Decrease in primary but not in secondary abdominal surgery for Crohn's disease: nationwide cohort study, 1990–2014

A modified totally stapled KONO-S anastomosis for ileal and ileo-colic Crohn's disease: technical aspects and case series

Crohn's disease (CD) is a chronic immune-mediated disorder affecting the gastrointestinal tract. While medical therapies have advanced, approximately 80% of CD patients will require surgery due to disease recurrence. A significant debate exists regarding the primary site of post-operative recurrence. This discrepancy in recurrence patterns underscores the complexity of CD management and the ongoing need for tailored surgical approaches. It has been recently demonstrated that the Kono-S anastomosis is safe and efficient in reducing endoscopic and surgical recurrence. Newer versions of the Kono-S anastomosis using staplers have been reported to further simplify the procedure and decrease operative time. The aim of this paper was to describe a distinct version of a totally stapled Kono-S anastomosis and provide preliminary results from our center. The technical procedure of a totally stapled Kono-S anastomosis is illustrated. A consecutive series of patients undergoing ileal or ileo-colic resection followed by totally stapled Kono-S anastomosis was identified from a prospectively collated database. Data included patient demographics and baseline characteristics, intraoperative details, short- and long-term post-operative outcomes. Between January and November 2023, 41 patients (mean age 36.4 years, 61% males) underwent ileal or ileo-colic resection followed by totally stapled Kono-S anastomosis for Crohn's disease. Mean operative time was 150.76 ± 43.22 min, and mean time of anastomotic construction was 19.71 ± 4.24. Time to flatus and stool were 2.73 ± 0.70 and 3.51 ± 1.16 days, respectively, and the length of post-operative stay was 6.80 ± 2.13 days. Only two patients (4.8%) presented complications following surgery, namely anastomotic bleeding. At a mean follow-up of 17.0 ± 2.1 months, no patient needed re-do surgery for disease recurrence at anastomotic site. The endoscopic recurrence rate was 14.4% (4/28). Our fully stapled version of the Kono-S anastomosis is safe and feasible, and short construction time and low technical complexity may help its diffusion among colorectal surgeons. Long-term outcomes on disease recurrence are still to be defined.

Impact of biologics on stoma creation and reversal in Crohn's disease: a retrospective analysis from 2007 to 2021

BACKGROUND

Trends of stoma creation at index surgery for Crohn's disease (CD) in the biologics era has not been thoroughly investigated. This study aimed to assess the impact of increasing biologics use on stoma rates at index surgery of CD, as well as identifying risk factors for the creation and nonreversal of CD-related stoma.

METHODS

In this single-center retrospective analysis, consecutive CD patients who underwent index bowel surgery from 2007 to 2021 were reviewed. The rates of diverting stoma formation and reversal were compared across different time periods, delineated by January 2019, as biologics [anti-tumor necrosis factor (anti-TNF)] were included in national health insurance coverage in China. Logistic regression models and Cox proportional hazards models were utilized to assess factors influencing stoma creation and its reversal, respectively.

RESULTS

Among 1022 CD patients, 27.9% received a diverting stoma during index surgery. Despite increasing preoperative use of biologics, the incidence of stoma creation remained statistically unchanged pre- and post-2019 (29.5% versus 25.2%; P = 0.14). Factors contributing to stoma creation included colonic and perianal involvement, penetrating CD, poorer preoperative conditions, and preoperative steroid usage, but not preoperative biologics. Among diverted patients, 68.8% underwent successful bowel restoration, with the reversal rate significantly increasing from 63.0% before 2019 to 80.2% after 2019 (P < 0.01). Patients with postoperative use of immunomodulators and biologics were more likely to have the stoma closed, with a reversal rate of 90.0% for those receiving biologics compared with 64.0% for those not.

CONCLUSIONS

Increasing prevalence of biologics did not alter the stoma rates in CD patients. Additionally, postoperative biologics were independently associated with a higher probability of stoma reversal.

Prior Appendectomy Is Associated With a Milder Clinical Course in Crohn's Disease: A Nationwide Population-based Cohort Study

BACKGROUND

Appendectomy may affect the clinical course of Crohn's disease (CD), but rigorous evidence is sparse and contradicting. The aim of this study was to examine the association between appendectomy and the clinical course of CD.

METHODS

All patients diagnosed with CD in Denmark in the period from 1977 to 2017 were identified from the Danish National Patient Registry. Patients with appendectomy were matched with up to 10 comparators with CD and no appendectomy; and rates of CD-related hospital admissions were compared between CD patients with and without appendectomy using incidence rate ratios (IRRs). We used stratified Cox regression analysis to calculate adjusted hazard ratios (aHRs) of initiating treatment with biologics or undergoing intestinal resections.

RESULTS

In all, 21 189 CD patients (1936 with appendectomy and 19 253 without) were identified and followed for a median of 13.6 years. Crohn's disease patients who had undergone appendectomy experienced a lower rate of CD-related hospital admissions (appendectomy before CD: IRR = 0.83; 95% confidence interval [CI], 0.81-0.85; appendectomy after CD: IRR = 0.85; 95% CI, 0.81-0.88) compared with CD patients without appendectomy. For patients with appendectomy before CD diagnosis, the rate of initiating biologics was lower compared with CD patients with no appendectomy (aHR1-<5 years = 0.61; 95% CI, 0.46-0.81; aHR5-<10 years 0.47; 95% CI, 0.33-0.66; aHR10-20 years = 0.61; 95% CI, 0.47-0.79), as was the risk of undergoing colorectal resections (aHR1-<5 years = 0.94; 95% CI, 0.77-1.15; aHR5-<10 years 0.63; 95% CI, 0.47-0.85; aHR10-20 years = 0.75; 95% CI, 0.54-1.04). Rates of small bowel resections were comparable for CD patients with or without appendectomy prior to CD. Appendectomy performed after CD did not influence the rate of initiating treatment with biologics or undergoing intestinal resections.

CONCLUSION

The clinical course of CD is milder for those who have previously undergone appendectomy.

Safety and Efficacy of Infusional Perioperative Tacrolimus Therapy in Crohn's Disease Patients Undergoing Intestinal Resection

Introduction

Perioperative optimization of Crohn's disease (CD) patients is mandatory in order to ensure favorable outcomes and limit perioperative morbidity such as anastomosis-related complications. The use of perioperative tacrolimus may offer beneficial inflammatory control and improve postoperative outcome. However, it also may exhibit unwanted effects of immunosuppression on infectious complications and wound healing.

Methods

This is a single-center, retrospective study of CD patients undergoing intestinal resection between 2009 and 2018. Characteristics of CD patients receiving infusional perioperative tacrolimus or not were systematically evaluated and exploratively compared. To investigate the impact of tacrolimus and other predictors on postoperative infectious complications, simple regression with a threshold of p < 0.05 was used. Significant predictors of the simple regression analysis, as well as tacrolimus, were then included into multiple logistic regression.

Results

This analysis included 30 patients (34.88%) having received tacrolimus perioperatively and 56 patients (65.12%) that were not treated with tacrolimus. In median, 1 mg/day of tacrolimus was given intravenously for 11 days. Adverse events occurred in 3 patients (10%). The most common adverse events were headache and paresthesia. Tacrolimus showed no significant correlation to postoperative infectious complications. Furthermore, multiple regression analysis found no significant effect of tacrolimus on postoperative infectious complications when controlling for previously identified confounders.

Conclusion

Administration of tacrolimus showed no negative impact on postoperative infectious complications in the study cohort, indicating safety of perioperative tacrolimus therapy. By describing in detail our study population of patients receiving perioperative tacrolimus, we provide data guiding future prospective studies.

Endoscopic Assessment of Postoperative Recurrence in Crohn's Disease: Evolving Concepts

Endoscopic assessment within 6 to 12 months of ileocolonic resection has been the mainstay of management of postoperative Crohn's disease. The original Rutgeerts score to grade endoscopic recurrence was designed for predicting prognosis after resection. However, it is increasingly recognized that the clinical course of disease varied based on anatomic location of lesion rather than only severity of endoscopic lesions. It is also important to recognize several anatomic landmarks around surgical anastomosis, given the vast technical modifications in surgical technique over the past few decades. It is important to understand the changing paradigm of assessing endoscopic recurrence as it considerably influences subsequent therapeutic management.

A Population-Based Matched Cohort Study of Digestive System Cancer Incidence and Mortality in Individuals With and Without Inflammatory Bowel Disease

INTRODUCTION

To study digestive system cancer risks in individuals with inflammatory bowel diseases (IBDs) in the biologic era.

METHODS

We used population-level administrative and cancer registry data from Ontario, Canada, (1994-2020) to compare people with IBD to matched controls (1:10 by sex and birth year) on trends in age-sex standardized cancer incidence and risk ratios of incident cancers and cancer-related deaths.

RESULTS

Among 110,919 people with IBD and 1,109,190 controls, colorectal cancer incidence (per 100,000 person-years) declined similarly in people with ulcerative colitis (average annual percentage change [AAPC] -1.81; 95% confidence interval [CI] -2.48 to -1.156) and controls (AAPC -2.79; 95% CI -3.44 to -2.14), while small bowel cancer incidence rose faster in those with Crohn's disease (AAPC 9.68; 95% CI 2.51-17.3) than controls (AAPC 3.64; 95% CI 1.52-5.80). Extraintestinal digestive cancer incidence rose faster in people with IBD (AAPC 3.27; 95% CI 1.83-4.73) than controls (AAPC -1.87; 95% CI -2.33 to -1.42), particularly for liver (IBD AAPC 8.48; 95% CI 4.11-13.1) and bile duct (IBD AAPC 7.22; 95% CI 3.74-10.8) cancers. Beyond 2010, the incidences (and respective mortality rates) of colorectal (1.60; 95% CI 1.46-1.75), small bowel (4.10; 95% CI 3.37-4.99), bile duct (2.33; 95% CI 1.96-2.77), and pancreatic (1.19; 95% CI 1.00-1.40) cancers were higher in people with IBD.

DISCUSSION

Cancer incidence is declining for colorectal cancer and rising for other digestive cancers in people with IBD. Incidence and mortality remain higher in people with IBD than controls for colorectal, small bowel, bile duct, and pancreatic cancers.

Appearance of the Bowel and Mesentery During Surgery Is Not Predictive of Postoperative Recurrence After Ileocecal Resection for Crohn's Disease: A Prospective Monocentric Study

BACKGROUND

Very few risk factors for postoperative recurrence (POR) of Crohn's Disease (CD) after ileocecal resection have been identified. The aim of the present study was to verify the association between an a priori defined list of intraoperative macroscopic findings and POR.

METHODS

This was a prospective observational study including patients undergoing primary ileocecal resection for CD. Four intraoperative factors were independently evaluated by 2 surgeons: length of resected ileum, mesentery thickness, presence of areas of serosal fat infiltration, or abnormal serosal vasodilation on normal bowel proximal to the resected bowel. The primary end point was early endoscopic POR at month 6 and defined as modified Rutgeerts score ≥i2b. Secondary end points were clinical and surgical recurrence.

RESULTS

Between September 2020 and November 2022, 83 consecutive patients were included. Early endoscopic recurrence occurred in 45 of 76 patients (59.2%). Clinical and biochemical recurrence occurred in 17.3% (95% confidence interval, [CI], 10.4%-28.0%) and 14.6% of the patients after 12 months. The risk of developing endoscopic and clinical recurrence was 1.127 (95% CI, 0.448;2.834, P = .799) and 0.896 (95% CI, 0.324-2.478, P = .832) when serosal fat infiltration was observed, and 1.388 (95% CI, 0.554-3.476, P = .484), and 1.153 (95% CI, 0.417;3.187, P = .783) when abnormal serosal vasodilation was observed. Similarly, length of the resected bowel and mesentery thickness showed no association with POR. A subgroup analysis on patients who received no postoperative medical prophylaxis did not identify any risk factor for endoscopic POR.

CONCLUSIONS

The macroscopic appearance of the bowel and associated mesentery during surgery does not seem to be predictive of POR after ileocecal resection for CD.

Long-Term Risk of Myocarditis in Patients With Inflammatory Bowel Disease: A Nationwide Cohort Study in Sweden

INTRODUCTION

Despite a suggested link between inflammatory bowel disease (IBD) and myocarditis, the association has not been well established. This study aimed to investigate the long-term risk of myocarditis in patients with IBD.

METHODS

This nationwide cohort involved all patients with biopsy-confirmed IBD in Sweden (1969-2017) (n = 83,264, Crohn's disease [CD, n = 24,738], ulcerative colitis [UC, n = 46,409], and IBD-unclassified [IBD-U, n = 12,117]), general population reference individuals (n = 391,344), and IBD-free full siblings (n = 96,149) and followed until 2019. Primary outcome was incident myocarditis, and secondary outcome was severe myocarditis (complicated with heart failure, death, or readmission). Flexible parametric survival models were used to estimate adjusted hazard ratios (aHRs) and cumulative incidence of outcomes, along with 95% confidence intervals.

RESULTS

During a median follow-up of 12 years, there were 256 myocarditis cases in patients with IBD (incidence rate [IR] = 22.6/100,000 person-years) and 710 in reference individuals (IR = 12.9), with an aHR of 1.55 (95% confidence interval 1.33-1.81). The increased risk persisted through 20 years after IBD diagnosis, corresponding to 1 extra myocarditis case in 735 patients with IBD until then. This increased risk was observed in CD (aHR = 1.48 [1.11-1.97]) and UC (aHR = 1.58 [1.30-1.93]). IBD was also associated with severe myocarditis (IR: 10.1 vs 3.5; aHR = 2.44 [1.89-3.15]), irrespective of IBD subtypes (CD: aHR = 2.39 [1.43-4.01], UC: aHR = 2.82 [1.99-4.00], and IBD-U: aHR = 3.14 [1.55-6.33]). Sibling comparison analyses yielded similar results.

DISCUSSION

Patients with IBD had an increased risk of myocarditis, especially severe myocarditis, for ≥20 years after diagnosis, but absolute risks were low.

Interventional endoscopy in inflammatory bowel disease: a comprehensive review

Interventional endoscopy can play a key role in the multidisciplinary management of complex inflammatory bowel disease (IBD) as an adjunct to medical and surgical therapy. The primary role of interventional IBD (IIBD) includes the treatment of Crohn's disease-related stricture, fistula, and abscess. Endoscopic balloon dilation (EBD), endoscopic stricturotomy, and placement of endoscopic stents are different forms of endoscopic stricture therapy. EBD is the most widely used therapy whereas endoscopic stricturotomy has higher long-term efficacy than EBD. Fully covered and partially covered self-expanding metal stents are useful in long and refractory strictures whereas lumen-apposing metal stents can be used in short, and anastomotic strictures. Endoscopic fistula/abscess therapy includes endoscopic fistulotomy, seton placement, endoscopic ultrasound-guided drainage of rectal/pelvic abscess, and endoscopic injection of filling agents (fistula plug/glue/stem cell). Endoscopic seton placement and fistulotomy are mainly feasible in short, superficial, single tract fistula and in those with prior surgical seton placement. Similarly, endoscopic fistulotomy is usually feasible in short, superficial, single-tract fistula. Endoscopic closure therapies like over-the-scope clips, suturing, and self-expanding metal stent should be avoided for de novo/bowel to hollow organ fistulas. Other indications include management of postoperative complications in IBD such as management of surgical leaks and complications of pouchitis in ulcerative colitis. Additional indications include endoscopic resection of ulcerative colitis-associated neoplasia (by endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection), retrieval of retained capsule endoscope, and control of bleeding. IIBD therapies can potentially act as a bridge between medical and surgical therapy for properly selected IBD patients.

Impact of Kono-S anastomosis on quality of life after ileocolic resection in Crohn's disease: an analysis from the SuPREMe-CD trial

AIM

Crohn's disease has debilitating effects on patients' quality of life. Currently, there are limited data on the effect of anastomotic configuration on health-related quality of life after ileocaecal resection for Crohn's disease. This study aimed to assess the impact of Kono-S anastomosis on quality of life after ileocolic resection, compared to the conventional side-to-side anastomosis.

METHOD

Patients with primary or recurrent Crohn's disease participating in the ongoing SuPREMe-CD trial were interviewed about quality of life using the Inflammatory Bowel Disease Questionnaire (IBDQ). The primary endpoint was disease-specific quality of life, assessed with IBDQ. Secondary outcomes were quality of life related to bowel symptoms, systemic symptoms, social function and emotional function.

RESULTS

Of the 94 patients included, 51 (54%) received the conventional side-to-side anastomosis and 43 (46%) the Kono-S anastomosis. Demographics were comparable between the two groups. The IBDQ was assessed at a mean follow-up of 54.0 ± 18.7 months from surgical intervention. The mean total IBDQ score was 155.1 ± 28.07 in the conventional group and 163.8 ± 25.23 in the Kono-S group (P = 0.11). When considering bowel symptoms and social function, mean scores were 50.7 and 23.5 in the conventional group, and 56.3 and 26.5 in the Kono-S group (P = 0.002 and P = 0.02, respectively). Kono-S anastomosis was independently associated with improved quality of life regarding bowel symptoms (P = 0.006) and social function (P = 0.03) after correcting for other confounding factors on linear regression analysis.

CONCLUSION

Compared to conventional side-to-side anastomosis, patients with Kono-S anastomosis presented significantly better bowel symptoms and social function scores at 54 months after surgery.

Long-Term Monitoring and Clinical Implications of Small Bowel Capsule Endoscopy in Patients with Crohn's Disease with Small Bowel Lesions: A Retrospective Analysis

INTRODUCTION

Crohn's disease (CD) induces persistent inflammation throughout the gastrointestinal (GI) tract, potentially resulting in complications such as intestinal stenosis and fistulas, particularly in the small bowel. Small bowel capsule endoscopy (SBCE) is recommended for monitoring CD, especially when GI tract patency is maintained. This study aimed to retrospectively assess patients with CD who underwent SBCE to determine the timing of clinical changes and address the current lack of evidence regarding GI tract patency loss during CD treatment.

METHODS

Of the 166 consecutive patients who underwent SBCE at our institution, 120 were followed up and included in this study. Forty-six patients were excluded due to colitis type or immediate treatment changes post-SBCE. This study focused on the primary and secondary endpoints, including the cumulative stricture-free rate of the GI tract, emergency hospitalization post-SBCE, and post-SBCE treatment strategies, at the discretion of the attending physicians.

RESULTS

Demographic data revealed that the mean age of the study population was 43 years and that there was a male predominance (75%). The median disease duration was 12 years and the mean Crohn's Disease Activity Index was 98. During a 1,486-day observation period, 37% of patients experienced treatment changes. A Lewis score of >264 and perianal lesions were identified as independent risk factors for additional treatment needs. Emergency hospitalization occurred in 6% of patients and GI patency failure in 11%. Female sex and Lewis score>264 were associated with higher risks. GI patency rate declined 2 years after SBCE.

CONCLUSIONS

For patients who experienced no treatment changes based on SBCE results, it is recommended to undergo SBCE monitoring at intervals of no longer than 2 years.

Crohn's disease after surgery: Changes in post-operative management strategies over time and their impact on long-term re-operation rate-A retrospective multicentre real-world study

BACKGROUND

Few data are available addressing the impact of post-operative management of Crohn's disease (CD) on long-term clinical course.

AIM

To assess the evolution of post-operative management strategies over the last 40 years and their impact on the re-operation rate of CD.

METHODS

We included 657 patients with CD who had undergone their first radical ileo-caecal resection between 1980 and 2020. Three cohorts were defined according to year of surgery: cohort 1 (1980-1998; n = 198), cohort 2 (1999-2009; n = 218) and cohort 3 (2010-2020; n = 241). We estimated exposure to immunomodulators and anti-TNFα agents after surgery and rates of re-operation using Kaplan-Meier survival analyses. We used Cox proportional hazards regression to assess the association of clinical variables with time to re-operation.

RESULTS

Immunosuppressants, (IMMs) and anti-TNFα exposure within 5 years after surgery increased significantly from cohort 1 to cohort 2 and cohort 3 (IMMs: 1.6%, 38.2% and 28.0%, respectively, p < 0.001; anti-TNFα: 0.0%, 20.7% and 52.0%, respectively, p < 0.001). There was no significant difference across cohorts regarding the cumulative probability of re-operation within 5 and 10 years. Multivariate analysis identified IMMs/anti-TNFα exposure before the first surgery (HR 9.15; 95% CI 2.77-30.21) and post-operatively (HR: 0.24; 95% CI 0.07-0.74) as variables associated with the risk of re-operation. However, these associations had a time-varying effect and become non-significant after 5 and 2 years after surgery, respectively.

CONCLUSION

Despite increased post-operative use of IMMs and anti-TNFα agents in the last two decades, the impact of these strategies on the risk of long-term re-operation rate has been modest.

A biomarker-stratified comparison of top-down versus accelerated step-up treatment strategies for patients with newly diagnosed Crohn's disease (PROFILE): a multicentre, open-label randomised controlled trial

BACKGROUND

Management strategies and clinical outcomes vary substantially in patients newly diagnosed with Crohn's disease. We evaluated the use of a putative prognostic biomarker to guide therapy by assessing outcomes in patients randomised to either top-down (ie, early combined immunosuppression with infliximab and immunomodulator) or accelerated step-up (conventional) treatment strategies.

METHODS

PROFILE (PRedicting Outcomes For Crohn's disease using a moLecular biomarker) was a multicentre, open-label, biomarker-stratified, randomised controlled trial that enrolled adults with newly diagnosed active Crohn's disease (Harvey-Bradshaw Index ≥7, either elevated C-reactive protein or faecal calprotectin or both, and endoscopic evidence of active inflammation). Potential participants had blood drawn to be tested for a prognostic biomarker derived from T-cell transcriptional signatures (PredictSURE-IBD assay). Following testing, patients were randomly assigned, via a secure online platform, to top-down or accelerated step-up treatment stratified by biomarker subgroup (IBDhi or IBDlo), endoscopic inflammation (mild, moderate, or severe), and extent (colonic or other). Blinding to biomarker status was maintained throughout the trial. The primary endpoint was sustained steroid-free and surgery-free remission to week 48. Remission was defined by a composite of symptoms and inflammatory markers at all visits. Flare required active symptoms (HBI ≥5) plus raised inflammatory markers (CRP >upper limit of normal or faecal calprotectin ≥200 μg/g, or both), while remission was the converse-ie, quiescent symptoms (HBI <5) or resolved inflammatory markers (both CRP ≤ the upper limit of normal and calprotectin <200 μg/g) or both. Analyses were done in the full analysis (intention-to-treat) population. The trial has completed and is registered (ISRCTN11808228).

FINDINGS

Between Dec 29, 2017, and Jan 5, 2022, 386 patients (mean age 33·6 years [SD 13·2]; 179 [46%] female, 207 [54%] male) were randomised: 193 to the top-down group and 193 to the accelerated step-up group. Median time from diagnosis to trial enrolment was 12 days (range 0-191). Primary outcome data were available for 379 participants (189 in the top-down group; 190 in the accelerated step-up group). There was no biomarker-treatment interaction effect (absolute difference 1 percentage points, 95% CI -15 to 15; p=0·944). Sustained steroid-free and surgery-free remission was significantly more frequent in the top-down group than in the accelerated step-up group (149 [79%] of 189 patients vs 29 [15%] of 190 patients, absolute difference 64 percentage points, 95% CI 57 to 72; p<0·0001). There were fewer adverse events (including disease flares) and serious adverse events in the top-down group than in the accelerated step-up group (adverse events: 168 vs 315; serious adverse events: 15 vs 42), with fewer complications requiring abdominal surgery (one vs ten) and no difference in serious infections (three vs eight).

INTERPRETATION

Top-down treatment with combination infliximab plus immunomodulator achieved substantially better outcomes at 1 year than accelerated step-up treatment. The biomarker did not show clinical utility. Top-down treatment should be considered standard of care for patients with newly diagnosed active Crohn's disease.

FUNDING

Wellcome and PredictImmune Ltd.

Toward less invasive coloproctology: The future is out there

Medical care has undergone remarkable improvements over the past few decades. One of the most important innovative breakthroughs in modern medicine is the advent of minimally and less invasive treatments. The trend towards employing less invasive treatment has been vividly shown in the field of gastroenterology, particularly coloproctology. Parallel to foregut interventions, colorectal surgery has shifted towards a minimally invasive approach. Coloproctology, including both medical and surgical management of colorectal diseases, has undergone a remarkable paradigm shift. The treatment of both benign and malignant colorectal conditions has gradually transitioned towards more conservative and less invasive approaches. An interesting paradigm shift was the trend to avoid the need for radical resection of rectal cancer altogether in patients who showed complete response to neoadjuvant treatment. The trend of adopting less invasive approaches to treat various colorectal conditions does not seem to be stopping soon as further research on novel, more effective and safer methods is ongoing.

Endoscopic Lesions of Postoperative Anastomotic Area in Patients With Crohn's Disease in the Biologic Era: A Japanese Multi-Centre Nationwide Cohort Study

BACKGROUND AND AIMS

Many patients have endoscopic evidence of recurrent Crohn's disease [CD] at 1 year after intestinal resection. These lesions predict future clinical recurrence. We endoscopically evaluated postoperative anastomotic lesions in CD patients from a large cohort of postoperative CD patients.

METHODS

We retrospectively enrolled CD patients who underwent surgical resection between 2008 and 2013 at 19 inflammatory bowel disease [IBD]-specialist institutions. The initial analyses included patients who underwent ileocolonoscopy ~1 year after intestinal resection. Follow-up analyses assessed any changes in the endoscopic findings over time. We evaluated the postoperative endoscopic findings, which were classified into four categories [no lesion, mild, intermediate, severe] at the sites of the anastomotic line and peri-anastomosis.

RESULTS

In total, 267 CD patients underwent postoperative ileocolonoscopy. Postoperative anastomotic lesions were widely detected in index ileocolonoscopy [61.0%] and were more frequently detected in follow-up ileocolonoscopy [74.9%]. Endoscopic severity also increased. Patients with intermediate or severe peri-anastomotic or anastomotic line lesions at the index ileocolonoscopy required significantly more interventions, including endoscopic dilatation or surgery, than patients with mild lesions or no lesions.

CONCLUSIONS

Frequent anastomotic lesions were observed at the postoperative index ileocolonoscopy. These gradually increased for subsequent ileocolonoscopy, even in the biologic era. Regarding lesions on the anastomotic line, intermediate lesions on the anastomotic line [e.g. irregular or deep ulcers] might be considered recurrent disease, and mild lesions [e.g. linear superficial ulcers] might be considered non-recurrent disease. Prospective studies are needed to resolve this issue, including treatment enhancement.

The Management of Postoperative Recurrence in Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory bowel disease with different phenotypes of presentation, inflammatory, penetrating, or stricturing disease, that significantly impacts patient well-being and quality of life. Despite advances in medical therapy, surgery sometimes represents the only treatment to address complications, such as strictures, fistulas, or abscesses. Minimizing postoperative recurrence (POR) remains a major challenge for both clinicians and patients; consequently, various therapeutic strategies have been developed to prevent or delay POR. The current review outlines an updated overview of POR management. We focused on diagnostic assessment, which included endoscopic examination, biochemical analyses, and cross-sectional imaging techniques, all crucial tools used to accurately diagnose this condition. Additionally, we delved into the associated risk factors contributing to POR development. Furthermore, we examined recent advances in the prophylaxis and treatment of POR in CD.

Crossing barriers: the burden of inflammatory bowel disease across Western Europe

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis

Despite the introduction of biological therapies, an ileocolonic resection is often required in patients with Crohn's disease [CD]. Unfortunately, surgery is not curative, as many patients will develop postoperative recurrence [POR], eventually leading to further bowel damage and a decreased quality of life. The 8th Scientific Workshop of ECCO reviewed the available scientific data on both prevention and treatment of POR in patients with CD undergoing an ileocolonic resection, dealing with conventional and biological therapies, as well as non-medical interventions, including endoscopic and surgical approaches in case of POR. Based on the available data, an algorithm for the postoperative management in daily clinical practice was developed.

Reoperations and Long-term Survival of Kock's Continent Ileostomy in Patients With IBD: A Population-Based National Cohort Study From Sweden

BACKGROUND

Kock's continent ileostomy is an option after proctocolectomy for patients not suitable for IPAA or ileorectal anastomosis. Ulcerative colitis is the most common indication for continent ileostomy.

OBJECTIVE

The aim of this study was to evaluate the long-term outcome of continent ileostomy.

DESIGN

Retrospective cohort register study.

SETTINGS

Data were obtained from the Swedish National Patient Registry.

PATIENTS

All patients with IBD and a continent ileostomy were identified. Data on demographics, diagnosis, reoperations, and excisions of the continent ileostomy were obtained. Patients with inconsistent diagnostic coding were classified as IBD-unclassified.

MAIN OUTCOME MEASURES

The main outcome measures were number of reoperations, time to reoperations, and time to excision of continent ileostomy.

RESULTS

We identified 727 patients, 428 (59%) with ulcerative colitis, 45 (6%) with Crohn's disease, and 254 (35%) with IBD-unclassified. After a median follow-up time of 27 (interquartile range, 21-31) years, 191 patients (26%) never had revision surgery. Some 1484 reoperations were performed on 536 patients (74%), and the median number of reoperations was 1 (interquartile range, 0-3) per patient. The continent ileostomy was excised in 77 patients (11%). Reoperation within the first year after reconstruction was associated with a higher rate of revisions (incidence rate ratio, 2.90; p < 0.001) and shorter time to excision (HR 2.38; p < 0.001). Constructing the continent ileostomy after year 2000 was associated with increased revision and excision rates (incidence rate ratio, 2.7; p < 0.001 and HR 2.74; p = 0.013). IBD-unclassified was associated with increased revisions (incidence rate ratio, 1.3; p < 0.001)' and the proportion of IBD-unclassified patients almost doubled from the 1980s (32%) to after 2000 (50%).

LIMITATIONS

Retrospective design, data from a register, and no data on quality of life were available were the limitations of this study.

CONCLUSION

Continent ileostomy is associated with substantial need for revision surgery, but most patients keep their reconstruction for a long time. See Video Abstract at http://links.lww.com/DCR/C122 .

REOPERACIONES Y SUPERVIVENCIA A LARGO PLAZO DE LA ILEOSTOMA CONTINENTE DE KOCK EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL UN ESTUDIO DE COHORTE NACIONAL BASADO EN LA POBLACIN DE SUECIA

ANTECEDENTES:La ileostomía continente de Kock es una opción después de la proctocolectomía para los pacientes que no son aptos para la anastomosis ileoanal con reservorio o la anastomosis ileorrectal. La colitis ulcerativa es la indicación más común para la ileostomía continente.OBJETIVO:El objetivo de este estudio fue evaluar el resultado a largo plazo de la ileostomía continente.DISEÑO:Estudio de registro de cohorte retrospectivo.AJUSTES:Los datos se obtuvieron del Registro Nacional de Pacientes de Suecia.PACIENTES:Se identificaron todos los pacientes con enfermedad inflamatoria intestinal e ileostomía continente. Se obtuvieron datos demograficos, diagnóstico, reoperaciones y extirpaciones de la ileostomía continente. Los pacientes con codificación diagnóstica inconsistente se clasificaron como no clasificados con EII.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron el número de reoperaciones, el tiempo hasta las reoperaciones y el tiempo hasta la escisión de la ileostomía continente.RESULTADOS:Identificamos 727 pacientes, 428 (59%) con colitis ulcerativa, 45 (6%) con enfermedad de Crohn y 254 (35%) con EII no clasificada. Después de una mediana de tiempo de seguimiento de 27 (IQR 21-31) años, 191 (26%) pacientes nunca se habían sometido a una cirugía de revisión. Se realizaron 1.484 reintervenciones en 536 (74%) pacientes, la mediana de reintervenciones fue de 1 (RIC 0-3) por paciente. La ileostomía continente se extirpó en 77 (11%) pacientes. La reoperación dentro del primer año después de la reconstrucción se asoció con una mayor tasa de revisiones (IRR 2,90 p < 0,001) y un tiempo más corto hasta la escisión (HR 2,38 p < 0,001). La construcción de la ileostomía continente después del año 2000 se asoció con mayores tasas de revisión y escisión (IRR 2,7 p < 0,001 y HR 2,74 p = 0,013). La EII no clasificada se asoció con un aumento de las revisiones (IRR 1,3 p < 0,001) y la proporción de pacientes con EII no clasificada casi se duplicó desde la década de 1980 (32%) hasta después de 2000 (50%).LIMITACIONES:Diseño retrospectivo, datos de registro. No hay datos disponibles sobre la calidad de vida.CONCLUSIÓN:La ileostomía continente se asocia con una necesidad sustancial de cirugía de revisión, pero la mayoría de los pacientes logran mantener su reconstrucción durante mucho tiempo. Consulte Video Resumen en http://links.lww.com/DCR/C122 . (Traducción-Dr. Yolanda Colorado ).

Results of the Eighth Scientific Workshop of ECCO: Diagnosing Postoperative Recurrence of Crohn's Disease After an Ileocolonic Resection With Ileocolonic Anastomosis

Despite the introduction of potent biologic therapies, many patients with Crohn's disease [CD] still require an ileocolonic resection [ICR] during the course of their disease. Furthermore, the need of redo ICR has not decreased over the past few decades, highlighting the need for better strategies to prevent and treat postoperative recurrence [POR]. The first step to develop such a strategy would be to define and standardise the description of POR with adequate diagnostic instruments. In this article, we will describe the different methodologies used to report POR [endoscopic, histological, radiological, biochemical, clinical, and surgical], and review their potential benefits and limitations, as well as the optimal timing of evaluation.

Increasing healthcare costs in inflammatory bowel disease 2007-2020 in Sweden

BACKGROUND

Inflammatory bowel disease has been linked to increasing healthcare costs, but longitudinal data on other societal costs are scarce.

AIM

To assess costs, including productivity losses, in patients with prevalent Crohn's disease (CD) or ulcerative colitis (UC) in Sweden between 2007 and 2020.

METHODS

We linked data from national registers on all patients with CD or UC and a matched (sex, birthyear, healthcare region and education) reference population. We assessed mean costs/year in Euros, inflation-adjusted to 2020, for hospitalisations, out-patient visits, medications, sick leave and disability pension. We defined excess costs as the mean difference between patients and matched comparators.

RESULTS

Between 2007 and 2020, absolute mean annual societal costs in working-age (18-64 years) individuals decreased by 17% in CD (-24% in the comparators) and by 20% in UC (-27% in comparators), due to decreasing costs from sick leave and disability, a consequence of stricter sick leave regulations. Excess costs in 2007 were dominated by productivity losses. In 2020, excess costs were mostly healthcare costs. Absolute and excess costs increased in paediatric and elderly patients. Overall, costs for TNF inhibitors/targeted therapies increased by 274% in CD and 638% in UC, and the proportion treated increased from 5% to 26% in CD, and from 1% to 10% in UC.

CONCLUSION

Between 2007 and 2020, excess costs shifted from productivity losses to direct healthcare costs; that is, the patients' compensation for sickness absence decreased, while society increased its spending on medications. Medication costs were driven both by expanding use of TNF inhibitors and by high costs for newer targeted therapies.

Effect of anastomotic configuration on Crohn's disease recurrence after primary ileocolic resection: a comparative monocentric study of end-to-end versus side-to-side anastomosis

There is ongoing debate whether the type of anastomosis following intestinal resection for Crohn's disease (CD) can impact on complications and postoperative recurrence. The aim of the present study is to describe the outcomes of side-to-side (S-S) vs end-to-end (E-E) anastomosis after ileocecal resection for CD. A retrospective comparative study was conducted in consecutive CD patients who underwent primary ileocecal resection between 2005 and 2013. All patients underwent colonoscopy 6 months postoperatively to assess endoscopic recurrence, defined as Rutgeerts' score (RS) ≥ i2. Surgical recurrence implied reoperation due to CD activity at the anastomotic site. Modified surgical recurrence was defined as the need for reoperation or balloon-dilation. Perioperative factors related to recurrence were evaluated. Of the 127 patients included, 51 (40.2%) received an E-E anastomosis. Median follow-up was longer in the E-E group (8.62 vs 13.68 years). Apart from the microscopic resection margins, patient, disease and surgical characteristics were similar between both groups. Anastomotic complications were comparable (S-S 5.3% vs E-E 5.8%, p = 1.00)0. Postoperatively, biologicals were used in 55.3% and 62.7% (p = 0.47) in S-S and E-E patients, respectively. Endoscopic recurrence did not differ between S-S and E-E patients (78.9 vs 72.9%, p = 0.37), with no significant difference in RS values between both groups (p = 0.87). Throughout follow-up, a higher surgical (p = 0.04) and modified surgical recurrence (p = 0.002) rate was observed in the E-E anastomosis group. Type of anastomosis was an independent risk factor for modified surgical recurrence. The type of anastomosis did not influence endoscopic recurrence and immediate postoperative disease complications. However, the wide diameter and the morphologic characteristic of the stapled S-S anastomosis resulted in a significant reduced risk for surgical and endoscopic reintervention on the long term.

Stemming the tide with ileocecal Crohn's disease: when is pharmacotherapy enough?

INTRODUCTION

Crohn's disease (CD) mostly affects the terminal ileum and ileocecal region and up to 80% of patients end up requiring surgery. Previously reserved for complicated or refractory forms, surgery is now considered as an alternative to medical treatment in localized ileocecal disease.

AREAS COVERED

This review examines factors associated with response to medical treatment and those associated with the need for surgery in ileocecal CD to identify the patients' profile for whom pharmacotherapy might be enough. Factors associated with the recurrence and the postoperative complications are also reviewed to help the clinician identify patients for whom medical therapy might be preferred.

EXPERT’S OPINION

LIR!C study long-term follow-up data show that 38% of infliximab-treated patients were still treated with infliximab at the end of their follow-up, while 14% had switched to another biologic or had received immunomodulator or corticosteroid and 48% had CD-related surgery. Only the combination with an immunomodulator was associated with a greater likelihood of continuing infliximab. Patients with ileocecal CD for whom pharmacotherapy might be sufficient are probably those with no risk factors for CD-related surgery.In addition, patients with high risk of recurrence or of post-operative complications may benefit more from medical treatment than from surgery.

Postoperative Crohn's Disease

Although surgery rates in Crohn's disease are declining in the past twenty years, bowel resection remains an important and still commonly used therapeutic option in Crohn's disease. Preoperatively, patients clinical status must be optimized including preparation for perioperative recovery including with nutrition optimization and preparation for postoperative pharmacotherapy. Postoperatively a medical therapy is often required and in recent years it has often been a biological therapy. One randomized controlled study suggested that infliximab is more likely to prevent endoscopic recurrence than placebo. But other biologicals have been used as well. Ileocolonoscopy should be undertaken by 6 months after an ileal or ileocecal resection especially. Adjunctive imaging such as transabdominal ultrasound, capsule endoscopy or cross sectional imaging may be required. Biomarker measurement with fecal calprotectin especially, or C-reactive protein, serum ferritin, serum albumin and serum hemoglobin will also be helpful.

Biological therapy prior to repeat ileocolic resection in Crohn's disease can reduce the postoperative complication rate

BACKGROUND

The aim of this study was to assess the effect of preoperative biologic therapy on the surgical outcome of Crohn's disease (CD) patients undergoing repeat ileocolic resection.

METHODS

This was a retrospective analysis of all CD patients who underwent repeat ileocolic resection at Cleveland Clinic Florida between January 2011 and April 2021. Patients were divided into two groups: treatment biologic therapy prior to surgery and controls.

RESULTS

Sixty-five patients (31males, median age 54 [range 23-82] years) were included in the study. Twenty nine (44.6%) were treated with biologic therapy prior to repeat ileocolic resection. No demographic differences were found between the biologic therapy and control groups. In addition, no differences were found in mean time from index ileocolic resection (p = 0.9), indication for surgery (p = 0.11), and preoperative albumin (p = 0.69). The majority of patients (57; 87.7%) were operated on laparoscopically, and mean overall operation time was 225 (SD 49.27) min. Overall, the postoperative complication rate was 43.1% (28 patients) and median length of stay was 5 (range 2-21) days. Postoperative complications were more common in the control group, compared to the biologic therapy group (55.6 vs 27.5%; p = 0.04). Conversion rate (35.7 vs 20.7%; p = 0.24), operation time (223 vs 219 min; p = 0.75), length of stay (5.2 vs 5.9 days; p = 0.4), and readmission (16.6 vs 11.1%; p = 0.72) were similar between the two groups. Multivariate analysis of risk factors for postoperative complications showed that biologic treatment was correlated with a lower risk (HR -0.28, CI 95% -0.5596 to -0.01898, p = 0.03).

CONCLUSIONS

Patients treated with biologic therapy for CD who underwent repeat ileocolic resection had fewer postoperative complications.

Comparison of two strategies for the management of postoperative recurrence in Crohn's disease patients with one clinical risk factor: A multicentre IG-IBD study

BACKGROUND

The management of postoperative recurrence (POR) in Crohn's disease (CD) after ileo-colonic resection is a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in the presence of at least one clinical risk factor.

OBJECTIVE

Our aim was to determine whether early immunosuppression can be avoided and guided by endoscopy in CD patients with only one risk factor.

METHODS

CD patients with only one risk factor for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, and active smoking, were retrospectively included. Two groups were formed based on whether immunosuppression was started immediately after surgery ("prophylaxis group") or guided by endoscopy ("endoscopy-driven group"). Primary endpoints were rates of any endoscopic recurrence (Rutgeerts ≥ i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence rates at 6, 12 and 24 months after surgery.

RESULTS

A total of 195 patients were enroled, of whom 61 (31.3%) received immunoprophylaxis. No differences between immunoprophylaxis and the endoscopy-driven approach were found regarding any endoscopic recurrence (36.1% vs. 45.5%, respectively, p = 0.10) and severe endoscopic recurrence (9.8% vs. 15.7%, respectively, p = 0.15) at the first endoscopic evaluation. Clinical recurrence rates were also not statistically different (p = 0.43, p = 0.09, and p = 0.63 at 6, 12, and 24 months, respectively).

CONCLUSIONS

In operated CD patients with only one risk factor for POR, immediate immunoprophylaxis does not decrease the rate of early clinical and endoscopic recurrence. Prospective studies are needed to confirm our results.

Comparison of the Risk of Crohn's Disease Postoperative Recurrence Between Modified Rutgeerts Score i2a and i2b Categories: An Individual Patient Data Meta-analysis

BACKGROUND

The modified Rutgeerts' score [RS] differentiates i2a-lesions confined to the anastomosis-and i2b-more than five aphthous ulcers in the neoterminal ileum with normal intervening mucosa, with or without anastomotic lesions-categories. Its relevance for the therapeutic management of Crohn's disease [CD] patients after ileocolic resection is still debated. Our objective was to compare the postoperative recurrence risk in patients with an i2a or i2b score, using an individual patient data meta-analysis.

METHODS

We conducted a systematic literature search until July 2020, to identify all relevant studies reporting the i2a/i2b status in the year following ileocolic resection and clinical and/or surgical postoperative CD recurrence in their follow-up. Individual patient-level data were obtained from the corresponding authors. The association between the modified RS and time-to-event was evaluated using a mixed Cox model with the centre as the random effect.

RESULTS

Seven studies published between 2008 and 2019 were included, corresponding to 400 patients: 189 [47%] i2a and 211 [53%] i2b. Median [interquartile range, IQR] time from ileocolic resection to ileocolonoscopy was 6.2 [5.5, 7.9] months and median [IQR] follow-up time after ileocolonoscopy was 4.5 [2.9, 7.3] years. The risk of clinical postoperative recurrence at 1 and 3 years was 11% [6-15%], and 25% [18-32%] in the i2a group versus 9% [5-13%] and 33% [26-41%] in the i2b group [p = 0.63 and p = 0.12, respectively]. No significant difference was observed in terms of time to clinical postoperative recurrence [p = 0.16] or surgical postoperative recurrence [p = 0.87]. Results did not change after excluding patients having initiated an immunosuppressant or a biologic in the 3 months after endoscopy [remaining cohort, n = 361].

CONCLUSIONS

In this individual patient data meta-analysis, no difference was observed between i2a and i2b subcategories with regards to clinical or surgical postoperative recurrence. As we wait for prospective trials, the same treatment strategy could be applied to all patients classified as i2 on the Rutgeerts score.

Risk factors and predictors of 30-day complications and conversion to open surgery after repeat ileocolic resection of Crohn's disease

BACKGROUND

Repeat ileocolic resection of Crohn's disease (CD) is a challenging procedure that can be followed by a high rate of complications. The present study aimed to identify the factors associated with complications and conversion to open surgery in patients undergoing repeat ileocolic resection for CD.

METHODS

This was a retrospective review of an IRB-approved prospective database of CD patients who underwent elective repeat ileocolic resection between 2011 and 2021. Univariate and multivariate analyses were performed to determine the predictive factors of postoperative complications and conversion to open surgery.

RESULTS

The present study included 65 patients (47.7% male) with a mean age of 52.5 years. 43.1% of patients developed short-term complications, most of which were of Clavien-Dindo class I-II. Longer operative time was found to be an independent predictor of complications (OR 1.016, p = 0.014). The preoperative use of biological therapy was an independent protective factor from complications (OR 0.243, p = 0.016). The only significant risk factor of a longer operation time was higher BMI (OR 3.11, p = 0.044). Overall, 28.1% of laparoscopic procedures were converted to laparotomy. According to bivariate analysis, previous ileocolic open resection (OR 190, p < 0.0001), longer operation time (OR 1.01; p = 0.036), and takedown of incidental fistula of incidental fistula (OR 3.78, p = 0.04) were associated with higher odds of conversion to open surgery.

CONCLUSION

Longer operation time was significantly associated with and predictive of complications after repeat ileocolic resection of CD. Preoperative biological therapy was predictive of a lower rate of complications. Previous ileocolic resection by laparotomy, longer operation time, and takedown of fistula were associated with a higher likelihood of conversion to open surgery.

Perioperative optimization of Crohn's disease

Crohn's disease (CD) is a chronic inflammatory disease mainly affecting the gastrointestinal tract. With the increased availability of modalities in the last two decades, the treatment of CD has advanced remarkably. Although medical treatment is the mainstay of therapy, most patients require surgery during the course of their illness, especially those who experience complications. Nutritional optimization and ERAS implementation are crucial for patients with CD who require surgical intervention to reduce postoperative complications. The increased surgical risk was found to be associated with the use of corticosteroids, but the association of surgical risk with immunomodulators, biologic therapy, such as anti-TNF mediations, anti-integrin medications, and anti-IL 12/23 was low in certainty. Decisions about preoperative medication must be made on an individual case-dependent basis. Preoperative imaging studies can assist in the planning of appropriate surgical strategies and approaches. However, patients must be informed of any alterations to their treatment. In summary, the management of perioperative medications and surgery-related decision-making should be individualized and patient-centered based on a multidisciplinary approach.

Redo ileocolic resection for recurrent Crohn's disease: A review and meta-analysis of surgical outcomes

BACKGROUND

Recurrence of postoperative Crohn's disease neccesitating repeat ileocolic resection is a common problem. The aim of this meta-analysis was to present the collective evidence on the surgical outcomes of this procedure.

METHODS

PubMed, Scopus, and Google Scholar were searched for eligible studies that reported the surgical outcomes of redo ileocolic resection for Crohn's disease. The primary outcomes were overall and major complication rates. The secondary outcome was anastomotic leak and conversion rate. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies - of Interventions tool.

RESULTS

This meta-analysis included 12 studies comprising 1,203 patients (50% men). The weighted mean rate of overall complications was 31.8% (95% confidence interval, 25-38.6) and rate of major complications was 8% (95% confidence interval, 5.7-10.2). The weighted mean rate of conversion was 20.9%, and the weighted mean rate of anastomotic leak was 3% (95% confidence interval, 1.8%-4.3%; inconsistency = 0). Male sex (slope coefficient = 0.0001; P = .01), American Society of Anesthesiologists score >3 (slope coefficient = 0.001; P = .04), smoking (slope coefficient = 0.0001; P = .008), preoperative use of steroid therapy (slope coefficient = 0.0001; P = .009), open approach (slope coefficient = 0.0001; P = .005), and having ≥2 previous resections (slope coefficient = 0.0001; P = .02) were significant risk factors for major complications.

CONCLUSION

Although redo ileocolic resection for patients with recurrent Crohn disease has a relatively high overall complication rate, a majority of these complications are minor and anastomotic leak rate is relatively low. Further prospective multicenter trials are warranted to confirm the conclusions of this meta-analysis.

Disease course and treatment outcomes of Crohn's disease patients with early or late surgery - A Danish nationwide cohort study from 1997 to 2015

BACKGROUND

Studies on early surgery among Crohn's disease patients are few and focus on ileocolonic resections.

AIM

The aim of this nationwide cohort study was to investigate the disease course in all Crohn's disease patients who underwent early and late major abdominal surgery.

METHODS

In a Danish nationwide cohort of Crohn's disease patients from 1997 to 2015 we included 493 patients (group 1) resected within 29 days, 472 patients (group 2) resected between 30 and 180 days, and 1,518 patients (group 3) resected after 180 days of diagnosis. Re-operation, hospitalisations and medications were analysed.

RESULTS

The cumulative risk of re-operation was lower among patients from group 1 (five-year risk: 16.5% vs. group 2: 18.2% and group 3: 21.2%, p = 0.004). Fewer patients from group 2 and 3 required hospitalisations (269 (56.5%) and 803 (52.8%) vs. group 1: 329 (66.8%) p<0.001). Patients from group 3 had a higher cumulative use of immunomodulators in the first three years after initial surgery (one-year risk: 24.6% vs. group 1: 19.4% and group 2: 17.0%, p<0.001).

CONCLUSION

Crohn's disease patients resected within 29 days of diagnosis had a lower cumulative risk of re-operation and a lower cumulative exposure to immunomodulators in the initial years after surgery.

Prevention of post-operative recurrence of Crohn's disease among patients with prior anti-TNFα failure: A retrospective multicenter study

BACKGROUND

Anti-TNFα are recommended for preventing Crohn's disease (CD) postoperative recurrence (POR) in patients with risk factors. However, few data exploring anti-TNFα efficacy in patients with preoperative anti-TNFα failure are available so far.

AIMS

The aim of the present study was to compare the efficacy of anti-TNFα with other biologics and immunosuppressants to prevent POR in this setting.

METHODS

Consecutive CD patients who underwent bowel resection between January 2010 and December 2019 after failure of at least one anti-TNFα were retrospectively included among three tertiary centers if they started a postoperative medical prophylaxis within the three months after index surgery. The main outcome was to compare rates of objective recurrence (endoscopic or radiological recurrence in absence of colonoscopy) between patients treated with an anti-TNFα agent or another treatment as prevention of POR.

RESULTS

Among the 119 patients included, 71 patients received an anti-TNFα (26 infliximab, 45 adalimumab) and 48 another treatment (18 ustekinumab, 7 vedolizumab, 20 azathioprine and 3 methotrexate) to prevent POR. Rates of objective recurrence at two years were 23.9% in patients treated with anti-TNFα and 44.9% in the others (p = 0.011).

CONCLUSION

Anti-TNFα remained an effective option to prevent POR for patients operated upon with previous anti-TNFα failure.

Steroid-Free Deep Remission at One Year Does Not Prevent Crohn's Disease Progression: Long-Term Data From the TAILORIX Trial

BACKGROUND & AIMS

Crohn's disease (CD) patients included in the Tailored Treatment With Infliximab for Active Crohn's Disease (TAILORIX) trial started infliximab in combination with an immunosuppressant for 1 year. The aim of the present study was to determine the long-term disease course beyond the study period.

METHODS

We compared the outcomes of patients who did or did not reach the primary end point of the TAILORIX trial, defined as sustained corticosteroid-free clinical remission from weeks 22 through 54, with no ulcers on ileocolonoscopy at week 54. The primary outcome of this follow-up study was the progression-free survival of CD defined by anal or major abdominal surgery, CD-related hospitalization, or the need for a new systemic CD treatment.

RESULTS

The 95 patients (median disease duration, 4.5 mo; interquartile range, 1.0-56.6 mo) analyzed, including 45 (47%) who achieved the primary end point, were followed up for a median duration of 64.2 months (interquartile range, 57.6-69.9 mo) after the end of the study period. There was no significant difference in CD progression-free survival at 1, 3, and 5 years between patients who achieved the TAILORIX primary end point and patients who did not (P = .64). No difference was observed between both groups for each component of CD progression: anal surgery, major abdominal surgery, CD-related hospitalization, or the need for a new systemic CD treatment.

CONCLUSIONS

Achieving a sustained clinical remission off steroids with complete endoscopic remission in this cohort of 95 patients with early CD was not associated with less disease progression. Prospective trials to define the therapeutic goals that change the natural history of CD and prevent complications are needed.

Therapeutic management and outcomes in inflammatory bowel diseases, 2010 to 2017 in cohorts from Denmark, Sweden and Norway

BACKGROUND

Despite the increasing use of biologics in patients with inflammatory bowel disease (IBD), real-world data about outcomes in the era of biologics remain inconclusive.

AIMS

To investigate trends in surgeries, hospitalisations and medication use in patients with IBD in a multinational, population-based cohort METHODS: We included 42,894 patients with ulcerative colitis (UC) and 24,864 with Crohn's disease (CD) who were diagnosed between 2010 and 2017 in Denmark, Norway and Sweden. We extracted data about surgeries, hospitalisations and medications from national registries and compared across countries and diagnosis years.

RESULTS

Between 2010 and 2017, 2-year surgery rates were 4-7% in UC and 10-15% in CD and were stable over time. Two-year hospitalisation rates increased in Denmark (UC: 20% to 35%; CD: 27% to 32%) but were stable in Norway and Sweden (fluctuating between 33% and 37% in UC, and 46% and 52% in CD). Two-year rates of biologic use increased in both UC (7% to 16% in Denmark, 8% to 18% in Norway) and CD (22% to 26% in Denmark; 21% to 35% in Norway). Two-year rates of immunomodulator use increased in Norway (from 14% to 23% in UC; 37% to 45% in CD) and Sweden (from 41% to 52% in CD), but were stable in Denmark (between 17% and 21% in UC; 39% to 46% in CD).

CONCLUSION

Between 2010 and 2017, surgery rates among Scandinavian patients with IBD remained stable, with no clear changes in hospitalisation rates despite the increasing use of immunomodulators and biologics.

Surgical Planning in Penetrating Abdominal Crohn's Disease

Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.

Tumour necrosis factor inhibitors in Crohn's disease and the effect on surgery rates

AIM

Surgery is an important therapeutic option for Crohn's disease. The need for first bowel surgery seems to have decreased with the introduction of tumour necrosis factor inhibitors (TNFi; adalimumab or infliximab). However, the impact of TNFi on the need for intestinal surgery in Crohn's disease patients irrespective of prior bowel resection is not known. The aim of this work is to compare the incidence of bowel surgery in Crohn's disease patients who remain on TNFi treatment versus those who discontinue it.

METHOD

We performed a nationwide register-based observational cohort study in Sweden of all incident and prevalent cases of Crohn's disease who started first-line TNFi treatment between 2006 and 2017. Patients were categorized according to TNFi treatment retention less than or beyond 1 year. The study cohort was evaluated with regard to incidence of bowel surgery from 12 months after the first ever TNFi dispensation.

RESULTS

We identified 5003 Crohn's disease patients with TNFi exposure: 3748 surgery naïve and 1255 with bowel surgery prior to TNFi initiation. Of these patients, 7% (n = 353) were subjected to abdominal surgery during the first 12 months after the start of TNFi and were subsequently excluded from the main analysis. A majority (62%) continued TNFi for 12 months or more. Treatment with TNFi for less than 12 months was associated with a significantly higher surgery rate compared with patients who continued on TNFi for 12 months or more (hazard ratio 1.26, 95% CI 1.09-1.46; p = 0.002).

CONCLUSION

Treatment with TNFi for less than 12 months was associated with a higher risk of bowel surgery in Crohn's disease patients compared with those who continued TNFi for 12 months or more.

Totally stapled Kono-S anastomosis for Crohn's disease

Postoperative recurrence (POR) rates after resection for Crohn's disease (CD) are high. Whether the type of anastomosis affects POR is still debated. Recently, an anti-mesenteric hand-sewn end-to-end anastomosis (Kono-S) has been proposed as an additional measure to reduce recurrence. A randomized controlled trial demonstrated a significant reduction of endoscopic and clinical POR when the Kono-S anastomosis was compared to stapled ileocolic side-to-side anastomosis. However the hand- sewn technique might potentially limit use of this new type of anastomosis. The aim of this paper was to illustrate the technique of a totally stapled Kono-S anastomosis, and to discuss its potential advantages in surgery for CD.

Surgery for inflammatory bowel disease in the era of biologics

Therapy for inflammatory bowel diseases (IBD) has changed dramatically in recent years with the wide use of biologics. Despite these advances in medical therapy, surgery still plays an indispensable role in the management of IBD. And with more and more patients receiving biologics, surgeons also need to adapt to the impact of biologics on the disease. The purpose of this article is to review the role of surgery in the treatment of IBD in the era of biologics and the impact of these medications on perioperative outcomes.

Increased use of biologics in the era of TNF-α inhibitors did not reduce surgical rate but prolonged the time from diagnosis to first time intestinal resection among patients with Crohn's disease and ulcerative colitis - a Danish register-based study from 2003-2016

BACKGROUND

During the last decade, a significant increase in the use of biologic medicine has occurred, accounting for the greatest healthcare expenditure, among inflammatory bowel disease (IBD) patients. The objective of this study was to analyse the prevalence of and time to first intestinal resection surgery in a Danish nationwide cohort of Crohn's disease (CD) and ulcerative colitis (UC) patients, stratified on biologic treatment status.

METHODS

This retrospective population-based study included IBD patients diagnosed between 2003 and 2015 identified in the Danish National Patient Registry (NPR). The frequency of first-time surgery with intestinal resection and time to surgery was analysed among CD and UC patients between 2003 and 2016.

RESULTS

A total of 2328 CD and 2128 UC patients underwent surgery between 2003 and 2016 (23% and 10% of all incident CD and UC patients, respectively). Up until 2008, the frequency of surgery gradually declined for both patient groups and an increase in the frequency of patients receiving biological treatment was observed. Subsequently, the frequency of surgery for both CD and UC patients remained stable despite a steady increase in biologic treatment use.

CONCLUSIONS

The registered increase in the fraction of patients on biologic treatment (mostly TNF-α inhibitors) did not result in changes in the rates of major surgeries with intestinal resection in CD and UC patients.

Women's Earnings are more Affected by Inflammatory Bowel Disease than Men's: A Register-Based Swedish Cohort Study

BACKGROUND AND AIMS

Patients with inflammatory bowel disease [IBD] are subject to more work disability than the general population. We aimed to estimate the monetary cost of IBD for the individual through assessment of earnings in relation to diagnosis.

METHODS

Through linkage of national registers, we identified patients aged 30-55 years at first IBD diagnosis in Sweden in 2002-2011, and same-sex IBD-free siblings. We estimated taxable earnings and disposable income from 5 years before to 5 years after diagnosis.

RESULTS

The 5961 patients [27% Crohn's disease, 68% ulcerative colitis, 4.3% IBD unclassified] had similar taxable earnings to their 7810 siblings until the year of diagnosis, when earnings decreased and remained lower than for siblings during follow-up. The adjusted difference in earnings over the entire 5-year period after diagnosis was -5% [-8212€; 95% confidence interval: -11 458 to -4967€]. The difference was greater in women than in men, and greater in Crohn's disease than in ulcerative colitis. When stratifying for sex and IBD subtype and comparing earnings during each year of follow-up, median annual earnings were lower in women with Crohn's disease and ulcerative colitis than in their sisters during all years of follow-up, whereas the men had similar annual taxable earnings to their brothers. Disposable income was similar between patients and siblings during the investigated time period.

CONCLUSION

From the year of diagnosis and at least 5 years onwards, patients with IBD had 5% lower earnings than siblings, mainly explained by differences between women with IBD and their sisters. However, there were no differences in disposable income.

Clinical course of Crohn's disease in a population-based cohort in Uppsala County followed for 10 years

BACKGROUND AND AIMS

There is a shortage of studies describing the outcome of patients with Crohn's disease (CD) where both biological therapy and immunomodulators (IMMs) have been available. The aim of the present study was to describe the clinical course of the disease, the use of drugs, the need for surgery and mortality in a prospectively recruited population-based cohort of patients followed for 10 years.

METHODS

All patients diagnosed with CD in the County of Uppsala in Sweden 2005-2009 were prospectively recruited and followed until the end of 2019. The medical notes were scrutinised and relevant information collected.

RESULTS

One hundred and fifty-four patients covering all age groups were diagnosed with CD and 145 (94.2%) could be followed for 10 years or until death. Nine patients were lost to follow up. The following drugs were used: 5-ASA 83%, steroids 84%, IMMs 69% and biologicals 23%. The proportion of penetrating disease increased from 9.7 to 14.5%. Primary bowel resections were performed in 22% of the patients, and none of these had any secondary surgery because of recurrent or progressive disease during the observation time. Twelve patients (7.8%) died during the follow up, and one of these because of a small bowel carcinoma.

CONCLUSIONS

In the present study, the clinical course of CD was similar to previous reports during the first year after diagnosis, but the following years were considerably more stable with moderate increase of intestinal damage and totally a low frequency of surgery and no repeated surgery.

Impaired Fertility in Women With Inflammatory Bowel Disease: A National Cohort Study From Sweden

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] has been associated with reduced female fertility. We analyse fertility in a national cohort of women with IBD.

METHODS

Fertility was assessed in women with IBD aged 15-44 years in 1964-2014, identified from the Swedish National Patient Register and a matched cohort [ratio 1:5]. Patients with indeterminate colitis or inconsistent IBD coding were classified as IBD-unclassified [IBD-U].

RESULTS

The cohorts included 27 331 women with IBD and 131 892 matched individuals. The fertility rate in IBD was 1.52 (standard deviation [SD] 1.22) births per 1000 person-years and 1.62 [SD 1.28] [p <0.001] in matched individuals. Fertility was impaired in all IBD subtypes compared with the matched cohort (hazard ratio Crohn's disease [CD] 0.88, 95% confidence interval [CI] 0.85-0.91; IBD-U 0.86, 95% CI 0.83-0.89; and ulcerative colitis [UC] 0.96, 95% CI 0.93-0.98). Fertility improved during the study period for the IBD cohort except for CD. Parity progression ratio, the proportion of IBD women progressing from one parity to the next compared with the matched cohort, was decreased at all parity levels for CD and IBD-U, but only for multiparous women in UC. Contraceptive usage was higher in IBD, both before and after the diagnosis. Disease severity, bowel resections, and perianal disease in CD affected fertility negatively.

CONCLUSIONS

Fertility was impaired mainly in women with CD and IBD-U, and less so in UC. During the study period, fertility improved in women with UC or IBD-U. Some results suggest a role of voluntarily reduced fertility.