Surgery in the age of biologics

Abdominal Surgery in Crohn's Disease: Risk Factors for Complications

Introduction

Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD.

Methods

A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018.

Results

Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively).

Conclusion

Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.

Living with Ulcerative Colitis Study (LUCY) in England: a retrospective study evaluating healthcare resource utilisation and direct healthcare costs of postoperative care in ulcerative colitis

Objective

Ulcerative colitis (UC) is a lifelong, relapsing-remitting disease. Patients non-responsive to pharmacological treatment may require a colectomy. We estimated pre-colectomy and post-colectomy healthcare resource utilisation (HCRU) and costs in England.

Design/Method

A retrospective, longitudinal cohort study indexing adult patients with UC undergoing colectomy (2009–2015), using linked Clinical Practice Research Datalink/Hospital Episode Statistics data, was conducted. HCRU, healthcare costs and pharmacological treatments were evaluated during 12 months prior to and including colectomy (baseline) and 24 months post-colectomy (follow-up; F-U), comparing baseline/F-U, emergency/elective colectomy and subtotal/full colectomy using descriptive statistics and paired/unpaired tests.

Results

249 patients from 26 165 identified were analysed including 145 (58%) elective and 184 (74%) full colectomies. Number/cost of general practitioner consultations increased post-colectomy (p<0.001), and then decreased at 13–24 months (p<0.05). From baseline to F-U, the number of outpatient visits, number/cost of hospitalisations and total direct healthcare costs decreased (all p<0.01). Postoperative HCRU was similar between elective and emergency colectomies, except for the costs of colectomy-related hospitalisations and medication, which were lower in the elective group (p<0.05). Postoperative costs were higher for subtotal versus full colectomies (p<0.001). At 1–12 month F-U, 30%, 19% and 5% of patients received aminosalicylates, steroids and immunosuppressants, respectively.

Conclusion

HCRU/costs increased for primary care in the first year post-colectomy but decreased for secondary care, and varied according to the colectomy type. Ongoing and potentially unnecessary pharmacological therapy was seen in up to 30% of patients. These findings can inform patients and decision-makers of potential benefits and burdens of colectomy in UC.

Kono-S anastomosis for Crohn's disease: a systemic review, meta-analysis, and meta-regression

The Kono-S anastomosis was introduced in 2011 as an alternative anastomosis in Crohn's disease (CD) surgery. Since then, prevailing evidence of the favorable results of the Kono-S anastomosis has been published from around the world. We conducted this study to analyze the effectiveness of the Kono-S anastomosis, by searching Medline, Embase, CNKI, and google scholar. Binominal data were analyzed after Freeman-Tukey double-arcsine transformation. Comparative data were analyzed using the Mantel-Haenszel model for dichotomous outcomes and the mean difference for continuous outcomes. We identified 676 patients who underwent surgery with a Kono-S anastomosis. Surgical recurrence was pooled at an average of 0% (CI: 0.00-0.01) and a reduced mean Rutgeerts score of 1.375 (CI: 0.727-2.023) after Kono-S anastomosis. Endoscopic recurrence after sensitivity analysis was 5% (CI: 0.00-0.15). Complications were rare, with a 3% incidence of ileus (CI: 0.01-0.05), a 4% incidence of small bowel obstruction (CI: 0.01-0.10), a 1% incidence of an anastomotic leak incidence (CI: 0.00-0.03), and a 10% incidence of postoperative infection (CI: 0.03-0.20). Evidence from this meta-analysis favors the Kono-S anastomosis for CD patients, especially for ileocolic anastomosis. Thus, clinicians should consider the applicability of Kono-S anastomosis in respective institutions.

Trends in Colectomies for Colorectal Neoplasms in Ulcerative Colitis: a National Inpatient Sample Database Analysis over Two Decades

BACKGROUND

Rates of colectomy for ulcerative colitis have been decreasing, particularly since the advent of biologics, but the subsequent impact of reduced colectomy rates on the development of neoplasms in chronically treated ulcerative colitis colons is unknown.

PURPOSE

To determine trends in colectomy for colorectal neoplasms in adult patients with ulcerative colitis.

METHODS

Adult admissions with ulcerative colitis were identified from the National Inpatient Sample from 1993 to 2015. The rate of colectomy with concurrent colorectal neoplasm served as the primary outcome and was evaluated using time trend linear and multivariable regression.

RESULTS

There were 366,286 admissions with ulcerative colitis including 16,556 (4.5%) total colectomies. Of those undergoing colectomy, 2018 (12.2%) had a concurrent diagnosis of colorectal neoplasm. The proportion of colectomies for ulcerative colitis with concurrent colorectal neoplasm increased from 10.3 to 12.5% (p_Trend = 0.004). Specifically, the proportion of colectomies performed for dysplasia/benign neoplasm and rectal cancer increased from 3.5 to 5.6% (p_Trend < 0.001) and from 2.6 to 3.0% (p_Trend = 0.028) respectively, and those for colon cancer remained stable (4.5 to 3.9%, p_Trend = 0.423). On multivariate regression, year of colectomy was a significant predictor of colectomy for colorectal neoplasm (OR = 1.044, 95% CI = 1.025-1.062).

DISCUSSION

Operative management of ulcerative colitis appears to be slowly increasing in oncological indications. The rising proportions of colectomies performed for colorectal neoplasms suggest the need for continued screening in these patients, including rectal surveillance.

Differential regulation of JAK/STAT-signaling in patients with ulcerative colitis and Crohn’s disease

In 2018, the pan-Janus kinase (JAK) inhibitor tofacitinib was launched for the treatment of ulcerative colitis (UC). Although tofacitinib has proven efficacious in patients with active UC, it failed in patients with Crohn’s disease (CD). This finding strongly hints at a different contribution of JAK signaling in both entities. Here, we review the current knowledge on the interplay between the JAK/signal transducer and activator of transcription (STAT) pathway and inflammatory bowel diseases (IBD). In particular, we provide a detailed overview of the differences and similarities of JAK/STAT-signaling in UC and CD, highlight the impact of the JAK/STAT pathway in experimental colitis models and summarize the published evidence on JAK/STAT-signaling in immune cells of IBD as well as the genetic association between the JAK/STAT pathway and IBD. Finally, we describe novel treatment strategies targeting JAK/STAT inhibition in UC and CD and comment on the limitations and challenges of the new drug class.

Inflammatory Bowel Disease - Non-biological treatment

Nowadays, non-biological treatments remain valuable approaches among the therapeutic armamentarium of inflammatory bowel disease (IBD). Mesalamine is the core treatment of mild‑to‑moderate ulcerative colitis (UC) and corticosteroids are crucial for the induction of remission of moderate‑to‑severe flares in both UC and Crohn's disease (CD). Even approaches as cyclosporine, tacrolimus, azathioprine, methotrexate, and surgery still have a nuclear position as strategies to induce and/or maintain remission in IBD. Due to their particularities and to the accumulated evidence, each of these strategies conquered peculiar roles in the overall IBD strategy, all of them contributing to better outcomes. This review emphasizes the particular roles that non-biological treatments gained over time: recent mesalamine formulations to increase adhesion rates, higher doses of 5-ASA for high-risk patients, MMX technology to improve drug release and attain higher bowel concentrations, cyclosporine as a bridge to vedolizumab, tacrolimus as a potential alternative to thiopurines or infliximab, azathioprine in combination therapy with infliximab and dubious in monotherapy, and surgery as a mean to a "better end".

A Challenging Colectomy for Acute Severe Ulcerative Colitis Complicated by COVID-19

We present the case of a patient with acute severe ulcerative colitis and concomitant COVID-19-related pneumonia who required a colectomy after a prolonged and complicated hospitalization during the initial stages of the SARS-CoV-2 pandemic, before the establishment of official procedures.

Revisiting Inflammatory Bowel Disease: Pathology, Treatments, Challenges and Emerging Therapeutics Including Drug Leads from Natural Products

Inflammatory bowel disease (IBD) is a chronic and life-long disease characterized by gastrointestinal tract inflammation. It is caused by the interplay of the host's genetic predisposition and immune responses, and various environmental factors. Despite many treatment options, there is no cure for IBD. The increasing incidence and prevalence of IBD and lack of effective long-term treatment options have resulted in a substantial economic burden to the healthcare system worldwide. Biologics targeting inflammatory cytokines initiated a shift from symptomatic control towards objective treatment goals such as mucosal healing. There are seven monoclonal antibody therapies excluding their biosimilars approved by the US Food and Drug Administration for induction and maintenance of clinical remission in IBD. Adverse side effects associated with almost all currently available drugs, especially biologics, is the main challenge in IBD management. Natural products have significant potential as therapeutic agents with an increasing role in health care. Given that natural products display great structural diversity and are relatively easy to modify chemically, they represent ideal scaffolds upon which to generate novel therapeutics. This review focuses on the pathology, currently available treatment options for IBD and associated challenges, and the roles played by natural products in health care. It discusses these natural products within the current biodiscovery research agenda, including the applications of drug discovery techniques and the search for next-generation drugs to treat a plethora of inflammatory diseases, with a major focus on IBD.

Vedolizumab use in patients with inflammatory bowel diseases undergoing surgery: clinical trials and post-marketing experience

Background

Patients with inflammatory bowel diseases frequently require surgery, but immunotherapies used in disease management may increase the risk of post-operative complications. We investigated frequencies of post-operative complications in patients who received vedolizumab-a gut-selective antibody approved for the treatment of moderately to severely active ulcerative colitis and Crohn's disease-in clinical-trial and post-marketing settings.

Methods

This post hoc analysis of safety data from GEMINI 1, GEMINI 2, and long-term safety studies included patients who had had colectomy or bowel surgery/resection. Data from the post-marketing Vedolizumab Global Safety Database were also analysed (data cutoff point: 19 May 2016). Adverse events relating to post-operative complications were identified using Medical Dictionary for Regulatory Activities preferred terms.

Results

Of 58 total surgeries in patients included in GEMINI 1 and GEMINI 2, post-operative complications were reported for 3/51 vedolizumab-treated patients (5.9%) and 1/7 placebo-treated patients (14.3%). In the long-term safety study, 157/2,243 patients (7%) had colectomy or bowel surgery/resection; of these 157 patients who underwent surgery, 11 (7%) experienced a post-operative complication. Median time between last pre-operative vedolizumab dose and surgery was 23 days in GEMINI 1, 20 days in GEMINI 2, and 39‒40 days in the long-term safety study. In the post-marketing setting, based on data covering approximately 46,978 patient-years of vedolizumab exposure, post-operative complications were reported in 19 patients.

Conclusions

In clinical trials, complications of colectomy and bowel surgery/resection appeared infrequent, with minimal difference between vedolizumab and placebo. The frequency of post-operative complications in the post-marketing setting appears low.

Drug utilization and cost associated with inflammatory bowel disease management in Saudi Arabia

BACKGROUND

There has been an increase in incidence and prevalence of inflammatory bowel disease (IBD) outside the western countries. Treatment costs are an essential component for healthcare planning and priority setting. The utilization patterns and annual administration and cost of IBD medications are largely unknown in countries with an increasing incidence of disease, Saudi Arabia being an example.

AIM

To evaluate the use of non-biologic and biologic agents and their associated annual administration costs in a sample of patients with Crohn's disease (CD) and ulcerative colitis (UC) in Saudi Arabia.

METHODS

Single-center retrospective chart review was performed to determine the use of biologic and non-biologic medications among IBD patients in a tertiary care hospital in Riyadh, Saudi Arabia. Daily and the annual acquisition cost of different IBD therapeutic agents was calculated. The utilization rates and cost of each type of medication by CD and UC patients were compared.

RESULTS

Data of 258 CD patients and 249 UC patients were analyzed. Infliximab and adalimumab were the most commonly prescribed biologics among the study sample, however, their utilization rates were significantly higher among CD than UC patients (36.82% vs. 11.24%, and 20.54% vs. 9.64%, respectively, P < 0. 01). Azathioprine utilization rate was also higher among CD patients compared to their UC counterparts (71.71% vs. 40.16%, respectively, P < 0.01). However, the utilization rate of mesalazine in the UC patients was significantly higher than their CD counterparts (85.53% vs. 14.34% for CD, P < 0.01). The annual cost of biologics (including administration and lab test cost) ranged from 5572 USD for ustekinumab to 18,424 USD for vedolizumab. On the other hand, the annual cost of non-biologics ranged from 16 USD for prednisone to 527 USD for methotrexate.

CONCLUSION

Biologics are extensively used in the management of IBD, particularly CD, and their utilization costs are significantly higher than non-biologics. Future studies should examine the cost effectiveness of IBD medications especially in countries with increasing incidence such as Saudi Arabia.