51
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Li Wai Suen CFD, Choy MC, De Cruz P. Letter: how can we reduce mortality in elderly patients with acute severe ulcerative colitis? Aliment Pharmacol Ther 2020; 51:1444-1445. [PMID: 32445527 DOI: 10.1111/apt.15702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Christopher F D Li Wai Suen
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
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52
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Singh S, Allegretti JR, Siddique SM, Terdiman JP. AGA Technical Review on the Management of Moderate to Severe Ulcerative Colitis. Gastroenterology 2020; 158:1465-1496.e17. [PMID: 31945351 PMCID: PMC7117094 DOI: 10.1053/j.gastro.2020.01.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A subset of patients with ulcerative colitis (UC) present with, or progress to, moderate to severe disease activity. These patients are at high risk for colectomy, hospitalization, corticosteroid dependence, and serious infections. The risk of life-threatening complications and emergency colectomy is particularly high among those patients hospitalized with acute severe ulcerative colitis. Optimal management of outpatients or inpatients with moderate to severe UC often requires the use of immunomodulator and/or biologic therapies, including thiopurines, methotrexate, cyclosporine, tacrolimus, TNF-α antagonists, vedolizumab, tofacitnib, or ustekinumab, either as monotherapy or in combination (with immunomodulators), to mitigate these risks. Decisions about optimal drug therapy in moderate to severe UC are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Therefore, the American Gastroenterological Association prioritized development of clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework. Focused questions in adult outpatients with moderate to severe UC included: (1) overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to TNF-α antagonists, (2) comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, (3) comparative efficacy of top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up therapy (acceleration to biologic and/or immunomodulator therapy only after failure of 5-aminosalicylates, and (4) role of continuing vs stopping 5-aminosalicylates in patients being treated with immunomodulator and/or biologic therapy for moderate to severe UC. Focused questions in adults hospitalized with acute severe ulcerative colitis included: (5) overall and comparative efficacy of pharmacologic interventions for inpatients refractory to corticosteroids, in reducing risk of colectomy, (6) optimal dosing regimens for intravenous corticosteroids and infliximab in these patients, and (7) role of adjunctive antibiotics in the absence of confirmed infections.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jonathan P Terdiman
- Division of Gastroenterology, University of California, San Francisco, California
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53
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Day A, Wood J, Melton S, Bryant RV. Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease. JGH Open 2020; 4:260-266. [PMID: 32280775 PMCID: PMC7144766 DOI: 10.1002/jgh3.12256] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/09/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research. METHODS A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified. RESULTS An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed. CONCLUSION EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.
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Affiliation(s)
- Alice Day
- Department of Gastroenterology, The Queen Elizabeth HospitalAdelaideSouth AustraliaAustralia
| | - Jessica Wood
- Department Nutrition and Dietetics, The AlfredMelbourneVictoriaAustralia
| | - Sarah Melton
- Department Nutrition and Dietetics, The AlfredMelbourneVictoriaAustralia
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth HospitalAdelaideSouth AustraliaAustralia
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54
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Colectomy with ileostomy for severe ulcerative colitis-postoperative complications and risk factors. Int J Colorectal Dis 2020; 35:387-394. [PMID: 31865435 DOI: 10.1007/s00384-019-03494-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE In the era of biological therapy of ulcerative colitis (UC), surgical treatment frequently consists of colectomy, end ileostomy, and rectal stump closure before patients go on towards restorative proctocolectomy. We aimed to evaluate possible risk factors for the occurrence of postoperative complications and investigate those after initial colectomy in these patients. METHODS Retrospective analysis of 180 patients (76 female, 104 male) undergoing colectomy for UC with formation of a rectal stump and terminal ileostomy between March 2008 and March 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. A panel of possible postoperative complications was established, patient history was screened, and postoperative complications were analyzed using the Clavien Dindo Classification. RESULTS Postoperative complication rate was 27.7%. Mortality was 0.5%. Postoperative ileus occurred in 15.3% and rectal stump leakage in 14.8%. Complications were categorized as Clavien Dindo 3 in 80%. Risk factors for surgical complications after multivariate analysis were ASA classification (p = 0.004), preoperative anemia (Hemoglobin < 8 mg/dl) (p = 0.025), use of immunosuppressants (p = 0.003), more than two cardiovascular diseases (p = 0.016), and peritonitis (p = 0.000). Reoperation rate of patients with surgical complications was 27.7%. CONCLUSION Colectomy in high-risk UC patients is associated with significant morbidity. However, most of the surgical complications can be treated conservatively. Overall mortality is low. Patient-related risk factors are associated with postoperative complications. Optimizing these risk factors or earlier indication for surgery in the course of UC may help to reduce morbidity of this procedure.
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55
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Olén O, Askling J, Sachs MC, Neovius M, Smedby KE, Ekbom A, Ludvigsson JF. Mortality in adult-onset and elderly-onset IBD: a nationwide register-based cohort study 1964-2014. Gut 2020; 69:453-461. [PMID: 31092591 DOI: 10.1136/gutjnl-2018-317572] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 04/09/2019] [Accepted: 04/30/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine all-cause and cause-specific mortality in adult-onset and elderly-onset IBD and to describe time trends in mortality over the past 50 years. DESIGN Swedish nationwide register-based cohort study 1964-2014, comparing mortality in 82 718 incident IBD cases (inpatient and non-primary outpatient care) with 10 times as many matched general population reference individuals (n=801 180) using multivariable Cox regression to estimate HRs. Among patients with IBD, the number of participants with elderly-onset (≥60 years) IBD was 17 873. RESULTS During 984 330 person-years of follow-up, 15 698/82 718 (19%) of all patients with IBD died (15.9/1000 person-years) compared with 121 095/801 180 (15.1%) of reference individuals, corresponding to an HR of 1.5 for IBD (95% CI=1.5 to 1.5 (HR=1.5; 95% CI=1.5 to 1.5 in elderly-onset IBD)) or one extra death each year per 263 patients. Mortality was increased specifically for UC (HR=1.4; 95% CI=1.4 to 1.5), Crohn's disease (HR=1.6; 95% CI=1.6 to 1.7) and IBD-unclasssified (HR=1.6; 95% CI=1.5 to 1.8). IBD was linked to increased rates of multiple causes of death, including cardiovascular disease (HR=1.3; 1.3 to 1.3), malignancy (HR=1.4; 1.4 to 1.5) and digestive disease (HR=5.2; 95% CI=4.9 to 5.5). Relative mortality during the first 5 years of follow-up decreased significantly over time. Incident cases of 2002-2014 had 2.3 years shorter mean estimated life span than matched comparators. CONCLUSIONS Adult-onset and elderly-onset patients with UC, Crohn's disease and IBD-unclassified were all at increased risk of death. The increased mortality remained also after the introduction of biological therapies but has decreased over time.
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Affiliation(s)
- Ola Olén
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
| | - Johan Askling
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Michael C Sachs
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Martin Neovius
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
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56
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Dong C, Metzger M, Holsbø E, Perduca V, Carbonnel F. Systematic review with meta-analysis: mortality in acute severe ulcerative colitis. Aliment Pharmacol Ther 2020; 51:8-33. [PMID: 31821584 DOI: 10.1111/apt.15592] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 11/07/2019] [Accepted: 11/05/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a life-threatening condition. Mortality in ASUC decreased in published series but there is uncertainty as to whether this also applies to the real-life setting. AIM To perform a systematic review and meta-analysis of mortality in ASUC in studies from referral centres and in population-based studies, separately and combined. A second aim was to identify risk factors of mortality in ASUC. METHODS We searched pubmed and embase from 1998 to 2016, to identify studies that reported 3-month or 12-month mortalities of acute UC in adult patients treated in referral centres, and in population-based studies. RESULTS Six population-based studies with 741 743 patients and 47 referral centre-based studies with 2556 patients were included. The pooled 3-month and 12-month mortalities were respectively 0.84% and 1.01%. Advanced age was significantly associated with both 3 month and 12 month mortalities (OR = 1.15 per year, 95% CI: 1.10-1.20 and OR = 1.19 per year, 95% CI: 1.15-1.23 respectively). The pooled 3-month and 12-month mortalities were 0.78% and 0.85% in studies with median age of less than 50 and 2.81% and 4.17% in studies with median age of 50 or more, respectively. After adjustment for age, 3-month and 12-month mortalities did not differ between population-based and referral centre-based studies. CONCLUSIONS Mortality in acute severe ulcerative colitis is approximately 1%; it is higher in older patients. Efforts should be made to improve the care of elderly patients with severe UC.
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Affiliation(s)
- Catherine Dong
- Hôpital de Bicêtre, Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Marie Metzger
- Inserm U1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Villejuif, France
| | - Einar Holsbø
- Department of Computer Science, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Vittorio Perduca
- Inserm U1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Villejuif, France.,MAP5 laboratory (UMR CNRS 8145), Université Paris Descartes, Université de Paris, Paris, France
| | - Franck Carbonnel
- Hôpital de Bicêtre, Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France.,Inserm U1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Villejuif, France
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Le Berre C, Ananthakrishnan AN, Danese S, Singh S, Peyrin-Biroulet L. Ulcerative Colitis and Crohn's Disease Have Similar Burden and Goals for Treatment. Clin Gastroenterol Hepatol 2020; 18:14-23. [PMID: 31301452 DOI: 10.1016/j.cgh.2019.07.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/23/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
It is unclear whether ulcerative colitis (UC) is a progressive disease similar to Crohn's disease (CD). Patients with UC often are undertreated because of the possibility of curative colectomy and the perception that the disease burden is lower than that of CD. We discuss findings from studies that aimed to determine whether UC and CD have the same disease burden and should be treated in the same intensive way. We discuss the similarities between CD and UC, including effects on quality of life, long-term complications, strictures, increased risk of cancer, pseudopolyps, functional abnormalities, and anorectal dysfunction. Contrary to the generally accepted idea, surgery cannot cure UC. Postoperative complications, especially pouchitis and fecal incontinence, affect more than one third of patients. CD and UC each pose substantial economic burdens. Monitoring, treatments, and goals of therapy are similar for all inflammatory bowel diseases. Earlier initiation of disease-modifying drugs might reduce the progression of UC and reduce its burden after surgery, although UC might not cause the irreversible damage observed in patients with CD.
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Affiliation(s)
- Catherine Le Berre
- Inserm U954, Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France; Institut des Maladies de l'Appareil Digestif, Nantes University Hospital, Nantes, France
| | | | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Inflammatory Bowel Disease Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Laurent Peyrin-Biroulet
- Inserm U954, Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
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58
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Lin WC, Weng MT, Tung CC, Chang YT, Leong YL, Wang YT, Wang HY, Wong JM, Wei SC. Trends and risk factors of mortality analysis in patients with inflammatory bowel disease: a Taiwanese nationwide population-based study. J Transl Med 2019; 17:414. [PMID: 31831015 PMCID: PMC6909461 DOI: 10.1186/s12967-019-02164-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) was emerging as a worldwide epidemic disease, and the advanced therapy changed the clinical course and possibly the outcomes. Our previous study reported a higher mortality rate from (IBD) in Taiwan than in Western countries. We proposed to analyze the trend and risk factors of mortality in order to improve the care quality of IBD patients. Methods This retrospective study was conducted to analyze data for January 2001 to December 2015 from a registered database, compiled by the Taiwan’s National Health Insurance. Results Between 2001 and 2015, a total of 3806 IBD patients [Crohn’s disease (CD): 919; ulcerative colitis (UC): 2887] were registered as having catastrophic illness, and 8.2% of these patients died during follow-up. The standardized mortality ratios (SMRs) of CD and UC were 3.72 (95% CI 3.02–4.55) and 1.44 (95% CI 1.26–1.65), respectively, from 2001 to 2015, respectively. A comparison of the periods of 2011–2015 and 2001–2005 revealed a decrease in the mortality rates from both UC and CD. Multivariate Cox proportional hazards analysis identified elderly individuals; sepsis and pneumonia were the risk factors for IBD mortality. The specific risk factors of mortality were liver cancer for UC and surgeries for CD. Conclusion For further decreasing IBD-related mortality in Taiwan, we need to pay special attention toward elderly individuals, infection control, cancer screening and improvement in perioperative care.
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Affiliation(s)
- Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei City, Taiwan.,MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,MacKay Medical College, Taipei, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan.,School of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Chien-Chih Tung
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Yuan-Ting Chang
- Health Data Research Center, National Taiwan University, Taipei City, Taiwan
| | - Yew-Loong Leong
- Department of Internal Medicine, West Garden Hospital, Taipei City, Taiwan
| | - Yu-Ting Wang
- Inflammatory Bowel Disease Clinical and Study Integrated Center, National Taiwan University Hospital, Taipei City, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei City, Taiwan.,MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,MacKay Medical College, Taipei, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan. .,Inflammatory Bowel Disease Clinical and Study Integrated Center, National Taiwan University Hospital, Taipei City, Taiwan.
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Verdon C, Bessissow T, Lakatos PL. Management of Acute Severe Colitis in the Era of Biologicals and Small Molecules. J Clin Med 2019; 8:jcm8122169. [PMID: 31817972 PMCID: PMC6947608 DOI: 10.3390/jcm8122169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a medical emergency which occurs in about 20%–30% of patients with ulcerative colitis during their lifetime, and does carry a mortality risk of 1%. The management of inflammatory bowel diseases has evolved with changes in objective patient monitoring, as well as the availability of new treatment options with the development of new biological and small molecules; however, data is limited regarding their use in the context of ASUC. This review aims to discuss the emerging data regarding biologicals and small molecules therapies in the context of ASUC.
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Affiliation(s)
- Christine Verdon
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada; (C.V.); (T.B.)
- Department of Gastroenterology, Campbelltown Hospital, Sydney, NSW 2560, Australia
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada; (C.V.); (T.B.)
| | - Peter L. Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada; (C.V.); (T.B.)
- 1st Department of Medicine, Semmelweis University, Budapest H1083, Hungary
- Correspondence: ; Tel.: +514-934-1934 (ext. 45567)
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61
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Dong Y, Xu L, Fan Y, Xiang P, Gao X, Chen Y, Zhang W, Ge Q. A novel surgical predictive model for Chinese Crohn's disease patients. Medicine (Baltimore) 2019; 98:e17510. [PMID: 31725605 PMCID: PMC6867775 DOI: 10.1097/md.0000000000017510] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Due to the complexity of Crohn's disease (CD), it is difficult to predict disease course with a single stratification factor or biomarker. A logistic regression (LR) model has been proposed by Guizzetti et al to stratify patients with CD-related surgical risk, which could help decision-making on disease treatment. However, there are no reports on relevant studies on Chinese population. The aim of the study is to present and validate a novel surgical predictive model to facilitate therapeutic decision-making for Chinese CD patients. Data was extracted from retrospective full-mode electronic medical records, which contained 239 CD patients and 1524 instances. Two sub-datasets were generated according to different attribute selection strategies, both of which were split into training and testing sets randomly. The imbalanced data in the training sets was addressed by synthetic minority over-sampling technique (SMOTE) algorithm before model development. Seven predictive models were employed using 5 popular machine learning algorithms: random forest (RF), LR, support vector machine (SVM), decision tree (DT) and artificial neural networks (ANN). The performance of each model was evaluated by accuracy, precision, F1-score, true negative (TN) rate, and the area under the receiver operating characteristic curve (AuROC). The result revealed that RF outperformed all other baseline models on both sub-datasets. The 10 leading risk factors for CD-related surgery returned from RF for attribute ranking were changes of radiology, presence of a fistula, presence of an abscess, no infliximab use, enteroscopy findings, C-reactive protein, abdominal pain, white blood cells, erythrocyte sedimentation rate and platelet count. The proposed machine learning model can accurately predict the risk of surgical intervention in Chinese CD patients, which could be used to tailor and modify the treatment strategies for CD patients in clinical practice.
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Affiliation(s)
| | - Li Xu
- Department of Anorectal Surgery
| | | | - Ping Xiang
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of TCM, Zhejiang International Exchange Center of Clinical TCM
| | - Xuning Gao
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of TCM, Zhejiang International Exchange Center of Clinical TCM
| | - Yong Chen
- School of Information, Zhejiang University of Finance and Economics, Hangzhou 310018, China
| | - Wenyu Zhang
- School of Information, Zhejiang University of Finance and Economics, Hangzhou 310018, China
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Han W, Xie B, Li Y, Shi L, Wan J, Chen X, Wang H. Orally Deliverable Nanotherapeutics for the Synergistic Treatment of Colitis-Associated Colorectal Cancer. Theranostics 2019; 9:7458-7473. [PMID: 31695780 PMCID: PMC6831307 DOI: 10.7150/thno.38081] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/15/2019] [Indexed: 12/21/2022] Open
Abstract
Purpose: Colitis-associated colorectal cancer (CAC) poses substantial challenges for effective treatment. Currently, there is a considerable need for the development of orally bioavailable dosage forms that enable the safe and effective delivery of therapeutic drugs to local diseased lesions in the gastrointestinal tract. Experimental Design: In this study, we developed orally deliverable nanotherapeutics for the synergistic treatment of inflammatory bowel diseases (IBDs) and CAC. Water-insoluble curcumin (CUR) and 7-ethyl-10-hydroxycamptothecin (SN38), which served as anti-inflammatory and cytotoxic agents, respectively, were chemically engineered into hydrophilic mucoadhesive chitosan for the generation of chitosan-drug amphiphiles. Results: The resulting amphiphilic constructs formed core-shell nanostructures in aqueous solutions and were orally administered for in vivo therapeutic studies. Using a preclinical CAC mouse model, we showed that the orally delivered nanotherapeutics locally accumulated in inflamed intestinal regions and tumor tissues. Furthermore, the therapeutic synergy of the combined nanotherapeutics in CAC mice was evaluated. Compared with their individual drug forms, combined CUR and SN38 nanoparticles yielded synergistic effects to alleviate intestinal inflammation and protect mice from ulcerative colitis. Notably, the combinatorial therapy demonstrated a remarkable tumor shrinkage with only ~6% of the total tumors exceeding 4 mm in diameter, whereas ~35% of tumors were observed to exceed a diameter of 4 mm in the saline-treated CAC mice. These data suggest a new and reliable approach for improving the treatment of IBD and CAC. Conclusions: Our results showed that bioadhesive chitosan materials can be used to produce colloidal-stable nanotherapeutics that are suitable for oral delivery. Both nanotherapeutics exhibited substantial accumulation in inflamed intestinal regions and tumor tissues and showed good synergy for treating CAC, warranting further clinical translation.
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Affiliation(s)
- Weidong Han
- Department of Medical Oncology; Sir Run Run Shaw Hospital; School of Medicine, Zhejiang University, Hangzhou, 310016, PR China
| | - Binbin Xie
- Department of Medical Oncology; Sir Run Run Shaw Hospital; School of Medicine, Zhejiang University, Hangzhou, 310016, PR China
| | - Yiran Li
- Department of Medical Oncology; Sir Run Run Shaw Hospital; School of Medicine, Zhejiang University, Hangzhou, 310016, PR China
| | - Linlin Shi
- Department of Medical Oncology; Sir Run Run Shaw Hospital; School of Medicine, Zhejiang University, Hangzhou, 310016, PR China
| | - Jianqin Wan
- The First Affiliated Hospital; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health; School of Medicine, Zhejiang University, Hangzhou, 310003, PR China
| | - Xiaona Chen
- The First Affiliated Hospital; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health; School of Medicine, Zhejiang University, Hangzhou, 310003, PR China
| | - Hangxiang Wang
- The First Affiliated Hospital; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health; School of Medicine, Zhejiang University, Hangzhou, 310003, PR China
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Wang SL, Shao BZ, Zhao SB, Chang X, Wang P, Miao CY, Li ZS, Bai Y. Intestinal autophagy links psychosocial stress with gut microbiota to promote inflammatory bowel disease. Cell Death Dis 2019; 10:391. [PMID: 31564717 PMCID: PMC6766473 DOI: 10.1038/s41419-019-1634-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/14/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
Abstract
Psychosocial stress is a critical inducing factor of inflammatory bowel diseases (IBD), while autophagy is a novel central issue of IBD development. The present study investigated the potential role of autophagy in stress-related IBD in patients and animal model. The correlation between psychosocial stress and intestinal autophagy was determined in 23 patients with IBD. Corticotropin-releasing hormone (CRH), a well-established inducer of psychosocial stress, was administrated in dextran sulfate sodium (DSS)-induced IBD mice and lipopolysaccharide (LPS)-stimulated bone marrow-derived macrophages (BMDM). In IBD patients, the autophagy markers beclin-1, LC3-II/I ratio, Atg16L1, and Atg4B were significantly enhanced. The psychosocial stress score was positively associated with the levels of beclin-1 and the LC3II/I ratio in intestinal biopsy specimens. In IBD mouse model, CRH significantly aggravated intestinal inflammation, increased Paneth cell metaplasia, and enhanced intestinal autophagy (beclin-1, Atg16L1, PIK3R4, and Atg4B upregulation; GAA, CTSD, and PPKAA1 downregulation). Additionally, the CRH-induced gut microbial dysbiosis was evidenced by a marked increase in the number of detrimental bacteria. In LPS-stimulated BMDM, CRH substantially increased M1/M2 polarization and thus promoted inflammation. In both IBD mice and LPS-treated BMDM, blockade of autophagy by chloroquine abrogated the unbeneficial effects of CRH, whereas autophagy inducer rapamycin resulted in a pronounced protective effect against IBD lesion. Our data demonstrate that psychosocial stress may link the enhanced intestinal autophagy by modulating gut microbiota and inflammation to aggravate IBD. These data indicate autophagy as a promising therapeutic target for psychosocial stress-related IBD.
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Affiliation(s)
- Shu-Ling Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Bo-Zong Shao
- General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Sheng-Bing Zhao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Xin Chang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Pei Wang
- Department of Pharmacology, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Chao-Yu Miao
- Department of Pharmacology, Second Military Medical University/Naval Medical University, Shanghai, China.
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China.
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China.
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64
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Choy MC, Seah D, Faleck DM, Shah SC, Chao CY, An YK, Radford-Smith G, Bessissow T, Dubinsky MC, Ford AC, Churilov L, Yeomans ND, De Cruz PP. Systematic Review and Meta-analysis: Optimal Salvage Therapy in Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2019; 25:1169-1186. [PMID: 30605549 PMCID: PMC6783899 DOI: 10.1093/ibd/izy383] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Infliximab is an effective salvage therapy in acute severe ulcerative colitis; however, the optimal dosing strategy is unknown. We performed a systematic review and meta-analysis to examine the impact of infliximab dosage and intensification on colectomy-free survival in acute severe ulcerative colitis. METHODS Studies reporting outcomes of hospitalized steroid-refractory acute severe ulcerative colitis treated with infliximab salvage were identified. Infliximab use was categorized by dose, dose number, and schedule. The primary outcome was colectomy-free survival at 3 months. Pooled proportions and odds ratios with 95% confidence intervals were reported. RESULTS Forty-one cohorts (n = 2158 cases) were included. Overall colectomy-free survival with infliximab salvage was 79.7% (95% confidence interval [CI], 75.48% to 83.6%) at 3 months and 69.8% (95% CI, 65.7% to 73.7%) at 12 months. Colectomy-free survival at 3 months was superior with 5-mg/kg multiple (≥2) doses compared with single-dose induction (odds ratio [OR], 4.24; 95% CI, 2.44 to 7.36; P < 0.001). However, dose intensification with either high-dose or accelerated strategies was not significantly different to 5-mg/kg standard induction at 3 months (OR, 0.70; 95% CI, 0.39 to 1.27; P = 0.24) despite being utilized in patients with a significantly higher mean C-reactive protein and lower albumin levels. CONCLUSIONS In acute severe ulcerative colitis, multiple 5-mg/kg infliximab doses are superior to single-dose salvage. Dose-intensified induction outcomes were not significantly different compared to standard induction and were more often used in patients with increased disease severity, which may have confounded the results. This meta-analysis highlights the marked variability in the management of infliximab salvage therapy and the need for further studies to determine the optimal dose strategy.
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Affiliation(s)
- Matthew C Choy
- Department of Gastroenterology, Austin Hospital, Melbourne, Australia,Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Dean Seah
- Department of Gastroenterology, Austin Hospital, Melbourne, Australia
| | - David M Faleck
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shailja C Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York,Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Che-Yung Chao
- Division of Gastroenterology, McGill University, Montreal, Canada,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | - Yoon-Kyo An
- Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Talat Bessissow
- Division of Gastroenterology, McGill University, Montreal, Canada
| | - Marla C Dubinsky
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, Florey Institute of Neuroscience & Mental Health, The University of Melbourne, Melbourne, Australia
| | - Neville D Yeomans
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Peter P De Cruz
- Department of Gastroenterology, Austin Hospital, Melbourne, Australia,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia,Address correspondence to: Peter De Cruz, MBBS, PhD, FRACP, Department of Gastroenterology, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia ()
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65
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Gutiérrez A, Rivero M, Martín-Arranz MD, García Sánchez V, Castro M, Barrio J, de Francisco R, Barreiro-de Acosta M, Juliá B, Cea-Calvo L, Romero C, Borruel Sainz N, Domènech E. Perioperative management and early complications after intestinal resection with ileocolonic anastomosis in Crohn's disease: analysis from the PRACTICROHN study. Gastroenterol Rep (Oxf) 2019; 7:168-175. [PMID: 31217980 PMCID: PMC6573802 DOI: 10.1093/gastro/goz010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/07/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This study is aimed at describing the prevalence of and risk factors associated with early post-operative complications after Crohn's disease-related intestinal resection. METHODS This was a retrospective analysis of data from the PRACTICROHN cohort. Adult Crohn's disease patients who underwent ileocolonic resection with ileocolonic anastomosis between January 2007 and December 2010 were included. The complications evaluated included death, ileus, anastomotic leak, abscess, wound infection, catheter-related infection, digestive bleeding and other extra-abdominal infections that occurred in the 30 days after surgery. RESULTS A total of 364 patients (median age at surgery 38 years and 50% men) were included. Indication for surgery was: stricturing disease (46.4%), penetrating disease (31.3%), penetrating and stricturing disease (14.0%) or resistance to medical treatment (5.8%). Early complications were recorded in 100 (27.5%) patients, with wound infection, intra-abdominal abscess and anastomotic leakage being the most frequent complications. Median hospitalization duration was 16 days for patients with complications vs. 9 days without complications (P < 0.001). Complications were more common among patients with penetrating disease (36/114, 31.6%) and those refractory to treatment (9/21, 42.9%) compared with stricturing disease (45/169, 26.6%) or stricturing + penetrating disease (6/51, 11.8%) (P = 0.040). The rate of complications was higher among patients with diagnosis made at the time of surgery (15/31, 48.4%) compared with the rest (85/331, 25.7%) (P = 0.013). Medication received at the time of surgery did not affect the rate of complications. CONCLUSIONS Almost a quarter of patients developed early complications after intestinal resection. Penetrating disease and urgent surgery were associated with an increased risk of complications.
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Affiliation(s)
- Ana Gutiérrez
- Gastroenterology Department, General University Hospital of Alicante and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III Health Institute, Madrid, Spain
| | - Montserrat Rivero
- Gastroenterology Department, Marques de Valdecilla General University Hospital, Santander, Spain
| | - Maria Dolores Martín-Arranz
- Gastroenterology Department, La Paz General University Hospital, Instituto de Investigación Biomédica La Paz (IdiPaz), Madrid, Spain
| | - Valle García Sánchez
- Clinical Management of Gastrointestinal Tract Diseases Unit, Reina Sofia University Hospital, Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Cordoba University, Cordoba, Spain
| | - Manuel Castro
- Gastroenterology Department, Valme University Hospital, Sevilla, Spain
| | - Jesús Barrio
- Gastroenterology Department, University Hospital, Río Hortega, Valladolid, Spain
| | - Ruth de Francisco
- Gastroenterology Department, University Hospital Central de Asturias, Oviedo, Spain
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Inflammatory Bowel Disease Unit, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Berta Juliá
- Medical Department, Merck Sharp and Dohme, Madrid, Spain
| | - Luis Cea-Calvo
- Medical Department, Merck Sharp and Dohme, Madrid, Spain
| | | | - Natalia Borruel Sainz
- Crohn-Colitis Care Unit (UACC), Digestive Tract Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Germans Trias i Pujol University Hospital and CIBERehd, Badalona, Spain
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66
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Immunosuppressed Patients with Crohn's Disease Are at Increased Risk of Postoperative Complications: Results from the ACS-NSQIP Database. J Gastrointest Surg 2019; 23:1188-1197. [PMID: 30887300 DOI: 10.1007/s11605-019-04186-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of immunosuppressants on postoperative complications following colon resections for Crohn's disease remains controversial. This study aimed to compare postoperative outcomes between immunosuppressed and immunocompetent patients with Crohn's disease undergoing elective colon resection. METHODS Analysis of 30-day outcomes using a cohort from the American College of Surgeons National Surgical Quality Improvement Program colectomy-specific database was performed. The database is populated by trained clinical reviewers who collect 30-day postoperative outcomes for patients treated at participating North-American institutions. Adult patients who underwent an elective colectomy between 2011 and 2015 were included. Immunosuppression for Crohn's disease was predefined as use of regular corticosteroids or immunosuppressants within 30 days of the operation. Patients who received chemotherapy within 90 days of surgery, and patients who had disseminated cancer, preoperative shock, or emergency surgery were excluded. Primary outcome was infectious complications. RESULTS Three thousand eight hundred sixty patients with Crohn's disease required elective colon resection and met the inclusion criteria. Of these, 2483 were immunosuppressed and 1377 were immunocompetent. On multivariate analysis, the odds of infectious complications [OR 1.25; 95% CI (1.033-1.523)], overall surgical site infection [1.40; (1.128-1.742)], organ space surgical site infection [1.47; (1.094-1.984)], and anastomotic leak [1.51; (1.018-2.250)] were significantly higher for immunosuppressed compared to immunocompetent patients with Crohn's disease. CONCLUSIONS Patients with Crohn's disease who were on immunosuppressant medications within 30 days of elective colectomy had significantly increased rates of infectious complications, overall surgical site infection, organ space surgical site infection, and anastomotic leak compared to patients who were not on immunosuppressive agents.
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67
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Lee H, Schneider Y, Lichtenstein GR. Going Third Class: Treatment of Steroid-Dependent Ulcerative Colitis. Dig Dis Sci 2019; 64:1138-1141. [PMID: 31016561 DOI: 10.1007/s10620-019-05610-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Helen Lee
- Center for Inflammatory Bowel Disease, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Room 753 - South Pavilion, Philadelphia, PA, 19104, USA
| | - Yecheskel Schneider
- Center for Inflammatory Bowel Disease, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Room 753 - South Pavilion, Philadelphia, PA, 19104, USA
| | - Gary R Lichtenstein
- Center for Inflammatory Bowel Disease, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Room 753 - South Pavilion, Philadelphia, PA, 19104, USA.
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68
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Macaluso FS, Cavallaro F, Felice C, Mazza M, Armuzzi A, Gionchetti P, Vecchi M, Orlando A. Risk factors and timing for colectomy in chronically active refractory ulcerative colitis: A systematic review. Dig Liver Dis 2019; 51:613-620. [PMID: 30826279 DOI: 10.1016/j.dld.2019.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with chronic refractory ulcerative colitis (UC) the precise timing for indication to colectomy is unclear. AIMS We performed a systematic review of the literature on the risk factors for colectomy in patients with chronic refractory UC in the biologic era. METHODS PubMed Central/Medline and Embase were systemically searched for records published between January 2000 and December 2017. Current evidence was summarized and filtered by expert opinion. RESULTS 70 studies were included in the qualitative synthesis. Several factors were found to be associated with a higher or reduced risk for colectomy, including variables at baseline - such as progression from proctitis/left-sided to extensive colitis, extensive colitis at diagnosis, high baseline C Reactive Protein or erythrocyte sedimentation rate, male gender, and younger age at diagnosis - previous medical history, and factors arising during therapy with biologics, including the absence of clinical response after induction with infliximab or adalimumab, and the lack of mucosal healing during therapy with anti-TNFs. CONCLUSIONS Two main points may help physicians to decide when the surgical option may be considered in patients with chronic refractory UC: (1) a first risk stratification can be obtained by analyzing factors at baseline and medical history, including the previous exposure to anti-TNFs; (2) during therapy with biologics, the early assessment (after 12-16 weeks of treatment) of clinical and endoscopic response is a strong predictor of the subsequent risk of colectomy.
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Affiliation(s)
| | - Flaminia Cavallaro
- Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, Milano, Italy
| | - Carla Felice
- IBD Unit, "Presidio Columbus" Foundation Hospital "A. Gemelli IRCCS" - Sacro Cuore Catholic University, Rome
| | - Marta Mazza
- Department of Medical and Surgical Sciences (DIMEC), Policlinico S.Orsola-Malpighi, University of Bologna, Italy
| | - Alessandro Armuzzi
- IBD Unit, "Presidio Columbus" Foundation Hospital "A. Gemelli IRCCS" - Sacro Cuore Catholic University, Rome
| | - Paolo Gionchetti
- Department of Medical and Surgical Sciences (DIMEC), Policlinico S.Orsola-Malpighi, University of Bologna, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Organ Transplantation, University of Milan, Italy
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69
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Justiniano CF, Aquina CT, Becerra AZ, Xu Z, Boodry CI, Swanger AA, Monson JRT, Fleming FJ. Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics. Ann Surg 2019; 269:686-691. [PMID: 29232213 DOI: 10.1097/sla.0000000000002628] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.
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Affiliation(s)
- Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Courtney I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Alex A Swanger
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, FL
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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70
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Liu RQ, Qiao SH, Wang KH, Guo Z, Li Y, Cao L, Gong JF, Wang ZM, Zhu WM. Prospective evaluation of intestinal decompression in treatment of acute bowel obstruction from Crohn's disease. Gastroenterol Rep (Oxf) 2019; 7:263-271. [PMID: 31413833 PMCID: PMC6688739 DOI: 10.1093/gastro/goz002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/27/2018] [Accepted: 09/16/2018] [Indexed: 02/03/2023] Open
Abstract
Background Conservative therapy for Crohn’s disease (CD)-related acute bowel obstruction is essential to avoid emergent surgery. The present study aimed to evaluate the efficacy of using a long intestinal decompression tube (LT) in treatment of CD with acute intestinal obstruction. Methods This is a prospective observational study. Comparative analysis was performed in CD patients treated with LT (the LT group) and nasogastric tube (the GT group). The primary outcome was the avoidance of emergent surgery. Additionally, predictive factors for failure of decompression and subsequent surgery were investigated. Results There were 27 and 42 CD patients treated with LT and GT, respectively, in emergent situations. Twelve (44.4%) patients using LT were managed conservatively without laparotomy, while only nine (21.4%) patients in the GT group were spared from emergent surgery (P < 0.05). Both in surgery-free and in surgery patients, the time to alleviation of symptoms was significantly shorter in the LT groups than in the GT groups (both P < 0.01). C-reactive protein decrease after intubation and 48-hour drainage volume >500 mL were predictors of unavoidable surgery (both P < 0.05). The rate of temporary stoma and incidence of incision infection in the LT surgery group were significantly lower than those in the GT group (both P < 0.05). No significant differences were observed in the frequency of medical and surgical recurrences between the LT and GT groups (all P > 0.05). Conclusions Endoscopic placement of LT could improve the emergent status in CD patients with acute bowel obstruction. The drainage output and changes in C-reactive protein after intubation could serve as practical predictive indices for subsequent surgery. Compared to traditional GT decompression, LT decompression was associated with fewer short-term complications and did not appear to affect long-term recurrence.
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Affiliation(s)
- Rui-Qing Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shuai-Hua Qiao
- Department of Cardiology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ke-Hao Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Jian-Feng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Zhi-Ming Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Wei-Ming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Jain S, Ahuja V, Limdi JK. Optimal management of acute severe ulcerative colitis. Postgrad Med J 2019; 95:32-40. [PMID: 30636193 DOI: 10.1136/postgradmedj-2018-136072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/09/2018] [Accepted: 12/01/2018] [Indexed: 12/12/2022]
Abstract
Acute severe ulcerative colitis is a life-threatening medical emergency, which can be associated with significant morbidity and is preventable through prompt and effective management. Corticosteroids remain the cornerstone of initial therapy, although a third of patients will not respond. Further management hinges on timely decisions with use of rescue therapy with ciclosporin or infliximab, without compromising the health or safety of the patient, or timely surgery. Although such patients need specialist care, it is imperative that emergency care physicians are aware of the important principles of management of this condition to achieve successful outcomes. Risk stratification and the use of predictive models using clinical parameters have reduced the morbidity associated with this condition.We discuss current evidence and present a clinical approach to clinicians involved in the emergency care of patients with acute severe ulcerative colitis in this review.
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Affiliation(s)
- Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Jimmy K Limdi
- Department of Gastroenterology, Inflammatory Bowel Diseases Section, University of Manchester, Manchester, UK
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Kuenzig ME, Benchimol EI, Lee L, Targownik LE, Singh H, Kaplan GG, Bernstein CN, Bitton A, Nguyen GC, Lee K, Cooke-Lauder J, Murthy SK. The Impact of Inflammatory Bowel Disease in Canada 2018: Direct Costs and Health Services Utilization. J Can Assoc Gastroenterol 2018; 2:S17-S33. [PMID: 31294382 PMCID: PMC6512251 DOI: 10.1093/jcag/gwy055] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022] Open
Abstract
Direct health care costs of illness reflect the costs of medically necessary services and treatments paid for by public and private payers, including hospital-based care, outpatient physician consultations, prescription medications, diagnostic testing, complex continuing care, and home care. The costs of caring for persons with inflammatory bowel disease (IBD) have been rising well above inflation over the past fifteen years in Canada, largely due to the introduction and penetration of expensive biologic therapies. Changing paradigms of care toward frequent patient monitoring and achievement of stricter endpoints for disease control have also increased health services utilization and costs among IBD patients. While the frequency and costs of surgeries and hospitalizations have declined slightly in parallel with increased biologic use (due to better overall disease control), the direct medical costs of care for IBD patients are largely dominated by prescription drug costs. Introduction and penetration of biosimilar agents (at a markedly lower price point than the originator drugs) and increasing gastroenterologist involvement in the care of IBD patients may help to balance rising health care costs while improving health outcomes and quality of life for IBD patients. Ultimately, however, the predicted rise in the prevalence of IBD over the next decade, combined with increasing use of expensive biologic therapies, will likely dictate a continued rise in the direct costs of IBD patient care in Canada for years to come. In 2018, direct health care costs of IBD are estimated to be at least $1 billion Canadian dollars (CAD) and possibly higher than $2 billion CAD. Highlights 1. In Canada, the direct cost of caring for people living with IBD is estimated in 2018 to be close to $1.28 billion (roughly $4731 per person with IBD).2. The costs of caring for people living with IBD are dominated by prescription drugs, followed by hospitalization costs. There has been a shift away from hospitalizations and toward pharmaceuticals as the predominant driver of direct health care costs in IBD patients, due to the introduction and widespread use of expensive biologic therapies.3. The rates of hospitalizations and major abdominal surgeries have been declining in IBD patients in Canada over the past two decades, possibly due to penetration of biologic therapies and advances in patient management paradigms.4. Inflammatory bowel disease patients cared for by gastroenterologists have better outcomes, including lower risks of surgery and hospitalization. Canadians who live in rural and underserviced areas are less likely to receive gastroenterologist care, potentially due to care preferences or poorer access, which may result in poorer long-term outcomes.5. Introduction of biosimilar agents at a lower price point than originator biologic therapies, increased gastroenterologist care of IBD patients, and improvements in IBD care paradigms may balance overall treatment costs while improving health outcomes and quality of life for IBD patients. However, in the long-term, direct costs of care may continue to increase, dictated by a rising IBD prevalence and increasing use of biologic therapies. Key Summary Points 1. The costs of health care for patients with IBD are more than double those without IBD.2. Prescription drug use accounts for 42% of total direct costs in IBD patients, and costs to treat IBD continue to rise due to increased use of existing biologic therapies and the introduction of several new biologic therapies in recent years.3. In Manitoba, the mean health care utilization and medication costs for persons with IBD in the year before beginning anti-TNF therapy was $10,206 and increased to $44,786 in the first year of therapy.4. Biosimilar agents to anti-TNF drugs are now entering the Canadian marketplace and may result in cost savings in patients using biologic agents to treat their IBD.5. Timely gastroenterologist care has been associated with reduced risks of requiring surgery and emergency care among ambulatory IBD patients and a reduced risk of death among hospitalized patients with ulcerative colitis.6. Inflammatory bowel disease care provided by gastroenterologists has increased over the past two decades. Even then, the average time from symptom onset to IBD diagnosis exceeds six months, and only one-third of IBD patients receive continuing care with a gastroenterologist during the first five years following diagnosis.7. Senior (age ≥65), rural-dwelling, and non-immigrant IBD patients have less frequent gastroenterologist care than other groups.8. About one in five adults with Crohn's disease and one in eight adults with ulcerative colitis are hospitalized in Ontario every year. Hospitalizations are most common during the first year following IBD diagnosis. Children with IBD (age <18) have the highest rates of hospitalizations and hospital re-admissions.9. In Canada, 16% of patients hospitalized for Crohn's disease undergo an intestinal resection, and 11% of patients hospitalized for ulcerative colitis undergo a colectomy during their initial hospitalization. Rates of intestinal resection and colectomy are declining in Canada in persons with Crohn's disease and ulcerative colitis, respectively.10. In Ontario, one-third of adult-onset Crohn's disease patients undergo intestinal resection within ten years of diagnosis. Among Canadian children with Crohn's disease, approximately one in fifteen children will require intestinal surgery within the first year of diagnosis, and up to one-third will require surgery within ten years of diagnosis.11. In Ontario, the ten-year colectomy risk following ulcerative colitis diagnosis is 13.3% among young persons and adults and 18.5% among individuals with senior-onset ulcerative colitis. In children with ulcerative colitis, the risk of colectomy is 4.8% to 6% in the first year following diagnosis and increases to 15% to 17% by ten years. Gaps in Knowledge and Future Directions 1. Forecasting models are necessary to predict the rising costs attributable to biologics associated with increasing prevalence of IBD, more frequent use of these medications, and the introduction of newer agents.2. Research into ways to minimize the escalating costs associated with increasing use of biologic therapies to treat IBD (and other chronic diseases) is necessary to ensure sustainability of our publicly funded health care system. Biosimilars offer an opportunity to drive down the cost of biologic therapies, and future research should assess the uptake of biosimilars as new biosimilars are introduced into the marketplace.3. Cost-utility models and budget impact analyses that integrate changes in direct costs (i.e., reduced hospitalizations and increased pharmaceutical costs) with indirect cost savings from improved quality of life are necessary to inform policy decisions.4. Research into ways to reduce IBD hospitalizations further through targeted outpatient interventions is equally important for health system sustainability and to improve patient quality of life.5. Research into reasons for reduced gastroenterologist care among rural and underserviced IBD residents would allow targeted interventions to improve specialist care and thereby improve patient health outcomes and quality of life.
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Affiliation(s)
- M Ellen Kuenzig
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Lawrence Lee
- McGill University Health Centre (MUHC) IBD Centre, McGill University, Montreal, Quebec, Canada
| | - Laura E Targownik
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Charles N Bernstein
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,McGill University Health Centre (MUHC) IBD Centre, McGill University, Montreal, Quebec, Canada
| | - Geoffrey C Nguyen
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Mount Sinai Hospital Centre for IBD, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | | | - Sanjay K Murthy
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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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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75
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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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76
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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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77
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Sacleux SC, Sarter H, Fumery M, Charpentier C, Guillon-Dellac N, Coevoet H, Pariente B, Peyrin-Biroulet L, Gower-Rousseau C, Savoye G. Post-operative complications in elderly onset inflammatory bowel disease: a population-based study. Aliment Pharmacol Ther 2018; 47:1652-1660. [PMID: 29737553 DOI: 10.1111/apt.14790] [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] [Received: 07/12/2017] [Revised: 08/06/2017] [Accepted: 04/08/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND IBD diagnosed after the age of 60 is increasing. Data on post-operative complications in elderly onset IBD are scarce. AIM To describe the incidence of and factors associated with post-operative complications in elderly onset IBD, diagnosed after the age of 60. METHODS Using EPIMAD Cohort (1988-2006), among 841 incident IBD patients, 139 (17%) underwent intestinal surgery, including 100 Crohn's disease (CD) and 39 ulcerative colitis (UC). RESULTS After a median post-operative follow-up of 6 years (2-10), 50 (36%) patients experienced at least 1 complication with a total of 69. During the first 30 post-operative days, the mortality rate was 4%. Thirty-two early complications (<30 days) were observed in 23 patients (17%), with 15 infectious, without significant difference between CD and UC. More than half early post-operative complications (n = 19, 59%) were severe (>grade 2) without significant difference between CD and UC (P = 0.28). Thirty-seven long-term adverse effects of surgical therapy (≥30 days) were observed in 33 patients (24%). Multivariate analysis found (1) acute severe colitis (OR = 7.84 [2.15-28.52]) and emergency surgery (OR = 4.46 [1.75-11.36]) were associated with early post-operative complications, and (2) Female gender (HR = 2.10 [1.01-4.37]) and delay before surgery >3 months (HR = 2.09 [1.01-4.31]) with long-term adverse effects of surgical therapy. CONCLUSIONS One-third of elderly IBD patients experienced at least 1 post-operative complication. Half of the early complications were severe, and infectious. Emergency surgery was the key driver for post-operative complication.
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Affiliation(s)
- S-C Sacleux
- Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - H Sarter
- Public Health, Epidemiology and Economic Health, Epimad Registry, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - M Fumery
- Epimad Registry, CHU Amiens Sud, Avenue Laennec-Salouel, Amiens University Hospital, Amiens, France
| | - C Charpentier
- Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - N Guillon-Dellac
- Public Health, Epidemiology and Economic Health, Epimad Registry, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - H Coevoet
- Clinique des Bonnettes, Arras, France
| | - B Pariente
- Hôpital Huriez, Lille University Hospital, Lille, France
| | | | - C Gower-Rousseau
- Public Health, Epidemiology and Economic Health, Epimad Registry, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - G Savoye
- Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
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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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Fumery M, Singh S, Dulai PS, Gower-Rousseau C, Peyrin-Biroulet L, Sandborn WJ. Natural History of Adult Ulcerative Colitis in Population-based Cohorts: A Systematic Review. Clin Gastroenterol Hepatol 2018; 16. [PMID: 28625817 PMCID: PMC6658168 DOI: 10.1016/j.cgh.2017.06.016] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A comprehensive knowledge of the natural history of ulcerative colitis (UC) helps understand disease evolution, identify poor prognostic markers and impact of treatment strategies, and facilitates shared decision-making. We systematically reviewed the natural history of UC in adult population-based cohort studies with long-term follow-up. METHODS Through a systematic literature review of MEDLINE through March 31, 2016, we identified 60 studies performed in 17 population-based inception cohorts reporting the long-term course and outcomes of adult-onset UC (n = 15,316 UC patients). RESULTS Left-sided colitis is the most frequent location, and disease extension is observed in 10%-30% of patients. Majority of patients have a mild-moderate course, which is most active at diagnosis and then in varying periods of remission or mild activity; about 10%-15% of patients experience an aggressive course, and the cumulative risk of relapse is 70%-80% at 10 years. Almost 50% of patients require UC-related hospitalization, and 5-year risk of re-hospitalization is ∼50%. The 5-year and 10-year cumulative risk of colectomy is 10%-15%; achieving mucosal healing is associated with lower risk of colectomy. About 50% of patients receive corticosteroids, although this proportion has decreased over time, with a corresponding increase in the use of immunomodulators (20%) and anti-tumor necrosis factor (5%-10%). Although UC is not associated with an increased risk of mortality, it is associated with high morbidity and work disability, comparable to Crohn's disease. CONCLUSIONS UC is a disabling condition over time. Prospective cohorts are needed to evaluate the impact of recent strategies of early use of disease-modifying therapies and treat-to-target approach with immunomodulators and biologics. Long-term studies from low-incidence areas are also needed.
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Affiliation(s)
- Mathurin Fumery
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Gastroenterology Unit, Epimad Registry, Amiens University Hospital, Amiens, France.
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California;,Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Corinne Gower-Rousseau
- LIRIC Inserm, Unit 995, Lille University, France; Epidemiology Unit, Epimad egistry, Lille University Hospital, France
| | | | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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Surgical Rates for Crohn's Disease are Decreasing: A Population-Based Time Trend Analysis and Validation Study. Am J Gastroenterol 2017; 112:1840-1848. [PMID: 29087396 PMCID: PMC5729339 DOI: 10.1038/ajg.2017.394] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/10/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Temporal changes for intestinal resections for Crohn's disease (CD) are controversial. We validated administrative database codes for CD diagnosis and surgery in hospitalized patients and then evaluated temporal trends in CD surgical resection rates. METHODS First, we validated International Classification of Disease (ICD)-10-CM coding for CD diagnosis in hospitalized patients and Canadian Classification of Health Intervention coding for surgical resections. Second, we used these validated codes to conduct population-based surveillance between fiscal years 2002 and 2010 to identify adult CD patients undergoing intestinal resection (n=981). Annual surgical rate was calculated by dividing incident surgeries by estimated CD prevalence. Time trend analysis was performed and annual percent change (APC) with 95% confidence intervals (CI) in surgical resection rates were calculated using a generalized linear model assuming a Poisson distribution. RESULTS In the validation cohort, 101/104 (97.1%) patients undergoing surgery and 191/200 (95.5%) patients admitted without surgery were confirmed to have CD on chart review. Among the 116 administrative database codes for surgical resection, 97.4% were confirmed intestinal resections on chart review. From 2002 to 2010, the overall CD surgical resection rate was 3.8 resections per 100 person-years. During the study period, rate of surgery decreased by 3.5% per year (95% CI: -1.1%, -5.8%), driven by decreasing emergent operations (-10.1% per year (95% CI: -13.4%, -6.7%)) whereas elective surgeries increased by 3.7% per year (95% CI: 0.1%, 7.3%). CONCLUSIONS Overall surgical resection rates in CD are decreasing, but a paradigm shift has occurred whereby elective operations are now more commonly performed than emergent surgeries.
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81
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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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82
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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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83
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Heerasing N, Thompson B, Hendy P, Heap GA, Walker G, Bethune R, Mansfield S, Calvert C, Kennedy NA, Ahmad T, Goodhand JR. Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease. Aliment Pharmacol Ther 2017; 45:660-669. [PMID: 28105752 DOI: 10.1111/apt.13934] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/20/2016] [Accepted: 12/18/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have reported the systematic use of exclusive enteral nutrition in the perioperative setting. AIM To test the hypothesis that exclusive enteral nutrition provides a safe and effective bridge to surgery and reduces post-operative complications, in adult patients with Crohn's disease requiring urgent surgery for stricturing or penetrating complications. METHODS Patients treated with exclusive enteral nutrition prior to surgery were each matched with two control patients for disease behaviour, type of surgery, age at diagnosis and disease duration. Data on disease phenotype, nutritional status, operative course and post-operative complications were obtained. RESULTS Twenty-five per cent [13/51] patients treated with exclusive enteral nutrition avoided surgery. Exclusive enteral nutrition had no effect on pre-operative weight, but it significantly reduced serum CRP [median at baseline 36 (interquartile range, IQR: 13-91] vs. pre-operation 8 (4-31) mg/L, P = 0.02]. The median (IQR) length of surgery was shorter in patients pre-optimised with exclusive enteral nutrition than controls [3.0 (2.5-3.5) vs. 3.5 (3.0-4.0) hours respectively, P < 0.001]. Multivariable logistic regression analysis confirmed that going straight-to-surgery compared exclusive enteral nutrition pre-optimisation was associated with a ninefold increase in the incidence of post-operative abscess and/or anastomotic leak [OR 9.1; 95% CI (1.2-71.2), P = 0.04]. CONCLUSIONS Exclusive enteral nutrition frequently down-stages the need for surgery in patients presenting with stricturing or penetrating complications of Crohn's disease; it is associated with a reduction in systemic inflammation, operative times and the incidence of post-operative abscess or anastomotic leak. Further trials are needed to elucidate how exclusive enteral nutrition may improve operative outcomes.
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Affiliation(s)
- N Heerasing
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - B Thompson
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - P Hendy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G A Heap
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G Walker
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - R Bethune
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - S Mansfield
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - C Calvert
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - N A Kennedy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - T Ahmad
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J R Goodhand
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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84
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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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85
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Mao EJ, Hazlewood GS, Kaplan GG, Peyrin-Biroulet L, Ananthakrishnan AN. Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn's disease and ulcerative colitis. Aliment Pharmacol Ther 2017; 45:3-13. [PMID: 27862107 DOI: 10.1111/apt.13847] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 08/26/2016] [Accepted: 10/09/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Crohn's disease (CD) and ulcerative colitis (UC) have a progressive course leading to hospitalisation and surgery. The ability of existing therapies to alter disease course is not clearly defined. AIM To investigate the comparative efficacy of currently available inflammatory bowel disease (IBD) therapies to reduce hospitalisation and surgery. METHODS We conducted a systematic review in MEDLINE/PubMed for randomised controlled trials (RCT) published between January 1980 and May 2016 examining efficacy of biological or immunomodulator therapy in IBD. We performed direct comparisons of pooled proportions of hospitalisation and surgery. Pair-wise comparisons using a random-effects Bayesian network meta-analysis were performed to assess comparative efficacy of different treatments. RESULTS We identified seven randomised controlled trials (5 CD; 2 UC) comparing three biologics and one immunomodulator with placebo. In CD, anti-TNF biologics significantly reduced hospitalisation [Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.36-0.60] and surgery (OR 0.23, 95% CI 0.13-0.42) compared to placebo. No statistically significant reduction was noted with azathioprine or vedolizumab. Azathioprine was inferior to both infliximab and adalimumab in preventing CD-related hospitalisation (>97.5% probability). Anti-TNF biologics significantly reduced hospitalisation (OR 0.48, 95% CI 0.29-0.80) and surgery (OR 0.67, 95% CI 0.46-0.97) in UC. There were no statistically significant differences in the pair-wise comparisons between active treatments. CONCLUSIONS In CD and UC, anti-TNF biologics are efficacious in reducing the odds of hospitalisation by half and surgery by 33-77%. Azathioprine and vedolizumab were not associated with a similar improvement, but robust conclusions may be limited due to paucity of RCTs.
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Affiliation(s)
- E J Mao
- Division of Gastroenterology, Alpert Medical School of Brown University, Providence, RI, USA
| | - G S Hazlewood
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - L Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre, France
| | - A N Ananthakrishnan
- Gastroenterology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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86
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Macaluso FS, Renna S, Orlando A, Cottone M. The biologics of ulcerative colitis. Expert Opin Biol Ther 2016; 17:175-184. [DOI: 10.1080/14712598.2017.1271871] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - Sara Renna
- Di.Bi.M.I.S., Division of Internal Medicine, ‘Villa Sofia-Cervello’ Hospital, Palermo, Italy
| | - Ambrogio Orlando
- Di.Bi.M.I.S., Division of Internal Medicine, ‘Villa Sofia-Cervello’ Hospital, Palermo, Italy
| | - Mario Cottone
- Di.Bi.M.I.S., Division of Internal Medicine, ‘Villa Sofia-Cervello’ Hospital, Palermo, Italy
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87
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de Bruyn M, Vandooren J, Ugarte-Berzal E, Arijs I, Vermeire S, Opdenakker G. The molecular biology of matrix metalloproteinases and tissue inhibitors of metalloproteinases in inflammatory bowel diseases. Crit Rev Biochem Mol Biol 2016; 51:295-358. [DOI: 10.1080/10409238.2016.1199535] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Petkau JM, Eksteen B. Selective biologics for ulcerative colitis and Crohn's disease - clinical utility of vedolizumab. Biologics 2016; 10:33-52. [PMID: 27022240 PMCID: PMC4790488 DOI: 10.2147/btt.s71679] [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] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Inflammatory bowel disease (IBD) encompasses a cluster of different disease phenotypes which are broadly classified into ulcerative colitis and Crohn’s disease. Disease pathogenesis is driven by abnormal host immune responses to their resident gut microbiome in genetically susceptible individuals. Clinical disease features and outcomes are heterogenous and not unexpected as over 163 genetic loci are associated with disease susceptibility, and there are great variability in environmental exposures. Despite this variability, there has been relatively few efficacious therapies for particularly moderate-to-severe IBD. Treatment has been dominated by antitumor necrosis alpha agents with significant success but equally potentially serious adverse events. Therapeutic targeting of leucocyte trafficking has emerged as a viable alternative therapy, with vedolizumab being the lead compound. This review focuses primarily on its biological function as a selective gut immunotherapy, its safety and efficacy, and its emerging role as a mainstream therapy in managing IBD.
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Affiliation(s)
- Jill Mv Petkau
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bertus Eksteen
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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90
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Smoking Cessation for Crohn's Disease: Clearing the Haze. Am J Gastroenterol 2016; 111:420-2. [PMID: 27018116 DOI: 10.1038/ajg.2016.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
The TABACROHN Study Group conducted a multicenter prospective cohort study, demonstrating that smoking cessation improved the prognosis of Crohn's disease. Patients who continued to smoke were 50% more likely to relapse compared with non-smokers. Smoking cessation reduced the risk of flaring, regardless of exposure to anti-tumor necrosis factor agents. Despite the evidence that smoking cessation is beneficial, many patients do not quit smoking after their diagnosis of Crohn's disease. Lack of awareness, physical addiction, and social context of smoking inhibit smoking cessation. In spite of this, comprehensive smoking cessation programs have been shown to be effective and reduce costs.
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91
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Seah D, De Cruz P. Review article: the practical management of acute severe ulcerative colitis. Aliment Pharmacol Ther 2016; 43:482-513. [PMID: 26725569 DOI: 10.1111/apt.13491] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 09/10/2015] [Accepted: 11/11/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a life-threatening condition for which optimal management strategies remain ill-defined. AIM To review the evidence regarding the natural history, diagnosis, monitoring and treatment of ASUC to inform an evidence-based approach to management. METHODS Relevant articles addressing the management of ASUC were identified from a search of MEDLINE, the Cochrane Library and conference proceedings. RESULTS Of ASUC, 31-35% is steroid-refractory. Infliximab and ciclosporin salvage therapies have improved patient outcomes in randomised controlled trials. Short-term response rates (within 3 months) have ranged from 40% - 54% for ciclosporin and 46-83% for infliximab. Long-term clinical response rates (≥1 year) have ranged from 42%-50% for ciclosporin and 50-65% for infliximab. Short-term and long-term colectomy rates have been respectively: 26-47% and 36-58% for ciclosporin, and 0-50% and 35-50% for infliximab. Mortality rates for ciclosporin and infliximab-treated patients have been: 0-5% and 0-2%, respectively. At present, management challenges include the selection, timing and assessment of response to salvage therapy, utilisation of therapeutic drug monitoring and long-term maintenance of remission. CONCLUSIONS Optimal management of acute severe ulcerative colitis should be guided by risk stratification using predictive indices of corticosteroid response. Timely commencement and assessment of response to salvage therapy is critical to reducing morbidity and mortality. Emerging pharmacokinetic models and therapeutic drug monitoring may assist clinical decision-making and facilitate a shift towards individualised acute severe ulcerative colitis therapies.
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Affiliation(s)
- D Seah
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia
| | - P De Cruz
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia
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92
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Naidu H, Farraye FA, Noronha A. Elective colectomy for severe ulcerative colitis may reduce mortality more than medical therapy. EVIDENCE-BASED MEDICINE 2015; 21:29. [PMID: 26642847 DOI: 10.1136/ebmed-2015-110311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Harini Naidu
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Francis A Farraye
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Ansu Noronha
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
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Abstract
Over 1 million residents in the USA and 2.5 million in Europe are estimated to have IBD, with substantial costs for health care. These estimates do not factor in the 'real' price of IBD, which can impede career aspirations, instil social stigma and impair quality of life in patients. The majority of patients are diagnosed early in life and the incidence continues to rise; therefore, the effect of IBD on health-care systems will rise exponentially. Moreover, IBD has emerged in newly industrialized countries in Asia, South America and Middle East and has evolved into a global disease with rising prevalence in every continent. Understanding the worldwide epidemiological patterns of IBD will prepare us to manage the burden of IBD over time. The goal of this article is to establish the current epidemiology of IBD in the Western world, contrast it with the increase in IBD in newly industrialized countries and forecast the global effects of IBD in 2025.
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