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Nardone OM, Calabrese G, Barberio B, Giglio MC, Castiglione F, Luglio G, Savarino E, Ghosh S, Iacucci M. Rates of Endoscopic Recurrence In Postoperative Crohn's Disease Based on Anastomotic Techniques: A Systematic Review And Meta-Analysis. Inflamm Bowel Dis 2024; 30:1877-1887. [PMID: 37931290 DOI: 10.1093/ibd/izad252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Patients with Crohn's disease (CD) after ileocolic resection may develop an endoscopic postoperative recurrence (ePOR) that reaches 40% to 70% of incidence within 6 months. Recently, there has been growing interest in the potential effect of anastomotic configurations on ePOR. Kono-S anastomosis has been proposed for reducing the risk of clinical and ePOR. Most studies have assessed the association of ileocolonic anastomosis and ePOR individually, while there is currently limited data simultaneously comparing several types of anastomosis. Therefore, we performed a systematic review and meta-analysis to assess the impact of different ileocolonic anastomosis on ePOR in CD. METHODS We searched PubMed and Embase from inception to January 2023 for eligible studies reporting the types of anastomoses and, based on these, the rate of endoscopic recurrence at ≥6 months. Studies were grouped by conventional anastomosis, including side-to-side, end-to-end, and end-to-side vs Kono-S, and comparisons were made between these groups. Pooled incidence rates of ePOR were computed using random-effect modelling. RESULTS Seventeen studies, with 2087 patients who underwent ileocolic resection for CD were included. Among these patients, 369 (17,7%) Kono-S anastomoses were performed, while 1690 (81,0%) were conventional ileocolic anastomosis. Endoscopic postoperative recurrence at ≥6 months showed a pooled incidence of 37.2% (95% CI, 27.7-47.2) with significant heterogeneity among the studies (P < .0001). In detail, patients receiving a Kono-S anastomosis had a pooled incidence of ePOR of 24.7% (95% CI, 6.8%-49.4%), while patients receiving a conventional anastomosis had an ePOR of 42.6% (95% CI, 32.2%-53.4%). CONCLUSIONS Kono-S ileocolic anastomosis was more likely to decrease the risk of ePOR at ≥6 months compared with conventional anastomosis. Our findings highlight the need to implement the use of Kono-S anastomosis, particularly for difficult to treat patients. However, results from larger randomized controlled trials are needed to confirm these data.
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Affiliation(s)
- Olga Maria Nardone
- Gastroenterology, Department of Public Health, School of Medicine, Federico II University of Naples, Naples, Italy
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Giulio Calabrese
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Mariano Cesare Giglio
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Fabiana Castiglione
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Gaetano Luglio
- Department of Public Health, Endoscopic Surgery Unit, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, College Road, National University of Ireland, T12 K8AF Cork, Ireland
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, College Road, National University of Ireland, T12 K8AF Cork, Ireland
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2
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Grellier N, Kirchgesner J, Uzzan M, McLellan P, Stefanescu C, Lefevre JH, Treton X, Panis Y, Sokol H, Beaugerie L, Seksik P. Early ileal resection in Crohn's disease is not associated with severe long-term outcomes: The ERIC study. Aliment Pharmacol Ther 2024. [PMID: 39234950 DOI: 10.1111/apt.18247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/13/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Early complicated Crohn's disease (CD) may require ileal resection as first-line treatment. AIM To evaluate the long-term outcomes of patients who underwent early ileal resection. METHODS We conducted a retrospective study in two inflammatory bowel diseases (IBD) referral centres, including patients with ileocaecal resection and segmental ileal resection within 5 years of CD diagnosis. Early resection was defined as within 6 months of diagnosis, intermediate resection between 6 months and 2 years, and late resection between 2 and 5 years. The primary outcome was the cumulative risk of a second ileal surgery. Secondary outcomes included the use of postoperative treatments and morphological recurrence after initial surgery (Rutgeerts score ≥i2, or recurrence on imaging). RESULTS Among 393 patients who underwent ileal resection within 5 years of diagnosis, 130, 128 and 135, respectively, had early, intermediate and late resection. The cumulative risk of second surgery at 10 years was not significantly different in the early resection group (25.0% [95% CI 17.4-35.2]), than the intermediate (16.8% [95% CI 10.5-26.2]; p = 0.17) or late resection group (22.7% [95% CI 15.1-33.3]; p = 0.83). The early resection group required fewer postoperative treatments than the late resection group with median survivals without treatments of 3.7 and 0.9 years, respectively (p = 0.002). Patients who had early resection had significantly less morphological recurrence than the late resection group (p = 0.02). CONCLUSION Early ileal resection in CD is not associated with a higher risk of a second resection. It may be associated with reduced use of medical treatments and fewer morphological recurrences.
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Affiliation(s)
- N Grellier
- Department of Gastroenterology, Poitiers University Hospital, Poitiers, France
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - J Kirchgesner
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - M Uzzan
- Department of Gastroenterology, Mondor Hospital, Paris, France
| | - P McLellan
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - C Stefanescu
- Department of Gastroenterology and Nutrition Beaujon Hospital, Clichy, France
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - J H Lefevre
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
| | - X Treton
- Department of Gastroenterology and Nutrition Beaujon Hospital, Clichy, France
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - Y Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - H Sokol
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - L Beaugerie
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - P Seksik
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
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Hammoudi N, Sachar D, D'Haens G, Reinisch W, Kotze PG, Vermeire S, Schölmerich J, Kamm MA, Griffiths A, Panes J, Ghosh S, Siegel CA, Bemelman W, O'Morain C, Steinwurz F, Fleshner P, Mantzaris GJ, Sands B, Abreu MT, Dotan I, Turner D, Dignass A, Allez M. Outcomes and Endpoints of Postoperative Recurrence in Crohn's Disease: Systematic Review and Consensus Conference. J Crohns Colitis 2024; 18:943-957. [PMID: 38112601 DOI: 10.1093/ecco-jcc/jjad205] [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: 09/18/2023] [Revised: 10/24/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Outcomes after ileocolonic resection in Crohn's disease [CD] are heterogeneous, and a clear definition of postoperative recurrence remains to be determined. Our Endpoints Working Group of the International Organization for the study of Inflammatory Bowel Disease [IOIBD] aimed to standardise postoperative outcomes, to discuss which endpoints should be used for postoperative clinical trials, and to define those which could be used in trials or registries. METHODS Based on a systematic review of the literature, recommendations and statements were drafted and sent to all IOIBD members for a first round of voting. Recommendations and statements were revised based on the voters' comments during a consensus hybrid conference open to all IOIBD members. If no agreement was reached after two rounds of voting, the statement was excluded. RESULTS In the systematic review, 3071 manuscripts were screened of which 434 were included. Sixteen recommendations were identified, of which 11 were endorsed. Recommendations and statements include that endoscopy remains the gold standard and should be used as a short-term primary endpoint in both observational cohorts and randomised controlled trials. Clinical symptoms classically used in clinical trials for luminal CD are not reliable in this specific situation. For that reason, longer-term endpoints should be based on the evidence of macroscopic inflammation assessed by imaging techniques, endoscopy, or as reflected by the presence of complications. CONCLUSIONS Agencies recommend the use of clinical evaluations, as in the case of luminal CD, and do not recognise primary endpoints based solely on endoscopy. This consensus has led to agreement on the need to define postoperative endoscopy-based and/or imaging-based endpoints.
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Affiliation(s)
- Nassim Hammoudi
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - David Sachar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Geert D'Haens
- Department of Gastroenterology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Walter Reinisch
- Department Internal Medicine III, Division Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Severine Vermeire
- Department of Gastroenterology & Hepatology, University Hospital Leuven, Leuven, Belgium
| | | | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anne Griffiths
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Julian Panes
- Formerly Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Corey A Siegel
- IBD Center, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, USA
| | - Willem Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Colm O'Morain
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Flavio Steinwurz
- Department of Gastroenterology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Bruce Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria T Abreu
- Department of Medicine, Division of Gastroenterology, Crohn's and Colitis Center, Leonard M. Miller School of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medica Center, Petah-Tikva, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt Am Main, Germany
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
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Rimola J, Colombel JF, Bressler B, Adsul S, Siegelman J, Cole PE, Lindner D, Danese S. Magnetic Resonance Enterography Assessment of Transmural Healing with Vedolizumab in Moderate to Severe Crohn's Disease: Feasibility in the VERSIFY Phase 3 Clinical Trial. Clin Exp Gastroenterol 2024; 17:9-23. [PMID: 38298861 PMCID: PMC10829592 DOI: 10.2147/ceg.s429039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/14/2024] [Indexed: 02/02/2024] Open
Abstract
Purpose The VERSIFY phase 3 trial in patients with Crohn's disease (CD) treated with vedolizumab was the first to include a substudy that used a standardized magnetic resonance enterography (MRE) protocol to assess features of transmural inflammation (bowel edema and wall thickness) and extramural disease activity (enlarged lymph nodes). Patients and Methods Patients received intravenous vedolizumab (300 mg) at weeks 0 (baseline), 2, and 6, and then every 8 weeks for 26 or 52 weeks. Post hoc analyses included a subpopulation with a Magnetic Resonance Index of Activity score of ≥7 in at least one bowel segment at baseline and at least one postbaseline MRE assessment. Changes in transmural inflammation, including intramural bowel edema and wall thickness, were evaluated. Patient-level and segment-level analyses were performed. Results MRE images were evaluated in 27 patients with 83 evaluable bowel segments at baseline and week 26, and 13 patients with 38 evaluable segments at baseline, week 26, and week 52. At baseline, all patients had bowel wall edema and wall thickness of >3 mm in at least one bowel segment. The proportion of patients with edema decreased at weeks 26 (17/27 [63.0%]) and 52 (4/13 [30.8%]) and the proportion with bowel wall thickness of >3 mm decreased at weeks 26 (25/27 [92.6%]) and 52 (10/13 [76.9%]). Conclusion In patients with CD treated with vedolizumab for 26 and 52 weeks, the number of patients, and bowel segments, with MRE-detected transmural inflammation was reduced. These results highlight the impact of vedolizumab on components of transmural inflammation in CD and demonstrate that using MRE in CD multicenter clinical trials is feasible. Trial Registration ClinicalTrials.gov NCT02425111, April 23, 2015, http://www.clinicaltrials.gov NCT02425111; EU Clinical Trials Register EudraCT 2014-003509-13, https://www.clinicaltrialsregister.eu.
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Affiliation(s)
- Jordi Rimola
- IBD Unit, Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jean-Frédéric Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Bressler
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Shashi Adsul
- Takeda Pharmaceuticals International, Zurich, Switzerland
| | | | | | - Dirk Lindner
- Takeda Pharmaceuticals International, Zurich, Switzerland
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
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5
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Dragoni G, Allocca M, Myrelid P, Noor NM, Hammoudi N, Rivière P, Panis Y, Ferrante M. Results of the Eighth Scientific Workshop of ECCO: Diagnosing Postoperative Recurrence of Crohn's Disease After an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis 2023; 17:1373-1386. [PMID: 37070339 DOI: 10.1093/ecco-jcc/jjad055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Despite the introduction of potent biologic therapies, many patients with Crohn's disease [CD] still require an ileocolonic resection [ICR] during the course of their disease. Furthermore, the need of redo ICR has not decreased over the past few decades, highlighting the need for better strategies to prevent and treat postoperative recurrence [POR]. The first step to develop such a strategy would be to define and standardise the description of POR with adequate diagnostic instruments. In this article, we will describe the different methodologies used to report POR [endoscopic, histological, radiological, biochemical, clinical, and surgical], and review their potential benefits and limitations, as well as the optimal timing of evaluation.
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Affiliation(s)
- Gabriele Dragoni
- IBD Referral Center, Department of Gastroenterology, Careggi University Hospital, Florence, Italy
- Gastroenterology Research Unit, Department of Experimental and Clinical Biochemical Sciences 'Mario Serio', University of Florence, Florence, Italy
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin M Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nassim Hammoudi
- Gastroenterology Department, Hôpital Saint-Louis - APHP, Université Paris Cité, INSERM U1160, Paris, France
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases and Metabolism [CHROMETA], KU Leuven, Leuven, Belgium
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Replacing Endoscopy with Magnetic Resonance Enterography for Mucosal Activity Assessment in Terminal Ileal Crohn’s Disease: Are We There Yet? Diagnostics (Basel) 2023; 13:diagnostics13061061. [PMID: 36980368 PMCID: PMC10046927 DOI: 10.3390/diagnostics13061061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Crohn’s disease (CD) is a chronic immune mediated disorder that most commonly affects the small bowel and/or the large bowel. Treatment targets in CD include mucosal healing assessed via ileocolonoscopy and transmural healing assessed through cross-sectional imaging modalities such as magnetic resonance enterography (MRE). More recently, histological healing in CD has emerged as a treatment target, though it is made cumbersome given its reliance on frequent endoscopic examinations. With expert guidelines now recommending regular objective assessments as part of a treat-to-target approach, accurate non-invasive assessment will become increasingly critical. MRE has an established role in the assessment of small bowel CD, with growing data supportive of its ability in detecting disease activity at mucosal and histological levels. This could therefore potentially reduce the need for serial endoscopic assessment. Thus, this review will assess the capacity of individual MRE parameters and MRE indices for detecting mucosal and histological small bowel CD activity. Furthermore, challenging scenarios, such as CD activity detection in post-operative clinical scenarios and abnormal findings in the context of a normal ileocolonoscopy, will be explored.
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Le Cosquer G, Altwegg R, Rivière P, Bournet B, Boivineau L, Poullenot F, Bozon A, Buscail L, Laharie D, Gilletta C. Prevention of post-operative recurrence of Crohn's disease among patients with prior anti-TNFα failure: A retrospective multicenter study. Dig Liver Dis 2022; 55:727-734. [PMID: 36192340 DOI: 10.1016/j.dld.2022.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/24/2022] [Accepted: 09/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-TNFα are recommended for preventing Crohn's disease (CD) postoperative recurrence (POR) in patients with risk factors. However, few data exploring anti-TNFα efficacy in patients with preoperative anti-TNFα failure are available so far. AIMS The aim of the present study was to compare the efficacy of anti-TNFα with other biologics and immunosuppressants to prevent POR in this setting. METHODS Consecutive CD patients who underwent bowel resection between January 2010 and December 2019 after failure of at least one anti-TNFα were retrospectively included among three tertiary centers if they started a postoperative medical prophylaxis within the three months after index surgery. The main outcome was to compare rates of objective recurrence (endoscopic or radiological recurrence in absence of colonoscopy) between patients treated with an anti-TNFα agent or another treatment as prevention of POR. RESULTS Among the 119 patients included, 71 patients received an anti-TNFα (26 infliximab, 45 adalimumab) and 48 another treatment (18 ustekinumab, 7 vedolizumab, 20 azathioprine and 3 methotrexate) to prevent POR. Rates of objective recurrence at two years were 23.9% in patients treated with anti-TNFα and 44.9% in the others (p = 0.011). CONCLUSION Anti-TNFα remained an effective option to prevent POR for patients operated upon with previous anti-TNFα failure.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France.
| | - Romain Altwegg
- Department of Hepato-gastroenterology, Hôpital Saint-Eloi, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France
| | - Lucile Boivineau
- Department of Hepato-gastroenterology, Hôpital Saint-Eloi, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Florian Poullenot
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Anne Bozon
- Department of Hepato-gastroenterology, Hôpital Saint-Eloi, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France
| | - David Laharie
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France
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8
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Kucharzik T, Tielbeek J, Carter D, Taylor SA, Tolan D, Wilkens R, Bryant RV, Hoeffel C, De Kock I, Maaser C, Maconi G, Novak K, Rafaelsen SR, Scharitzer M, Spinelli A, Rimola J. ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:523-543. [PMID: 34628504 DOI: 10.1093/ecco-jcc/jjab180] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The diagnosis and follow up of patients with inflammatory bowel disease [IBD] requires cross-sectional imaging modalities, such as intestinal ultrasound [IUS], magnetic resonance imaging [MRI] and computed tomography [CT]. The quality and homogeneity of medical reporting are crucial to ensure effective communication between specialists and to improve patient care. The current topical review addresses optimized reporting requirements for cross-sectional imaging in IBD. METHODS An expert consensus panel consisting of gastroenterologists, radiologists and surgeons convened by the ECCO in collaboration with ESGAR performed a systematic literature review covering the reporting aspects of MRI, CT, IUS, endoanal ultrasonography and transperineal ultrasonography in IBD. Practice position statements were developed utilizing a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥80% of the participants agreed on a recommendation. RESULTS Twenty-five practice positions were developed, establishing standard terminology for optimal reporting in cross-sectional imaging. Assessment of inflammation, complications and imaging of perianal CD are outlined. The minimum requirements of a standardized report, including a list of essential reporting items, have been defined. CONCLUSIONS This topical review offers practice recommendations to optimize and homogenize reporting in cross-sectional imaging in IBD.
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Affiliation(s)
- Torsten Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Jeroen Tielbeek
- Department of Radiology, Spaarne Gasthuis, Boerhaavelaan 22, Haarlem, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hasomher, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Radiology Department, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, UK
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Hvidovre University Hospital, Copenhagen, Denmark; Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - Christine Hoeffel
- Department of Abdominal Radiology, CHU Reims and CRESTIC, URCA, 51100 Reims, France
| | - Isabelle De Kock
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Giovanni Maconi
- Gastroenterology Unit, 'Luigi Sacco' University Hospital, Milan, Italy
| | - Kerri Novak
- Department of Radiology and Medicine, Division of Gastroenterology, University of Calgary, Alberta, Canada
| | - Søren R Rafaelsen
- Department of Radiology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Jordi Rimola
- IBD unit, Radiology Department, Hospital Clínic Barcelona, Barcelona, Catalonia, Spain
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Schaefer M, Laurent V, Grandmougin A, Vuitton L, Bourreille A, Luc A, Clerc-Urmes I, Orry X, Frampas E, De Billy M, Pouillon L, Le Berre C, Gay C, Meyer J, Baumann C, Peyrin-Biroulet L. A Magnetic Resonance Imaging Index to Predict Crohn's Disease Postoperative Recurrence: The MONITOR Index. Clin Gastroenterol Hepatol 2022; 20:e1040-e1049. [PMID: 34216820 DOI: 10.1016/j.cgh.2021.06.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/01/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS We developed and validated a magnetic resonance imaging-based index to predict Crohn's disease (CD) postoperative recurrence (POR). METHODS Patients with CD who underwent a postoperative evaluation for recurrence (with colonoscopy and MRI no longer than 105 days apart) were included between 2006 and 2016 in University Hospital of Nancy, France. MRI items with good levels of intra-rater and inter-rater agreement (Gwet's coefficient ≥0.5) were selected. The MRI in Crohn's Disease to Predict Postoperative Recurrence (MONITOR) index's performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and accuracy, by considering the Rutgeerts score as the gold standard. The MONITOR index was validated with a bootstrap method and an independent cohort. RESULTS Seventy-three MRI datasets were interpreted by 2 radiologists. Seven items (bowel wall thickness, contrast enhancement, T2 signal increase, diffusion-weighted signal increase, edema, ulcers, and the length of the diseased segment) had a Gwet's coefficient ≥0.5 and were significantly associated with the Rutgeerts score, leading to their inclusion in the MONITOR index. All the items had a weighting of 1, except the "ulcers" item weighting 2.5, reflecting the higher adjusted odds ratio. The AUROC [95% confidence interval] for the prediction of endoscopic POR (Rutgeerts score >i1) was 0.80 [0.70-0.90]. The optimal threshold was a MONITOR index ≥1, giving a sensitivity of 79%, a specificity of 55%, a predictive positive value of 68%, and a predictive negative value of 68%. The bootstrap validation gave an AUROC of 0.85 [0.73-0.97]. In the validation cohort, a MONITOR index ≥1 gave a sensitivity of 87%, a specificity of 75%, a predictive positive value of 84.6%, and a predictive negative value of 75%. CONCLUSIONS The MONITOR index is an efficient, reliable, easy-to-apply tool that can be used in clinical practice to predict the POR of CD.
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Affiliation(s)
- Marion Schaefer
- Department of Hepatogastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Valérie Laurent
- Central Department of Radiology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Aurélie Grandmougin
- Central Department of Radiology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Lucine Vuitton
- Department of Gastroenterology, Besançon University Hospital, Besancon
| | | | - Amandine Luc
- Unit of Methodology, Data Management and Statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Isabelle Clerc-Urmes
- Unit of Methodology, Data Management and Statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Xavier Orry
- Central Department of Radiology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Eric Frampas
- Department of Radiology, Nantes University Hospital, Nantes
| | | | - Lieven Pouillon
- Department of Hepatogastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | | | - Claire Gay
- Department of Gastroenterology, Besançon University Hospital, Besancon
| | - Jeremy Meyer
- Department of Radiology, Nantes University Hospital, Nantes
| | - Cédric Baumann
- Unit of Methodology, Data Management and Statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Laurent Peyrin-Biroulet
- Department of Hepatogastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy; INSERM U1256, Nutrition-Génétique et Exposition aux Risques Environnementaux, Faculté de Médecine, Université de Lorraine, Vandoeuvre-les-Nancy, France.
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10
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Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
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11
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Pozzessere C, Boudiaf M, Cirigliano A, Dohan A, Mazzei MA, Barat M, Volterrani L, Soyer P. MR-enterography: role in the assessment of suspected anastomotic recurrence of Crohn disease after ileocolic resection. Radiol Med 2022; 127:238-250. [PMID: 35050452 DOI: 10.1007/s11547-022-01452-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the potential of magnetic resonance-enterography (MRE) in the assessment of the anastomotic status in patients with Crohn disease and prior ileocolic resection. METHODS A total of 62 MRE examinations obtained in 52 patients with Crohn disease who had previously undergone ileocolic resection were retrospectively reviewed by two readers in consensus. MRE features (anastomotic wall thickening, wall stratification, wall enhancement pattern and degree, DWI signal intensity, ADC values, lymph nodes, comb sign and complications) were compared to clinical, endoscopic and histological findings that served as standard of reference. Sensitivity, specificity and accuracy of MRE were calculated. RESULTS At univariate analysis, anastomotic wall thickening, anastomotic wall stratification, segmental wall enhancement, moderate wall enhancement, early and mucosal enhancement, and moderate/marked hyperintensity on diffusion-weighed imaging (DWI) were the most discriminative MRE features for differentiating between normal and abnormal anastomoses (p < 0.001 for all variables). Anastomotic wall thickening and segmental anastomotic wall enhancement were the two most sensitive and accurate MRE variables for the diagnosis of abnormal anastomosis with sensitivities of 82% (95% CI: 67-92%) and accuracies of 84% (95% CI: 72-92%). At univariate analysis, hyperintensity on DWI of the anastomotic site was the most sensitive finding for distinguishing between inflammatory recurrence and fibrostenosis (sensitivity, 89%; 95% CI: 67-99%). CONCLUSIONS MRE provides objective and relatively specific morphological criteria that help detect abnormal ileocolic anastomosis, but performances are lower when differentiating between inflammatory recurrence and fibrostenosis. DWI may be useful in identifying pathologic anastomosis and, in particular, in distinguishing between inflammatory recurrence and fibrostenosis.
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Affiliation(s)
- Chiara Pozzessere
- Department of Medical, Surgical and Neuro Sciences, Unit of Diagnostic Imaging, University Hospital of Siena, Azienda Ospedaliera Universitaria Senese, 53100, Siena, Italy. .,Department of Radiology, AUSL Toscana Centro, San Giuseppe Hospital, Viale Giovanni Boccaccio, 16, 50053, Empoli, Italy.
| | - Mourad Boudiaf
- Department of Radiology, AP-HP Cochin Hospital, 27 rue du Faubourg Saint-Jacques, 5014, Paris, France
| | - Alfredo Cirigliano
- Department of Medical, Surgical and Neuro Sciences, Unit of Diagnostic Imaging, University Hospital of Siena, Azienda Ospedaliera Universitaria Senese, 53100, Siena, Italy
| | - Anthony Dohan
- Department of Radiology, AP-HP Cochin Hospital, 27 rue du Faubourg Saint-Jacques, 5014, Paris, France.,Université de Paris, 75006, Paris, France
| | - Maria Antonietta Mazzei
- Department of Medical, Surgical and Neuro Sciences, Unit of Diagnostic Imaging, University Hospital of Siena, Azienda Ospedaliera Universitaria Senese, 53100, Siena, Italy
| | - Maxime Barat
- Department of Radiology, AP-HP Cochin Hospital, 27 rue du Faubourg Saint-Jacques, 5014, Paris, France.,Université de Paris, 75006, Paris, France
| | - Luca Volterrani
- Department of Medical, Surgical and Neuro Sciences, Unit of Diagnostic Imaging, University Hospital of Siena, Azienda Ospedaliera Universitaria Senese, 53100, Siena, Italy
| | - Philippe Soyer
- Department of Radiology, AP-HP Cochin Hospital, 27 rue du Faubourg Saint-Jacques, 5014, Paris, France.,Université de Paris, 75006, Paris, France
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12
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Dasharathy SS, Limketkai BN, Sauk JS. What's New in the Postoperative Management of Crohn's Disease? Dig Dis Sci 2022; 67:3508-3517. [PMID: 34406585 PMCID: PMC9287204 DOI: 10.1007/s10620-021-07205-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 12/14/2022]
Abstract
Patients with Crohn's disease (CD) often require surgical resection due to complications, such as strictures and abscesses, or disease refractory to medical therapy. To understand the evolving management of patients with CD after surgery, we outline the risk factors for postoperative recurrence, advances in postoperative endoscopic evaluation and characterization of recurrence, noninvasive methods of assessing postoperative recurrence, use of postoperative prophylactic medical therapy including newer biologics, and novel surgical methods to reduce postoperative recurrence. The Rutgeerts score (RS) was developed to predict progression of disease based on endoscopic appearance postoperatively and to guide medical therapy. However, this scoring system groups ileal and anastomotic lesions into the same category. A modified RS was developed to separate lesions isolated to the anastomosis and those in the neo-terminal ileum to further understand the role of anastomotic lesions in CD progression. Additional scoring systems have also been evaluated to better understand these differences. In addition, noninvasive diagnostic methods, such as small bowel ultrasound, have high sensitivity and specificity for the detection of postoperative recurrence and are being evaluated as independent methods of assessment. Studies have also shown a reduction in endoscopic recurrence with postoperative anti-TNFα therapy. However, preoperative exposure to anti-TNFα therapy may impact postoperative response to these medications, and therefore, determining optimal postoperative prophylaxis strategy for biologic-experienced patients requires further exploration. Lastly, new surgical modalities to reduce postoperative recurrence are currently being investigated with preliminary data suggesting that an antimesenteric functional end-to-end anastomosis (Kono-S) may decrease postoperative recurrence.
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Affiliation(s)
- Sonya S Dasharathy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Berkeley N Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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13
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Zhang Z, He X, Hu J, Zheng Z, Chen Y, Tang J, Li S, Ke J, Lian L, Lan P, Wu X. Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease. Surgery 2021; 171:1486-1493. [PMID: 34863524 DOI: 10.1016/j.surg.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease. METHODS A retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach. RESULTS A total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) CONCLUSION: Split stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.
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Affiliation(s)
- Zongjin Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zheyu Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongle Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian Tang
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Senmao Li
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiaojian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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14
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Friedman AB. Radiological targets in inflammatory bowel disease: An evolving paradigm. J Gastroenterol Hepatol 2021; 36 Suppl 1:10-11. [PMID: 33817844 DOI: 10.1111/jgh.15448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Antony B Friedman
- Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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15
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MRE Evaluation of Intestinal Inflammation: Qualitative and Quantitative Assessment. Top Magn Reson Imaging 2021; 30:13-22. [PMID: 33528208 DOI: 10.1097/rmr.0000000000000270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
ABSTRACT Magnetic resonance enterography (MRE) is a powerful tool for evaluation and management of patients with Crohn disease. Changes of active inflammation of the small bowel can reliably and reproducibly be detected and monitored. Findings indicative of active inflammation include bowel wall thickening, intramural edema and mural hyperenhancement. These changes are most commonly reported qualitatively; however, quantitative indices have also been developed and validated to measure and monitor inflammation both for clinical care and research purposes. This article describes the essential findings of active inflammation on MRE as well as the fundamentals of both qualitative and quantitative assessment and reporting.
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16
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Rodrigues BL, Mazzaro MC, Nagasako CK, Ayrizono MDLS, Fagundes JJ, Leal RF. Assessment of disease activity in inflammatory bowel diseases: Non-invasive biomarkers and endoscopic scores. World J Gastrointest Endosc 2020; 12:504-520. [PMID: 33362904 PMCID: PMC7739141 DOI: 10.4253/wjge.v12.i12.504] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 02/05/2023] Open
Abstract
Inflammatory bowel diseases (IBD) comprise two major forms: Crohn's disease and ulcerative colitis. The diagnosis of IBD is based on clinical symptoms combined with results found in endoscopic and radiological examinations. In addition, the discovery of biomarkers has significantly improved the diagnosis and management of IBD. Several potential genetic, serological, fecal, microbial, histological and immunological biomarkers have been proposed for IBD, and they have been evaluated for clinical routine and clinical trials. Ileocolonoscopy, especially with biopsy collection, has been considered the standard method to diagnose IBD and to assess clinical activity of the disease, but it is limited to the colon and terminal ileum and is considered invasive. For this reason, non-invasive biomarkers are necessary for this type of chronic inflammatory disease, which affects mostly young individuals, as they are expected to have a long follow-up.
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Affiliation(s)
- Bruno Lima Rodrigues
- Inflammatory Bowel Disease Research Laboratory, Gastrocenter, Colorectal Surgery Unit, Department of Surgery, School of Medical Sciences, University of Campinas (UNICAMP), Campinas 13083-878, São Paulo, Brazil
| | - Márcia Carolina Mazzaro
- Inflammatory Bowel Disease Research Laboratory, Gastrocenter, Colorectal Surgery Unit, Department of Surgery, School of Medical Sciences, University of Campinas (UNICAMP), Campinas 13083-878, São Paulo, Brazil
| | - Cristiane Kibune Nagasako
- Department of Gastroenterology, Gastrocenter, School of Medical Sciences, University of Campinas (UNICAMP), Campinas 13083-878, São Paulo, Brazil
| | - Maria de Lourdes Setsuko Ayrizono
- Inflammatory Bowel Disease Research Laboratory, Gastrocenter, Colorectal Surgery Unit, Department of Surgery, School of Medical Sciences, University of Campinas (UNICAMP), Campinas 13083-878, São Paulo, Brazil
| | - João José Fagundes
- Inflammatory Bowel Disease Research Laboratory, Gastrocenter, Colorectal Surgery Unit, Department of Surgery, School of Medical Sciences, University of Campinas (UNICAMP), Campinas 13083-878, São Paulo, Brazil
| | - Raquel Franco Leal
- Inflammatory Bowel Disease Research Laboratory, Gastrocenter, Colorectal Surgery Unit, Department of Surgery, School of Medical Sciences, University of Campinas (UNICAMP), Campinas 13083-878, São Paulo, Brazil
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17
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Vavricka SR, Greuter T, Brüngger B, Blozik E, Celeiro J, Schoepfer AM, Bähler C. Follow-Up Ileocolonoscopy Is Underused in Crohn's Disease Patients after Ileocecal Resection despite Higher Total and Inpatient Health-Care Costs Compared to Controls. Inflamm Intest Dis 2020; 5:100-108. [PMID: 32999882 DOI: 10.1159/000507115] [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] [Received: 10/12/2019] [Accepted: 03/11/2020] [Indexed: 11/19/2022] Open
Abstract
Background Postoperative recurrence is frequently observed after ileocecal resection in Crohn's disease (CD) patients. Since 2010, endoscopy within 1 year is considered the gold standard for its diagnosis. However, if and how frequent such endoscopies are performed in clinical practice remains unknown. Methods We analyzed 1-year follow-up data on CD patients who underwent ileocecal resection between 2012 and 2014 and compared them with hospitalized, non-resected CD controls. Data were extracted from the Helsana database. Helsana is one of the largest Swiss health insurance companies providing coverage for 1.2 million individuals. Results A total of 645 CD patients were identified with ≥1 hospitalization between 2012 and 2014 and a follow-up of 1 year. Of these, 79 (12.2%) underwent ileocecal resection. Although endoscopy rates increased over time and were higher in patients with resection versus controls (p = 0.029), in only 54.4% a 1-year follow-up ileocolonoscopy was performed. Postoperative prophylaxis with anti-tumor necrosis factor or azathioprine was prescribed in 63.3%. Female sex and age >60 years were independent predictors for not receiving prophylaxis (odds ratio [OR] 0.36, p = 0.048, and OR 0.2, p = 0.022). Patients with resection had significantly lower numbers of rehospitalizations (1.2 vs. 1.8, p = 0.021), with resection being an independent negative predictor for number of rehospitalizations in a Poisson regression model (incident risk ratio 0.64, p = 0.029). However, disease-related surgery was more often the cause for rehospitalization after resection versus controls (47.6 vs. 22.1%, p = 0.015). Total and inpatient health-care costs were higher in these patients. Conclusion Endoscopies are underused after ileocecal resection. This contrasts current guidelines. Physicians should be aware of this underuse and perform follow-up examinations more often.
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Affiliation(s)
- Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Zentrum für Gastroenterologie und Hepatologie, Zurich, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,GZO - Zurich Regional Health Center, Wetzikon, Switzerland
| | - Beat Brüngger
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | | | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, CHUV - University Hospital Lausanne, Lausanne, Switzerland
| | - Caroline Bähler
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
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18
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Affiliation(s)
- Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Metabolism & Endocrinology, Medical University Innsbruck, Innsbruck, Austria.
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, Netherlands.
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19
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The prevention and management of Crohn's disease postoperative recurrence: results from the Y-ECCO/ClinCom 2019 Survey. Eur J Gastroenterol Hepatol 2020; 32:1062-1066. [PMID: 32282539 DOI: 10.1097/meg.0000000000001729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Prevention and management of postoperative recurrence (POR) is a controversial field in Crohn's disease. The aim of this survey was to report common practice in real-life settings. METHODS An 11-question survey was distributed among gastroenterologists attending the 14th European Crohn's and Colitis Organisation (ECCO) congress. RESULTS Postoperative endoscopy to assess recurrence was routinely performed within 12 months by 87% of respondents. Forty-six percent of clinicians reported to maintain endoscopic assessment in routine follow-up even after first negative colonoscopy. Most respondents (60%) considered starting postoperative immunoprophylaxis in naïve patients if one or more known risk factors were present. The number of risk factors was an important driver for prescribing biologics over immunosuppressants for 60% of respondents.In case of fistulizing phenotype, perianal disease, or concomitant colonic involvement, the majority of physicians reported to start an immediate prophylaxis in 85, 98 and 88% of patients, respectively. A significant percentage of clinicians were more prone to an endoscopy-driven treatment in long-standing disease after failure of thiopurines (51%) and elderly (43%). CONCLUSION Endoscopy within the first year after surgery to assess POR has become routine in most centres. The high rate of early prophylaxis with expensive biologics despite missing solid evidence highlights the need for more randomized trials.
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20
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Abstract
PURPOSE OF REVIEW Despite multiple advances in the medical treatment of Crohn's disease, it is recognized that a significant proportion of patients will ultimately require surgical resection at some point during their disease course. This review focuses on the postoperative management of patients with Crohn's disease, with the goal of preventing endoscopic and clinical recurrence, and future surgery. RECENT FINDINGS Surgery is an integral part of the multidisciplinary approach to the management of patients with Crohn's disease. Recent literature and guidelines have focused on a standardized and evidence-based approach to the management of patients in the postoperative setting. This approach should utilize risk stratification at the time of surgery, initiation of appropriate therapy among high-risk patients, and objective evaluation in the postoperative period, including ileocolonoscopy at 6-12 months after a surgical resection. SUMMARY A standardized approach to the postoperative management of patients with Crohn's disease is critical. Identifying those patients at high-risk for endoscopic and clinical recurrence is essential, as these patients will likely require early medical therapy. While novel objective assessments are emerging, all patients should undergo ileocolonoscopy at 6-12 months and further decision making should be based on the presence of endoscopic recurrence.
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21
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Barnes EL, Lightner AL, Regueiro M. Perioperative and Postoperative Management of Patients With Crohn's Disease and Ulcerative Colitis. Clin Gastroenterol Hepatol 2020; 18:1356-1366. [PMID: 31589972 DOI: 10.1016/j.cgh.2019.09.040] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/18/2019] [Accepted: 09/28/2019] [Indexed: 02/07/2023]
Abstract
Although the number of available therapies for the treatment of ulcerative colitis and Crohn's disease (CD) continues to expand, a significant portion of patients with inflammatory bowel disease will require surgical intervention. Surgery remains an integral part of the treatment algorithm for patients with ulcerative colitis and CD, and thus multidisciplinary approaches to the perioperative and postoperative management of patients with inflammatory bowel disease are critical to improving outcomes during these periods. New mechanisms of biologic therapies are emerging and new treatment strategies focused on earlier and potentially more aggressive use of immunosuppressive therapies are advocated in the current treatment era. In this review, we outline multidisciplinary strategies for the preoperative management of immunosuppressive therapies, including a discussion of the most recent evidence regarding the safety of biologic therapy in the preoperative period. We also discuss the postoperative medical management of patients undergoing intestinal resection for CD, with a particular focus on risk stratification and appropriate therapy selection in the immediate postoperative setting. Finally, we review potential postoperative complications after restorative proctocolectomy with ileal pouch-anal anastomosis and their management.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, The Pier C. and Renee A. Borra Family Endowed Chair in Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio; Digestive Disease and Surgery Institute, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
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22
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1309] [Impact Index Per Article: 261.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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23
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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24
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Pous-Serrano S, Frasson M, Pàmies-Guilabert J, Rudenko P, Puchades-Román I, Beltrán B, Nos Mateu P, García-Granero E. Use of magnetic resonance index of activity (MaRIA) in the preoperative assessment of small bowel Crohn's disease. Cir Esp 2019; 97:582-589. [PMID: 31585676 DOI: 10.1016/j.ciresp.2019.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/25/2019] [Accepted: 06/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Accurate quantification of the inflammatory activity in Crohn's Disease is essential to determine adequate treatment for each patient. The aim of the present study is to assess the correlation between the pre-operative Magnetic Resonance Index of Activity (MaRIA) and the histologic degree of inflammation from surgically resected intestinal Crohn's Disease lesions. METHODS This is a prospective study including a consecutive case series of patients with small bowel Crohn's Disease, who underwent surgical resection. Magnetic resonance enterography was performed in the 3months prior to surgery, applying a pre-established protocol. Relative contrast enhancements, wall thickness, presence of edema or ulcerations were the parameters used to calculate the MaRIA Index. All patients underwent surgery and every specimen was analyzed. The modified Chiorean classification was applied for the histological analysis and an ordinal regression analysis was used to correlate MaRIA and the grade of inflammation for each lesion. RESULTS 59 lesions from 35 different patients were analyzed. The degree of inflammation of the lesions was statistically correlated to the MaRIA values (P=.002). The MaRIA index was significantly different (P<.001) between the different histological types of the Crohn's Disease lesions (inflammatory/ fibrotic). The best cut-off for detecting severe inflammation using MaRIA was 20 (AUC: 0.741; 74.1% sensitivity and 78.1% specificity). CONCLUSION MaRIA is a reliable tool to distinguish inflammatory from fibrotic lesions. Therefore, it could be considered essential for determining the most appropriate Crohn's Disease treatment for each patient.
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Affiliation(s)
- Salvador Pous-Serrano
- Departamento de Cirugía General, Unidad de Coloproctología, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
| | - Matteo Frasson
- Departamento de Cirugía General, Unidad de Coloproctología, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España.
| | - José Pàmies-Guilabert
- Departamento de Radiología, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
| | - Polina Rudenko
- Departamento de Radiología, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
| | - Icíar Puchades-Román
- Departamento de Radiología, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
| | - Belén Beltrán
- Departamento de Gastroenterología, Unidad de Enfermedad Inflamatoria Intestinal, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
| | - Pilar Nos Mateu
- Departamento de Gastroenterología, Unidad de Enfermedad Inflamatoria Intestinal, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
| | - Eduardo García-Granero
- Departamento de Cirugía General, Unidad de Coloproctología, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España
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25
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Prichard DO, Hamilton Z, Savage T, Smyth M, Penner C, Lakhani A, Carroll MW, Al Sarkhy A, Lemberg DA, Enns R, Jamieson D, Jacobson K. Capsule Endoscopy Complements Magnetic Resonance Enterography and Endoscopy in Evaluating Small Bowel Crohn's Disease. J Can Assoc Gastroenterol 2019; 3:279-287. [PMID: 33241181 PMCID: PMC7678730 DOI: 10.1093/jcag/gwz028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aims Wireless capsule endoscopy (WCE) and magnetic resonance enterography (MRE) are increasingly utilized to evaluate the small bowel (SB) in Crohn's disease (CD). The primary aims were to compare the ability of WCE and MRE to detect SB inflammation in children with newly diagnosed CD, and in the terminal ileum (TI) to compare them to ileo-colonoscopy. Secondary aims were to compare diagnostic accuracy of WCE and MRE and changes in Paris classification after each study. Methods Patients (10 to 17 years of age) requiring ileo-colonoscopy for suspected CD were invited to participate. Only patients with endoscopic/histologic evidence of CD underwent MRE and WCE. SB inflammation and extent were documented and comparative analyses performed. Results Of 38 initially recruited subjects, 20 completed the study. WCE and MRE were similarly sensitive in identifying active TI inflammation (16 [80%] versus 12 [60%]) and any SB inflammation (17 [85%] versus 16 [80%]). However, WCE detected more extensive SB disease than MRE with active inflammation throughout the SB in 15 [75%] versus 1 [5%] patient (P < 0.001). Moreover, WCE was more likely to detect proximal SB disease (jejunum and ileum) compared to MRE (85% versus 50%, P = 0.04). Overall, the Paris classification changed in 65% and 85% of patients following MRE and WCE, respectively. Conclusions WCE is as sensitive as MRE for identifying active TI inflammation, but appears more sensitive in identifying more proximal SB inflammation. In the absence of concern regarding stricturing or extra-luminal disease WCE can be considered for the evaluation of suspected SB CD.
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Affiliation(s)
- David O Prichard
- Department of Gastroenterology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Department of Gastroenterology and Hepatology, Mayo Clinic Health System La Crosse - Franciscan Healthcare, La Crosse, Wisconsin, USA.,Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Hamilton
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas Savage
- Department of Radiology, Royal Hospital for Sick Children, Glasgow, UK
| | - Matthew Smyth
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Carlie Penner
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Alam Lakhani
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew W Carroll
- Department of Paediatrics, Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmed Al Sarkhy
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Department of Paediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Daniel A Lemberg
- Department of Gastroenterology, Sydney Children's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Robert Enns
- Department of Gastroenterology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Douglas Jamieson
- Department of Radiology, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevan Jacobson
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,British Columbia Children's Hospital Research Institute, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.,Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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26
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Cerrillo E, Moret I, Iborra M, Pamies J, Hervás D, Tortosa L, Sáez-González E, Nos P, Beltrán B. A Nomogram Combining Fecal Calprotectin Levels and Plasma Cytokine Profiles for Individual Prediction of Postoperative Crohn's Disease Recurrence. Inflamm Bowel Dis 2019; 25:1681-1691. [PMID: 30925193 DOI: 10.1093/ibd/izz053] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aims of this study were to characterize the immune response profile in patients with Crohn's disease (CD) and early postoperative recurrence (POR), to identify predictive biomarkers, and to develop a noninvasive predictive tool for individual estimation of POR risk. METHODS Sixty-one patients who had undergone ileocolonic resection for CD were prospectively included and followed up for 24 months. Fecal calprotectin (FC), analytical parameters, and plasma cytokines were obtained before surgery and at various time points during postoperative follow-up. Morphological recurrence was assessed by ileocolonoscopy or magnetic resonance enterography within 6-12 months after surgery. Clinical activity was scored using the Harvey-Bradshaw Index. RESULTS Twenty-seven patients (44.3%) had morphological recurrence during follow-up. Fecal calprotectin values were significantly associated with POR risk over time. The receiver operating characteristic curve for FC provided an area under the curve (AUC) of 0.88 (95% confidence interval, 0.75-0.96), and morphological recurrence was best predicted by FC ≥160 μg/g at 6 months after surgery (85% sensitivity, 70% specificity, 26% predictive positive value, 98% negative predictive value [NPV]). The plasma cytokine profile showed higher presurgery interleukin (IL)-13 plasma levels and higher IL-6 and interferon (IFN)-γ levels at 6 months after surgery in patients with POR compared with patients without recurrence. The combination of FC, IL-6, and IFN-γ values at 6 months gave an AUC of 0.90 for predicting an early recurrence. CONCLUSIONS FC values <160 μg/g at 6 months have a high NPV to rule out early lesions. Combined values of FC, IL-6, and IFN-γ levels at 6 months postsurgery constitute a prognostic index with a high predictive capacity to assess the risk of early POR.
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Affiliation(s)
- Elena Cerrillo
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain.,Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III, Madrid, Spain
| | - Inés Moret
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain.,Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III, Madrid, Spain
| | - Marisa Iborra
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain.,Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III, Madrid, Spain
| | - José Pamies
- Radiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - David Hervás
- Biostatistics Unit, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
| | - Luis Tortosa
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
| | - Esteban Sáez-González
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
| | - Pilar Nos
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain.,Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III, Madrid, Spain
| | - Belén Beltrán
- Inflammatory Bowel Disease Unit, Gastroenterology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.,Inflammatory Bowel Disease Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain.,Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III, Madrid, Spain
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27
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Kedia S, Sharma R, Makharia G, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan R, Madhusudhan KS, Philip M, Puri A, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement. Indian J Radiol Imaging 2019; 29:111-132. [PMID: 31367083 PMCID: PMC6639863 DOI: 10.4103/ijri.ijri_153_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Radiadiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | | | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - R Karthikeyan
- Department of Radiodiagnosis, SRM Institute of Medical Sciences and Research, Chennai, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, Kerala, India
| | - Amarender Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Mumbai, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, Bengaluru, Karnataka, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Jodhpur, Rajasthan, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, Guwahati, Assam, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Bhilai, Chhattishgarh, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, UP, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Jodhpur, Rajasthan, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | - B S Ramakrishna
- Department of Gastroenterology, SRM Institute of Medical Sciences and Research, Chennai, India
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28
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Intravenous Contrast-Enhanced Ultrasound for Assessing and Grading Postoperative Recurrence of Crohn's Disease. Dig Dis Sci 2019; 64:1640-1650. [PMID: 30604372 DOI: 10.1007/s10620-018-5432-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim was to investigate the contribution of contrast-enhanced ultrasound (CEUS) to improve the results of US in the evaluation of recurrence in postsurgical Crohn's disease (CD) and establish its role in the assessment of the severity. METHODS Anastomotic site was assessed in 108 postsurgical CD patients with B-mode, color Doppler and CEUS. Bowel wall thickness (WT), transmural complications or stenosis, color Doppler grade, and bowel wall contrast enhancement (BWCE)-using time-intensity curves-were correlated with endoscopic Rutgeerts score. A receiver operating characteristic (ROC) curve was built to establish the best cutoff to predict recurrence and the severity. A US scoring system was elaborated in order to determine the grade of recurrence. RESULTS Ileocolonoscopy detected recurrence in 90 (83.3%) subjects and severe recurrence in 62. WT ≥ 3 mm had an accuracy of 90.7% in the detection of endoscopic recurrence. The combination of parameters-WT ≥ 3 mm and BWCE (≥ 46%)-demonstrated similar accuracy (90.7%). A WT ≥ 5 mm showed the best specificity (100%) for the diagnosis of recurrence and a WT ≥ 6 mm the best specificity (95.7%) for the detection of severe recurrence. The combination of sonographic parameters-WT ≥ 6 mm or WT between 5 and 6 mm with BWCE ≥ 70%, or complications-obtained the best results grading the recurrence (sensitivity, specificity, and accuracy of 90.3%, 87%, and 88.9%, respectively). CONCLUSIONS US shows high sensitivity and specificity for the diagnosis of postsurgical recurrence. When combined with CEUS, it can improve the detection of severe recurrence.
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Sturm A, Maaser C, Calabrese E, Annese V, Fiorino G, Kucharzik T, Vavricka SR, Verstockt B, van Rheenen P, Tolan D, Taylor SA, Rimola J, Rieder F, Limdi JK, Laghi A, Krustiņš E, Kotze PG, Kopylov U, Katsanos K, Halligan S, Gordon H, González Lama Y, Ellul P, Eliakim R, Castiglione F, Burisch J, Borralho Nunes P, Bettenworth D, Baumgart DC, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 2: IBD scores and general principles and technical aspects. J Crohns Colitis 2019; 13:273-284. [PMID: 30137278 DOI: 10.1093/ecco-jcc/jjy114] [Citation(s) in RCA: 241] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Belgium
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza - University of Rome, Rome, Italy
| | - Eduards Krustiņš
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná PUCPR, Curitiba, Brazil
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Hannah Gordon
- Section of Gastroenterology & Hepatology, Royal London Hospital, London, UK
| | - Yago González Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda Madrid, Spain
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center AMC, University of Amsterdam, Amsterdam, The Netherlands
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Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 909] [Impact Index Per Article: 181.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
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31
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Park SH, Ye BD, Lee TY, Fletcher JG. Computed Tomography and Magnetic Resonance Small Bowel Enterography: Current Status and Future Trends Focusing on Crohn's Disease. Gastroenterol Clin North Am 2018; 47:475-499. [PMID: 30115433 DOI: 10.1016/j.gtc.2018.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are presently state-of-the-art radiologic tests used to examine the small bowel for various indications. This article focuses on CTE and MRE for the evaluation of Crohn disease. The article describes recent efforts to achieve more standardized interpretation of CTE and MRE, summarizes recent research studies investigating the role and impact of CTE and MRE more directly for several different clinical and research issues beyond general diagnostic accuracy, and provides an update on progress in imaging techniques. Also addressed are areas that need further exploration in the future.
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Affiliation(s)
- Seong Ho Park
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.
| | - Byong Duk Ye
- Department of Gastroenterology, Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Tae Young Lee
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
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32
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Rozendorn N, Amitai MM, Eliakim RA, Kopylov U, Klang E. A review of magnetic resonance enterography-based indices for quantification of Crohn's disease inflammation. Therap Adv Gastroenterol 2018; 11:1756284818765956. [PMID: 29686731 PMCID: PMC5900818 DOI: 10.1177/1756284818765956] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/28/2018] [Indexed: 02/04/2023] Open
Abstract
Magnetic resonance enterography (MRE) is a leading radiological modality in Crohn's disease (CD) and is used together with laboratory findings and endoscopic examinations for the evaluation of patients during initial diagnosis and follow up. Over the years, there has been great progress in the understanding of CD and there is a continuous strive to achieve better monitoring of patients and to develop new modalities which will predict disease course and thus help in clinical decisions making. An objective evaluation of CD using a quantification score is not a new concept and there are different clinical, endoscopies, radiological and combined indices which are used in clinical practice. Such scores are a necessity in clinical trials on CD for evaluation of disease response, however, there is no consensus of the preferred MRE score and they are not routinely used. This review presents MRE-based indices in use in the last decade: the Magnetic Resonance Index of Activity (MaRIA), the Clermont score, the Crohn's Disease Magnetic Resonance Imaging (MRI) Index (CDMI), the Magnetic Resonance Enterography Global Score (MEGS) and the Lemann index. We compare the different indices and evaluate the clinical research that utilized them. The aim of this review is to provide a reference guide for researchers and clinicians who incorporate MRE indices in their work. When devising future indices, accumulated data of the existing indices must be taken into account, as each of the current indices has its own strengths and weakness.
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Affiliation(s)
| | | | | | - Uri Kopylov
- Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
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33
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Baillet P, Cadiot G, Goutte M, Goutorbe F, Brixi H, Hoeffel C, Allimant C, Reymond M, Obritin-Guilhen H, Magnin B, Bommelaer G, Pereira B, Hordonneau C, Buisson A. Faecal calprotectin and magnetic resonance imaging in detecting Crohn’s disease endoscopic postoperative recurrence. World J Gastroenterol 2018; 24:641-650. [PMID: 29434453 PMCID: PMC5799865 DOI: 10.3748/wjg.v24.i5.641] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/05/2018] [Accepted: 01/15/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess magnetic resonance imaging (MRI) and faecal calprotectin to detect endoscopic postoperative recurrence in patients with Crohn’s disease (CD).
METHODS From two tertiary centers, all patients with CD who underwent ileocolonic resection were consecutively and prospectively included. All the patients underwent MRI and endoscopy within the first year after surgery or after the restoration of intestinal continuity [median = 6 mo (5.0-9.3)]. The stools were collected the day before the colonoscopy to evaluate faecal calprotectin level. Endoscopic postoperative recurrence (POR) was defined as Rutgeerts’ index ≥ i2b. The MRI was analyzed independently by two radiologists blinded from clinical data.
RESULTS Apparent diffusion coefficient (ADC) was lower in patients with endoscopic POR compared to those with no recurrence (2.03 ± 0.32 vs 2.27 ± 0.38 × 10-3 mm²/s, P = 0.032). Clermont score (10.4 ± 5.8 vs 7.4 ± 4.5, P = 0.038) and relative contrast enhancement (RCE) (129.4% ± 62.8% vs 76.4% ± 32.6%, P = 0.007) were significantly associated with endoscopic POR contrary to the magnetic resonance index of activity (MaRIA) (7.3 ± 4.5 vs 4.8 ± 3.7; P = 0.15) and MR scoring system (P = 0.056). ADC < 2.35 × 10-3 mm²/s [sensitivity = 0.85, specificity = 0.65, positive predictive value (PPV) = 0.85, negative predictive value (NPV) = 0.65] and RCE > 100% (sensitivity = 0.75, specificity = 0.81, PPV = 0.75, NPV = 0.81) were the best cut-off values to identify endoscopic POR. Clermont score > 6.4 (sensitivity = 0.61, specificity = 0.82, PPV = 0.73, NPV = 0.74), MaRIA > 3.76 (sensitivity = 0.61, specificity = 0.82, PPV = 0.73, NPV = 0.74) and a MR scoring system ≥ MR1 (sensitivity = 0.54, specificity = 0.82, PPV = 0.70, and NPV = 0.70) demonstrated interesting performances to detect endoscopic POR. Faecal calprotectin values were significantly higher in patients with endoscopic POR (114 ± 54.5 μg/g vs 354.8 ± 432.5 μg/g; P = 0.0075). Faecal calprotectin > 100 μg/g demonstrated high performances to detect endoscopic POR (sensitivity = 0.67, specificity = 0.93, PPV = 0.89 and NPV = 0.77).
CONCLUSION Faecal calprotectin and MRI are two reliable tools to detect endoscopic POR in patients with CD.
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Affiliation(s)
- Pierre Baillet
- Université Clermont Auvergne, CHU Clermont-Ferrand, Service de radiologie, Clermont-Ferrand 63000, France
| | - Guillaume Cadiot
- CHU de Reims, Service d’Hépato-Gastro Entérologie, Reims 51100, France
| | - Marion Goutte
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
- Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand 63000, France
| | - Felix Goutorbe
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
- CH de Bayonne, Service d’Hépato-Gastro Entérologie, Bayonne 64100, France
| | - Hedia Brixi
- CHU de Reims, Service d’Hépato-Gastro Entérologie, Reims 51100, France
| | | | - Christophe Allimant
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
| | - Maud Reymond
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
| | - Hélène Obritin-Guilhen
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
| | - Benoit Magnin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Service de radiologie, Clermont-Ferrand 63000, France
| | - Gilles Bommelaer
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
- Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand 63000, France
| | - Bruno Pereira
- CHU Clermont-Ferrand, DRCI, Unité de Biostatistiques, Clermont-Ferrand 63000, France
| | - Constance Hordonneau
- Université Clermont Auvergne, CHU Clermont-Ferrand, Service de radiologie, Clermont-Ferrand 63000, France
| | - Anthony Buisson
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d’Hépato-Gastro Entérologie, Clermont-Ferrand 63000, France
- Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand 63000, France
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Yung DE, Har-Noy O, Tham YS, Ben-Horin S, Eliakim R, Koulaouzidis A, Kopylov U. Capsule Endoscopy, Magnetic Resonance Enterography, and Small Bowel Ultrasound for Evaluation of Postoperative Recurrence in Crohn's Disease: Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2017; 24:93-100. [PMID: 29272490 DOI: 10.1093/ibd/izx027] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anastomotic recurrence is frequent in patients with Crohn's disease (CD) following ileocecal resection. The degree of endoscopic recurrence, quantified by the Rutgeerts score (RS), is correlated with the risk of clinical and surgical recurrence. Noninvasive modalities such as capsule endoscopy (CE), magnetic resonance enterography (MRE), and intestinal ultrasound (US) may yield similar information without the need for ileocolonoscopy (IC). The aim of our meta-analysis was to evaluate the accuracy of those modalities for detection of endoscopic recurrence in postoperative CD patients. METHODS We performed a systematic literature search for studies comparing the accuracy of CE, MRE, and US with IC for detection of postoperative recurrence in CD. We calculated pooled diagnostic sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) for each comparison. RESULTS A total of 135 studies were retrieved; 14 studies were eligible for analysis. For CE, the pooled sensitivity was 100% (95% CI, 91%-100%), specificity was 69% (95% CI, 52%-83%), DOR was 30.8 (95% CI, 6.9-138), and AUC was 0.94. MRE had pooled sensitivity of 97% (95% CI, 89%-100%), specificity of 84% (95% CI, 62%-96%), DOR of 129.5 (95% CI, 16.4-1024.7), and AUC of 0.98. US had pooled sensitivity of 89% (95% CI, 85%-92%), specificity of 86% (95% CI, 78%-93%), DOR of 42.3 (95% CI, 18.6-96.0), and AUC 0.93. CONCLUSIONS CE, MRE, and US provide accurate assessment of postoperative endoscopic recurrence in CD. These modalities should gain wider use for detection of postoperative recurrence; the prognostic value of those diagnostic findings merits evaluation in further prospective studies.
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Affiliation(s)
- Diana E Yung
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Ofir Har-Noy
- Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yuen Sau Tham
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Shomron Ben-Horin
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anastasios Koulaouzidis
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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35
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Kopylov U, Koulaouzidis A, Klang E, Carter D, Ben-Horin S, Eliakim R. Monitoring of small bowel Crohn's disease. Expert Rev Gastroenterol Hepatol 2017; 11:1047-1058. [PMID: 28737951 DOI: 10.1080/17474124.2017.1359541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In recent years, the therapeutic paradigm in Crohn's disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such 'treat-to-target' approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn's disease, the small bowel is affected in the majority of patients; frequently, Crohn's involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment. Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn's disease. Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn's disease.
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Affiliation(s)
- Uri Kopylov
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Anastasios Koulaouzidis
- b Centre for Liver & Digestive Disorders , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Eyal Klang
- c Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Dan Carter
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Shomron Ben-Horin
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Rami Eliakim
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
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36
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Kedia S, Sharma R, Makharia GK, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan D, Madhusudhan KS, Philip M, Puri AS, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association. Indian J Gastroenterol 2017; 36:487-508. [PMID: 29307029 DOI: 10.1007/s12664-017-0804-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 02/07/2023]
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Sawarkar Marg, Mumbai, 400 016, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, 632 004, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H N Reliance Foundation Hospital and Research Centre, Prarthana Samaj, Raja Rammohan Roy Road, Mumbai, 400 004, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - D Karthikeyan
- Department of Radiodiagnosis, SRM Institutes for Medical Science, 1, Jawaharlal Nehru Salai, Vadapalani, Chennai, 600 026, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - Amarender Singh Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, 500 082, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, 43/2, New Airport Road, NH.7, Sahakara Nagar, Bengaluru, 560 092, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Residency Road, Shastri Nagar, Jodhpur, 342 003, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, 700 020, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, GMC Hospital Road, Bhangagarh, Guwahati, 781 032, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Hospital Sector, Bhilai, 490 009, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, 439, Cheran Nagar, Perumbakkam, Chennai, 600 100, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, 211 002, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College, J L N. Marg, Jaipur, 302 004, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Cantt Area, Jodhpur, 342 006, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, 700 020, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, 753 007, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Sawarkar Marg, Mumbai, 400 016, India
| | - B S Ramakrishna
- Institute of Gastroenterology, SRM Institutes for Medical Science, 1, Jawaharlal Nehru Salai, Vadapalani, Chennai, 600 026, India
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López-Sanromán A, Vera-Mendoza I, Domènech E, Taxonera C, Vega Ruiz V, Marín-Jiménez I, Guardiola J, Castro L, Esteve M, Iglesias E, Ceballos D, Martínez-Montiel P, Gisbert JP, Mínguez M, Echarri A, Calvet X, Barrio J, Hinojosa J, Martín-Arranz MD, Márquez-Mosquera L, Bermejo F, Rimola J, Pons V, Nos P. Adalimumab vs Azathioprine in the Prevention of Postoperative Crohn's Disease Recurrence. A GETECCU Randomised Trial. J Crohns Colitis 2017; 11:1293-1301. [PMID: 28402454 DOI: 10.1093/ecco-jcc/jjx051] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/05/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Postoperative recurrence of Crohn's disease [POR-CD] is almost certain if no prophylaxis is administered. Evidence for optimal treatment is lacking. Our aim was to compare the efficacy of adalimumab [ADA] and azathioprine [AZA] in this setting. METHODS We performed a phase 3, 52-week, multicentre, randomised, superiority study [APPRECIA], in which patients with ileocolonic resection were randomised either to ADA 160-80-40 mg subcutaneously [SC] or AZA 2.5 mg/kg/day, both associated with metronidazole. The primary endpoint was endoscopic recurrence at 1 year [Rutgeerts i2b, i3, i4], as evaluated by a blinded central reader. RESULTS We recruited 91 patients [median age 35.0 years, disease duration 6.0 years, 23.8% smokers, 7.1% previous resections]. The study drugs were administered to 84 patients. Treatment was discontinued owing to adverse events in 11 patients [13.1%]. Discontinuation was significantly less frequent in the ADA [4.4%] than in the AZA group [23.2%] (dif.: 18.6% [95% CI 4.1-33.2], p = 0.011). According to the intention-to-treat analysis, therapy failed in 23/39 patients in the AZA group [59%] and 19/45 patients in the ADA group [42.2%] [p = 0.12]. In the per-protocol analysis [61 patients with centrally evaluable images], recurrence was recorded in 8/24 [33.3%] patients in the AZA and 11/37 [29.7%] in the ADA group [p = 0.76]. No statistically significant differences between the groups were found for recurrence in magnetic resonance images, biological markers of activity, surgical procedures, or hospital admissions. CONCLUSIONS ADA has not demonstrated a better efficacy than AZA [both associated with metronidazole] for prophylaxis of POR-CD in an unselected population, although tolerance to ADA is significantly better. ClinicalTrials.gov NCT01564823.
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Affiliation(s)
| | - Isabel Vera-Mendoza
- Gastroenterology-Hepatology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - Eugeni Domènech
- Gastroenterology-Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Taxonera
- Digestive Diseases Unit, Hospital Clínico San Carlos, Instituto Investigación Sanitaria San Carlos [IdISSC], Madrid, Spain
| | - Vicente Vega Ruiz
- General Surgery Unit, Hospital Universitario Puerto Real, Puerto Real, Spain
| | - Ignacio Marín-Jiménez
- Digestive Diseases Unit, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón [IiSGM], Madrid, Spain
| | - Jordi Guardiola
- Gastroenterology-Hepatology Unit, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Luisa Castro
- Digestive Diseases Unit, Hospital Universitario Virgen de Macarena, Sevilla, Spain
| | - María Esteve
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Gastroenterology-Hepatology Unit, Hospital Universitari Mutua Terrassa, Terrassa, Spain
| | - Eva Iglesias
- Digestive Diseases Unit, Hospital Reina Sofía, Córdoba, Spain
| | - Daniel Ceballos
- Gastroenterology-Hepatology Unit, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa [IIS-IP], Madrid, Spain
| | - Miguel Mínguez
- Digestive Diseases Unit, Hospital Clínic de Valencia, University of Valencia, Valencia, Spain
| | - Ana Echarri
- Digestive Diseases Unit, Hospital Arquitecto Marcide, Ferrol, Spain
| | - Xavier Calvet
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Jesús Barrio
- Digestive Diseases Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | | | - Fernando Bermejo
- Digestive Diseases Unit, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Jordi Rimola
- Radiology Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Vicente Pons
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Hospital Universitario y Politécnico de La Fe, Valencia, Spain
| | - Pilar Nos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Hospital Universitario y Politécnico de La Fe, Valencia, Spain
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Abstract
Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.
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Gklavas A, Dellaportas D, Papaconstantinou I. Risk factors for postoperative recurrence of Crohn's disease with emphasis on surgical predictors. Ann Gastroenterol 2017; 30:598-612. [PMID: 29118554 PMCID: PMC5670279 DOI: 10.20524/aog.2017.0195] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/10/2017] [Indexed: 12/12/2022] Open
Abstract
Intestinal resection for Crohn’s disease is not curative and postoperative recurrence rates remain high. Early detection of indices associated with recurrence and risk stratification are fundamental for the postoperative management of patients. Early endoscopy at 6-12 months is the “gold standard” procedure, whereas other modalities such as fecal calprotectin and imaging techniques can contribute to the diagnosis of recurrence. The purpose of this review is to summarize current data regarding risk factors correlated with postoperative relapse. Smoking is a well-established, modifiable risk factor. There are sufficient data that correlate penetrating disease, perianal involvement, extensive resections, prior surgery, histological features (plexitis and granulomas), and improper management after resection with high rates for recurrence. The literature provides conflicting data for other possible predictors, such as age, sex, family history of inflammatory bowel disease, location of disease, strictureplasties, blood transfusions, and postoperative complications, necessitating further evidence. On the other hand, surgical factors such as anastomotic configuration, open or laparoscopic approach, and microscopic disease at specimen margins when macroscopic disease is resected, seem not to be related with an increased risk of recurrence. Further recognition of histological features as well as gene-related factors are promising fields for research.
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Affiliation(s)
- Antonios Gklavas
- 2 Department of Surgery, Aretaieion University Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Dionysios Dellaportas
- 2 Department of Surgery, Aretaieion University Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Papaconstantinou
- 2 Department of Surgery, Aretaieion University Hospital, University of Athens, School of Medicine, Athens, Greece
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40
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Choi IY, Park SH, Park SH, Yu CS, Yoon YS, Lee JL, Ye BD, Kim AY, Yang SK. CT Enterography for Surveillance of Anastomotic Recurrence within 12 Months of Bowel Resection in Patients with Crohn's Disease: An Observational Study Using an 8-Year Registry. Korean J Radiol 2017; 18:906-914. [PMID: 29089823 PMCID: PMC5639156 DOI: 10.3348/kjr.2017.18.6.906] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/17/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To investigate the diagnostic yield and accuracy of CT enterography (CTE) for early (< 12 postoperative months) surveillance of anastomotic recurrence after bowel resection for Crohn's disease (CD). MATERIALS AND METHODS We analyzed 88 adults (60 males and 28 females; mean age, 31.4 ± 9.6 years) who underwent bowel surgery for CD that created ileocolic anastomosis without enteric stoma, and underwent CTE for surveillance of CD recurrence/aggravation within 12 post-operative months. The CD activity index (CDAI) at the time of CTE was < 150 (i.e., clinically silent) in 51 patients, and ≥ 150 in 37 patients. Diagnostic yields of CTE regarding CD recurrence in the ileocolic anastomosis and extraluminal penetrating complications were determined. CTE-related step-up therapy was recorded. These outcomes were compared between the two CDAI groups after accounting for major risk factors for CD recurrence. In a subgroup of 31 patients who underwent both CTE and ileocolonoscopy within 1 month, CTE accuracy for anastomotic recurrence was assessed using the Rutgeerts scoring as the reference standard. RESULTS CTE diagnostic yield was 35.2% (31/88) for the anastomotic recurrence and 9.1% (8/88) for penetrating complications. 20.5% (18/88) of the patients underwent step-up therapy after CTE detection of anastomotic recurrence. These outcomes were not significantly different between CDAI < 150 and CDAI ≥ 150, except that CTE yield for extraluminal penetrating complications was significantly higher in CDAI ≥ 150 (16.2% [6/37] vs. 3.9% [2/51]; multivariable-adjusted p = 0.029). CTE showed 92.3% (12/13) sensitivity and 83.3% (15/18) specificity for anastomotic recurrence. CONCLUSION CTE may be a viable option for the early postsurgical surveillance of recurred disease in CD patients.
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Affiliation(s)
- In Young Choi
- Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan 15355, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Chang Sik Yu
- Department of Colorectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Yong Sik Yoon
- Department of Colorectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Jong Lyul Lee
- Department of Colorectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Ah Young Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
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Hausmann J, Schmelz R, Walldorf J, Filmann N, Zeuzem S, Albert JG. Pan-intestinal capsule endoscopy in patients with postoperative Crohn's disease: a pilot study. Scand J Gastroenterol 2017; 52:840-845. [PMID: 28431493 DOI: 10.1080/00365521.2017.1310289] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients are at increased risk of disease recurrence after surgical treatment of Crohn's disease. Endoscopic detection of postoperative, ileo-colonic inflammation is well established, but the potential of pan-intestinal endoscopy is yet unknown. METHODS This prospective multicenter pilot study assessed the value of pan-intestinal capsule endoscopy using a colon capsule endoscope for the detection of inflammatory recurrence of Crohn´s disease. Patients who had been operatively treated for Crohn´s disease were included. Colon capsule endoscopy was performed 4-8 weeks (d1) and 4-8 months (d2) postoperatively together with ileo-colonoscopy at d2 using a modified Ruttgeerts index for evaluating disease activity. RESULTS Twenty-two patients were included into this study. At d1, significant disease activity (Ruttgeerts index ≥2) was detected in 3/16 (19%) of the patients. At d2, half of the patients (6/12) showed active disease, whereas ileo-colonoscopy revealed significant inflammation in 5/15 (33%). All patients rated as having active disease by ileo-colonoscopy had been revealed by PICE as well. These findings influenced the medical treatment in every case. CONCLUSION Pan-intestinal capsule endoscopy seems to be feasible in the postoperative surveillance of Crohn's disease. Disease activity is reliably detected. Especially, the findings in the small bowl might be a significant advantage in comparison to ileo-colonoscopy, as they can have significant impact on clinical management. Further studies with a larger number of patients are needed to confirm these findings and might lead to a replacement of the flexible ileo-colonoscopy with pan-intestinal capsule endoscopy in this indication in the future.
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Affiliation(s)
- Johannes Hausmann
- a Department of Internal Medicine 1 , J.W. Goethe University Hospital Frankfurt , Frankfurt , Germany
| | - Renate Schmelz
- b Department of Internal Medicine 1 , University Hospital Carl Gustav Carus , Dresden , Germany
| | - Jens Walldorf
- c Department of Internal Medicine 1 , University Hospital Halle (Saale) , Halle , Germany
| | - Natalie Filmann
- d Institute of Biostatistics and Math Modeling, J.W. Goethe University Hospital Frankfurt , Frankfurt , Germany
| | - Stefan Zeuzem
- a Department of Internal Medicine 1 , J.W. Goethe University Hospital Frankfurt , Frankfurt , Germany
| | - Jörg G Albert
- a Department of Internal Medicine 1 , J.W. Goethe University Hospital Frankfurt , Frankfurt , Germany
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Dirrenberger B, Clerc-Urmès I, Germain A, Bresler L, Olivera P, Martelli L, Danese S, Baumann C, Laurent V, Peyrin-Biroulet L. Value of cross-sectional imaging in assessing active Crohn's disease before stoma reversal. Dig Liver Dis 2017; 49:864-871. [PMID: 28454853 DOI: 10.1016/j.dld.2017.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/28/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are currently no guidelines on the need to assess disease activity before stoma reversal in Crohn's disease (CD). We sought to determine the value of cross-sectional imaging for detecting active CD before stoma reversal. METHODS 38 CD patients underwent cross-sectional imaging before stoma reversal. CD activity was blindly evaluated by an independent radiologist. Postoperative outcomes were recorded. RESULTS Before stoma reversal, cross-sectional imaging identified active CD in 20 of the 38 study participants (52.6%). In 9 out of 10 tested patients, radiologic and endoscopic assessments gave concordant findings with regard to CD recurrence before stoma reversal. Stoma reversal was delayed in half of the patients with active CD and in none of the patients without active CD. Before stoma reversal, tumor necrosis factor alpha antagonists or immunosuppressants were initiated in 45% of the patients with active CD and 5.6% of the patients without active CD. In the year following stoma reversal, the recurrence rate (in a radiologic assessment) was higher in patients with active CD than in patients without active CD (75.0% vs. 30.8%, respectively; p=0.04). CONCLUSION Cross-sectional imaging revealed postoperative recurrence in about a quarter of patients before stoma reversal; this finding may influence the postoperative treatment strategy and outcomes.
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Affiliation(s)
- Bastien Dirrenberger
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | - Isabelle Clerc-Urmès
- ESPRI-BioBase Unit, PARC Clinical Research Support Facility, Nancy University Medical Center, Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, Nancy University Medical Center, Nancy, France
| | - Laurent Bresler
- Department of Digestive Surgery, Nancy University Medical Center, Nancy, France
| | - Pablo Olivera
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | - Laura Martelli
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | | | - Cédric Baumann
- ESPRI-BioBase Unit, PARC Clinical Research Support Facility, Nancy University Medical Center, Nancy, France
| | - Valérie Laurent
- Department of Radiology, Nancy University Medical Center, Nancy, France
| | - Laurent Peyrin-Biroulet
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France.
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Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre la monitorización, prevención y tratamiento de la recurrencia posquirúrgica en la enfermedad de Crohn. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:472-483. [DOI: 10.1016/j.gastrohep.2017.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/13/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022]
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44
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Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
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Ding NS, Yip WM, Choi CH, Saunders B, Thomas-Gibson S, Arebi N, Humphries A, Hart A. Endoscopic Dilatation of Crohn's Anastomotic Strictures is Effective in the Long Term, and Escalation of Medical Therapy Improves Outcomes in the Biologic Era. J Crohns Colitis 2016; 10:1172-8. [PMID: 26971054 DOI: 10.1093/ecco-jcc/jjw072] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS To investigate the long-term efficacy of endoscopic dilatation of Crohn's anastomotic strictures and to identify risk and protective factors associated with the need for repeat dilatation or surgery. METHODS A total of 54 patients who had endoscopic balloon dilatations for anastomotic Crohn's strictures between 2004 and 2009, with follow-up until June 2014, were identified from a single tertiary center. The primary end points were repeat dilatation or surgical resection, and the impact of radiology, medical therapy, and endoscopic data on these outcomes was analysed with Cox proportional hazards analysis. RESULTS A total of 151 dilatations were performed on patients with a median age of 52 years [interquartile range (IQR), 46-62 years]. The median duration from the first to the second dilatation was 6 years (IQR, 5-7 years). The median disease duration was 28 years (IQR, 19-32 years). At endoscopy, disease activity was reported in 50/54 (92%) cases, with a median Rutgeerts grading of i2 (range, i0-i4). A median of two (IQR 1-9) dilatations was required, with a time to repeat dilatation of 23 months (IQR 7.2-56.9). Escalation of medical therapy was adopted in 22/54 patients (41% of the study population). On multivariate analysis, only combination therapy (anti-TNFα and immunomodulator) was significantly associated with the (decreased) need for repeated dilatation [hazard ratio (HR) 0.23; 95% CI, 0.07-0.67; p = 0.01]. Anastomotic resections were performed in 10 (18%) patients, with a Rutgeerts score of i4 at initial endoscopic balloon dilatation being associated with this outcome (HR 4.55; 95% CI 1.08-19.29; p = 0.04) on multivariate analysis. CONCLUSION Endoscopic balloon dilatation of Crohn's anastomotic strictures is safe and effective in the long term. We demonstrate that active disease predicts for future surgery, while escalation of medical therapy may decrease the need for repeat dilatation.
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Affiliation(s)
- Nik Sheng Ding
- Inflammatory Bowel Disease, St Mark's Hospital, London, UK Faculty of Medicine, Imperial College, London, UK
| | - Wai Man Yip
- Inflammatory Bowel Disease, St Mark's Hospital, London, UK
| | - C H Choi
- Inflammatory Bowel Disease, St Mark's Hospital, London, UK
| | - Brian Saunders
- Faculty of Medicine, Imperial College, London, UK Wolfson Endoscopy Unit, St Mark's Hospital, London, UK
| | - Siwan Thomas-Gibson
- Faculty of Medicine, Imperial College, London, UK Wolfson Endoscopy Unit, St Mark's Hospital, London, UK
| | - Naila Arebi
- Inflammatory Bowel Disease, St Mark's Hospital, London, UK Faculty of Medicine, Imperial College, London, UK
| | - Adam Humphries
- Faculty of Medicine, Imperial College, London, UK Wolfson Endoscopy Unit, St Mark's Hospital, London, UK
| | - Ailsa Hart
- Inflammatory Bowel Disease, St Mark's Hospital, London, UK Faculty of Medicine, Imperial College, London, UK
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46
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Evolving roles of cross-sectional imaging in Crohn's disease. Dig Liver Dis 2016; 48:975-83. [PMID: 27338853 DOI: 10.1016/j.dld.2016.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/13/2016] [Accepted: 05/21/2016] [Indexed: 12/11/2022]
Abstract
The implementation of cross-sectional imaging techniques for the clinical management of Crohn's disease patients has steadily grown over the recent years, thanks to a series of technological advances, including the evolution of contrast media for magnetic resonance, computed tomography and bowel ultrasound. This has resulted in a continuous improvement of diagnostic accuracy and capability to detect Crohn's disease-related complications. Additionally, a progressive widening of indications for cross-sectional imaging in Crohn's disease has been put forward, thus leading to hypothesize that in the near future imaging techniques can increasingly complement endoscopy in most clinical settings, including the grading of disease activity and the assessment of mucosal healing or Crohn's disease post-surgical recurrence.
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47
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Campbell JP, Vaughn BP. Optimal delivery of follow-up care after surgery for Crohn's disease: current perspectives. Clin Exp Gastroenterol 2016; 9:237-48. [PMID: 27540307 PMCID: PMC4982489 DOI: 10.2147/ceg.s96078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite improvements in medical therapies for Crohn’s disease (CD), up to 70% of patients require surgery within 10 years of diagnosis. Surgery is not curative, and almost all patients will experience endoscopic recurrence, and many will go on to clinical recurrence. Identifying patients at high-risk of endoscopic recurrence and standardizing postoperative assessments are essential in preventing clinical recurrence of CD. In this review, we discuss the assessment, monitoring, and treatment of postoperative CD patients. We address the various individual risk factors as well as composite risk factors. Medications used for primary CD treatment can be used in the postoperative setting to prevent endoscopic or clinical recurrence with varying efficacy, although the cost-effectiveness of these approaches are not fully understood. Future directions for postoperative CD management include evaluation of newer biologic agents such as anti-integrin therapy and fecal microbiota transplant for prevention of recurrence. Development of a standard preoperative risk assessment tool to clearly stratify those at high-risk of recurrence is necessary to guide empiric therapy. Lastly, the incorporation of noninvasive testing into disease monitoring will likely lead to early detection of endoscopic recurrence that will allow for tailored treatment to prevent clinical recurrence.
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Affiliation(s)
- James P Campbell
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Byron P Vaughn
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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48
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Kim DH, Carucci LR, Baker ME, Cash BD, Dillman JR, Feig BW, Fowler KJ, Gage KL, Noto RB, Smith MP, Yaghmai V, Yee J, Lalani T. ACR Appropriateness Criteria Crohn Disease. J Am Coll Radiol 2016; 12:1048-57.e4. [PMID: 26435118 DOI: 10.1016/j.jacr.2015.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/08/2015] [Indexed: 12/11/2022]
Abstract
Crohn disease is a chronic inflammatory disorder involving the gastrointestinal tract, characterized by episodic flares and times of remission. Underlying structural damage occurs progressively, with recurrent bouts of inflammation. The diagnosis and management of this disease process is dependent on several clinical, laboratory, imaging, endoscopic, and histologic factors. In recent years, with the maturation of CT enterography, and MR enterography, imaging has played an increasingly important role in relation to Crohn Disease. In addition to these specialized examination modalities, ultrasound and routine CT have potential uses. Fluoroscopy, radiography, and nuclear medicine may be less beneficial depending on the clinical scenario. The imaging modality best suited to evaluating this disease may change, depending on the target population, severity of presentation, and specific clinical situation. This document presents seven clinical scenarios (variants) in both the adult and pediatric populations and rates the appropriateness of the available imaging options. They are summarized in a consolidated table, and the underlying rationale and supporting literature are presented in the accompanying narrative. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- David H Kim
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin.
| | - Laura R Carucci
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | | | | | | | - Barry W Feig
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Richard B Noto
- Brown University Rhode Island Hospital, Providence, Rhode Island
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Judy Yee
- University of California San Francisco, San Francisco, California
| | - Tasneem Lalani
- Inland Imaging Associates and University of Washington, Seattle, Washington
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CT and MR enterography in Crohn's disease: current and future applications. ACTA ACUST UNITED AC 2016; 40:965-74. [PMID: 25637127 DOI: 10.1007/s00261-015-0360-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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50
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Defining Disease Severity in Inflammatory Bowel Diseases: Current and Future Directions. Clin Gastroenterol Hepatol 2016; 14:348-354.e17. [PMID: 26071941 DOI: 10.1016/j.cgh.2015.06.001] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 02/07/2023]
Abstract
Although most treatment algorithms in inflammatory bowel disease (IBD) begin with classifying patients according to disease severity, no formal validated or consensus definitions of mild, moderate, or severe IBD currently exist. There are 3 main domains relevant to the evaluation of disease severity in IBD: impact of the disease on the patient, disease burden, and disease course. These measures are not mutually exclusive and the correlations and interactions between them are not necessarily proportionate. A comprehensive literature search was performed regarding current definitions of disease severity in both Crohn's disease and ulcerative colitis, and the ability to categorize disease severity in a particular patient. Although numerous assessment tools for symptoms, quality of life, patient-reported outcomes, fatigue, endoscopy, cross-sectional imaging, and histology (in ulcerative colitis) were identified, few have validated thresholds for categorizing disease activity or severity. Moving forward, we propose a preliminary set of criteria that could be used to classify IBD disease severity. These are grouped by the 3 domains of disease severity: impact of the disease on the patient (clinical symptoms, quality of life, fatigue, and disability); measurable inflammatory burden (C-reactive protein, mucosal lesions, upper gastrointestinal involvement, and disease extent), and disease course (including structural damage, history/extension of intestinal resection, perianal disease, number of flares, and extraintestinal manifestations). We further suggest that a disease severity classification should be developed and validated by an international group to develop a pragmatic means of identifying patients with severe disease. This is increasingly important to guide current therapeutic strategies for IBD and to develop treatment algorithms for clinical practice.
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