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Yıldırım M, Kocabay A, Koca B, Saglam AI, Ozkan N. The effect of ileal resection length on postoperative complications and prognosis in right colon cancer. Langenbecks Arch Surg 2024; 409:206. [PMID: 38967821 PMCID: PMC11226531 DOI: 10.1007/s00423-024-03395-9] [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: 01/15/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND There is a lack of literature on the length of the terminal ileum to be resected in right hemicolectomy for colon cancer. Therefore, we aimed to determine the mean ileal loop length and the effect of this variation on postoperative complications and long-term oncological outcomes in patients who underwent right hemicolectomy. METHODS Right hemicolectomy surgeries performed for colon cancer in a tertiary care hospital between January 2011 and December 2018 were retrospectively analyzed from a prospective database. Two patient groups were established based on the mean length of the resected ileum above and below 7 cm. The two groups were compared for clinicopathological data, postoperative complications, mortality, long-term overall survival (OS) and disease-free survival (DFS). The factors contributing to OS and DFS were analyzed. RESULTS The study included 217 patients. Body mass index (BMI) values were significantly higher in the ileum resection length > 7 cm group (p = 0.009). Pathological N stage, tumor diameter, and number of metastatic lymph nodes were significantly higher in the ileum resection length > 7 cm group (p = 0.001, p = 0.001, and p = 0.026, respectively). There was no significant difference for postoperative complication and mortality rates between the two groups. The mean follow-up period was 61.2 months (2-120) in all patients. The total number of deaths was 29 (11.7%) while the 60-month OS was 83.5% and 50-month DFS was 81.8%. There was no significant difference between the groups in terms of OS and DFS rates (p > 0.05). CONCLUSIONS Excessive resection of the distal ileum in right hemicolectomy does not provide any benefit in terms of prognosis and complications.The ileum resection length and values close to it in our study appear to be sufficient.
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Affiliation(s)
- Murat Yıldırım
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Sevki Erek Yerleskesi, Tokat, 60030, Turkey.
| | - Asım Kocabay
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Sevki Erek Yerleskesi, Tokat, 60030, Turkey
| | - Bulent Koca
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Sevki Erek Yerleskesi, Tokat, 60030, Turkey
| | - Ali Ihsan Saglam
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Sevki Erek Yerleskesi, Tokat, 60030, Turkey
| | - Namık Ozkan
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Sevki Erek Yerleskesi, Tokat, 60030, Turkey
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Ravn S, Grønfeldt JM, Thaysen HV, Iversen LH. The impact of the extent of surgery on late adverse effects following cytoreductive surgery and HIPEC. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107105. [PMID: 38096698 DOI: 10.1016/j.ejso.2023.107105] [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: 03/08/2023] [Revised: 09/07/2023] [Accepted: 09/28/2023] [Indexed: 01/16/2024]
Abstract
AIM To investigate the impact of the surgical extent on late adverse effects (LAE) following cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). METHOD A prospective cohort study including patients undergoing CRS + HIPEC due to peritoneal metastases from gastrointestinal tumour origin. From 2006 through 2019, consecutive patients treated with CRS + HIPEC were followed at 3, 6 and 12 months, and LAEs were assessed using the symptom scales and items from the European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30). Surgical extent was categorized into three groups (major, intermediate, minor) based on peritonectomy procedures and colorectal resections performed as part of CRS. EORTC data were analysed using a linear mixed effects regression model adjusted for age, gender, origin of tumour and comorbidity. RESULTS In total, 257 patients who responded to at least one questionnaire during the follow-ups were included. Only diarrhoea symptoms were positively associated with surgical extent (mean differences: major vs. minor: 8.4 (-0.5; 17.2) (p = 0.06) and major vs. intermediate: 10.9 (3.8; 18.0) (p = 0.00)). Additionally, diarrhoea symptoms persisted throughout the study period and did not change over time (mean difference 12-3 months: -3.6 (-9.1; 1.7) (p-value = 0.18)). Overall, the levels of different symptom scales (fatigue, nausea and vomiting, pain, dyspnoea, and appetite loss) significantly decreased from 3 to 12 months. CONCLUSION Patients undergoing extensive CRS suffer from persistent impaired gastrointestinal function in terms of diarrhoea compared patients undergoing to less extensive surgery. Attention should be directed at detecting such LAE and to guide patients accordingly.
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Affiliation(s)
- Sissel Ravn
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.
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Richard N, Savoye G, Leboutte M, Amamou A, Ghosh S, Marion-Letellier R. Crohn’s disease: Why the ileum? World J Gastroenterol 2023; 29:3222-3240. [PMID: 37377591 PMCID: PMC10292140 DOI: 10.3748/wjg.v29.i21.3222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/23/2023] [Accepted: 05/08/2023] [Indexed: 06/01/2023] Open
Abstract
Crohn’s disease (CD) is an inflammatory bowel disease characterized by immune-mediated flares affecting any region of the intestine alternating with remission periods. In CD, the ileum is frequently affected and about one third of patients presents with a pure ileal type. Moreover, the ileal type of CD presents epidemiological specificities like a younger age at onset and often a strong link with smoking and genetic susceptibility genes. Most of these genes are associated with Paneth cell dysfunction, a cell type found in the intestinal crypts of the ileum. Besides, a Western-type diet is associated in epidemiological studies with CD onset and increasing evidence shows that diet can modulate the composition of bile acids and gut microbiota, which in turn modulates the susceptibility of the ileum to inflammation. Thus, the interplay between environmental factors and the histological and anatomical features of the ileum is thought to explain the specific transcriptome profile observed in CD ileitis. Indeed, both immune response and cellular healing processes harbour differences between ileal and non-ileal CD. Taken together, these findings advocate for a dedicated therapeutic approach to managing ileal CD. Currently, interventional pharmacological studies have failed to clearly demonstrate distinct response profiles according to disease site. However, the high rate of stricturing disease in ileal CD requires the identification of new therapeutic targets to significantly change the natural history of this debilitating disease.
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Affiliation(s)
- Nicolas Richard
- University of Rouen Normandie, INSERM, ADEN UMR 1073, Nutrition, Inflammation and Microbiota-Gut-Brain Axis, Rouen F-76000, France
- CHU Rouen, Department of Gastroenterology, Rouen University Hospital-Charles Nicolle, Rouen F-76000, France
- Institute for Research and Innovation in Biomedicine, University of Rouen Normandie, Rouen F-76000, France
| | - Guillaume Savoye
- University of Rouen Normandie, INSERM, ADEN UMR 1073, Nutrition, Inflammation and Microbiota-Gut-Brain Axis, Rouen F-76000, France
- CHU Rouen, Department of Gastroenterology, Rouen University Hospital-Charles Nicolle, Rouen F-76000, France
- Institute for Research and Innovation in Biomedicine, University of Rouen Normandie, Rouen F-76000, France
| | - Mathilde Leboutte
- University of Rouen Normandie, INSERM, ADEN UMR 1073, Nutrition, Inflammation and Microbiota-Gut-Brain Axis, Rouen F-76000, France
- Institute for Research and Innovation in Biomedicine, University of Rouen Normandie, Rouen F-76000, France
| | - Asma Amamou
- APC Microbiome Ireland, Biosciences Building, University College Cork, Cork T12 YT20, Ireland
| | - Subrata Ghosh
- APC Microbiome Ireland, Biosciences Building, University College Cork, Cork T12 YT20, Ireland
| | - Rachel Marion-Letellier
- University of Rouen Normandie, INSERM, ADEN UMR 1073, Nutrition, Inflammation and Microbiota-Gut-Brain Axis, Rouen F-76000, France
- Institute for Research and Innovation in Biomedicine, University of Rouen Normandie, Rouen F-76000, France
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Bischoff SC, Bager P, Escher J, Forbes A, Hébuterne X, Hvas CL, Joly F, Klek S, Krznaric Z, Ockenga J, Schneider S, Shamir R, Stardelova K, Bender DV, Wierdsma N, Weimann A. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2023; 42:352-379. [PMID: 36739756 DOI: 10.1016/j.clnu.2022.12.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Johanna Escher
- Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France.
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, CHU de Beaujon, APHP, University of Paris, Paris, France.
| | - Stansilaw Klek
- Surgical Oncology Clinic, Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland.
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre Zagreb, University of Zagreb, Croatia.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Stéphane Schneider
- Department of Gastroenterology and Clinical Nutrition, CHU de Nice, University Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Campus "Mother Theresa", University St Cyrul and Methodius, Skopje, North Macedonia.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
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Ismail FQ, Öberg S, Wozniak AB, Oggesen BT, Rosenberg J. Variation in the length of terminal ileum specimen in right hemicolectomy: a descriptive study. ANZ J Surg 2022; 93:951-955. [PMID: 36368701 DOI: 10.1111/ans.18153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/22/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022]
Abstract
AIM The aim of this study was to clarify the length of the bowel specimen and to assess if the length was affected by certain characteristics. METHODS Eligible patients were adults who had undergone right hemicolectomy for cancer in caecum, appendix, ascending colon or transverse colon from September 2019 to September 2020 at Herlev Hospital, Denmark. Data were collected from medical records. The primary outcome was the length of the resected terminal ileum. Secondary outcomes were to assess if body mass index (BMI), surgical approach, and neoadjuvant chemotherapy affected the length of the terminal ileum specimen, and to report the length of the colon specimen subdivided on the cancer locations. RESULTS In total, 50 patients were included. The median age was 74 years (range 36-91), 30 patients (60%) were females, and BMI was median 26 (range 17-45). The variation in the length of terminal ileum specimen was median 5 cm (range 1-17). The explorative analyses showed significant positive correlation between the length of terminal ileum specimen and BMI (P = 0.050) but not surgical approach (P = 0.23) nor neoadjuvant chemotherapy (P = 0.51). The length of the colon specimen naturally differed according to the cancer location with a median length of 26 cm (range 14-90). CONCLUSION We found a variation in the length of the terminal ileum specimen without an apparent explanation for this variation. The colon specimen also varied naturally according to cancer location.
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Affiliation(s)
- Fatima Qays Ismail
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Stina Öberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Anita Bilde Wozniak
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Birthe Thing Oggesen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
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Larsen HM, Krogh K, Borre M, Gregersen T, Mejlby Hansen M, Arveschoug AK, Christensen P, Drewes AM, Emmertsen KJ, Laurberg S, Ladefoged Fassov J. Chronic loose stools following right-sided hemicolectomy for colon cancer and the association with bile acid malabsorption and small intestinal bacterial overgrowth. Colorectal Dis 2022; 25:600-607. [PMID: 36347822 DOI: 10.1111/codi.16409] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/08/2022] [Accepted: 10/01/2022] [Indexed: 11/10/2022]
Abstract
AIM Patients treated with right-sided hemicolectomy for colon cancer may suffer from long-term bowel dysfunction, including loose stools, urgency and faecal incontinence. The underlying causes are poorly understood. The aim of this case-control study was to investigate the aetiology of chronic loose stools among patients with right-sided hemicolectomy curatively operated for cancer. METHOD Cases with chronic loose stools (Bristol stool type 6-7) after right-sided hemicolectomy were compared with a control group of patients with right-sided hemicolectomy without loose stools. All patients underwent a selenium-75 homocholic acid taurine (SeHCAT) scan to diagnose bile acid malabsorption (BAM) and a glucose breath test to diagnose small intestinal bacterial overgrowth (SIBO). Gastrointestinal transit time (GITT) was assessed with radiopaque markers. In a subgroup of patients, fibroblast growth factor 19 (FGF19) was measured in fasting blood. SIBO was treated with antibiotics and BAM was treated with bile acid sequestrants. RESULTS We included 45 cases and 19 controls. In the case group, 82% (n = 36) had BAM compared with 37% (n = 7) in the control group, p < 0.001. SIBO was diagnosed in 73% (n = 33) of cases with chronic loose stools and in 74% (n = 14) of controls, p = 0.977. No association between BAM and SIBO was observed. GITT was similar in cases and controls. No difference in median FGF19 was observed between cases and controls (p = 0.894), and no correlation was seen between FGF19 and SeHCAT retention (rs 0.20, p = 0.294). Bowel symptoms among cases were reduced after treatment. CONCLUSION BAM and SIBO are common in patients having undergone right-sided hemicolectomy for cancer. Chronic loose stools were associated with BAM but not with SIBO.
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Affiliation(s)
- Helene Mathilde Larsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Borre
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Tine Gregersen
- Department of Nuclear Medicine & PET, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Mejlby Hansen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne K Arveschoug
- Department of Nuclear Medicine & PET, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Christensen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Katrine Jøssing Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Surgery, Regional Hospital Randers, Randers, Denmark
| | - Søren Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Janne Ladefoged Fassov
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Abstract
BACKGROUND Chronic diarrhea in patients with neuroendocrine tumors (NET) may be caused by bioactive products of NET, bile acid malabsorption (BAM), ileal resection (IR) or steatorrhea. AIM To quantitate BA and fat malabsorption in NET with diarrhea. METHODS Part of evaluation in medical oncology clinical practice, 67 patients [42F, 25 M; median age 64.0 y (17.0 IQR)] with well-differentiated NET and diarrhea underwent clinically indicated measurements of 48-h fecal BA [(FBA), fecal weight (normal < 400 g/48 h), fecal fat (normal < 7 g/day) in n = 52] and fasting serum 7αC4 (marker of hepatic BA synthesis, n = 30) between 01/2018 and 11/2020. IR had been performed in 45 patients. BAM diagnosis was based on FBA criteria: elevated total FBA (> 2337 µmol/48 h) or > 10% primary FBA or combination > 4% primary FBA plus > 1000 µmol total FBA/48 h. We also measured fecal elastase (for pancreatic insufficiency) in 13 patients. RESULTS BAM was present in 48/52 (92%) patients with NET. There were significant correlations between total FBA and 48-h fecal weight (Rs = 0.645, P < 0.001). Mean length of IR was 47 cm; in patients with IR < 25 cm, total FBA was elevated in 85% and primary FBA > 10% in 69%. In 22 patients with no IR, 13/15 tested (87%) had BAM. Among 6 patients with pancreatic NET and no IR, 80% had BAM. Fecal fat was ≥ 15 g/day in 18/42 (43%). In 4/17 (24%) with IR < 25 cm and 8/19 (42%) patients with IR > 25 cm fecal fat was 44.0 (40.5) and 38.0 (38.0)g/day, respectively. CONCLUSION A majority of patients with NET and diarrhea had BAM, even with < 25 cm or no IR.
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Ble A, Renzulli C, Cenci F, Grimaldi M, Barone M, Sedano R, Chang J, Nguyen TM, Hogan M, Zou G, MacDonald JK, Ma C, Sandborn WJ, Feagan BG, Merlo Pich E, Jairath V. The Relationship Between Endoscopic and Clinical Recurrence in Postoperative Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2021; 16:490-499. [PMID: 34508572 PMCID: PMC8919832 DOI: 10.1093/ecco-jcc/jjab163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND AIMS We aimed to quantify the magnitude of the association between endoscopic recurrence and clinical recurrence [symptom relapse] in patients with postoperative Crohn's disease. METHODS Databases were searched to October 2, 2020, for randomised controlled trials [RCTs] and cohort studies of adult patients with Crohn's disease with ileocolonic resection and anastomosis. Summary effect estimates for the association between clinical recurrence and endoscopic recurrence were quantified by risk ratios [RR] and 95% confidence intervals [95% CI]. Mixed-effects meta-regression evaluated the role of confounders. Spearman correlation coefficients were calculated to assess the relationship between these outcomes as endpoints in RCTs. An exploratory mixed-effects meta-regression model with the logit of the rate of clinical recurrence as the outcome and the rate of endoscopic recurrence as a predictor was also evaluated. RESULTS In all, 37 studies [N = 4053] were included. For eight RCTs with available data, the RR for clinical recurrence for patients who experienced endoscopic recurrence was 10.77 [95% CI 4.08 to 28.40; GRADE moderate certainty evidence]; the corresponding estimate from 11 cohort studies was 21.33 [95% CI 9.55 to 47.66; GRADE low certainty evidence]. A single cohort study showed a linear relationship between Rutgeerts score and clinical recurrence risk. There was a strong correlation between endoscopic recurrence and clinical recurrence treatment effect estimates as trial outcomes [weighted Spearman correlation coefficient 0.51]. CONCLUSIONS The associations between endoscopic recurrence and subsequent clinical recurrence lend support to the choice of endoscopic recurrence to monitor postoperative disease activity and as a primary endpoint in clinical trials of postoperative Crohn's disease.
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Affiliation(s)
| | | | - Fabio Cenci
- Corporate R&D, Alfasigma S.p.A., Bologna, Italy
| | | | | | - Rocio Sedano
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - Joshua Chang
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Tran M Nguyen
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Malcolm Hogan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Guangyong Zou
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John K MacDonald
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - William J Sandborn
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G Feagan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Vipul Jairath
- Corresponding author: Vipul Jairath, MB, ChB, DPhil, Department of Medicine, Western University, 399 Windermere Road, London, ON, Canada N6A 5A5. Tel.: 519-685-8500, ext. 33655;
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Biochemical Diagnosis of Bile Acid Diarrhea: Prospective Comparison With the 75Seleno-Taurohomocholic Acid Test. Am J Gastroenterol 2020; 115:2086-2094. [PMID: 32740083 DOI: 10.14309/ajg.0000000000000772] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The diagnosis of bile acid diarrhea is often missed because the availability of the seleno-taurohomocholic acid (SeHCAT) test is limited. We aimed to compare the biomarkers 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor 19 (FGF19) with the SeHCAT test. METHODS Patients with chronic diarrhea without intestinal resection referred for SeHCAT were prospectively recruited for this diagnostic accuracy study. Blood was sampled at fasting and after a stimulation meal with chenodeoxycholic acid. SeHCAT retention ≤10% defined bile acid diarrhea and >10% defined miscellaneous diarrhea. Receiver operating characteristics (ROC) were analyzed with SeHCAT as the gold standard. www.clinicaltrials.gov (NCT03059537). RESULTS Patients with bile acid diarrhea (n = 26) had mean C4 of 30 ng/mL (95% confidence interval: 19-46) vs 8 (7-11; P < 0.001) in the miscellaneous diarrhea group (n = 45). Area under the ROC curve (ROCAUC) for C4 was 0.83 (0.72-0.93). C4 < 15 ng/mL had 85% (74%-96%) negative predictive value; C4 > 48 ng/mL had 82% (59%-100%) positive predictive value. Twenty patients had C4 values 15-48 ng/mL, of whom 11/20 had SeHCAT ≤10%. Median fasting FGF19 was 72 pg/mL (interquartile range: 53-146) vs 119 (84-240) (P = 0.004); ROCAUC was 0.71 (0.58-0.83). Stimulated FGF19 responses did not differ (P = 0.54). DISCUSSION We identified C4 thresholds with clinically useful predictive values for the diagnosis of and screening for bile acid diarrhea in patients with chronic watery diarrhea. Further validation of the cutoff values with the placebo-controlled effect of sequestrant therapy is warranted (see Visual Abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B603).
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Abstract
PURPOSE OF REVIEW Despite multiple advances in the medical treatment of Crohn's disease, it is recognized that a significant proportion of patients will ultimately require surgical resection at some point during their disease course. This review focuses on the postoperative management of patients with Crohn's disease, with the goal of preventing endoscopic and clinical recurrence, and future surgery. RECENT FINDINGS Surgery is an integral part of the multidisciplinary approach to the management of patients with Crohn's disease. Recent literature and guidelines have focused on a standardized and evidence-based approach to the management of patients in the postoperative setting. This approach should utilize risk stratification at the time of surgery, initiation of appropriate therapy among high-risk patients, and objective evaluation in the postoperative period, including ileocolonoscopy at 6-12 months after a surgical resection. SUMMARY A standardized approach to the postoperative management of patients with Crohn's disease is critical. Identifying those patients at high-risk for endoscopic and clinical recurrence is essential, as these patients will likely require early medical therapy. While novel objective assessments are emerging, all patients should undergo ileocolonoscopy at 6-12 months and further decision making should be based on the presence of endoscopic recurrence.
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