for ulcerative colitis (UC) following the introduction of infliximab have not been evaluated. OBJECTIVE To study predictors of costs for UC patients who were hospitalized for a flare or colectomy. METHODS Population-based surveillance identified adults (≥18 years of age) admitted to hospital for UC flare or colectomy between 2001 and 2009 in the Calgary Health Zone (Alberta). Medical charts were reviewed and patients stratified into three admission types: responsive to inpatient medical therapy (n=307); emergent colectomy (n=227); and elective colectomy (n=208). The annual median cost with interquartile range (IQR) was calculated. Linear regression determined the effect of admission type on hospital charges after adjusting for age, sex, smoking, comorbidities, disease extent, medication use (eg, infliximab) and year. The adjusted cost increase was presented as the percent increase with 95% CIs. Joinpoint analysis assessed for an inflection point in hospital cost after the introduction of infliximab. RESULTS Median hospitalization cost for UC flare, emergent colectomy and elective colectomy, respectively, were: $5,499 (IQR $3,374 to $8,904), $23,698 (IQR $17,981 to $32,385) and $14,316 (IQR $11,932 to $18,331). Adjusted hospitalization costs increased approximately 6.0% annually (95% CI 4.5% to 7.5%). Adjusted costs were higher for patients who underwent an elective colectomy (percent increase cost 179.8% [95% CI 151.6% to 211.1%]) or an emergent colectomy (percent increase cost 211.1% [95% CI 183.2% to 241.6%]) than medically responsive patients. Infliximab in hospital was an independent predictor of increased costs (percent increase cost 69.5% [95% CI 49.2% to 92.5%]). No inflection points were identified. CONCLUSION Hospitalization costs for UC increased due to colectomy and infliximab.
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96
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Singh S, Al-Darmaki A, Frolkis AD, Seow CH, Leung Y, Novak KL, Ghosh S, Eksteen B, Panaccione R, Kaplan GG. Postoperative Mortality Among Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis of Population-Based Studies. Gastroenterology 2015; 149:928-37. [PMID: 26055136 DOI: 10.1053/j.gastro.2015.06.001] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 05/02/2015] [Accepted: 06/01/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS There have been varying reports of mortality after intestinal resection for the inflammatory bowel diseases (IBDs). We performed a systematic review and meta-analysis of population-based studies to determine postoperative mortality after intestinal resection in patients with IBD. METHODS We searched Medline, EMBASE, and PubMed, from 1990 through 2015, to identify 18 articles and 3 abstracts reporting postoperative mortality among patients with IBD. The studies included 67,057 patients with ulcerative colitis (UC) and 75,971 patients with Crohn's disease (CD), from 15 countries. Mortality estimates stratified by emergent and elective surgeries were pooled separately for CD and UC using a random-effects model. To assess changes over time, the start year of the study was included as a continuous variable in a meta-regression model. RESULTS In patients with UC, postoperative mortality was significantly lower among patients who underwent elective (0.7%; 95% confidence interval [CI], 0.6%-0.9%) vs emergent surgery (5.3%; 95% CI, 3.8%-7.4%). In patients with CD, postoperative mortality was significantly lower among patients who underwent elective (0.6%; 95% CI, 0.2%-1.7%) vs emergent surgery (3.6%; 95% CI, 1.8%-6.9%). Postoperative mortality did not differ for elective (P = .78) or emergent (P = .31) surgeries when patients with UC were compared with patients with CD. Postoperative mortality decreased significantly over time for patients with CD (P < .05) but not UC (P = .21). CONCLUSIONS Based on a systematic review and meta-analysis, postoperative mortality was high after emergent, but not elective, intestinal resection in patients with UC or CD. Optimization of management strategies and more effective therapies are necessary to avoid emergent surgeries.
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Affiliation(s)
- Sunny Singh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Al-Darmaki
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra D Frolkis
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Subrata Ghosh
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Bertus Eksteen
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada.
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97
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Pang JXQ, Ross E, Borman MA, Zimmer S, Kaplan GG, Heitman SJ, Swain MG, Burak KW, Quan H, Myers RP. Validation of coding algorithms for the identification of patients hospitalized for alcoholic hepatitis using administrative data. BMC Gastroenterol 2015; 15:116. [PMID: 26362871 PMCID: PMC4566395 DOI: 10.1186/s12876-015-0348-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 09/09/2015] [Indexed: 12/20/2022] Open
Abstract
Background Epidemiologic studies of alcoholic hepatitis (AH) have been hindered by the lack of a validated International Classification of Disease (ICD) coding algorithm for use with administrative data. Our objective was to validate coding algorithms for AH using a hospitalization database. Methods The Hospital Discharge Abstract Database (DAD) was used to identify consecutive adults (≥18 years) hospitalized in the Calgary region with a diagnosis code for AH (ICD-10, K70.1) between 01/2008 and 08/2012. Medical records were reviewed to confirm the diagnosis of AH, defined as a history of heavy alcohol consumption, elevated AST and/or ALT (<300 U/L), serum bilirubin >34 μmol/L, and elevated INR. Subgroup analyses were performed according to the diagnosis field in which the code was recorded (primary vs. secondary) and AH severity. Algorithms that incorporated ICD-10 codes for cirrhosis and its complications were also examined. Results Of 228 potential AH cases, 122 patients had confirmed AH, corresponding to a positive predictive value (PPV) of 54 % (95 % CI 47–60 %). PPV improved when AH was the primary versus a secondary diagnosis (67 % vs. 21 %; P < 0.001). Algorithms that included diagnosis codes for ascites (PPV 75 %; 95 % CI 63–86 %), cirrhosis (PPV 60 %; 47–73 %), and gastrointestinal hemorrhage (PPV 62 %; 51–73 %) had improved performance, however, the prevalence of these diagnoses in confirmed AH cases was low (29–39 %). Conclusions In conclusion the low PPV of the diagnosis code for AH suggests that caution is necessary if this hospitalization database is used in large-scale epidemiologic studies of this condition.
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Affiliation(s)
- Jack X Q Pang
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Erin Ross
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada.
| | - Meredith A Borman
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada.
| | - Scott Zimmer
- Medical Services, Alberta Health Services, Calgary, AB, Canada.
| | - Gilaad G Kaplan
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Steven J Heitman
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Mark G Swain
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada.
| | - Kelly W Burak
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Robert P Myers
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
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98
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Robotic single docking total colectomy for ulcerative colitis: First experience with a novel technique. Int J Surg 2015. [DOI: 10.1016/j.ijsu.2015.07.642] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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99
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miR-195 plays a role in steroid resistance of ulcerative colitis by targeting Smad7. Biochem J 2015; 471:357-67. [PMID: 26303523 DOI: 10.1042/bj20150095] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 08/24/2015] [Indexed: 12/18/2022]
Abstract
An imbalance in pro- and anti-inflammation is an important mechanism of steroid resistance in UC (ulcerative colitis), and miRNAs may participate in this process. The present study aimed to explore whether miRNAs play a role in the steroid resistance of UC by regulating gene expression of the inflammation signal pathway. SS (steroid-sensitive) patients, SR (steroid-resistant) patients and healthy individuals were recruited. In vivo miRNA profiles of serum samples showed that miR-195 was decreased significantly in the SR group compared with the SS group (P<0.05). This result was confirmed by qPCR (quantitative real-time PCR) and miRNA ISH (in situ hybridization) in serum and colon tissue samples. Online software was used to identify Smad7 mRNA as a potential target of miR-195. The direct interaction of miR-195 and Smad7 mRNA was investigated using a biotinylated miR-195 pull-down assay. Overexpression of a miR-195 precursor lowered cellular levels of Smad7 protein; conversely, antagonism of miR-195 enhanced Smad7 translation without disturbing Smad7 mRNA levels. A luciferase reporter assay revealed a repressive effect of miR-195 via a single Smad7 3'-UTR target site, and point mutation of this site prevented miR-195-induced repression of Smad7 translation. Furthermore, increased levels of miR-195 led to a decrease in c-Jun and p65 expression. In contrast, transfection with anti-miR-195 led to increased levels of c-Jun and p65 protein. The decrease in miR-195 led to an increase in Smad7 expression and corresponding up-regulation of p65 and the AP-1 (activator protein 1) pathway, which might explain the mechanism of steroid resistance in UC patients.
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100
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Abstract
BACKGROUND No previous studies have evaluated the long-term outcomes of acute severe ulcerative colitis (ASUC) in non-Caucasian populations. The purposes of this study were to evaluate the short- and long-term outcomes of Korean patients with ASUC. METHODS We retrospectively analyzed 99 Korean patients with ASUC who satisfied the criteria given by Truelove and Witts between 1999 and 2005. The short-term outcome parameter was the colectomy rate during index hospitalization, and the long-term outcome parameters were the rates of colectomy and rehospitalization after discharge from index hospitalization. RESULTS During index hospitalization, 16 of 99 patients (16.2%) underwent colectomy: 6 of 71 responders (8.5%) to intravenous steroids on day 3 versus 10 of 28 nonresponders (35.7%), as assessed using the Oxford index (P = 0.002). Among 83 patients who avoided colectomy during index hospitalization, 13 patients (15.7%) underwent colectomy during the median follow-up period of 10.6 years. The cumulative probability of colectomy tended to be lower in complete responders on day 7 of intravenous steroid therapy (CR7) than in others: 3.7% versus 13.9% at 5 years and 7.6% versus 18.2% at 10 years (P = 0.100). The cumulative probability of rehospitalization was significantly lower in CR7 than in other patients: 20.5% versus 37.5% at 5 years and 31.4% versus 48.2% at 10 years (P = 0.043). CONCLUSIONS Assessing the degree of response to intravenous steroids helps predict the short- and long-term outcomes in patients with ASUC. Korean patients with ASUC may have better clinical courses than Caucasians, as indicated by the lower colectomy rate.
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