1
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Scow JS. Modern surgery for Crohn's disease: When to divert, impact of biologics on infectious complications, and surgical techniques to decrease post-operative recurrence of Crohn's disease. Surg Open Sci 2024; 19:20-23. [PMID: 38585036 PMCID: PMC10995856 DOI: 10.1016/j.sopen.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/14/2024] [Indexed: 04/09/2024] Open
Abstract
Crohn's disease is a complex condition that confers a significant risk of requiring multiple surgeries. Questions that surgeons must frequently answer include: which patients benefit from diversion? Does monoclonal antibody therapy increase post-operative complications? And, are there surgical techniques that can prevent the recurrence of Crohn's disease? This review examines current data to answer these questions.
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Affiliation(s)
- Jeffrey S. Scow
- Division of Colorectal Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, United States of America
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2
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Casas Deza D, Polo Cuadro C, de Francisco R, Vela González M, Bermejo F, Blanco I, de la Serna Á, Bujanda L, Bernal L, Rueda García JL, Gargallo-Puyuelo CJ, Fuentes-Valenzuela E, Castro B, Guardiola J, Ladrón G, Suria C, Sáez Fuster J, Gisbert JP, Sicilia B, Gomez R, Muñoz Vilafranca C, Barreiro-De Acosta M, Peña E, Castillo Pradillo M, Cerrillo E, Calvet X, Manceñido N, Monfort I Miquel D, Marín S, Roig C, Marce A, Ramírez de Piscina P, Betoré E, Martin-Cardona A, Teller M, Alonso Abreu I, Maroto N, Frago S, Gardeazabal D, Pérez-Martínez I, Febles González ÁD, Barrero S, Taxonera C, García de la Filia I, Ezkurra-Altuna A, Madero L, Martín-Arranz MD, Gomollón F, Domènech E, García-López S. Initial Management of Intra-abdominal Abscesses and Preventive Strategies for Abscess Recurrence in Penetrating Crohn's Disease: A National, Multicentre Study Based on ENEIDA Registry. J Crohns Colitis 2024; 18:578-588. [PMID: 37930823 DOI: 10.1093/ecco-jcc/jjad184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Intra-abdominal abscesses complicating Crohn's disease [CD] are a challenging situation. Their management, during hospitalisation and after resolution, is still unclear. METHODS Adult patients with CD complicated with intra-abdominal abscess. who required hospitalisation, were included from the prospectively maintained ENEIDA registry from GETECCU. Initial strategy effectiveness and safety to resolve abscess was assessed. Survival analysis was performed to evaluate recurrence risk. Predictive factors associated with resolution were evaluated by multivariate regression and predictive factors associated with recurrence were assessed by Cox regression. RESULTS In all, 520 patients from 37 Spanish hospitals were included; 322 [63%] were initially treated with antibiotics alone, 128 [26%] with percutaneous drainage, and 54 [17%] with surgical drainage. The size of the abscess was critical to the effectiveness of each treatment. In abscesses < 30 mm, the antibiotic was as effective as percutaneous or surgical drainage. However, in larger abscesses, percutaneous or surgical drainage was superior. In abscesses > 50 mm, surgery was superior to percutaneous drainage, although it was associated with a higher complication rate. After abscess resolution, luminal resection was associated with a lower 1-year abscess recurrence risk [HR 0.43, 95% CI 0.24-0.76]. However, those patients who initiated anti-TNF therapy had a similar recurrence risk whether luminal resection had been performed. CONCLUSIONS Small abscesses [<30mm] can be managed with antibiotics alone; larger ones require drainage. Percutaneous drainage will be effective and safer than surgery in many cases. After discharge, anti-TNF therapy reduces abscess recurrence risk in a similar way to bowel resection.
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Affiliation(s)
- Diego Casas Deza
- Gastroenterology Department, University Hospital Miguel Servet, Zaragoza, Spain
- Institute for Health Research Aragón [IIS Aragón], Zaragoza, Spain
| | | | - Ruth de Francisco
- Gastroenterology Department, University Hospital Central de Asturias, and Instituto de Investigación Sanitaria del Principado de Asturias [ISPA], Oviedo, Spain
| | - Milagros Vela González
- Gastroenterology Department, University Hospital Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Fernando Bermejo
- Gastroenterology Department, University Hospital of Fuenlabrada, Fuenlabrada, Spain
| | - Ignacio Blanco
- Gastroenterology Department, University Hospital Clínico San Carlos, Madrid, Spain
| | - Álvaro de la Serna
- Gastroenterology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Luis Bujanda
- Gastroenterology Department, University Hospital of Donostia, San Sebastian, Spain; Instituto Biodonostia, Universidad del País Vasco [UPV/EHU], CIBERehd, Spain
| | - Lorena Bernal
- Gastroenterology Department, Hospital General de Alicante, Alicante, Spain
| | - José Luis Rueda García
- Gastroenterology Department, La Paz University Hospital. School of Medicine; Universidad Autónoma de Madrid. Hospital La Paz Institute for Health Research, La Paz Hospital, Madrid, Spain
| | - Carla J Gargallo-Puyuelo
- Gastroenterology Department, University Hospital Lozano Blesa, Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Spain
- Institute for Health Research Aragón [IIS Aragón], Zaragoza, Spain
| | | | - Beatriz Castro
- Gastroenteroly Department, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Jordi Guardiola
- Gastroenterology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Gemma Ladrón
- Gastroenterology Department, University Hospital General de Castelló, Castellón, Spain
| | - Carles Suria
- Gastroenterology Department, University Hospital Clínico de Valencia, Valencia, Spain
| | - Julia Sáez Fuster
- Gastroenterology Department, University Hospital General de Elche, Spain
| | - Javier P Gisbert
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-Princesa], Universidad Autónoma de Madrid [UAM], Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Spain
| | - Beatriz Sicilia
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Raquel Gomez
- Gastroenterology Department, University Hospital Fundación de Alcorcón, Alcorcón, Spain
| | | | | | - Elena Peña
- Gastroenterology Department, Hospital Royo Villanova, Zaragoza, Spain
| | | | - Elena Cerrillo
- Gastroenterology Department, University Hospital La Fe, Valencia, Spain
| | - Xavier Calvet
- Gastroenterology Department, University Hospital Parc Taulí, Sabadel, Spain and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Spain
| | - Noemí Manceñido
- Gastroenterology Department, University Hospital Infanta Sofía, San Sebastián de los Reyes, Spain
| | | | - Sandra Marín
- Gastroenterology Department, University Hospital Reina Sofía, Córdoba, Spain
| | - Cristina Roig
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ainhoa Marce
- Gastroenterology Department, Hospital Moisès Broggi, Sant Joan Despí, Spain
| | | | - Elena Betoré
- Gastroenterology Department, Hospital Universitario San Jorge, Huesca, Spain
| | - Albert Martin-Cardona
- Gastroenterology Department, Hospital Universitari Mútua Terrassa, Spain
- University of Barcelona, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Spain
| | - Marta Teller
- Gastroenterology Department, Althaia Xarxa Assistencial Universitaria de Manresa, Manresa, Spain
| | | | - Nuria Maroto
- Gastroenterology Department, Hospital de Manises, Manises, Spain
| | - Santiago Frago
- Gastroenterology Department, Hospital Santa Bárbara, Soria, España
| | | | - Isabel Pérez-Martínez
- Gastroenterology Department, University Hospital Central de Asturias, and Instituto de Investigación Sanitaria del Principado de Asturias [ISPA], Oviedo, Spain
| | - Ángel David Febles González
- Gastroenterology Department, University Hospital Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Sara Barrero
- Gastroenterology Department, University Hospital of Fuenlabrada, Fuenlabrada, Spain
| | - Carlos Taxonera
- Gastroenterology Department, University Hospital Clínico San Carlos, Madrid, Spain
| | | | - Ander Ezkurra-Altuna
- Gastroenterology Department, University Hospital of Donostia, San Sebastian, Spain; Instituto Biodonostia, Universidad del País Vasco [UPV/EHU], CIBERehd, Spain
| | - Lucía Madero
- Gastroenterology Department, Hospital General de Alicante, Alicante, Spain
| | - María Dolores Martín-Arranz
- Gastroenterology Department, La Paz University Hospital. School of Medicine; Universidad Autónoma de Madrid. Hospital La Paz Institute for Health Research, La Paz Hospital, Madrid, Spain
| | - Fernando Gomollón
- Gastroenterology Department, University Hospital Lozano Blesa, Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Spain
- Institute for Health Research Aragón [IIS Aragón], Zaragoza, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Spain
- Universitat Autònoma de Barcelona, Spain
| | - Santiago García-López
- Gastroenterology Department, University Hospital Miguel Servet, Zaragoza, Spain
- Institute for Health Research Aragón [IIS Aragón], Zaragoza, Spain
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3
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Ullrich SJ, Frischer JS. Surgical management of complicated Crohn's disease. Semin Pediatr Surg 2024; 33:151399. [PMID: 38642531 DOI: 10.1016/j.sempedsurg.2024.151399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2024]
Abstract
Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population - notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.
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Affiliation(s)
- Sarah J Ullrich
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA
| | - Jason S Frischer
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA.
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4
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Fansiwala K, Rusher A, Shore B, Herfarth HH, Barnes E, Kochar B, Chang S. Oral vs Intravenous Discharge Antibiotic Regimens in the Management of Intra-abdominal Abscesses in Penetrating Crohn's Disease. Inflamm Bowel Dis 2023:izad299. [PMID: 38150318 DOI: 10.1093/ibd/izad299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Antibiotics are a cornerstone in management of intra-abdominal abscesses in Crohn's disease (CD). Yet, the optimal route of antibiotic administration is poorly studied. We aimed to compare surgical and nonsurgical readmission outcomes for patients hospitalized for intra-abdominal abscesses from CD discharged on oral (PO) or intravenous (IV) antibiotics. METHODS Data for patients with CD hospitalized for an intra-abdominal abscess were obtained from 3 institutions from January 2010 to December 2020. Baseline patient characteristics were obtained. Primary outcomes of interest included need for surgery and hospital readmission within 1 year from hospital discharge. We used multivariable logistic regression models and Cox regression analysis to adjust for abscess size, history of prior surgery, history of penetrating disease, and age. RESULTS We identified 99 patients discharged on antibiotics (PO = 74, IV = 25). Readmissions related to CD at 12 months were less likely in the IV group (40% vs 77% PO, P = .01), with the IV group demonstrating a decreased risk for nonsurgical readmissions over time (hazard ratio, 0.376; 95% confidence interval, 0.176-0.802). Requirement for surgery was similar between the groups. There were no differences in time to surgery between groups. CONCLUSIONS In this retrospective, multicenter cohort of CD patients with intra-abdominal abscess, surgical outcomes were similar between patients receiving PO vs IV antibiotics at discharge. Patients treated with IV antibiotics demonstrated a decreased risk for nonsurgical readmission. Further prospective trials are needed to better delineate optimal route of antibiotic administration in patients with penetrating CD.
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Affiliation(s)
- Kush Fansiwala
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alison Rusher
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Shore
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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5
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Constant BD, de Zoeten EF, Weinman JP, Albenberg L, Scott FI. Early Anti-Tumor-Necrosis-Factor Therapy for Crohn's Disease-Related Abdominal Abscesses and Phlegmon in Children. Dig Dis Sci 2023; 68:877-888. [PMID: 35790702 DOI: 10.1007/s10620-022-07604-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Internally penetrating Crohn's Disease complications, including abscesses and phlegmon, represent a high-risk Crohn's Disease phenotype. Anti-tumor-necrosis-factor-α (Anti-TNF) therapies are effective in treating penetrating Crohn's Disease and early initiation has shown unique benefits. However, timing of anti-TNF initiation in the setting of internally penetrating Crohn's Disease complications is typically heterogenous due to concern over precipitating serious infections. Recent studies demonstrate such an association may not exist. AIMS We aimed to describe the multidisciplinary management of pediatric patients with internally penetrating Crohn's Disease complications, focusing on the utilization and timing of anti-TNF therapy relative to complication resolution and adverse events. METHODS We performed a single-center retrospective cohort study of pediatric patients with internally penetrating Crohn's Disease complications from 2007 to 2021. The safety and effectiveness of anti-TNF therapy initiation prior to complication resolution was assessed by comparing rates of infectious and Crohn's Disease-related adverse events between those who received anti-TNF therapy prior to complication resolution, versus those who did not. RESULTS Twenty-one patients with internally penetrating Crohn's Disease complications were identified. 7/21 received anti-TNF therapy prior to complication resolution. Infectious adverse events within 90 days of complication occurred in 0/7 patients initiating anti-TNF therapy prior to complication resolution and 10/14 patients who did not (p = 0.004). Crohn's Disease-related surgeries and hospitalizations within 1 year of complication occurred in 12/20 patients, with similar frequency between groups. CONCLUSIONS Initiating anti-TNF therapy prior to internally penetrating Crohn's Disease complication resolution may be a safe and effective strategy to improve clinical outcomes.
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Affiliation(s)
- Brad D Constant
- Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA.
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Edwin F de Zoeten
- Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA
| | - Jason P Weinman
- Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave. B158, Aurora, CO, 80045, USA
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6
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Fenneman AC, Weidner M, Chen LA, Nieuwdorp M, Blaser MJ. Antibiotics in the pathogenesis of diabetes and inflammatory diseases of the gastrointestinal tract. Nat Rev Gastroenterol Hepatol 2023; 20:81-100. [PMID: 36258032 PMCID: PMC9898198 DOI: 10.1038/s41575-022-00685-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 02/06/2023]
Abstract
Antibiotic use is increasing worldwide. However, the use of antibiotics is clearly associated with changes in gut microbiome composition and function, and perturbations have been identified as potential environmental risk factors for chronic inflammatory disorders of the gastrointestinal tract. In this Review, we examine the association between the use of antibiotics and the onset and development of both type 1 and type 2 diabetes, inflammatory bowel disease, including ulcerative colitis and Crohn's disease, as well as coeliac disease and eosinophilic oesophagitis. We discuss the key findings of epidemiological studies, provide mechanistic insights into the pathways by which the gut microbiota might contribute to these diseases, and assess clinical trials investigating the effects of antibiotics. Such studies indicate that antibiotic exposures, varying in type, timing and dosage, could explain differences in disease risk. There seems to be a critical window in early life in which perturbation of the microbiome has a substantial effect on disease development. Identifying the antibiotic-perturbed gut microbiota as a factor that contributes to the pathophysiology of these inflammatory disorders might stimulate new approaches to prevention, diagnosis and treatment.
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Affiliation(s)
- Aline C. Fenneman
- Department of Clinical and Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Melissa Weidner
- Department of Paediatrics, Rutgers University, New Brunswick, NJ, USA
| | - Lea Ann Chen
- Department of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Max Nieuwdorp
- Department of Clinical and Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Martin J. Blaser
- Department of Medicine, Rutgers University, New Brunswick, NJ, USA.,Department of Pathology and Laboratory Medicine, Rutgers University, New Brunswick, NJ, USA
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Kusan S, Surat G, Kelm M, Anger F, Kim M, Germer CT, Schlegel N, Flemming S. Microbial Spectrum and Antibiotic Resistance in Patients Suffering from Penetrating Crohn's Disease. J Clin Med 2022; 11:jcm11154343. [PMID: 35893433 PMCID: PMC9330589 DOI: 10.3390/jcm11154343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 01/27/2023] Open
Abstract
Intraabdominal abscess formation occurs in up to 30% of patients suffering from Crohn´s disease (CD). While international guidelines recommend a step-up approach with a combination of empiric antibiotic therapy and percutaneous drainage to delay or even avoid surgery, evidence about microbial spectrum in penetrating ileitis is sparse. We retrospectively assessed outcomes of 46 patients with terminal penetrating Ileitis where microbial diagnostics have been performed and compared microbial spectrum and antibiotic resistance profile of CD patients with patients suffering from diverticulitis with intraabdominal abscess formation. In both groups, the most frequently isolated pathogen was the gram-negative bacterium E. coli belonging to the family of Enterobacterales. However, overall Enterobacterales were significantly more often verifiable in the control group than in CD patients. Furthermore, microbial analysis showed significant differences regarding isolation of anaerobic pathogens with decreased frequency in patients with CD. Subgroup analysis of CD patients to evaluate a potential influence of immunosuppressive therapy on microbial spectrum only revealed that Enterobacterales was less frequently detected in patients treated with steroids. Immunosuppressive therapy did not show any impact on all other groups of pathogens and did not change antibiotic resistance profile of CD patients. In conclusion, we were able to demonstrate that the microbial spectrum of CD patients does differ only for some pathogen species without increased rate of antibiotic resistance. However, the empiric antibiotic therapy for CD-associated intra-abdominal abscess remains challenging since different points such as local epidemiological and microbiological data, individual patient risk factors, severity of infection, and therapy algorithm including non-surgical and surgical therapy options should be considered before therapeutical decisions are made.
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Affiliation(s)
- Simon Kusan
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Güzin Surat
- Unit for Infection Control and Antimicrobial Stewardship, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany;
| | - Matthias Kelm
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Mia Kim
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
- Correspondence:
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8
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Chiarello MM, Pepe G, Fico V, Bianchi V, Tropeano G, Altieri G, Brisinda G. Therapeutic strategies in Crohn’s disease in an emergency surgical setting. World J Gastroenterol 2022; 28:1902-1921. [PMID: 35664965 PMCID: PMC9150057 DOI: 10.3748/wjg.v28.i18.1902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/28/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD) remains a chronic, incurable disorder that presents unique challenges to the surgeon. Multiple factors must be considered to allow development of an appropriate treatment plan. Medical therapy often precedes or complements the surgical management. The indications for operative management of CD include acute and chronic disease complications and failed medical therapy. Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype. Toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage represent indications for emergency surgery. These patients are generally in critical conditions and present with intra-abdominal sepsis and a preoperative status of immunosuppression and malnutrition that exposes them to a higher risk of complications and mortality. A multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care. Moreover, the recurrent nature of disease mandates that we continue searching for innovative medical therapies and operative techniques that reduce the need to repeat surgical operations. In this review, we aimed to discuss the acute complications of CD and their treatment.
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Affiliation(s)
- Maria Michela Chiarello
- Department of Surgery, San Giovanni in Fiore Hospital, Azienda Sanitaria Provinciale di Cosenza, Cosenza 87100, Italy
| | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Brisinda
- Department of Surgery, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Medical and Surgical Science, Università Cattolica del Sacro Cuore, Rome 00168, Italy
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9
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Liu J, Gong W, Liu P, Li Y, Zheng T, Hong Z, Ren H, Gu G, Wang G, Wu X, Zhao Y, Ren J. Trocar Puncture With a Sump Drain for Crohn's Disease With Intra-Abdominal Abscess: A 10-Year Retrospective Cohort Study. Front Surg 2022; 9:816245. [PMID: 35310442 PMCID: PMC8929425 DOI: 10.3389/fsurg.2022.816245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background Traditional percutaneous catheter drainage (PCD) and surgical intervention could not always achieve satisfactory results for patients with Crohn's disease (CD) who have complications with intra-abdominal abscess. We proposed a trocar puncture with sump drainage for the treatment of CD with intra-abdominal abscess and compared it with the conventional PCD and surgical intervention. Methods Crohn's disease patients with intra-abdominal abscess and admitted to our hospital from 2011 to 2020 were identified by reviewing the electronic medical records. We divided them into Trocar, PCD, and fecal diverting (FD) groups, according to the ways of treating an abscess. Outcomes, risk factors for abscess recurrence, and postoperative complications were compared among the three groups. Results A total of 69 patients were included and they were divided into Trocar (n = 18), PCD (n = 29), and FD (n = 22) groups. Four patients in the PCD group were transferred to receive the FD surgery due to the failure of initial treatment. The incidence of abscess recurrence was significantly higher in the PCD (48%) and FD (50%) groups compared to the patients using the trocar puncture with the sump drain (Trocar group) (16.7%). There were 8 patients in Trocar, 22 in PCD, and 20 s in the FD group who received enterectomy. None of the patients in the Trocar had an ultimate stoma and the incidence of postoperative complications was statistically lower [0% (Trocar) vs. 31.8% (PCD) vs. 45% (FD), P < 0.05]. The way of initial treating of the abscess was significantly correlated with the abscess recurrence and postoperative complications. Conclusions Trocar puncture with a sump drain had a lower incidence of abscess recurrence, abdominal adhesions, postdrainage, and postoperative complications compared to the conventional PCD or surgical intervention.
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Affiliation(s)
- Juanhan Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wenbin Gong
- School of Medicine, Southeast University, Nanjing, China
| | - Peizhao Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yangguang Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tao Zheng
- Department of General Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiwu Hong
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Huajian Ren
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Guosheng Gu
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Gefei Wang
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Xiuwen Wu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Yun Zhao
- Department of General Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Jianan Ren
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
- *Correspondence: Jianan Ren
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10
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Rakowsky S, Papamichael K, Cheifetz AS. Choosing the right biologic for complications of inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2022; 16:235-249. [PMID: 35094628 DOI: 10.1080/17474124.2022.2036122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic, inflammatory condition that involves the intestinal tract, and can also present with extra-intestinal manifestations (EIM). Choosing the right treatment for IBD is often nuanced and decisions can become even more complicated when a patient presents with or develops a complication of the disease. AREAS COVERED We aimed to provide an overview of the most common complications of IBD, specifically intestinal and EIM, and summarize the data regarding biologic therapy for treatment of these conditions. A comprehensive literature review was performed using PubMed and Medline databases to identify studies published in the English language relevant to the broad scope of this review. EXPERT OPINION There are still significant gaps in our understanding of the pathophysiology of IBD and its treatment, especially in regards to complications of the disease. As novel therapies continue to emerge for treatment of IBD, we feel concurrent examination of their impact on intestinal complications and EIM of IBD is important and should be a priority of future research.
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Affiliation(s)
- Shana Rakowsky
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Konstantinos Papamichael
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Adam S Cheifetz
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA USA
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11
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Peyser DK, Carmichael H, Dean A, Baratta VM, D’Andrea AP, Kang G, Bhasin D, Greenstein AJ, Khaitov SK, Steinhagen RM, Sylla P. Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary? Surg Endosc 2022; 36:4290-4298. [PMID: 34988744 PMCID: PMC8730747 DOI: 10.1007/s00464-021-08773-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.
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Affiliation(s)
- Daniel K. Peyser
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Heather Carmichael
- Department of General Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Adrienne Dean
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Vanessa M. Baratta
- Department of Surgery, Yale University School of Medicine, New Haven, USA
| | - Anthony P. D’Andrea
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Gurpawan Kang
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Deepika Bhasin
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Sergey K. Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029 USA
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12
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Abstract
Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.
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Affiliation(s)
- Dakota T Thompson
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
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13
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Waked B, Holvoet T, Geldof J, Baert F, Pattyn P, Lobatón T, Hindryckx P. Conservative management of spontaneous intra-abdominal abscess in Crohn's disease: Outcome and prognostic factors. J Dig Dis 2021; 22:263-270. [PMID: 33742782 DOI: 10.1111/1751-2980.12984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/07/2021] [Accepted: 03/15/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the outcomes of different treatments for spontaneous intra-abdominal abscesses (IAA) in active Crohn's disease (CD). METHODS A retrospective analysis of patients with CD between January 2007 and December 2018 was performed in two Belgian inflammatory bowel disease centers. Successful conservative management was defined as complete resolution of abscesses without the need for bowel resection. The primary outcome was suboptimal evolution, defined as a composite outcome of recurrence of abscess, postoperative complications or the need for a non-elective resection. RESULTS Forty CD patients presenting with 43 independent episodes of spontaneous IAA development were included. One underwent immediate bowel resection. In all other 42 cases a conservative approach was taken, which led to a complete abscess resolution rate of 28.6% (12/42). The remaining abscesses required bowel resection. Anti-tumor necrosis factor (TNF) agent use was associated with successful conservative management (odds ratio [OR] 13.36, 95% confidence interval [CI] 11.19-15.52, P = 0.006), while the opposite trend was found for corticosteroids (OR 0.14, 95% CI 0.02-1.26, P = 0.055). There was a trend towards suboptimal evolution in case of previous bowel resection (OR 4.77, 95% CI 0.77-29.66, P = 0.094) or in patients aged above 50 years (OR 5.17, 95% CI 0.86-30.91, P = 0.072). CONCLUSIONS Bowel resection appears to be inevitable in most CD patients presenting with IAA. An attempt at conservative treatment may be particularly successful with anti-TNF agents in younger patients who have not undergone previous bowel resection. Large-scale prospective studies are needed to confirm these findings.
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Affiliation(s)
- Bruno Waked
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - Tom Holvoet
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium.,Department of Gastroenterology, AZ Nikolaas General Hospital, Sint-Niklaas, Belgium
| | - Jeroen Geldof
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - Filip Baert
- Department of Gastroenterology, AZ Delta General Hospital, Roeselare, Belgium
| | - Piet Pattyn
- Department of Abdominal Surgery, University Hospital of Ghent, Ghent, Belgium
| | - Triana Lobatón
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - Pieter Hindryckx
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
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14
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Alharbi O, Almadi MA, Azzam N, Aljebreen AM, AlAmeel T, Schreiber S, Mosli MH. Clinical characteristics, natural history, and outcomes of Crohn's-related intra-abdominal collections. Saudi J Gastroenterol 2021; 27:79-84. [PMID: 33723092 PMCID: PMC8183360 DOI: 10.4103/sjg.sjg_89_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Intra-abdominal collections in the form of abscesses or matted bowel loops, called phlegmons, might occur in patients with Crohn's disease (CD). The clinical characteristics and management of such conditions are not well described. We aim to characterize CD-related intra-abdominal collections clinically, and identify predictors of need for surgical interventions and the time to surgery. METHODS We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify all patients treated for radiologically proven intra-abdominal abscesses or phlegmons since inception. Demographics, clinical data, clinical course, and treatment outcomes were recorded. Logistic regression analysis and survival analysis were used to identify predictors of surgical resection and differences in time to surgery between patient subgroups, respectively. RESULTS A total of 734 patients with a diagnosis of CD were screened and 75 patients were identified. The mean age was 25.6 ± 9.9 years and 51% were males. Nearly 60% of patients had abscesses larger than 3 cm while 13% had smaller abscesses and 36% had phlegmons. On presentation, the most commonly reported symptom was abdominal pain (99%) followed by weight loss (27%). About 89% of patients were treated with antibiotics during hospitalization for an average of 2.7 weeks. Steroids were prescribed for 52% of patients and tumor necrosis factor alpha (TNF-alpha) antagonists for 17%. Surgical resection was required for 33 patients (44% of the cohort) while 51% were managed with antibiotics and/or percutaneous drainage. The most common surgical intervention was ileocecal resection (45%). Although patients who underwent follow-up imaging were more likely to require early surgical intervention (P = 0.04), no statistically significant predictor of surgery could be identified from this cohort. Time to surgery varied numerically according to abscess size (HR = 1.18, 95% CI = 0.62-2.27, P = 0.61). CONCLUSIONS Although the majority of patients with CD-related intra-abdominal collections underwent surgical resection in this cohort, no obvious predictors of surgical intervention could be identified. The decision to perform early surgery appeared to be influenced by the findings observed on cross-sectional imaging during the follow-up of these collections.
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Affiliation(s)
- Othman Alharbi
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia,Address for correspondence: Dr. Othman Alharbi, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail:
| | - Majid A. Almadi
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Nahla Azzam
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman M. Aljebreen
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
| | - Stefan Schreiber
- Department of Internal Medicine, Institute of Clinical Molecular Biology, Christian-Albrechts-University, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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15
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Jeong SH, Choi JS, Kim JW, Kim HM, Kim HS, Im JP, Kim JS, Kim YS, Cheon JH, Kim WH, Ye BD, Kim YH, Han DS. Clinical Features of Intra-Abdominal Abscess and Intestinal Free-Wall Perforation in Korean Patients with Crohn's Disease: Results from the CONNECT Study. J Clin Med 2020; 10:jcm10010116. [PMID: 33396251 PMCID: PMC7794699 DOI: 10.3390/jcm10010116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/24/2020] [Accepted: 12/28/2020] [Indexed: 01/04/2023] Open
Abstract
Background: In Crohn's disease (CD), intra-abdominal abscess (IA) and intestinal free-wall perforation (IP) have a common mechanism of transmural inflammation; however, their manifestation is different. Objective: This study aimed to investigate differences in the clinical features between IA and IP in Korean patients with Crohn's disease. Design: A retrospective cohort study. Setting: Thirty university hospitals and two local hospitals in Korea. Patients: Patients who were diagnosed with CD between July 1982 and December 2008 were enrolled. Main Outcome Measures: Clinical characteristics of IA and IP. Results: Among 1286 patients with CD, 147 (11.4%) had IA and 83 (6.5%) had IP. IA patients were younger than those of IP (24.2 ± 8.6 vs. 30.4 ± 11.1 years, p = 0.001). Location and behavior were significantly different between IA and IP (p = 0.035 and 0.021). In multivariate analyses, perianal fistula was not associated with increased risk of IA and IP, while intestinal stricture was associated with increased risk of IA (OR: 2.72, p < 0.0001) and IP (OR: 2.76, p < 0.0001). In subgroup analyses, 55 (36.5%) IA patients were diagnosed at the diagnosis of CD, and 92 (63.5%) during follow-up of CD, while 47 (56.6%) IP patients were diagnosed at the diagnosis of CD, and 36 (43.3%) during follow-up of CD. Conclusions: There are several differences in the clinical features of IA and IP in Korean patients with CD. The development mechanism is considered as identical, but further investigation should be needed for clinical implication.
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Affiliation(s)
- Seok-Hoo Jeong
- Department of Internal Medicine, Catholic Kwandong University International St. Mary’s Hospital, Incheon 22711, Korea; (S.-H.J.); (J.S.C.)
| | - Ja Sung Choi
- Department of Internal Medicine, Catholic Kwandong University International St. Mary’s Hospital, Incheon 22711, Korea; (S.-H.J.); (J.S.C.)
| | - Jin Woo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26526, Korea; (J.W.K.); (H.-S.K.)
| | - Hee Man Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26526, Korea; (J.W.K.); (H.-S.K.)
- Correspondence:
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26526, Korea; (J.W.K.); (H.-S.K.)
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, Korea; (J.P.I.); (J.S.K.)
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, Korea; (J.P.I.); (J.S.K.)
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul 04551, Korea;
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (J.H.C.); (W.H.K.)
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (J.H.C.); (W.H.K.)
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea;
| | - Young-Ho Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 03181, Korea;
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University College of Medicine, Guri 11923, Korea;
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16
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Gecse KB, Buskens CJ. Implication of Medical Treatment for Surgical Strategies in IBD. Curr Drug Targets 2020; 20:1363-1368. [PMID: 31113342 DOI: 10.2174/1389450120666190515095520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 04/15/2019] [Accepted: 04/19/2019] [Indexed: 01/14/2023]
Abstract
Despite changing medical paradigm, still a significant proportion of patients with IBD require surgery. The patient's general condition, including nutritional status and the use of immunosuppressive medications is of great importance with regard to surgical complications, as well as the choice of optimal surgical strategy. The indication and the timing of surgery are key factors for the multidisciplinary management of IBD patients. The purpose of this review is to provide an overview on the impact of medical treatment on surgical strategies in IBD.
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Affiliation(s)
- Krisztina B Gecse
- Departement of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Christianne J Buskens
- Departement of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
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17
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Kaur M, Dalal RL, Shaffer S, Schwartz DA, Rubin DT. Inpatient Management of Inflammatory Bowel Disease-Related Complications. Clin Gastroenterol Hepatol 2020; 18:1346-1355. [PMID: 31927105 DOI: 10.1016/j.cgh.2019.12.040] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023]
Abstract
Despite advances in therapeutic options, a sizeable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. While current treatment guidelines for the management of ulcerative colitis and Crohn's disease cover the spectrum of disease severity and behavior, management of acute complications of inflammatory bowel disease can present unique challenges that are not always addressed in these guidelines. In this review, the authors provide a comprehensive summary of the existing literature focused on management of patients hospitalized with complications of inflammatory bowel disease. Proposed management algorithms are provided to guide clinicians through common scenarios to determine the most appropriate interventions - escalation of medical therapies, non-surgical therapeutic interventions (drainage of intra-abdominal abscess or endoscopic balloon dilation) or surgery. Prevention of complications is proposed through a multi-disciplinary approach that involves surgeons, dieticians, radiologists, pathologists and infectious disease consultants.
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Affiliation(s)
- Manreet Kaur
- Section of Gastroenterology, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas.
| | - Robin L Dalal
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Seth Shaffer
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
| | - David A Schwartz
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
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19
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Perl D, Waljee AK, Bishu S, Higgins PDR, Wasnik AP, Stidham RW. Imaging Features Associated With Failure of Nonoperative Management of Intraabdominal Abscesses in Crohn Disease. Inflamm Bowel Dis 2019; 25:1939-1944. [PMID: 31294779 PMCID: PMC6855277 DOI: 10.1093/ibd/izz069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intraabdominal abscess management decisions in the treatment of Crohn disease (CD) can be challenging. Our aim was to determine the effect of clinical, medication use, and imaging disease characteristics on the need for future surgical management. METHODS A retrospective chart review was performed in patients with CD hospitalized for abscess confirmed by imaging between 2008 and 2016. Selection criteria included nonoperative management with intravenous antibiotics at the index hospitalization and a minimum of 2 years of follow up. Demographic, disease, and medication history were extracted from electronic medical records. Radiographic disease features were assessed by an expert abdominal radiologist, blinded to clinical data. The primary outcome was resection of the bowel segment involving the abscess within 2 years of index hospitalization. Cox proportional hazards regression and statistical methods were performed using SAS 9.4. RESULTS Of the 121 patients meeting the selection criteria, 36.4% avoided surgery after 2 years of follow up. On adjusted multivariable analysis, disease-activity factors including bowel wall thickness (HR 3.08, 95% CL 1.20-6.21), disease length (HR 2.67, 95% CL 1.40-6.20), bowel dilation (HR 2.19, 95% CL 1.02-4.68), and abscess size of greater than 6 cm (HR 2.47, 95%CL 1.17-5.21) were independent risk factors for future surgery in patients not undergoing immediate bowel resection for abscess management. Biologic use and percutaneous drainage were not risk factors for ultimate surgical management. CONCLUSIONS Radiographic CD features and abscess size over 6 cm are predictors of ultimately requiring bowel resection. Radiographic measures may help stratify patients to immediate surgery or conservative management for intraabdominal CD-related abscesses.
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Affiliation(s)
- Daniel Perl
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akbar K Waljee
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA,Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA,University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA
| | - Shrinivas Bishu
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashish P Wasnik
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan W Stidham
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA,University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA,Address correspondence to Ryan W. Stidham, MD, MSc, University of Michigan School of Medicine, 1500 East Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI 48109 ()
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20
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Toh JWT, Hammam E, Cocco A, Albayati S, Ctercteko G. Management of intra-abdominal abscess in Crohn's disease. ANZ J Surg 2019; 89:E572-E573. [PMID: 30675978 DOI: 10.1111/ans.14977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- James W T Toh
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Elie Hammam
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Western Sydney University, Sydney, New South Wales, Australia
| | - Annelise Cocco
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sinan Albayati
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Grahame Ctercteko
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
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21
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Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort. Ann Surg 2019; 267:221-228. [PMID: 29300710 DOI: 10.1097/sla.0000000000002017] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). SUMMARY BACKGROUND DATA The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. METHODS From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. RESULTS Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54-4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009). CONCLUSIONS Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.
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22
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Reuken PA, Kruis W, Maaser C, Teich N, Büning J, Preiß JC, Schmelz R, Bruns T, Fichtner-Feigl S, Stallmach A. Microbial Spectrum of Intra-Abdominal Abscesses in Perforating Crohn's Disease: Results from a Prospective German Registry. J Crohns Colitis 2018; 12:695-701. [PMID: 29415186 DOI: 10.1093/ecco-jcc/jjy017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/02/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intra-abdominal abscesses [IAAs] are common life-threatening complications in patients with Crohn's disease [CD]. In addition to interventional drainage and surgical therapy, empirical antibiotic therapy represents a cornerstone of treatment, but contemporary data on microbial spectra and antimicrobial resistance are scarce. METHODS We recruited 105 patients with CD and IAAs from nine German centres for a prospective registry in order to characterize the microbiological spectrum, resistance profiles, antibiotic therapy and outcome. RESULTS In 92 of 105 patients, microbial investigations of abscess material revealed pathogenic microorganisms. A total of 174 pathogens were isolated, with a median of 2 pathogens per culture [range: 1-6]. Most frequently isolated pathogens were E. coli [45 patients], Streptococcus spp. [28 patients], Enterococci [27 patients], Candida [13 patients] and anaerobes [12 patients]. Resistance to third-generation cephalosporins, penicillins with beta-lactamase inhibitors and quinolones were observed in 51, 36 and 35 patients, respectively. Seven patients had multiple-drug-resistant bacteria. Thirty patients received inadequate empirical treatment, and this was more frequent in patients receiving steroids or immunosuppression [37%] than in patients without immunosuppression [10%: p = 0.001] and was associated with a longer hospital stay [21 days vs 13 days, p = 0.003]. CONCLUSION Based on antimicrobial resistance profiles, we herein report a high rate of inadequate empirical first-line therapy for IAAs in CD, especially in patients receiving immunosuppression, and this is associated with prolonged hospitalization.
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Affiliation(s)
- P A Reuken
- Department of Internal Medicine IV [Gastroenterology, Hepatology, and Infectious Diseases], Jena University Hospital, Jena, Germany
| | - W Kruis
- Klinik für Gastroenterologie, Pulmonologie und Allgemeine Innere Medizin, Evangelisches Krankenhaus Köln Kalk, University of Cologne, Cologne, Germany
| | - C Maaser
- Ambulanzzentrum Gastroenterologie, University Teaching Hospital Lüneburg, Lüneburg, Germany
| | - N Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten Leipzig und Schkeuditz, Leipzig, Germany.,Medical Faculty, Friedrich-Schiller University, Jena, Germany
| | - J Büning
- Department of Internal Medicine I [Gastroenterology], University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - J C Preiß
- Department of Medicine I [Gastroenterology, Infectious Diseases, Rheumatology], Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - R Schmelz
- Department of Internal Medicine 1, University Hospital Carl Gustav Carus, Dresden, Germany
| | - T Bruns
- Department of Internal Medicine IV [Gastroenterology, Hepatology, and Infectious Diseases], Jena University Hospital, Jena, Germany
| | - S Fichtner-Feigl
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - A Stallmach
- Department of Internal Medicine IV [Gastroenterology, Hepatology, and Infectious Diseases], Jena University Hospital, Jena, Germany
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23
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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24
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Alkhouri RH, Bahia G, Smith AC, Thomas R, Finck C, Sayej W. Outcome of medical management of intraabdominal abscesses in children with Crohn disease. J Pediatr Surg 2017; 52:1433-1437. [PMID: 28427855 DOI: 10.1016/j.jpedsurg.2017.03.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Crohn disease (CD) is a chronic inflammatory condition of the gastrointestinal tract that is complicated by fistulas, strictures, and intraabdominal abscesses (IAA) in 10%-30% of patients. To avoid surgical resection of the bowel, medical therapy with antibiotics (Ab) with or without percutaneous drainage (PD) is first undertaken. Our objectives are to examine the outcome of IAA in CD patients treated with antibiotics alone vs antibiotics and PD, and to identify risk factors for medical therapy failure. METHODS Charts for patient with CD who were diagnosed between 2004 and 2016 at the Women and Children's Hospital of Buffalo were retrospectively reviewed. We compared the two modalities of medical therapy (Ab + PD vs Ab alone) in terms of abscess resolution and the need for surgical intervention. RESULTS Twenty-nine patients, ages ranging from 12 to 18years, mean 15.5±2.5, 48% Male with IAA were identified. Overall, 69% of abscesses failed medical therapy including 87% of the drained abscesses and 50% of nondrained abscesses, p=0.04. The abscesses that failed medical therapy were more likely to have been drained (P=0.03) as they were larger in size (P = 0.03), patients were more likely to have a known CD on immunosuppression (P=0.016), and more likely to have an associated upper GI disease (P=0.002), when compared to those that were successful with medical therapy alone. CONCLUSION Our results show that the majority of our patients required surgical intervention for abscess treatment and resolution of associated findings despite drainage. Risk factors include big drainable abscesses, developing IAA while on immunosuppression, and a more extensive disease with associated fistulae and strictures. Small undrainable abscesses are likely to resolve with antibiotics alone, therefore early detection and treatment are essential. TYPE OF STUDY Level 2, retrospective study.
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Affiliation(s)
- Razan H Alkhouri
- Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, SUNY at Buffalo.
| | - Gracielle Bahia
- Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, SUNY at Buffalo
| | - Ashley C Smith
- Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, SUNY at Buffalo
| | - Richard Thomas
- Department of Radiology, Women and Children's Hospital of Buffalo, SUNY at Buffalo
| | - Christine Finck
- Digestive Diseases, Hepatology & Nutrition Center, Connecticut Children's Medical Center, University of Connecticut School of Medicine
| | - Wael Sayej
- Department of Pediatric Surgery, Connecticut Children's Medical Center, University of Connecticut School of Medicine
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25
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Safety and Efficacy of Exclusive Enteral Nutrition for Percutaneously Undrainable Abdominal Abscesses in Crohn's Disease. Gastroenterol Res Pract 2017; 2017:6360319. [PMID: 28947899 PMCID: PMC5602481 DOI: 10.1155/2017/6360319] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/27/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022] Open
Abstract
Background The percutaneously undrainable abdominal abscesses in Crohn's disease (CD) are not uncommon. The treatment protocol is still under debate. This study was conducted to assess the safety and efficacy of exclusive enteral nutrition (EEN) for percutaneously undrainable abscesses in CD. Methods A consecutive cohort of 83 CD patients with percutaneously undrainable abdominal abscesses between January 2011 and June 2015 was retrospectively analyzed. They were divided into the EEN group and the non-EEN group. Results The cumulative surgical rate was significantly lower in the EEN group than in the non-EEN group (P = 0.001). Fifteen percent patients treated with EEN avoided surgery. EEN (P = 0.002) was associated with a decreased need for surgery. Previous abdominal surgery (P = 0.009) and abscess diameter > 3 cm (P = 0.022) were associated with an increased need for operation. EEN increased the albumin level, while decreased ESR and CRP significantly for patients requiring surgery. The risk of postoperative intra-abdominal septic complications (P = 0.036) was significantly lower in the EEN group compared with the non-EEN group. Conclusions EEN is feasible in CD patients presenting with percutaneously undrainable abdominal abscesses. It is associated with a reduction in surgical rate, optimized preoperative condition, and improved postoperative outcomes in these specific groups of patients.
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26
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Graham E, Rao K, Cinti S. Medical Versus Interventional Treatment of Intra-Abdominal Abscess in Patients With Crohn Disease. Infect Dis (Lond) 2017; 10:1179916117701736. [PMID: 28469460 PMCID: PMC5398645 DOI: 10.1177/1179916117701736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/01/2017] [Indexed: 12/26/2022] Open
Abstract
Background: Few studies exist to guide the treatment approach to intra-abdominal abscesses in Crohn disease, which can include antimicrobials alone or in conjunction with percutaneous drainage or surgery. The primary aim of this study is to review outcomes from different treatment approaches to intra-abdominal abscess in Crohn disease. Methods: Medical records were reviewed for patients admitted to the University of Michigan health care system with Crohn disease and intra-abdominal abscess over a 4-year period. Outcomes were compared among medical and interventional approaches. The χ2 test was used to test for statistical significance. Results: Of the 33 patients included, 13 were in the medical group and 20 were in the interventional group. Abscess recurrence/nonresolution occurred in 31% of patients in the medical group and 25% of patients in the interventional group (P = .7). Conclusions: In this study, there was no significant difference in outcome between medical and interventional therapy for intra-abdominal abscess in Crohn disease.
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Affiliation(s)
- Emily Graham
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sandro Cinti
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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27
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Abstract
The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.
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28
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Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
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29
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Raza A, Safar B, Jamil R, Goldstein L, Tan S, Iqbal A. Concomitant Laparoscopic Ileocolectomy and Ladd's Procedure for Crohn's Ileocolitis with Mesenteric Abscess and Congenital Megacolon. Am Surg 2016. [DOI: 10.1177/000313481608200923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ahsan Raza
- Department of Surgery University of Florida Gainesville, Florida
| | - Bashar Safar
- Department of Surgery John Hopkins University Hospital Baltimore, Maryland
| | - Rida Jamil
- Department of Surgery University of Florida Gainesville, Florida
| | | | - Sanda Tan
- Department of Surgery University of Florida Gainesville, Florida
| | - Atif Iqbal
- Department of Surgery University of Florida Gainesville, Florida
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30
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Warnke-Sommer J, Ali H. Graph mining for next generation sequencing: leveraging the assembly graph for biological insights. BMC Genomics 2016; 17:340. [PMID: 27154001 PMCID: PMC4859950 DOI: 10.1186/s12864-016-2678-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 04/22/2016] [Indexed: 01/02/2023] Open
Abstract
Background The assembly of Next Generation Sequencing (NGS) reads remains a challenging task. This is especially true for the assembly of metagenomics data that originate from environmental samples potentially containing hundreds to thousands of unique species. The principle objective of current assembly tools is to assemble NGS reads into contiguous stretches of sequence called contigs while maximizing for both accuracy and contig length. The end goal of this process is to produce longer contigs with the major focus being on assembly only. Sequence read assembly is an aggregative process, during which read overlap relationship information is lost as reads are merged into longer sequences or contigs. The assembly graph is information rich and capable of capturing the genomic architecture of an input read data set. We have developed a novel hybrid graph in which nodes represent sequence regions at different levels of granularity. This model, utilized in the assembly and analysis pipeline Focus, presents a concise yet feature rich view of a given input data set, allowing for the extraction of biologically relevant graph structures for graph mining purposes. Results Focus was used to create hybrid graphs to model metagenomics data sets obtained from the gut microbiomes of five individuals with Crohn’s disease and eight healthy individuals. Repetitive and mobile genetic elements are found to be associated with hybrid graph structure. Using graph mining techniques, a comparative study of the Crohn’s disease and healthy data sets was conducted with focus on antibiotics resistance genes associated with transposase genes. Results demonstrated significant differences in the phylogenetic distribution of categories of antibiotics resistance genes in the healthy and diseased patients. Focus was also evaluated as a pure assembly tool and produced excellent results when compared against the Meta-velvet, Omega, and UD-IDBA assemblers. Conclusions Mining the hybrid graph can reveal biological phenomena captured by its structure. We demonstrate the advantages of considering assembly graphs as data-mining support in addition to their role as frameworks for assembly. Electronic supplementary material The online version of this article (doi:10.1186/s12864-016-2678-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julia Warnke-Sommer
- College of Information Science and Technology, University of Nebraska Omaha, Omaha, NE, 68182, USA.,Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Hesham Ali
- College of Information Science and Technology, University of Nebraska Omaha, Omaha, NE, 68182, USA. .,Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA.
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31
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Current challenges in the surgical management of Crohn's disease: a systematic review. Am J Surg 2016; 212:345-51. [PMID: 27182048 DOI: 10.1016/j.amjsurg.2015.12.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/19/2015] [Accepted: 12/02/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Crohn's disease is a chronic inflammatory disorder, and the broad variability in phenotypic presentations makes the treatment of this disease a true multidisciplinary approach. We sought to review the current recommendations regarding the surgical management of Crohn's disease. DATA SOURCE A Systematic literature review of surgical techniques was performed from 1979 through 2015. We evaluated 30 articles focusing on findings over the past 5 years. CONCLUSIONS Crohn's is a complex disease with no surgical cure. Invasive techniques vary from strictureplasty to resection and percutaneous drainage of penetrating disease when indicated. There is a paucity of well-controlled randomized studies evaluating these surgical techniques, and therefore, we continue to rely on smaller studies and historical data. The surgical goals are to minimize postoperative complications while preserving intestinal length and slowing the progression to clinical recurrence. The evidence discussed is one strategy against this complex pathology.
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32
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Clancy C, Boland T, Deasy J, McNamara D, Burke JP. A Meta-analysis of Percutaneous Drainage Versus Surgery as the Initial Treatment of Crohn's Disease-related Intra-abdominal Abscess. J Crohns Colitis 2016; 10:202-8. [PMID: 26512133 DOI: 10.1093/ecco-jcc/jjv198] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/15/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Spontaneous intra-abdominal abscess formation is a common complication of Crohn's disease. Percutaneous drainage [PD] may avoid surgery and preserve bowel length, although there is no consensus on its efficacy as the initial treatment and the associated outcomes if unsuccessful. This study uses meta-analytical techniques to compare the outcomes of PD alone versus primary surgery for Crohn's-related intra-abdominal abscess. METHODS A comprehensive search for comparative studies examining the use of PD and surgery for spontaneous Crohn's-related intra-abdominal abscess was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data. RESULTS There were six studies including a total of 333 patients that met the inclusion criteria. Surgery was performed initially in 184 patients, PD was performed in 149. Groups were similar in demographics and abscess characteristics. There was a significantly higher risk of abscess recurrence following PD (odds ratio [OR]: 6.544, 95% confidence interval [CI]: 1.783-24.010, p: 0.005]. The pooled proportion of PD patients requiring subsequent surgery was 70.7%. There was no significant difference between approaches in post-procedural complication rate [OR: 0.657, 95% CI: 0.175-2.476, p: 0.535], ultimate permanent stoma requirement [OR: 0.557, 95% CI: 0.147-2.111, p: 0.389] or length of hospital stay [difference in means: -1.006 days, 95% CI: -28.762-26.749, p: 0.943]. CONCLUSIONS PD can avoid surgery in up to 30% of patients presenting with spontaneous Crohn's-related intra-abdominal abscesses. However, the suggested advantages over surgery in relation to complications and length of stay were not apparent. Further studies in this area are needed.
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Affiliation(s)
- Cillian Clancy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Therese Boland
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Joseph Deasy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Deborah McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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33
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Li G, Ren J, Wu Q, Hu D, Wang G, Wu X, Liu S, Wu Y, Gu G, Li J. Bacteriology of Spontaneous Intra-Abdominal Abscess in Patients with Crohn Disease in China: Risk of Extended-Spectrum Beta-Lactamase-Producing Bacteria. Surg Infect (Larchmt) 2015; 16:461-5. [PMID: 26070032 DOI: 10.1089/sur.2013.181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Guanwei Li
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Qin Wu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Dong Hu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Xiuwen Wu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Song Liu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Yin Wu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Guosheng Gu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, P.R. China
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Hansen JJ, Sartor RB. Therapeutic Manipulation of the Microbiome in IBD: Current Results and Future Approaches. ACTA ACUST UNITED AC 2015; 13:105-20. [PMID: 25595930 DOI: 10.1007/s11938-014-0042-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT Despite recent major strides in our understanding of the genetic and microbial influences that contribute to the development of the inflammatory bowel diseases (IBDs), their etiology continues to be enigmatic. Results from experiments in animal models of IBDs overwhelmingly support a causal role of the microbiota in these diseases, though whether such a cause-effect relationship exists in human IBDs is still uncertain. Therefore, virtually all currently approved and most often prescribed treatments for IBDs are directed toward the over-active immune response in these diseases rather than the intestinal bacteria. Nevertheless, there is an important need for non-immunosuppressive therapies that may present a more favorable risk-benefit profile such as those that selectively target the disruptions in gut microbiota that accompany IBDs. This need has led to clinical trials of various microbial-directed therapies including fecal microbial transplant, antibiotics, probiotics, and prebiotics. Unfortunately, these published studies, many of which are small, have generally failed to demonstrate a consistent benefit of these agents in IBDs, thus leading to slow acceptance of microbe-focused treatments for these conditions. In this article, we review and summarize the microbial basis for IBDs and the results of the most recent trials of fecal microbial transplant, antibiotics, probiotics, and prebiotics in IBDs. We also comment on possible safety concerns with these agents, speculate on why they have failed to show efficacy in certain clinical settings, and propose strategies to improve their usefulness.
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Affiliation(s)
- Jonathan J Hansen
- Department of Medicine, University of North Carolina at Chapel Hill, CB 7032, Chapel Hill, NC, 27599, USA,
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Ramakrishna BS, Makharia GK, Ahuja V, Ghoshal UC, Jayanthi V, Perakath B, Abraham P, Bhasin DK, Bhatia SJ, Choudhuri G, Dadhich S, Desai D, Goswami BD, Issar SK, Jain AK, Kochhar R, Loganathan G, Misra SP, Ganesh Pai C, Pal S, Philip M, Pulimood A, Puri AS, Ray G, Singh SP, Sood A, Subramanian V. Indian Society of Gastroenterology consensus statements on Crohn's disease in India. Indian J Gastroenterol 2015; 34:3-22. [PMID: 25772856 DOI: 10.1007/s12664-015-0539-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 01/29/2015] [Indexed: 02/07/2023]
Abstract
In 2012, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on Crohn's disease (CD). This consensus, produced through a modified Delphi process, reflects our current recommendations for the diagnosis and management of CD in India. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.
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de Groof EJ, Carbonnel F, Buskens CJ, Bemelman WA. Abdominal abscess in Crohn's disease: multidisciplinary management. Dig Dis 2014; 32 Suppl 1:103-9. [PMID: 25531361 DOI: 10.1159/000367859] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Crohn's disease (CD) is characterized by full-thickness inflammation of the bowel. For this reason, perforating complications such as intra-abdominal abscesses or fistulas are common. A concomitant intra-abdominal abscess with active CD of the small bowel is a challenging dilemma for gastroenterologists and surgeons. Since there is active and severe disease, this should be treated with immunosuppressive drugs. However, in the presence of an intra-abdominal abscess, immunosuppression can be dangerous. There are several treatment options for intra-abdominal abscesses in CD. Nowadays, the first-line treatment is antibiotic therapy with or without percutaneous drainage. Historically, patients were treated with surgical drainage. With the development of percutaneous drainage, treatment shifted to a more nonsurgical approach. Success rates for percutaneous drainage in the literature vary from 74 to 100%, and it is considered to be a relatively safe procedure. It has been reported that surgery can be avoided after successful percutaneous drainage in a variable number of patients (14-85%). If sepsis is controlled, CD medication should be started to prevent recurrence. It is important to monitor the effect upon CD lesions to avoid further perforating complications. Finally, an undrainable or small abscess can be treated with antibiotics alone, although high recurrence rates have been described with this approach. Patients with a concomitant stenosis, an enterocutaneous fistula or refractory active disease are likely to require surgery. Percutaneous drainage in combination with delayed surgery is useful to improve the patient's condition prior to surgery and is associated with less morbidity, a lower stoma rate and more limited resection. In conclusion, when feasible, percutaneous drainage and antibiotics should be the treatment of choice in patients with an intra-abdominal abscess in CD. If surgery is inevitable, this must be delayed to reduce postoperative septic complications and high stoma rates.
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Affiliation(s)
- E Joline de Groof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Lobatón T, Guardiola J, Rodriguez-Moranta F, Millán-Scheiding M, Peñalva M, De Oca J, Biondo S. Comparison of the long-term outcome of two therapeutic strategies for the management of abdominal abscess complicating Crohn's disease: percutaneous drainage or immediate surgical treatment. Colorectal Dis 2014; 15:1267-72. [PMID: 24102970 DOI: 10.1111/codi.12419] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 03/21/2013] [Indexed: 02/08/2023]
Abstract
AIM The management of abdominal abscesses complicating Crohn's disease is complex and involves a difficult choice between medical, radiological and surgical procedures. The long-term outcome was compared for two strategies for the management of abdominal abscess: percutaneous drainage (PD) followed by rescue surgery in the case of failure vs direct immediate surgery (IS). We also compared the results of IS with surgery performed after PD failure. METHODS We retrospectively identified 44 patients with Crohn's disease with an abdominal abscess from January 2000 to December 2009. Therapeutic success was defined as abscess resolution and no reappearance within 1 year of follow-up. RESULTS The first therapeutic approach was PD in 22 cases and IS in the other 22 cases. IS had a higher therapeutic success rate than PD (95.5% vs 27.2% respectively; P < 0.001). PD was the only independent variable related to treatment failure in the multivariate analysis after adjustment for possible confounders such as abscess size, multilocularity, presence of fistula and corticosteroid use (OR 88.26, 95% CI 7.38-1055.36; P < 0.001). Surgery after failure of PD (n = 16) was associated with longer total hospitalization (56.12 ± 35.89 vs 27.52 ± 15.11 days; P = 0.017) and longer postoperative stay (44.0 ± 83.7 vs 14.3 ± 30 days; P = 0.179) and needed a second operation more often (5/16, 31% vs 1/22, 4.5%; P = 0.065) than IS. CONCLUSIONS Percutaneous drainage provided durable abscess resolution in only one-third of the patients compared with more than 90% of those treated with IS. In addition, surgery performed after PD failure results in a poorer outcome than IS.
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Affiliation(s)
- T Lobatón
- Department of Gastroenterology, Bellvitge University Hospital - IDIBELL, Barcelona, Spain
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Ruemmele FM, Veres G, Kolho KL, Griffiths A, Levine A, Escher JC, Amil Dias J, Barabino A, Braegger CP, Bronsky J, Buderus S, Martín-de-Carpi J, De Ridder L, Fagerberg UL, Hugot JP, Kierkus J, Kolacek S, Koletzko S, Lionetti P, Miele E, Navas López VM, Paerregaard A, Russell RK, Serban DE, Shaoul R, Van Rheenen P, Veereman G, Weiss B, Wilson D, Dignass A, Eliakim A, Winter H, Turner D. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014; 8:1179-207. [PMID: 24909831 DOI: 10.1016/j.crohns.2014.04.005] [Citation(s) in RCA: 741] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 02/07/2023]
Abstract
Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.
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Affiliation(s)
- F M Ruemmele
- Department of Paediatric Gastroenterology, APHP Hôpital Necker Enfants Malades, 149 Rue de Sèvres 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 2 Rue de l'École de Médecine, 75006 Paris, France; INSERM U989, Institut IMAGINE, 24 Bd Montparnasse, 75015 Paris, France.
| | - G Veres
- Department of Paediatrics I, Semmelweis University, Bókay János str. 53, 1083 Budapest, Hungary
| | - K L Kolho
- Department of Gastroenterology, Helsinki University Hospital for Children and Adolescents, Stenbäckinkatu 11, P.O. Box 281, 00290 Helsinki, Finland
| | - A Griffiths
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8 Toronto, ON, Canada
| | - A Levine
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, 62 HaLohamim Street, 58100 Holon, Israel
| | - J C Escher
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - J Amil Dias
- Unit of Paediatric Gastroenterology, Hospital S. João, A Hernani Monteiro, 4202-451, Porto, Portugal
| | - A Barabino
- Gastroenterology and Endoscopy Unit, Istituto G. Gaslini, Via G. Gaslini 5, 16148 Genoa, Italy
| | - C P Braegger
- Division of Gastroenterology and Nutrition, and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - J Bronsky
- Department of Pediatrics, University Hospital Motol, Uvalu 84, 150 06 Prague, Czech Republic
| | - S Buderus
- Department of Paediatrics, St. Marien Hospital, Robert-Koch-Str.1, 53115 Bonn, Germany
| | - J Martín-de-Carpi
- Department of Paediatric Gastroenterolgoy, Hepatology and Nutrition, Hospital Sant Joan de Déu, Paseo Sant Joan de Déu 2, 08950 Barcelona, Spain
| | - L De Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - U L Fagerberg
- Department of Pediatrics, Centre for Clinical Research, Entrance 29, Västmanland Hospital, 72189 Västerås/Karolinska Institutet, Stockholm, Sweden
| | - J P Hugot
- Department of Gastroenterology and Nutrition, Hopital Robert Debré, 48 Bd Sérurier, APHP, 75019 Paris, France; Université Paris-Diderot Sorbonne Paris-Cité, 75018 Paris France
| | - J Kierkus
- Department of Gastroenterology, Hepatology and Feeding Disorders, Instytut Pomnik Centrum Zdrowia Dziecka, Ul. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - S Kolacek
- Department of Paediatric Gastroenterology, Children's Hospital, University of Zagreb Medical School, Klaićeva 16, 10000 Zagreb, Croatia
| | - S Koletzko
- Department of Paediatric Gastroenterology, Dr. von Hauner Children's Hospital, Lindwurmstr. 4, 80337 Munich, Germany
| | - P Lionetti
- Department of Gastroenterology and Nutrition, Meyer Children's Hospital, Viale Gaetano Pieraccini 24, 50139 Florence, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Via S. Pansini, 5, 80131 Naples, Italy
| | - V M Navas López
- Paediatric Gastroenterology and Nutrition Unit, Hospital Materno Infantil, Avda. Arroyo de los Ángeles s/n, 29009 Málaga, Spain
| | - A Paerregaard
- Department of Paediatrics 460, Hvidovre University Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - R K Russell
- Department of Paediatric Gastroenterology, Yorkhill Hospital, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - D E Serban
- 2nd Department of Paediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Children's Hospital, Crisan nr. 5, 400177 Cluj-Napoca, Romania
| | - R Shaoul
- Department of Pediatric Gastroenterology and Nutrition, Rambam Health Care Campus Rappaport Faculty Of Medicine, 6 Ha'alya Street, P.O. Box 9602, 31096 Haifa, Israel
| | - P Van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, Netherlands
| | - G Veereman
- Department of Paediatric Gastroenterology and Nutrition, Children's University Hospital, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - B Weiss
- Paediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52625 Tel Hashomer, Israel
| | - D Wilson
- Child Life and Health, Paediatric Gastroenterology, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, United Kingdom
| | - A Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Wilhelm-Epstein-Str. 4, 60431 Frankfurt/Main, Gemany
| | - A Eliakim
- 33-Gastroenterology, Sheba Medical Center, 52621 Tel Hashomer, Israel
| | - H Winter
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mass General Hospital for Children, 175 Cambridge Street, 02114 Boston, United States
| | - D Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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Ripollés T, Martínez-Pérez MJ, Paredes JM, Vizuete J, García-Martínez E, Jiménez-Restrepo DH. Contrast-enhanced ultrasound in the differentiation between phlegmon and abscess in Crohn's disease and other abdominal conditions. Eur J Radiol 2013; 82:e525-31. [PMID: 23838329 DOI: 10.1016/j.ejrad.2013.05.043] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/22/2013] [Accepted: 05/25/2013] [Indexed: 12/16/2022]
Abstract
AIM To evaluate the diagnostic accuracy of the contrast-enhanced ultrasound (CEUS) to differentiate between intra-abdominal phlegmon and abscess. METHODS We retrospectively reviewed all contrast-enhanced ultrasound performed between June 2006 and May 2012 to identify patients with the terms "inflammatory mass", "phlegmon" or "abscess" on the sonographic report. The initial CEUS report was used for the diagnosis of phlegmon or abscess. RESULTS 71 inflammatory masses in 50 patients were identified in CEUS examination. 57 masses, 21 phlegmons and 36 abscesses, were confirmed by other imaging techniques, percutaneous drainage or surgery. CEUS specificity for the diagnosis of abscess was 100%. Kappa coefficient between CEUS and other techniques in the diagnosis of phlegmon or abscess was excellent (kappa=0.972). Only in one patient surgery detected a small abscess (<2 cm) within a phlegmon that not was detected by CEUS. Statistically significant differences were found between the size of the abscesses before and after contrast agent injection. The interobserver agreement in the diagnosis of phlegmon or abscess was excellent (kappa=0.953). CONCLUSIONS CEUS is an accurate method for differentiating between intra-abdominal phlegmon and abscess in gastrointestinal conditions, especially in CD. Its use may help to better define the size of the collections and avoid other techniques that use ionizing radiation. CEUS should be used to confirm an inflammatory mass identified at US.
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Affiliation(s)
- Tomás Ripollés
- Hospital Universitario Dr. Peset, Department of Radiology, 90 Gaspar Aguilar Avenue, 46017 Valencia, Spain.
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