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Mitelpunkt A, Stodola MA, Vargus-Adams J, Kurowski BG, Greve K, Bhatnagar S, Aronow B, Zahner J, Bailes AF. A big data approach to evaluate receipt of optimal care in childhood cerebral palsy. Disabil Rehabil 2024; 46:723-730. [PMID: 36755522 PMCID: PMC10406971 DOI: 10.1080/09638288.2023.2175919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
PURPOSE Through automated electronic health record (EHR) data extraction and analysis, this project systematically quantified actual care delivery for children with cerebral palsy (CP) and evaluated alignment with current evidence-based recommendations. METHODS Utilizing EHR data for over 8000 children with CP, we developed an approach to define and quantify receipt of optimal care, and pursued proof-of-concept with two children with unilateral CP, Gross Motor Function Classification System (GMFCS) Level II. Optimal care was codified as a cluster of four components including physical medicine and rehabilitation (PMR) care, spasticity management, physical therapy (PT), and occupational therapy (OT). A Receipt of Care Score (ROCS) quantified the degree of adherence to recommendations and was compared with the Pediatric Outcomes Data Collection Instrument (PODCI) and Pediatric Quality of Life Inventory (PEDS QL). RESULTS The two children (12 year old female, 13 year old male) had nearly identical PMR and spasticity component scores while PT and OT scores were more divergent. Functional outcomes were higher for the child who had higher adjusted ROCS. CONCLUSIONS ROCSs demonstrate variation in real-world care delivered over time and differentiate between components of care. ROCSs reflect overall function and quality of life. The ROCS methods developed are novel, robust, and scalable and will be tested in a larger sample.IMPLICATIONS FOR REHABILITATIONOptimal practice, with an emphasis on integrated multidisciplinary care, can be defined and quantified utilizing evidence-based recommendations.Receipt of optimal care for childhood cerebral palsy can be scored using existing electronic health record data.Big Data approaches can contribute to the understanding of current care and inform approaches for improved care.
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Affiliation(s)
- Alexis Mitelpunkt
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Pediatric Rehabilitation, Department of Rehabilitation, Dana-Dwek Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Jilda Vargus-Adams
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brad G. Kurowski
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelly Greve
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Surbhi Bhatnagar
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Bruce Aronow
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Janet Zahner
- Department of Information Services, University of Cincinnati, Cincinnati, OH, USA
| | - Amy F. Bailes
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati, Cincinnati, OH, USA
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Krasnovsky L, Weber AT, Gershuni V, Pettke E, Lewis JD. Preoperative Exclusive Enteral Nutrition Is Associated With Reduced Skin and Soft Tissue and Intra-abdominal Infections in Patients With Crohn's Disease Undergoing Intestinal Surgery: Results from a Meta-Analysis. Inflamm Bowel Dis 2024:izad304. [PMID: 38262631 DOI: 10.1093/ibd/izad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Malnutrition is an independent risk factor for adverse postoperative outcomes and is common among patients with Crohn's disease (CD). The objective of this meta-analysis was to precisely quantify the association of preoperative exclusive enteral nutrition (EEN) and total parenteral nutrition (TPN) with surgical outcomes in patients undergoing intestinal surgery for CD. METHODS PubMed, Embase, and Scopus were queried for comparative studies evaluating the impact of preoperative nutritional support on postoperative outcomes in patients undergoing surgery for CD. Random effects modeling was used to compute pooled estimates of risk difference. Heterogeneity was assessed using I2. RESULTS Fourteen studies, all nonrandomized cohort studies, met inclusion criteria for studying EEN. After pooling data from 14 studies (874 EEN treated and 1044 control patients), the relative risk of intra-abdominal septic complications was decreased 2.1-fold in patients receiving preoperative EEN (relative risk 0.47, 95% confidence interval [CI], 0.35-0.63, I2 = 0.0%). After pooling data from 9 studies (638 EEN treated and 819 control patients), the risk of skin and soft tissue infection was decreased 1.6-fold (relative risk 0.63; 95% CI, 0.42-0.94, I2 = 42.7%). No significant differences were identified in duration of surgery, length of bowel resected, or operative blood loss. Among the 9 studies investigating TPN, no significant differences were identified in infectious outcomes. CONCLUSIONS Preoperative nutritional optimization with EEN was associated with reduced risk of infectious complications in CD patients undergoing intestinal surgery. Preoperative nutritional support with EEN should be considered for optimizing outcomes in CD patients requiring bowel resection surgery.
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Affiliation(s)
- Lev Krasnovsky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew T Weber
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Gershuni
- Division of Gastrointestinal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erica Pettke
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Hill SS, Ottaviano KE, Palange DC, Chismark AD, Valerian BT, Canete JJ, Lee EC. Impact of Preoperative Factors in Patients With IBD on Postoperative Length of Stay: A National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative Analysis. Dis Colon Rectum 2024; 67:97-106. [PMID: 37410942 DOI: 10.1097/dcr.0000000000002831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Patients with IBD are challenging to manage perioperatively because of disease complexity and multiple comorbidities. OBJECTIVE To identify whether preoperative factors and operation type were associated with extended postoperative length of stay after IBD-related surgery, defined by 75th percentile or greater (n = 926; 30.8%). DESIGN This was a cross-sectional study based on a retrospective multicenter database. SETTING The National Surgery Quality Improvement Program-Inflammatory Bowel Disease Collaborative captured data from 15 high-volume sites. PATIENTS A total of 3008 patients with IBD (1710 with Crohn's disease and 1291 with ulcerative colitis) with a median postoperative length of stay of 4 days (interquartile range, 3-7) from March 2017 to February 2020. MAIN OUTCOME MEASURES The primary outcome was extended postoperative length of stay. RESULTS On multivariable logistic regression, increased odds of extended postoperative length of stay were associated with multiple demographic and clinical factors (model p < 0.001, area under receiver operating characteristic curve = 0.85). Clinically significant contributors that increased postoperative length of stay were rectal surgery (vs colon; OR, 2.13; 95% CI, 1.52-2.98), new ileostomy (vs no ileostomy; OR, 1.50; 95% CI, 1.15-1.97), preoperative hospitalization (OR, 13.45; 95% CI, 10.15-17.84), non-home discharge (OR, 4.78; 95% CI, 2.27-10.08), hypoalbuminemia (OR, 1.66; 95% CI, 1.27-2.18), and bleeding disorder (OR, 2.42; 95% CI, 1.22-4.82). LIMITATIONS Retrospective review of only high-volume centers. CONCLUSIONS Patients with IBD who were preoperatively hospitalized, who had non-home discharge, and who underwent rectal surgery had the highest odds of extended postoperative length of stay. Associated patient characteristics included bleeding disorder, hypoalbuminemia, and ASA classes 3 to 5. Chronic corticosteroid, immunologic, small molecule, and biologic agent use were insignificant on multivariable analysis. See Video Abstract. IMPACTO DE LOS FACTORES PREOPERATORIOS EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL EN LA DURACIN DE LA ESTANCIA POSTOPERATORIA UN ANLISIS COLABORATIVO DEL PROGRAMA NACIONAL DE MEJORA DE LA CALIDAD QUIRRGICAENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal son difíciles de manejar perioperatoriamente debido a la complejidad de la enfermedad y a múltiples comorbilidades.OBJETIVO:Este estudio tuvo como objetivo identificar si los factores preoperatorios y el tipo de operación se asociaron con una estadía postoperatoria prolongada después de una cirugía relacionada con enfermedad inflamatoria intestinal, definida por el percentil 75 o mayor (n = 926, 30.8%).DISEÑO:Este fue un estudio transversal basado en una base de datos multicéntrica retrospectiva.ESCENARIO:Datos capturados de quince sitios de alto volumen en El Programa Nacional de Mejoramiento de la Calidad de la Cirugía-Enfermedad Intestinal Inflamatoria en colaboración.PACIENTES:Un total de 3,008 pacientes con enfermedad inflamatoria intestinal (1,710 con enfermedad de Crohn y 1,291 con colitis ulcerosa) con una mediana de estancia postoperatoria de 4 días (RIC 3-7) desde marzo de 2017 hasta febrero de 2020.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la extensión de la estancia postoperatoria.RESULTADOS:En la regresión logística multivariable, el aumento de las probabilidades de prolongar la estancia postoperatoria se asoció con múltiples factores demográficos y clínicos (modelo p<0.001, área bajo la curva ROC - 0.85). Los contribuyentes clínicamente significativos que aumentaron la duración de la estancia postoperatoria fueron la cirugía rectal (frente al colon) (OR 2.13, IC del 95 %: 1.52 a 2.98), una nueva ileostomía (frente a ninguna ileostomía) (OR 1.50, IC del 95 %: 1.15 a 1.97), hospitalización preoperatoria (OR 13.45, IC 95% 10.15-17.84), alta no domiciliaria (OR 4.78, IC 95% 2.27-10.08), hipoalbuminemia (OR 1.66, IC 95% 1.27-2.18) y trastorno hemorrágico (OR 2.42, IC 95% 1.22-4.82).LIMITACIONES:Revisión retrospectiva de solo centros de alto volumen.CONCLUSIONES:Los pacientes con enfermedad inflamatoria intestinal que fueron hospitalizados antes de la operación, que tuvieron alta no domiciliaria y que se sometieron a cirugía rectal tuvieron las mayores probabilidades de prolongar la estancia postoperatoria. Las características asociadas de los pacientes incluyeron trastorno hemorrágico, hipoalbuminemia y clases ASA 3-5. El uso crónico de corticosteroides, inmunológicos, agentes de moléculas pequeñas y de agentes biológicos no fue significativo en el análisis multivariable. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Susanna S Hill
- Department of Surgery, Section of Colon and Rectal Surgery, Albany Medical Center, Albany, New York
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Vieujean S, Kotze PG, Netter P, Germain A, Louis E, Danese S, Peyrin-Biroulet L. Stemming the tide with ileocecal Crohn's disease: when is pharmacotherapy enough? Expert Opin Pharmacother 2023; 24:1595-1607. [PMID: 37401098 DOI: 10.1080/14656566.2023.2232726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 06/30/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Crohn's disease (CD) mostly affects the terminal ileum and ileocecal region and up to 80% of patients end up requiring surgery. Previously reserved for complicated or refractory forms, surgery is now considered as an alternative to medical treatment in localized ileocecal disease. AREAS COVERED This review examines factors associated with response to medical treatment and those associated with the need for surgery in ileocecal CD to identify the patients' profile for whom pharmacotherapy might be enough. Factors associated with the recurrence and the postoperative complications are also reviewed to help the clinician identify patients for whom medical therapy might be preferred. EXPERT’S OPINION LIR!C study long-term follow-up data show that 38% of infliximab-treated patients were still treated with infliximab at the end of their follow-up, while 14% had switched to another biologic or had received immunomodulator or corticosteroid and 48% had CD-related surgery. Only the combination with an immunomodulator was associated with a greater likelihood of continuing infliximab. Patients with ileocecal CD for whom pharmacotherapy might be sufficient are probably those with no risk factors for CD-related surgery.In addition, patients with high risk of recurrence or of post-operative complications may benefit more from medical treatment than from surgery.
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Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná, Curitiba, Brazil
| | - Patrick Netter
- Université de Lorraine, CNRS, Laboratoire IMoPa, Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-Les-Nancy, France
| | - Edouard Louis
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, INSERM, NGERE, Nancy, France
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Valvano M, Capannolo A, Cesaro N, Stefanelli G, Fabiani S, Frassino S, Monaco S, Magistroni M, Viscido A, Latella G. Nutrition, Nutritional Status, Micronutrients Deficiency, and Disease Course of Inflammatory Bowel Disease. Nutrients 2023; 15:3824. [PMID: 37686856 PMCID: PMC10489664 DOI: 10.3390/nu15173824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
During the disease course, most Inflammatory Bowel Disease patients present a condition of malnutrition, undernutrition, or even overnutrition. These conditions are mainly due to suboptimal nutritional intake, alterations in nutrient requirements and metabolism, malabsorption, and excessive gastrointestinal losses. A suboptimal nutritional status and low micronutrient serum levels can have a negative impact on both induction and maintenance of remission and on the quality of life of Inflammatory Bowel Disease patients. We performed a systematic review including all the studies evaluating the connection between nutrition, nutrition status (including undernutrition and overnutrition), micronutrient deficiency, and both disease course and therapeutic response in Inflammatory Bowel Disease patients. This systematic review was performed using PubMed/MEDLINE and Scopus. Four main clinical settings concerning the effect of nutrition on disease course in adult Inflammatory Bowel Disease patients were analyzed (induction of remission, maintenance of remission, risk of surgery, post-operative recurrence, and surgery-related complications). Four authors independently reviewed abstracts and manuscripts for eligibility. 6077 articles were found; 762 duplicated studies were removed. Out of 412 full texts analyzed, 227 were included in the review. The evidence summarized in this review showed that many nutritional aspects could be potential targets to induce a better control of symptoms, a deeper remission, and overall improve the quality of life of Inflammatory Bowel Disease patients.
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Affiliation(s)
- Marco Valvano
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
- Division of Gastroenterology, Galliera Hospital, 16128 Genoa, Italy;
| | - Annalisa Capannolo
- Diagnostic and Surgical Endoscopy Unit, San Salvatore Academic Hospital, 67100 L’Aquila, Italy;
| | - Nicola Cesaro
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | | | - Stefano Fabiani
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Sara Frassino
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Sabrina Monaco
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Marco Magistroni
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Angelo Viscido
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Giovanni Latella
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
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Sebastian S, Segal JP, Hedin C, Pellino G, Kotze PG, Adamina M, Campmans-Kuijpers M, Davies J, de Vries AC, Casbas AG, El-Hussuna A, Juillerat P, Meade S, Millán M, Spinelli A. ECCO Topical Review: Roadmap to Optimal Peri-Operative Care in IBD. J Crohns Colitis 2023; 17:153-169. [PMID: 36055337 DOI: 10.1093/ecco-jcc/jjac129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases [IBD] require surgical intervention. This Topical Review aims to offer expert consensus practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery. METHODS A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology. RESULTS A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care. CONCLUSION Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.
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Affiliation(s)
- Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals, Hull, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Jonathan P Segal
- Northern Hospital Epping, Melbourne, Australia
- University of Melbourne, Parkville, Melbourne, Australia
| | - Charlotte Hedin
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
- Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná [PUCPR], Curitiba, Brazil
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ana Gutiérrez Casbas
- Gastroenterology Department, Hospital General Universitario de Alicante, ISABIAL and CIBERehd, Alicante, Spain
| | - Alaa El-Hussuna
- OpenSourceResearch organisation (osrc.network), Aalborg, Denmark
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Susanna Meade
- Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
| | - Monica Millán
- General Surgery, Colorectal Unit, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
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Mullin G, Zager Y, Anteby R, Jacoby H, Kent I, Ram E, Nachmany I, Horesh N. Inflammatory markers may predict post-operative complications and recurrence in Crohn's disease patients undergoing gastrointestinal surgery. ANZ J Surg 2022; 92:2538-2543. [PMID: 35733396 PMCID: PMC9796487 DOI: 10.1111/ans.17852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Most Crohn's Disease (CD) patients will require surgical intervention over their lifetime, with considerably high rates of post-operative complications. Risk stratification with reliable prognostic tools may facilitate clinical decision making in these patients. Blood cell interaction based inflammatory markers have proven useful in predicting patient outcomes in oncological and benign diseases. The aim of this study was to investigate their prognostic value in CD patients undergoing surgery. METHODS A retrospective single institution study of CD patients who underwent surgery between the years 2008 and 2019 was conducted. Data were collected from medical records and analysed for association of Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Lymphocyte-to-Monocyte Ratio (LMR) and the modified Systemic Inflammatory Score (mSIS) with post-operative outcomes. RESULTS A total of 81 patients were included in the analysis. Half were females; mean age was 36 ± 15.54 years. Fifty seven percent (n = 46) were operated in expedited settings, with 23.5% developing post-operative complications. In elective patients, higher pre-operative NLR (P = 0.029) and PLR (P = 0.034) were associated with major post-operative complications, higher NLR (P = 0.029) and PLR (P = 0.034) were associated with re-operation and higher PLR correlated with Clavien-Dindo score (P = 0.032). In patients operated in expedited operations, higher pre-operative NLR (P = 0.021) and lower pre-operative LMR (P = 0.018) were associated with thromboembolic events and higher mSIS was associated with major post-operative complications (P = 0.032). CONCLUSIONS Blood cell interaction based inflammatory markers confer an association with post-operative complications in CD patients undergoing surgery. These indices may facilitate patient selection and optimization when considering the risks and benefits of surgical interventions.
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Affiliation(s)
- Gil Mullin
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Yaniv Zager
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Roi Anteby
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Harel Jacoby
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Ilan Kent
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Edward Ram
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Ido Nachmany
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
| | - Nir Horesh
- Department of Surgery and Transplantations BChaim Sheba Medical CenterTel‐HashomerIsrael
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Meade S, Patel KV, Luber RP, O'Hanlon D, Caracostea A, Pavlidis P, Honap S, Anandarajah C, Griffin N, Zeki S, Ray S, Mawdsley J, Samaan MA, Anderson SH, Darakhshan A, Adams K, Williams A, Sanderson JD, Lomer M, Irving PM. A retrospective cohort study: pre-operative oral enteral nutritional optimisation for Crohn's disease in a UK tertiary IBD centre. Aliment Pharmacol Ther 2022; 56:646-663. [PMID: 35723622 PMCID: PMC9544188 DOI: 10.1111/apt.17055] [Citation(s) in RCA: 11] [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: 12/20/2021] [Revised: 01/04/2022] [Accepted: 05/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low-quality evidence suggests that pre-operative exclusive enteral nutrition (E/EN) can improve postoperative outcomes in patients with Crohn's disease (CD). It is not standard practice in most centres. AIMS To test the hypothesis that pre-operative EN in patients undergoing ileal/ileocolonic surgery for CD is associated with improved postoperative outcome. METHODS We performed a single centre retrospective observational study comparing surgical outcomes in patients receiving pre-operative EN (≥600 kcal/day for ≥2 weeks) with those who received no nutritional optimisation. Consecutive adult patients undergoing ileal/ileocolonic resection from 2008 to 2020 were included. The primary outcome was postoperative complications <30 days. Secondary outcomes included EN tolerance, specific surgical complications, unplanned stoma formation, length of stay, length of bowel resected, readmission and biochemical/anthropometric changes. RESULTS 300 surgeries were included comprising 96 without nutritional optimisation and 204 optimised cases: oral EN n = 173, additional PN n = 31 (4 of whom had received nasogastric/nasojejunal EN). 142/204 (69.6%) tolerated EN. 125/204 (61.3%) initiated EN in clinic. Patients in the optimised cohort were younger at operation and diagnosis, with an increased frequency of penetrating disease and exposure to antibiotics or biologics, and were more likely to undergo laparoscopic surgery. The optimised cohort had favourable outcomes on multivariate analysis: all complications [OR 0.29; 0.15-0.57, p < 0.001], surgical complications [OR 0.41; 95% CI 0.20-0.87, p = 0.02], non-surgical complications [OR 0.24 95% CI 0.11-0.52, p < 0.001], infective complications [OR 0.32; 95% CI 0.16-0.66, p = 0.001]. CONCLUSIONS Oral EN was reasonably well tolerated and associated with a reduction in 30-day postoperative complications. Randomised controlled trials are required to confirm these findings.
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Affiliation(s)
- Susanna Meade
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Kamal V. Patel
- Department of GastroenterologySt George's HospitalLondonUK
| | | | | | | | | | - Sailish Honap
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Sebastian Zeki
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Shuvra Ray
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Joel Mawdsley
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Mark A. Samaan
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Katie Adams
- Department of Colorectal SurgerySt Thomas' HospitalLondonUK
| | | | | | | | - Peter M. Irving
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK,School of Immunology and Microbial SciencesKing's College LondonUK
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9
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Ferrandis C, Souche R, Bardol T, Boivineau L, Fabre JM, Altwegg R, Guillon F. Personalized pre-habilitation reduces anastomotic complications compared to up front surgery before ileocolic resection in high-risk patients with Crohn's disease: A single center retrospective study. Int J Surg 2022; 105:106815. [DOI: 10.1016/j.ijsu.2022.106815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 12/12/2022]
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10
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El-Hussuna A, Karer MLM, Uldall Nielsen NN, Mujukian A, Fleshner PR, Iesalnieks I, Horesh N, Kopylov U, Jacoby H, Al-Qaisi HM, Colombo F, Sampietro GM, Marino MV, Ellebæk M, Steenholdt C, Sørensen N, Celentano V, Ladwa N, Warusavitarne J, Pellino G, Zeb A, Di Candido F, Hurtado-Pardo L, Frasson M, Kunovsky L, Yalcinkaya A, Tatar OC, Alonso S, Pera M, Granero AG, Rodríguez CA, Minaya A, Spinelli A, Qvist N. Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease. BJS Open 2021; 5:6369776. [PMID: 34518869 PMCID: PMC8438259 DOI: 10.1093/bjsopen/zrab075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD. METHODS A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes. RESULTS The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042). CONCLUSION Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.
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Affiliation(s)
- A El-Hussuna
- Department of Clinical Medicin, Aalborg University, Aalborg, Denmark
| | - M L M Karer
- Department of Clinical Medicin, Aalborg University, Aalborg, Denmark
| | | | - A Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - P R Fleshner
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - I Iesalnieks
- Department of Surgery, Städtisches Klinikum München Bogenhausen, Munich, Germany
| | - N Horesh
- Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of gastroentrology, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel
| | - U Kopylov
- Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of gastroentrology, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel
| | - H Jacoby
- Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of gastroentrology, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel
| | - H M Al-Qaisi
- Department of Surgery, Aalborg University Hospital, Denmark
| | - F Colombo
- Division of General and HPB Surgery, Luigi Sacco Hospital, Milan, Italy
| | - G M Sampietro
- Department of Surgery, Università degli Studi di Milano, Milan, Italy
| | - M V Marino
- Department of Surgery, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - M Ellebæk
- Research Unit for Surgery and IBD-Care, Odense University Hospital, Odense, Denmark
| | - C Steenholdt
- Department of Gastroentrology, Herlev University Hospital, Herlev, Denmark
| | - N Sørensen
- Department of Surgery, Aalborg University Hospital, Denmark
| | - V Celentano
- Department of Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - N Ladwa
- Department of Surgery, St Mark's and Northwick Park Hospital, UK
| | - J Warusavitarne
- Department of Surgery, St Mark's and Northwick Park Hospital, UK
| | - G Pellino
- Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Zeb
- Department of Surgery, Hvidovre Hospital, Denmark
| | - F Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Centre IRCCS, Humanitas University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - L Hurtado-Pardo
- Department of Surgery, University Hospital La Fe, University of Valencia, Spain
| | - M Frasson
- Department of Surgery, University Hospital La Fe, University of Valencia, Spain
| | - L Kunovsky
- Department of Surgery, University Hospital Brno, Brno, Czech Republic.,Department of Gastroenterology and Internal Medicine, University Hospital Brno, Brno, Czech Republic
| | - A Yalcinkaya
- Department of Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - O C Tatar
- Department of Surgery, Kocaeli University School of Medicine, Turkey
| | - S Alonso
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - M Pera
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - A G Granero
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Mallorca, Spain
| | - C A Rodríguez
- Department of Surgery, Universidad Francisco de Vitoria, Madrid, Spain.,Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - A Minaya
- Department of Surgery, Universidad Francisco de Vitoria, Madrid, Spain.,Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Centre IRCCS, Humanitas University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - N Qvist
- Department of Clinical Medicin, Aalborg University, Aalborg, Denmark.,Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of Surgery, Aalborg University Hospital, Denmark.,Research Unit for Surgery and IBD-Care, Odense University Hospital, Odense, Denmark.,Department of Surgery, St Mark's and Northwick Park Hospital, UK.,Department of Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey.,Department of Surgery, Universidad Francisco de Vitoria, Madrid, Spain.,Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
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11
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Systematic review and meta-analysis: risks of postoperative complications with preoperative use of anti-tumor necrosis factor-alpha biologics in inflammatory bowel disease patients. Eur J Gastroenterol Hepatol 2021; 33:799-816. [PMID: 33079779 DOI: 10.1097/meg.0000000000001944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The preoperative use of anti-tumor necrosis factor-alpha (anti-TNF) in inflammatory bowel disease (IBD) patients undergoing surgery has been controversial due to concern for increased risks of postoperative complications. We aimed to determine the effect of preoperative anti-TNF therapy on postoperative complications in IBD patients undergoing abdominal surgery. METHODS A literature search of Google Scholar, PubMed, The Cochrane Library, EMBASE, and CINAHL was performed through October 2019. Studies reporting postoperative complication rates of Crohn's disease (CD), ulcerative colitis (UC), and IBD-unspecified patients with preoperative anti-TNF treatment undergoing abdominal surgery compared to controls without preoperative anti-TNF treatment were included. The main outcomes measured were overall, infectious, and noninfectious postoperative complications. RESULTS Forty-one studies totaling 20 274 patients were included. There was a significant increase in overall complications in all patients treated with anti-TNF vs. controls [odds ratio (OR) = 1.13, 95% confidence interval (CI), 1.01-1.25, P = 0.03, I2 = 6%] with an absolute risk increase (ARI) of 5.5% and a number needed to harm (NNH) of 18. There was also a significant increase in infectious complications in CD patients (OR = 1.44; 95% CI 1.02-2.03, P = 0.04, I2 = 49%, ARI = 5.5%, NNH = 20) only. Contrastingly, there was a significant increase in noninfectious complications in all patients (OR = 1.44, 95% CI 1.13-1.85, P = 0.003, I2 = 8%, ARI = 6.4%, NNH = 16) and UC patients (OR = 1.57, 95% CI 1.15-2.14, P = 0.005, I2 = 25%, ARI = 8.5%, NNH = 12) only. CONCLUSION Preoperative use of anti-TNF agents in IBD patients undergoing abdominal surgery is associated with increases in overall postoperative complications in all patients, infectious postoperative complications in CD patients, and noninfectious postoperative complications in UC patients.
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12
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Wickramasinghe D, Adegbola S, Sahnan K, Morar P, Carvello M, Di Candido F, Maroli A, Spinelli A, Warusavitarne J. A scoring system to predict a prolonged length of stay after surgery for Crohn's disease. Colorectal Dis 2021; 23:1205-1212. [PMID: 33539619 DOI: 10.1111/codi.15567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/13/2022]
Abstract
AIM Many factors influence the postoperative length of stay (LOS) in Crohn's disease (CD). This study aims to identify the factors associated with a prolonged LOS after ileocolic resection (ICR) for CD and to develop a scoring system to predict the postoperative LOS in CD. METHOD Patient data were collected from St Marks Hospital, London, UK, and the Humanitas Clinical and Research Center Milan, Italy, for all patients who underwent an ICR for CD from 2005 to 2017. Logistic regression was used for multivariate analysis. The scoring system was developed from the logistic regression model. The performance of the scoring system was evaluated using the area under the receiver operating characteristic curve (AUROC). RESULTS A total of 628 surgeries were included in the analysis. Eighty eight surgeries were excluded due to missing data. The remaining 543 were divided into two cohorts for the development (n = 418) and validation (n = 125) of the scoring system. The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included the time since diagnosis, American Society of Anesthesiologists (ASA) grade, perioperative use of steroids, surgical access, strictureplasty and platelet count. The AUROCs for the development and validation cohorts were 0.732 and 0.7, respectively (p < 0.0001). The cut-off score suggested by Youden's index was 50, with a sensitivity of 65.6% and a specificity of 73.3%. CONCLUSION The time since diagnosis, ASA grade, steroid use, surgical access, strictureplasty and platelet count were associated with a prolonged LOS and were used to develop a scoring system. The calculator is available online at https://rebrand.ly/Crohnscal.
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Affiliation(s)
- Dakshitha Wickramasinghe
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.,St Mark's Hospital, London, UK
| | | | | | | | - Michele Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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13
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A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease. Int J Colorectal Dis 2021; 36:253-263. [PMID: 33048241 DOI: 10.1007/s00384-020-03786-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection. METHOD The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures. RESULTS The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates. CONCLUSION Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.
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14
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Sakurai Kimura CM, Scanavini Neto A, Queiroz NSF, Horvat N, Camargo MGM, Borba MR, Sobrado CW, Cecconello I, Nahas SC. Abdominal Surgery in Crohn's Disease: Risk Factors for Complications. Inflamm Intest Dis 2020; 6:18-24. [PMID: 33850835 DOI: 10.1159/000510999] [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: 04/16/2020] [Accepted: 08/17/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD. Methods A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018. Results Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively). Conclusion Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.
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Affiliation(s)
- Cintia Mayumi Sakurai Kimura
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Arceu Scanavini Neto
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Natally Horvat
- Department of Radiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Marcelo Rodrigues Borba
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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15
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McLoughlin RJ, McKie K, Hirsh MP, Cleary MA, Aidlen JT. Impact of Nutritional Deficiencies on Children and Young Adults with Crohn's Disease Undergoing Intraabdominal Surgery. J Pediatr Surg 2020; 55:1556-1561. [PMID: 31706609 DOI: 10.1016/j.jpedsurg.2019.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/23/2019] [Accepted: 10/19/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE We examined the impact of comorbidities on length of stay and total hospital charges for children and young adults with Crohn's Disease (CD) undergoing surgery. METHODS Patients (<21 years) were identified with a diagnosis of CD and an intraabdominal surgery in the Kids' Inpatient Database for the years 2006, 2009 and 2012. Length of stay (LOS) and total hospital charges (THC; USD$) were stratified by anemia, anxiety, depression and nutritional deficiency. National estimates were obtained using case weighting and multivariable linear regression was performed. RESULTS We identified 3224 CD admissions with an intraabdominal surgery. The population was predominantly male, non-Hispanic white, and high school aged. There was an increase in LOS and THC for nutritional deficiency in all study years, and for depression and anemia in specific years. Multivariable linear regression revealed a 3.3-5.5 day increase in LOS associated with a comorbid diagnosis of nutritional deficiency. However, no increase in THC was seen for any comorbidity under evaluation. CONCLUSIONS Behavioral health and, particularly, nutritional status have a significant impact on the care of children and young adults with CD. Nutritional deficiency, anemia, and depression resulted in increased LOS for those undergoing surgery. Improved presurgical management of comorbidities may reduce LOS for these patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert J McLoughlin
- University of Massachusetts Medical School, Department of Surgery, 55 Lake Ave N, Worcester, MA 01655.
| | - Kerri McKie
- University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655
| | - Michael P Hirsh
- University of Massachusetts Medical School, Department of Surgery, Division of Pediatric Surgery, 55 Lake Ave N, Worcester, MA 01655
| | - Muriel A Cleary
- University of Massachusetts Medical School, Department of Surgery, Division of Pediatric Surgery, 55 Lake Ave N, Worcester, MA 01655
| | - Jeremy T Aidlen
- University of Massachusetts Medical School, Department of Surgery, Division of Pediatric Surgery, 55 Lake Ave N, Worcester, MA 01655
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16
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Ge X, Liu H, Tang S, Wu Y, Pan Y, Liu W, Qi W, Ye L, Cao Q, Zhou W. Preoperative hypoalbuminemia is an independent risk factor for postoperative complications in Crohn's disease patients with normal BMI: A cohort study. Int J Surg 2020; 79:294-299. [PMID: 32505647 DOI: 10.1016/j.ijsu.2020.05.064] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/08/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Malnutrition is universal in Crohn's disease (CD). The body mass index (BMI) is used to assess nutritional status to predict postoperative complications in CD patients. However, some CD patients have a normal BMI. The aim of this study was to evaluate risk factors for postoperative complications in CD patients with normal preoperative BMI values. METHODS This retrospective observational study included 315 CD patients who underwent surgical treatment between December 2012 and January 2020. Patient data were collected from a prospectively maintained database. The risk factors for postoperative complications in CD patients with normal BMI values were identified by univariate and multivariate analyses. RESULTS In total, 315 eligible patients were included. The incidence of postoperative complications was 30.8%, consisting of 22.5% mild complications and 18.4% major complications. The albumin level, the C-reactive protein level, laparoscopic surgery, and operative time were significantly associated with postoperative outcomes. Multivariate analysis showed that a low preoperative albumin level (P = 0.013, OR = 2.991, 95% CI: 1.255-7.131) was an independent risk factor for postoperative complications in CD patients with normal BMI values. CONCLUSIONS A low preoperative albumin level was a risk factor for postoperative complications in CD patients with normal BMI values. Although some patients have a normal BMI, clinicians should still consider the preoperative albumin level in CD patients to evaluate their nutritional status and provide timely intervention to reduce the risk of postoperative complications.
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Affiliation(s)
- Xiaolong Ge
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huaying Liu
- Department of Medicine, GuangXi Medical College, Nanning, China
| | - Shasha Tang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yan Wu
- Department of Pharmacy, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yipeng Pan
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Liu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weilin Qi
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lingna Ye
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qian Cao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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17
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Di Candido F, Moggia E, Spinelli A. Pre-operative optimisation in Crohn's Disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Adamina M, Gerasimidis K, Sigall-Boneh R, Zmora O, de Buck van Overstraeten A, Campmans-Kuijpers M, Ellul P, Katsanos K, Kotze PG, Noor N, Schäfli-Thurnherr J, Vavricka S, Wall C, Wierdsma N, Yassin N, Lomer M. Perioperative Dietary Therapy in Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:431-444. [PMID: 31550347 DOI: 10.1093/ecco-jcc/jjz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The incidence of inflammatory bowel disease [IBD] is rising worldwide and no cure is available. Many patients require surgery and they often present with nutritional deficiencies. Although randomised controlled trials of dietary therapy are lacking, expert IBD centres have long-established interdisciplinary care, including tailored nutritional therapy, to optimise clinical outcomes and resource utilisation. This topical review aims to share expertise and offers current practice recommendations to optimise outcomes of IBD patients who undergo surgery. METHODS A consensus expert panel consisting of dietitians, surgeons, and gastroenterologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. Nutritional evaluation and dietary needs, perioperative optimis ation, surgical complications, long-term needs, and special situations were critically appraised. Statements were developed using a Delphi methodology incorporating three successive rounds. Current practice positions were set when ≥80% of participants agreed on a recommendation. RESULTS A total of 26 current practice positions were formulated which address the needs of IBD patients perioperatively and in the long term following surgery. Routine screening, perioperative optimisation by oral, enteral, or parenteral nutrition, dietary fibre, and supplements were reviewed. IBD-specific situations, including management of patients with a restorative proctocolectomy, an ostomy, strictures, or short-bowel syndrome, were addressed. CONCLUSIONS Perioperative dietary therapy improves the outcomes of IBD patients who undergo a surgical procedure. This topical review shares interdisciplinary expertise and provides guidance to optimise the outcomes of patients with Crohn's disease and ulcerative colitis. taking advantage of contemporary nutrition science.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, Glasgow Royal Infirmary, Glasgow, UK
| | - Rotem Sigall-Boneh
- PIBD Research Center, Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Zmora
- Department of Surgery, Assaf Harofeh Medical Center, Tel Aviv, Israel
| | | | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | | | - Stephan Vavricka
- Department of Surgery, Kantonsspital Winterthur, Winerthur, Switzerland
| | - Catherine Wall
- Department of Nutritional Sciences, King's College London, London, UK
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Nuha Yassin
- Department of Colorectal Surgery, Wolverhampton Hospital, Wolverhampton, UK
| | - Miranda Lomer
- Department of Nutritional Sciences, King's College London, London, UK.,Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Zittan E, Gralnek IM, Hatoum OA, Sakran N, Kolonimos N. Preoperative Exclusive Total Parental Nutrition is Associated with Clinical and Laboratory Remission in Severe Active Crohn's Disease-A Pilot Study. Nutrients 2020; 12:nu12051244. [PMID: 32353942 PMCID: PMC7281989 DOI: 10.3390/nu12051244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The effect of 1-3 months of preoperative exclusive total parental nutrition (TPN) in active Crohn's disease (CD) patients is not well established. We investigated the efficacy of exclusive TPN in active CD patients. METHODS In a retrospective multi-visit study with data according to our standard care therapy, we assessed clinical and laboratory remission to refractory CD with exclusive preoperative TPN. Inclusion required exclusive preoperative home TPN without additional oral intake for 1-3 months prior to planning surgery. RESULTS Twenty preoperative CD patients (65% male; 35% female) were on exclusive TPN. The mean age of the cohort was 30.8 ± 11.6 years. Mean duration of preoperative TPN treatment was 73 days (range: 24-142 days). Most patients had terminal ileal (35%) or ileocolonic CD (30%), and with stricturing (B2) phenotype. All 20 patients had significant clinical improvement in all disease activity indices at the end of preoperative TPN (baseline vs. post TPN): HBI 14.5 vs. 4.0 (p = 0.001); BMI 19.2 vs. 19.7 kg/m2 (p = 0.017); CRP 57.2 vs. 10.3 mg/L (p = 0.001); Fecal calprotectin (FC) 672 vs. 200 (μg/g); albumin 2.7 vs. 3.6 g/dL (p = 0.001). Two patients (10%) no longer required surgery after completion of exclusive TPN. CONCLUSION Exclusive preoperative TPN was found to provide significant improvement in nutritional status, and clinical and laboratory remission in severe active Crohn's patients.
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Affiliation(s)
- Eran Zittan
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases and the Center for IBD, HaEmek Medical Center, Afula 1834111, Israel; (I.M.G.); (N.K.)
- Correspondence:
| | - Ian M. Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases and the Center for IBD, HaEmek Medical Center, Afula 1834111, Israel; (I.M.G.); (N.K.)
- Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa 31096, Israel; (O.A.H.); (N.S.)
| | - Ossama A. Hatoum
- Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa 31096, Israel; (O.A.H.); (N.S.)
- Department of Surgery B, HaEmek Medical Center, Afula 1834111, Israel
| | - Nasser Sakran
- Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa 31096, Israel; (O.A.H.); (N.S.)
- Department of Surgery A, HaEmek Medical Center, Afula 1834111, Israel
| | - Nitzan Kolonimos
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases and the Center for IBD, HaEmek Medical Center, Afula 1834111, Israel; (I.M.G.); (N.K.)
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Nguyen GC, Du L, Chong RY, Jackson TD. Hypoalbuminaemia and Postoperative Outcomes in Inflammatory Bowel Disease: the NSQIP Surgical Cohort. J Crohns Colitis 2019; 13:1433-1438. [PMID: 31253985 PMCID: PMC6821313 DOI: 10.1093/ecco-jcc/jjz083] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The inflammatory bowel diseases [IBD], including Crohn's disease [CD] and ulcerative colitis [UC], frequently lead to bowel surgery. Hypoalbuminaemia has been shown to be a prognostic factor for outcomes following surgery for other indications, and we sought to determine its role in predicting IBD-related postoperative outcomes. METHODS We included patients who underwent IBD-related major abdominal surgery in the American College of Surgeons' National Surgical Quality Improvement Program [ACS-NSQIP] between 2005 and 2012. We assessed the impact of indicators of protein-energy malnutrition [PEM] including hypoalbuminaemia, weight loss, and body mass index on postoperative outcomes. RESULTS We identified 10 913 IBD patients [6082 Crohn's disease and 4831 ulcerative colitis] who underwent bowel surgery. The prevalence of modest and severe hypoalbuminaemia was 17% and 24%, respectively; 30-day mortality was higher in Crohn's patients with modest and severe hypoalbuminaemia compared with those with normal albumin levels preoperatively [0.7% vs 0.2%, p <0.05; 2.4% vs 0.2%, p <0.01]. The same was true for patients with UC with modest and severe hypoalbuminaemia [0.9% vs 0.1%, p <0.01; 5.6% vs 0.1%, p <0.01]. Overall infectious complications were more common in the presence of severe hypoalbuminaemia for CD [20% vs 13%, p <0.01]. and UC [28% vs 15%, p <0.01] patients. Last, there were higher rates of extra-intestinal, non-septic complications in both CD and UC patients with hypoalbuminaemia compared with those with normal albumin levels. CONCLUSIONS This study suggests that moderate-severe hypoalbuminaemia is associated with worse IBD-related postoperative outcomes and may have a role in preoperative risk stratification.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada,Corresponding author: Geoffrey C. Nguyen, MD, PhD, FRCPC, 600 University Ave, Suite 437, Toronto, Ontario, M5G 1X5, Canada. Tel.: 416-586-4800 ext. 2819; Fax: 416-586-5971;
| | - Lillian Du
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada
| | - Rachel Y Chong
- Lakeridge Health, Department of Medicine, Queen’s University, Oshawa, ON, Canada
| | - Timothy D Jackson
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada,University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada
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El-Hussuna A, Myrelid P, Holubar SD, Kotze PG, Mackenzie G, Pellino G, Winter D, Davies J, Negoi I, Grewal P, Gallo G, Sahnan K, Rubio-Perez I, Clerc D, Demartines N, Glasbey J, Regueiro M, Sherif AE, Neary P, Pata F, Silverberg M, Clermont S, Chadi SA, Emile S, Buchs N, Millan M, Minaya-Bravo A, Elfeki H, De Simone V, Shalaby M, Gutierrez C, Ozen C, Yalçınkaya A, Rivadeneira D, Sturiale A, Yassin N, Spinelli A, Warusavitarne J, Ioannidis A, Wexner S, Mayol J. Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives. CROHN'S & COLITIS 360 2019; 1. [DOI: 10.1093/crocol/otz021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
AbstractBackgroundThere is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).AimWe aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.MethodThis is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.ResultsForty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.ConclusionAlthough a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.
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Affiliation(s)
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Stefan D Holubar
- Director of Research, Department of Colon & Rectal Surgery, Cleveland, OH
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | | | - Gianluca Pellino
- Department of Surgery, Università della Campania Luigi Vanvitelli, Aversa, Italy
| | - Des Winter
- Centre for Colorectal Disease, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, Romania
| | - Perbinder Grewal
- Department of Cardiovascular, University Hospital Southampton, UK
| | - Gaetano Gallo
- Department of General Surgery, “Magna Graecia” University, Catanzaro, Italy
| | - Kapil Sahnan
- Imperial College Faculty of Medicine, Department of Surgery and St Marks Hospital, London, UK
| | - Ines Rubio-Perez
- General and Digestive Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Daniel Clerc
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - James Glasbey
- Academic Department of Surgery, University of Birmingham Heritage Building, UK
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH
| | - Ahmed E Sherif
- Department of Clinical Surgery, University of Edinburgh, UK
| | - Peter Neary
- South East Cancer Governance Lead, University Hospital Waterford/Cork, Ireland
| | - Francesco Pata
- Department of Surgery, Sant’Antonio Abate Hospital, Gallarate, Italy
| | - Mark Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, ON, Canada
| | | | - Sami A Chadi
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sameh Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Nicolas Buchs
- Department of Surgery, University Hospitals of Geneva, Switzerland
| | - Monica Millan
- Department of Surgery, Joan XXIII University Hospital, Tarragona, Spain
| | | | - Hossam Elfeki
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Veronica De Simone
- Proctology Unit, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mostafa Shalaby
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Celestino Gutierrez
- Department of Suregry, Centre Hospitalier de Redon Ille-et-Vilaine Bretagne-France
| | - Cihan Ozen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - David Rivadeneira
- Colorectal Surgery & Surgical Services, Northwell Health in Huntington, NY, USA
| | - Alssandro Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Pisa, Italy
| | - Nuha Yassin
- Department of surgery, Royal Wolverhampton Hoaspital, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
| | | | - Argyrios Ioannidis
- Department of General, Laparoscopic and Robotic Surgery, Athens Medical Center
| | - Steven Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
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Patients with Crohn’s disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications’ rate. World J Gastrointest Surg 2019; 11:261-270. [PMID: 31171957 PMCID: PMC6536884 DOI: 10.4240/wjgs.v11.i5.261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Right hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn’s disease (CD) and malignant ones like colon cancer (CC).
AIM To investigate differences in pre- and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.
METHODS This is a sub-group analysis of the European Society of Coloproctology’s prospective, multi-centre snapshot audit. Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included. Primary outcome measure was 30-d post-operative complications. Secondary outcome measures were post-operative length of stay (LOS) at and readmission.
RESULTS Three hundred and seventy-five patients with CD and 2,515 patients with CC were included. Patients with CD were younger (median = 37 years for CD and 71 years for CC (P < 0.01), had lower American Society of Anesthesiology score (ASA) grade (P < 0.01) and less comorbidity (P < 0.01), but were more likely to be current smokers (P < 0.01). Patients with CD were more frequently operated on by colorectal surgeons (P < 0.01) and frequently underwent ileocecal resection (P < 0.01) with higher rate of de-functioning/primary stoma construction (P < 0.01). Thirty-day post-operative mortality occurred exclusively in the CC group (66/2515, 2.3%). In multivariate analyses, the risk of post-operative complications was similar in the two groups (OR 0.80, 95%CI: 0.54-1.17; P = 0.25). Patients with CD had a significantly longer LOS (Geometric mean 0.87, 95%CI: 0.79-0.95; P < 0.01). There was no difference in re-admission rates. The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.
CONCLUSION Patients with CD were younger, with lower ASA grade, less comorbidity, operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complications' rate was not different between the two groups.
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Daniel SK, Thornblade LW, Mann GN, Park JO, Pillarisetty VG. Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy. PLoS One 2018; 13:e0209608. [PMID: 30592736 PMCID: PMC6310358 DOI: 10.1371/journal.pone.0209608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Pancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations. We hypothesized that implementation of a standardized perioperative care pathway would facilitate safe discharge by five days after pancreaticoduodenectomy. METHODS We performed a retrospective cohort study of patients undergoing pancreaticoduodenectomy 18 months prior to and 18 months following implementation of a perioperative care pathway at a quaternary center performing high volume pancreatic surgery. RESULTS A total of 145 patients underwent pancreaticoduodenectomy (mean age 63 ± 10 years, 52% female), 81 before and 64 following pathway implementation, and the groups were similar in terms of preoperative comorbidities. The percentage of patients discharged within 5 days of surgery increased from 36% to 64% following pathway implementation (p = 0.001), with no observed differences in post-operative serious adverse events (p = 0.34), pancreatic fistula grade B or C (p = 0.28 and p = 0.27 respectively), or delayed gastric emptying (p = 0.46). Multivariate regression analysis showed length of stay ≤5 days three times more likely after pathway implementation. Rates of readmission within 30 days (20% pre- vs. 22% post-pathway (p = 0.75)) and 90 days (27% pre- vs. 36% post-pathway (p = 0.27)) were unchanged after pathway implementation, and were no different between patients discharged before or after day 5 at both 30 days (19% ≤5 days vs. 23% ≥ 6 days (p = 0.68)) and 90 days (32% ≤5 days vs. 30% ≥ 6 days (p = 0.81)). CONCLUSIONS Standardizing perioperative care via enhanced recovery protocols for patients undergoing pancreaticoduodenectomy facilitates safe discharge by post-operative day five.
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Affiliation(s)
- Sara K. Daniel
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - Lucas W. Thornblade
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - Gary N. Mann
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - James O. Park
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - Venu G. Pillarisetty
- University of Washington Department of Surgery, Seattle, WA, United States of America
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Galata C, Weiss C, Hardt J, Seyfried S, Post S, Kienle P, Horisberger K. Risk factors for early postoperative complications and length of hospital stay in ileocecal resection and right hemicolectomy for Crohn's disease: a single-center experience. Int J Colorectal Dis 2018; 33:937-945. [PMID: 29736773 DOI: 10.1007/s00384-018-3072-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine risk factors for early postoperative complications and longer hospital stay after ileocecal resection and right hemicolectomy in a single-center cohort of patients with Crohn's disease (CD). METHODS A retrospective analysis of the prospectively maintained surgical database for patients with CD at our institution was performed. All consecutive patients operated on between January 2010 and December 2016 were included. RESULTS A total of 305 patients were included. Median length of hospital stay was 7 days (interquartile range, IQR 6-10). Major postoperative complications were observed in 9.5% of patients (n = 29). Anastomotic leak was observed in five patients (1.8% of all patients with anastomosis). The rate of local septic complications was 4.3% (n = 13, anastomotic leak, postoperative abscess, and/or postoperative fistula). In multivariable analysis, independent risk factors for major postoperative complications were bowel perforation (odds ratio (OR) = 12.796, 95% CI = 1.144-143.178); elevated preoperative leucocyte levels (OR = 1.115, 95% CI = 1.013-1.228); and low levels of preoperative albumin (OR = 0.885, 95% CI = 0.827-0.948). The cutoff value for albumin was 32.5 g/L (sensitivity 75.9%, specificity 62.6%). CONCLUSIONS In this large cohort of patients surgically treated for CD in a tertiary referral center, 9.5% of the patients developed major postoperative complications. Preoperative albumin levels > 32.5 g/L significantly reduce the risk for postoperative complications and shorten the length of hospital stay. In a multidisciplinary concept with adequate preoperative management, surgery can be performed with a low rate of major complications and a very low rate of anastomotic leakage.
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Affiliation(s)
- Christian Galata
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julia Hardt
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Steffen Seyfried
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Stefan Post
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Peter Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Mannheim, Germany
| | - Karoline Horisberger
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
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Takaoka A, Sasaki M, Nakanishi N, Kurihara M, Ohi A, Bamba S, Andoh A. Nutritional Screening and Clinical Outcome in Hospitalized Patients with Crohn's Disease. ANNALS OF NUTRITION AND METABOLISM 2017; 71:266-272. [PMID: 29241167 DOI: 10.1159/000485637] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Hospitalized patients with Crohn's disease (CD) can develop severe nutritional deficits. However, the nutritional screening tools with the most utility for such patients are still unknown. METHODS Nutritional status of 40 CD patients was assessed on admission using several screening tools and laboratory tests. Their validity was evaluated in relation to length of hospital stay (LOS) and intestinal resection. Receiver operating characteristic analysis was performed to predict prolonged LOS (≥28 days). RESULTS Prolonged LOS was correlated with each of the following screening parameters: Subjective Global Assessment, Nutrition Risk Screening 2002 (NRS 2002), Onodera's Prognostic Nutritional Index (O-PNI), Controlling Nutritional Status, serum albumin level, and weight loss. These parameters were not correlated with intestinal resection. Evaluation of prognostic yield showed cutoff values of serum albumin 3.3 g/dL (AUC 0.797, sensitivity 57.1%, specificity 89.5%) and O-PNI 36.5 (0.749, 71.4%, 73.7%). By combining the serum albumin cutoff value and NRS 2002 score, patients were divided into 4 groups, with a prolonged LOS rate of 68.2% in the group with the worst prognosis. CONCLUSIONS A combination of serum albumin (given the simplicity of testing) and NRS 2002 as nutritional screening tools may be useful for hospitalized CD patients.
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Affiliation(s)
- Azusa Takaoka
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Naoko Nakanishi
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Mika Kurihara
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Akiko Ohi
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Shigeki Bamba
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
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Dreznik Y, Horesh N, Gutman M, Gravetz A, Amiel I, Jacobi H, Zmora O, Rosin D. Preoperative Nutritional Optimization for Crohn's Disease Patients Can Improve Surgical Outcome. Dig Surg 2017; 35:442-447. [PMID: 29130989 DOI: 10.1159/000481408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative preparation of patients with Crohn's disease is challenging and there are no specific guidelines regarding nutritional support. The aim of this study was to assess whether preoperative nutritional support influenced the postoperative outcome. METHODS A retrospective, cohort study including all Crohn's disease patients who underwent abdominal surgery between 2008 and 2014 was conducted. Patients' characteristics and clinical and surgical data were recorded and analyzed. RESULTS Eighty-seven patients were included in the study. Thirty-seven patients (42.5%) received preoperative nutritional support (mean albumin level 3.14 vs. 3.5 mg/dL in the non-optimized group; p < 0.02) to optimize their nutritional status prior to surgery. Preoperative albumin level, after adequate nutritional preparation, was similar between the 2 groups. The 2 groups differ neither in demographic and surgical data, overall post-op complication (p = 0.85), Clavien-Dindo score (p = 0.42), and length of stay (p = 0.1). Readmission rate was higher in the non-optimized group (p = 0.047). CONCLUSION Nutritional support can minimize postoperative complications in patients with low albumin levels. Nutritional status should be optimized in order to avoid hazardous complications.
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Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection An international audit by ESCP and S-ECCO. Colorectal Dis 2017; 20:219-227. [PMID: 28913968 DOI: 10.1111/codi.13889] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/30/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patient and disease-related factors, as well as operation technique all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. AIM To investigate the effect of pre- and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease. METHOD International prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. This study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien-Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, re-operation, surgical site infection and length of stay at hospital. Multivariable binary logistic regression analyses were used to produce odds ratios (OR) and 95% confidence intervals (CI). RESULTS Three hundred and seventy five resections in 375 patients were included. The median age was 37 and 57.1% were female. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36 95% CI 1.10-4.97)], urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13-3.55) and unplanned intraoperative adverse events (OR 2.30, 95% CI 1.20-4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, CI [1.08-1.61]) and those who had urgent/expedited operations (OR 1.21, CI [1.07-1.37]). CONCLUSION Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intraoperative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients. This article is protected by copyright. All rights reserved.
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Preoperative Nutritional Conditioning of Crohn’s Patients—Systematic Review of Current Evidence and Practice. Nutrients 2017. [DOI: 10.3390/nu9060661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Grass F, Pache B, Martin D, Hahnloser D, Demartines N, Hübner M. Preoperative Nutritional Conditioning of Crohn's Patients-Systematic Review of Current Evidence and Practice. Nutrients 2017; 9:nu9060562. [PMID: 28587182 PMCID: PMC5490541 DOI: 10.3390/nu9060562] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022] Open
Abstract
Crohn’s disease is an incurable and frequently progressive entity with major impact on affected patients. Up to half of patients require surgery in the first 10 years after diagnosis and over 75% of operated patients require at least one further surgery within lifetime. In order to minimize surgical risk, modifiable risk factors such as nutritional status need to be optimized. This systematic review on preoperative nutritional support in adult Crohn’s patients between 1997 and 2017 aimed to provide an overview on target populations, screening modalities, routes of administration, and expected benefits. Pertinent study characteristics (prospective vs. retrospective, sample size, control group, limitations) were defined a priori. Twenty-nine studies were retained, of which 14 original studies (9 retrospective, 4 prospective, and 1 randomized controlled trial) and 15 reviews. Study heterogeneity was high regarding nutritional regimens and outcome, and meta-analysis could not be performed. Most studies were conducted without matched control group and thus provide modest level of evidence. Consistently, malnutrition was found to be a major risk factor for postoperative complications, and both enteral and parenteral routes were efficient in decreasing postoperative morbidity. Current guidelines for nutrition in general surgery apply also to Crohn’s patients. The route of administration should be chosen according to disease presentation and patients’ condition. Further studies are needed to strengthen the evidence.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - David Martin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
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