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Fiorindi C, Giudici F, Testa GD, Foti L, Romanazzo S, Tognozzi C, Mansueto G, Scaringi S, Cuffaro F, Nannoni A, Soop M, Baldini G. Multimodal Prehabilitation for Patients with Crohn's Disease Scheduled for Major Surgery: A Narrative Review. Nutrients 2024; 16:1783. [PMID: 38892714 PMCID: PMC11174506 DOI: 10.3390/nu16111783] [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: 04/29/2024] [Revised: 05/25/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.
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Affiliation(s)
- Camilla Fiorindi
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Francesco Giudici
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 6, 50135 Florence, Italy; (F.G.); (S.S.)
| | - Giuseppe Dario Testa
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Division of Geriatric and Intensive Care Medicine, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Lorenzo Foti
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Section of Anesthesiology and Intensive Care, University of Florence, Largo Brambilla 3, 50139 Florence, Italy
| | - Sara Romanazzo
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Cristina Tognozzi
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Giovanni Mansueto
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Stefano Scaringi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 6, 50135 Florence, Italy; (F.G.); (S.S.)
| | - Francesca Cuffaro
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
| | - Anita Nannoni
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
| | - Mattias Soop
- Department for IBD and Intestinal Failure Surgery, Karolinska University Hospital, SE 177 76 Stockholm, Sweden;
| | - Gabriele Baldini
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Section of Anesthesiology and Intensive Care, University of Florence, Largo Brambilla 3, 50139 Florence, Italy
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Triantafillidis JK. Surgical treatment of inflammatory bowel disease: From the gastroenterologist's stand-point. World J Gastrointest Surg 2024; 16:1235-1254. [PMID: 38817292 PMCID: PMC11135302 DOI: 10.4240/wjgs.v16.i5.1235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/17/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024] Open
Abstract
Treatment of ulcerative colitis (UC) and Crohn's disease (CD) represents, in the majority of cases, a real challenge to the gastroenterologist's abilities and skills as well as a clinical test concerning his/her levels of medical knowledge and experience. During the last two decades, our pharmaceutical arsenal was significantly strengthened, especially after the introduction of the so-called biological agents, drugs which to a large extent not only improved the results of conservative treatment but also changed the natural history of the disease. However, colectomy is still necessary for some patients with severe UC although smaller compared to the past, precisely because of the improvements achieved in the available conservative treatment. Nevertheless, surgeries to treat colon dysplasia and cancer are increasing to some extent. At the same time, satisfactory improvements in surgical techniques, the pre-and post-operative care of patients, as well as the selection of the appropriate time for performing the surgery have been noticed. Regarding patients with CD, the improvement of conservative treatment did not significantly change the need for surgical treatment since two-thirds of patients need to undergo surgery at some point in the course of their disease. On the other hand, the outcome of the operation has improved through good preoperative care as well as the wide application of more conservative surgical techniques aimed at keeping as much of the bowel in situ as possible. This article discusses the indications for surgical management of UC patients from the gastroenterologist's point of view, the results of the emerging new techniques such as transanal surgery and robotics, as well as alternative operations to the classic ileo-anal-pouch anastomosis. The author also discusses the basic principles of surgical management of patients with CD based on the results of the relevant literature. The self-evident is emphasized, that is, to achieve an excellent therapeutic result in patients with severe inflammatory bowel disease in today's era; the close cooperation of gastroenterologists with surgeons, pathologists, imaging, and nutritionists is of paramount importance.
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Affiliation(s)
- John K Triantafillidis
- Inflammatory Bowel Disease Unit, “Metropolitan General” Hospital, Holargos 15562, Attica, Greece
- Hellenic Society of Gastrointestinal Oncology, Haidari 12461, Athens, Greece
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Buldukoglu OC. Factors influencing the outcomes of colonic resections for Crohn's colitis. Int J Colorectal Dis 2024; 39:67. [PMID: 38703191 PMCID: PMC11069470 DOI: 10.1007/s00384-024-04620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Osman Cagin Buldukoglu
- Department of Gastroenterology, Antalya Training and Research Hospital, University of Health Sciences, Varlik mah. Kazim Karabekir cad., 07100, Antalya, Turkey.
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Wang ZZ, Zhao CH, Shen H, Dai GP. Impact of different anastomosis methods on post-recurrence after intestinal resection for Crohn's disease: A meta-analysis. World J Gastrointest Surg 2024; 16:1165-1175. [PMID: 38690051 PMCID: PMC11056677 DOI: 10.4240/wjgs.v16.i4.1165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/18/2024] [Accepted: 03/28/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract, often requiring intestinal resection as a common treatment. However, recurrence after surgery is common. The anastomotic configuration after bowel resection appears to be associated with the recurrence of CD. Previous studies have suggested that the Kono-S anastomosis may help to reduce the recurrence rate. However, the results remain controversial. Therefore, evidence-based evidence is needed to prove the advantages of Kono-S anastomosis. AIM To measure the influence of anastomosis techniques on the long-term relapse rate of CD by conducting a meta-analysis. METHODS PubMed, Scopus, and Cochrane Library were searched until October 8, 2023. Patients who underwent intestinal resection due to CD were included. The intervention measures included Kono-S anastomosis, whereas the control group received traditional anastomosis such as end-to-end, end-to-side, and side-to-side anastomosis. Only randomized clinical trials and observational studies were included. The primary outcome measures were hospital stay post-surgery, overall postoperative complication incidence, the proportion of Clavien-Dindo grade IIIa or higher, overall postoperative recurrence rate, and Rutgeerts score. RESULTS From 2011 to 2023, six articles met the inclusion and exclusion criteria. The results indicated that Kono-S anastomosis can reduce the hospital stay post-surgery of patients with CD [MD = -0.26, 95%CI: -0.42 to -0.10, P = 0.002] than other traditional anastomosis methods. Compared to other traditional anastomosis methods, Kono-S anastomosis can significantly reduce the total recurrence rate [MD = 0.40, 95%CI: 0.17 to 0.98, P = 0.05] and postoperative Rutgeerts score [MD = -0.81, 95%CI: -0.96 to -0.66, P < 0.001] in patients with CD. However, there is no significant disparity in the overall occurrence of postoperative complications and the proportion of Clavien-Dindo ≥ IIIa. CONCLUSION Kono-S anastomosis has the potential to expedite the recuperation of CD and diminish relapse hazards; however, additional larger trials are necessary to authenticate its effectiveness.
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Affiliation(s)
- Zheng-Zuo Wang
- Department of Anorectal, Jiashan Hospital of Traditional Chinese Medicine, Jiaxing 314100, Zhejiang Province, China
| | - Chun-Hua Zhao
- Department of Oncology, Jiashan Hospital of Traditional Chinese Medicine, Jiaxing 314100, Zhejiang Province, China
| | - Hui Shen
- Department of Gastroenterology, Jiashan Hospital of Traditional Chinese Medicine, Jiaxing 314100, Zhejiang Province, China
| | - Gui-Ping Dai
- Department of Oncology, The Second Hospital of Jiaxing, Jiaxing 314000, Zhejiang Province, China
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Baloyiannis I, Perivoliotis K, Sarakatsianou C, Chatzinikolaou C, Tzovaras G. The Reduction of Anastomosis-Related Morbidity Using the Kono-S Anastomosis in Patients with Crohn's Disease: A Meta-Analysis. J Clin Med 2024; 13:2461. [PMID: 38730990 PMCID: PMC11084922 DOI: 10.3390/jcm13092461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
(1) Background: we conducted this study to evaluate the effect of Kono-S anastomosis on postoperative morbidity after bowel resection for Crohn's disease. (2) Methods: This study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint was the overall complications rate. Secondary outcomes included specific complications analyses, disease recurrence and efficiency endpoints. A systematic literature screening was performed in major electronic scholar databases (Medline, Scopus, Web of Science), from inception to 17 January 2024. Both Random (RE) and Fixed Effects (FE) models were estimated; the reported analysis was based on the Cochran Q test results. (3) Results: Overall, eight studies and 913 patients were included in this meta-analysis. Pooled analyses confirmed that Kono-S was not superior in terms of overall morbidity (OR: 0.69 [0.42, 1.15], p = 0.16). Kono-S displayed a reduced risk for anastomotic leakage (OR: 0.34 [0.16, 0.71], p = 0.004) and reoperation (OR: 0.12 [0.05, 0.27], p < 0.001), and a shortened length of hospital stay (WMD: -0.54 [-0.73, -0.34], p < 0.001). On the contrary, Kono-S results in higher rates of postoperative SSIs (OR: 1.85 [1.02, 3.35], p = 0.04). (4) Conclusions: This study confirms a comparable morbidity, but a lower risk of anastomotic leak and reoperation of Kono-S over conventional anastomoses. Further high quality studies are required to validate these findings.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, 41110 Larissa, Greece; (I.B.); (C.S.); (G.T.)
| | | | - Chamaidi Sarakatsianou
- Department of Surgery, University Hospital of Larissa, 41110 Larissa, Greece; (I.B.); (C.S.); (G.T.)
| | | | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, 41110 Larissa, Greece; (I.B.); (C.S.); (G.T.)
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Spertino M, Gabbiadini R, Dal Buono A, Busacca A, Franchellucci G, Migliorisi G, Repici A, Spinelli A, Bezzio C, Armuzzi A. Management of Post-Operative Crohn's Disease: Knowns and Unknowns. J Clin Med 2024; 13:2300. [PMID: 38673573 PMCID: PMC11051270 DOI: 10.3390/jcm13082300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by relapsing-remission phases. CD often requires surgical intervention during its course, mainly ileo-cecal/ileo-colonic resection. However, surgery in CD is not curative and post-operative recurrence (POR) can happen. The management of CD after surgery presents challenges. Ensuring timely, effective, and safe therapy to prevent POR is essential but difficult, considering that approximately 20-30% of subjects may not experience endoscopic POR and that 40-50% will only exhibit intermediate lesions, which carry a low risk of mid- and long-term clinical and surgical POR. Currently, there are two accepted intervention strategies: early post-operative prophylactic therapy (systematically or based on the patient's risk of recurrence) or starting therapy after confirming endoscopic POR 6-12 months after surgery (endoscopy-driven prophylactic therapy). The risk of overtreatment lies in exposing patients to undesired adverse events, along with the costs associated with medications. Conversely, undertreatment may lead to missed opportunities to prevent bowel damage and the necessity for additional surgery. This article aims to perform a comprehensive review regarding the optimal strategy to reduce the risk of POR in CD patients and the current therapeutic options.
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Affiliation(s)
- Matteo Spertino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Roberto Gabbiadini
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Arianna Dal Buono
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Anita Busacca
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Gianluca Franchellucci
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Giulia Migliorisi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Cristina Bezzio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
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Smalbroek BP, Poelmann FB, Smits AB. A new surgical technique: robotic intracorporeal Kono-S anastomosis in Crohn's - a safety and feasibility case series on short-term outcomes. Colorectal Dis 2024; 26:702-708. [PMID: 38369963 DOI: 10.1111/codi.16914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/10/2023] [Accepted: 01/12/2024] [Indexed: 02/20/2024]
Abstract
AIM The Kono-S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra-/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot-assisted intracorporeal Kono-S anastomosis. METHOD This is a prospective single-centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot-assisted intracorporeal Kono-S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow-up for postoperative complications was 30 days. RESULTS Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22-51 years] and the median BMI was 25 kg/m2 (IQR 19-28 kg/m2). Intracorporeal Kono-S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144-176 min) and the median length of stay was 3 days (IQR 1-5 days). No conversions or 30-day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days. CONCLUSION Performance of intracorporeal robot-assisted Kono-S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population-based cohort.
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Affiliation(s)
- Bo P Smalbroek
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Floris B Poelmann
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
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Shehada M, McMahon LE. Recurrent Crohn's disease. Semin Pediatr Surg 2024; 33:151403. [PMID: 38593515 DOI: 10.1016/j.sempedsurg.2024.151403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.
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Affiliation(s)
- Mahmoud Shehada
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Lisa E McMahon
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
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Olson S, Welton L, Jahansouz C. Perioperative Considerations for the Surgical Treatment of Crohn's Disease with Discussion on Surgical Antibiotics Practices and Impact on the Gut Microbiome. Antibiotics (Basel) 2024; 13:317. [PMID: 38666993 PMCID: PMC11047551 DOI: 10.3390/antibiotics13040317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
Crohn's disease, a chronic inflammatory process of the gastrointestinal tract defined by flares and periods of remission, is increasing in incidence. Despite advances in multimodal medical therapy, disease progression often necessitates multiple operations with high morbidity. The inability to treat Crohn's disease successfully is likely in part because the etiopathogenesis is not completely understood; however, recent research suggests the gut microbiome plays a critical role. How traditional perioperative management, including bowel preparation and preoperative antibiotics, further changes the microbiome and affects outcomes is not well described, especially in Crohn's patients, who are unique given their immunosuppression and baseline dysbiosis. This paper aims to outline current knowledge regarding perioperative management of Crohn's disease, the evolving role of gut dysbiosis, and how the microbiome can guide perioperative considerations with special attention to perioperative antibiotics as well as treatment of Mycobacterium avium subspecies paratuberculosis. In conclusion, dysbiosis is common in Crohn's patients and may be exacerbated by malnutrition, steroids, narcotic use, diarrhea, and perioperative antibiotics. Dysbiosis is also a major risk factor for anastomotic leak, and special consideration should be given to limiting factors that further perturb the gut microbiota in the perioperative period.
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Affiliation(s)
- Shelbi Olson
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.O.); (L.W.)
| | - Lindsay Welton
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.O.); (L.W.)
| | - Cyrus Jahansouz
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN 55455, USA
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10
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Pan T, Chen D, Yu Z, Liu Q, Chen Y, Zhang A, Kong F. Analysis of current situation and influencing factors of marital adjustment in patients with Crohn's disease and their spouses. Medicine (Baltimore) 2024; 103:e37527. [PMID: 38489689 PMCID: PMC10939668 DOI: 10.1097/md.0000000000037527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
The purpose of this study was to investigate the marital adjustment of patients with Crohn's disease and their spouses, and to analyze its influencing factors. It lays the investigation foundation for the follow-up binary study of Crohn's disease patients and their spouses. Using convenience sampling, 177 pairs of patients and their spouses from a tertiary hospital in Nanjing, China were selected. With face-to-face electronic questionnaires to survey the patient and spouse, the contents include the Lock-Wollance Marriage Adjustment Test, Subjective Well-Being Scale for Chinese Citizens, Couple Support Questionnaire, and Distress Self-Disclosure Scale. The marital adjustment score of patients was (99.03 ± 24.25), and the marital adjustment score of spouses was (99.61 ± 25.39). The proportions of patients with marital disorders and their spouses with marital disorders were 52.5% and 46.9%, respectively. Multiple linear regression showed that the spouse's age, family monthly income, time of diagnosis of Crohn's, distress self-disclosure, marital support, and subjective well-being were important factors influencing the marital adjustment of patients. Self-disclosure of spousal distress, marital support, age, and subjective well-being were important factors that influenced spouses' marital adjustment. Most couples with Crohn's disease have marital disorders, and their marital adjustment affects each other. However, the assessment results of one partner should not be limited to replacing those of the couple. In clinical practice, patient age, monthly family income, self-disclosure of distress, marital support, and subjective well-being should be considered. Spouses should be encouraged to participate in patient care and patient-spouse interventions should be implemented as a whole to improve marital stability.
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Affiliation(s)
- Ting Pan
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Danlei Chen
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhihui Yu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Qing Liu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Yan Chen
- Department of Nursing, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine (Nanjing Second Hospital), Nanjing, China
| | - Ailing Zhang
- Nanjing Hospital Affiliated to Nanjing Medical University (Nanjing First Hospital), Nanjing, China
| | - Fang Kong
- Digestive Disease Treatment Center, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine (Nanjing Second Hospital), Nanjing, China
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Loch FN, Kamphues C, Menzel P, Schwarzer R, Beyer K, Schineis C. Mucosal microbiome of surgically treated terminal ileal Crohn's disease. Front Cell Infect Microbiol 2024; 13:1324668. [PMID: 38282618 PMCID: PMC10811112 DOI: 10.3389/fcimb.2023.1324668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024] Open
Abstract
Crohn's disease (CD) is associated with changes in the microbiome. The role of these changes and their precise association with disease course and activity remain ambiguous. In this prospective single-center study, the mucosal microbiome of surgical CD and non-CD patients was compared at the time of surgery. Microbial analyses were individually performed for ileal and colonic tissue samples obtained during surgery using 16S-rRNA-gene amplicon sequencing. Three groups out of the 46 included patients were formed: 1) a study group of CD of patients who received ileocecal resection due to CD involvement (CD study, n=10); 2) a control group of non-CD of patients who received intestinal resection due to indications other than CD (non-CD control, n=27); and 3) a second control group of CD who underwent resection of the intestine not affected by CD (CD non-affected control, n=9). Species richness and Shannon diversity were not different between all formed groups and regions analyzed (p>0.05). Several significant taxonomic differences were seen at the phylum-, order-, and genus-levels between the formed groups, such as a decrease of Firmicutes (phylum-level) and an increase of Bacteroides and Escherichia/Shigella/Pseudescherichia (genus-level) in CD study - colon vs. the non-CD control - colon (p ≤ 0.05). The CD non-affected control presented the largest amount of differentially abundant taxa in comparison to the other groups. These results underline that CD is accompanied by changes in affected and non-affected intestinal regions compared to non-CD controls. This study contributes the mucosal microbiome of a well-defined subset of surgical CD patients without confounding aspects of the fecal microbiome or regional microbial differences to the existing literature.
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Affiliation(s)
- Florian N. Loch
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Peter Menzel
- Labor Berlin – Charité Vivantes GmbH, Berlin, Germany
| | | | - Katharina Beyer
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christian Schineis
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Gao B, Shentu H, Sha S, Wang D, Chen X, Huang Z, Dong N, Lai H, Xu J, Zhou X. Efficacy of IL-23 inhibitors and IL-12/23 inhibitors in the induction treatment of Crohn's disease: A meta-analysis based on randomized controlled trials. Cent Eur J Immunol 2024; 48:301-310. [PMID: 38558561 PMCID: PMC10976653 DOI: 10.5114/ceji.2023.134257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/15/2023] [Indexed: 04/04/2024] Open
Abstract
Introduction A growing number of randomized controlled trials (RCTs) have demonstrated the effectiveness of interleukin (IL)-23 and IL-12/23 inhibitors in treating Crohn's disease (CD). This study evaluated the efficacy of IL-23 and IL-12/23 inhibitors in the induction phase for the treatment of CD. Material and methods We searched the following databases from inception until December, 2022: Medline, Embase, Web of Science and the Cochrane Library. The primary outcome was the proportion of CD patients who achieved clinical remission at the end of the induction therapy period. Secondary outcomes included clinical response, endoscopic remission, endoscopic response and normalized C-reactive protein (CRP). Results After screening, 7 RCTs were included in our study. The meta-analysis showed that, in the induction period, more patients treated with IL-23 inhibitors and IL-12/23 inhibitors achieved clinical remission than patients with placebo therapy (RR = 2.11, 95% CI: 1.83-2.44; RR = 1.94, 95% CI: 1.64-2.29; respectively). The IL-23 inhibitor group and the IL-12/23 inhibitor group showed higher clinical response rates than the placebo group (RR = 1.92, 95% CI: 1.74-2,11; RR = 1.83, 95% CI: 1.61-2.09; respectively). In addition, the IL-23 inhibitor group had a higher endoscopic remission rate and endoscopic response rate than the placebo group; the corresponding pooled RRs were 3.40 (95% CI: 2.57-4.50) and 2.65 (95% CI: 2.65-3.12), respectively. Conclusions IL-23 and IL-12/23 inhibitors were efficient methods in the induction treatment of CD.
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Affiliation(s)
- Boyang Gao
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haojie Shentu
- The Medical Imaging College, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Suyong Sha
- Emergency Medical Center, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
| | - Dongying Wang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xi Chen
- The Medical Imaging College, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zhenwei Huang
- The Medical Imaging College, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Nan Dong
- The Medical Imaging College, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Haijia Lai
- The Medical Imaging College, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jianying Xu
- The Medical Imaging College, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaoshuai Zhou
- Department of Anus & Intestine Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
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13
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Cockburn E, Kamal S, Chan A, Rao V, Liu T, Huang JY, Segal JP. Crohn's disease: an update. Clin Med (Lond) 2023; 23:549-557. [PMID: 38065612 DOI: 10.7861/clinmed.2023-0493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Crohn's disease (CD) is a chronic, relapsing and remitting inflammatory bowel disease (IBD) that is increasing in incidence and prevalence globally. Management aims to achieve endoscopic healing, symptom resolution and improvement in quality of life. Therapeutic approaches in CD vary depending on disease phenotype. Thiopurines are important in steroid-sparing maintenance therapy, while anti-tumour necrosis factor agents play a fundamental role, especially in fistulising CD. Suboptimal response to these medications may require escalation to other immunosuppressive and biologic therapies, and surgical intervention is still required in a proportion of patients. Tailoring treatment to target specific patient phenotypes, disease severity and patient wishes is becoming more feasible with the growing array of therapeutic options in CD.
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Affiliation(s)
| | | | - Andrea Chan
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Tianwei Liu
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jonathan P Segal
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
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14
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Bin Traiki TA, Alshammari SA, Abdulla MA, Aldarsouni FG, Alhassan NS, Abdullah MH, Alqahtani A, Alkhayal KA. Surgical outcomes and stoma-related complications in inflammatory bowel disease in Saudi Arabia: a retrospective study. Ann Saudi Med 2023; 43:386-393. [PMID: 38071440 PMCID: PMC11182432 DOI: 10.5144/0256-4947.2023.386] [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] [Received: 08/09/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The prevalence of inflammatory bowel diseases (IBD), Crohn's (C) and ulcerative colitis (UC) has increased in Saudi Arabia during the past decade. Even though medical treatment is first-line therapy, most patients require surgery during the course of the disease. Stoma creation complications in IBD are underreported in the literature of the Middle East and especially in Saudi Arabia. OBJECTIVES Report the postoperative, stoma and peristomal complications following stoma creation in (C) versus UC. DESIGN Retrospective cohort study. SETTINGS Tertiary care center. PATIENTS AND METHODS Patients with IBD who underwent stoma creation for either UC or CD between August 2015 and July 2020 were included. The diseases were compared to assess their characteristics and association to postoperative, stoma and peristomal complications. All complications were reported over a 90-day duration from the surgery. Patients younger than 14 years of age were excluded. MAIN OUTCOME MEASURES Postoperative complications, stoma and peristomal complications in IBD patients who underwent stoma creation. SAMPLE SIZE 50. RESULTS Of 50 IBD patients underwent stoma creation, 32 patients (64%) were diagnosed with CD and 18 patients (36%) with UC. Most of the procedures in both groups were laparoscopic and elective. Low BMI and serum albumin were more prevalent in the CD group. Postoperative complications were higher in the CD patients compared to the UC patients (CD 40.6% vs UC 11.1%, P=.028) with the most common complication being abdominal collection[a]. Stoma complications were comparable between the two groups (UC 16.7% vs CD 15.6%). However, peristomal complications were higher clinically in UC patients in comparison with the CD patients (UC 61.1% vs CD 37.5% P=.095) with the most common complication being skin excoriation (UC 44.4% vs CD 37.5%). CONCLUSIONS CD has significantly higher postoperative complications compared to UC. Peristomal complications were high in both groups and had a negative impact on quality of life. Therefore, comprehensive stoma education and regular outpatient follow ups are recommended to improve the overall outcomes. LIMITATIONS Retrospective and conducted in one academic institution with a small sample size.
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Affiliation(s)
- Thamer A. Bin Traiki
- From the Colorectal Research Chair, Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Sulaiman A. Alshammari
- From the Colorectal Research Chair, Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Noura S. Alhassan
- From the Colorectal Research Chair, Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Maha-Hamdien Abdullah
- From the Colorectal Research Chair, Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Awadh Alqahtani
- From the Department of Surgery, College of Medicine, King Saud University, Riyadh Saudi Arabia
| | - Khayal A. Alkhayal
- From the Colorectal Research Chair, Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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15
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Xie J, Chen M, Wang W, Shao R. Factors associated with delayed diagnosis of Crohn's disease: A systematic review and meta-analysis. Heliyon 2023; 9:e20863. [PMID: 37860523 PMCID: PMC10582495 DOI: 10.1016/j.heliyon.2023.e20863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023] Open
Abstract
Background Delayed diagnosis is a major barrier to the effective management of Crohn's disease (CD). Several studies have investigated factors responsible for delays in diagnosis, but no meta-analyses have systematically assessed the impact of these factors. Aim To assess the impact of various factors on the delayed diagnosis of CD. Methods PubMed, EMBASE, and Web of Science databases were searched to identify observational studies published before April 2022 that assessed factors associated with delays in CD diagnosis. Further, we excluded review articles, case reports, or commentaries without original data. We pooled effect siee distinct samples. The assessment of study quality was performed utilizing the Newcastle-Ottawa Scale, while the presence of between-study heterogeneity was investigated. For a visual appraisal of potential publication bias, a funnel plot was employed. The study protocol was registered with PROSPERO, CRD42022322251. Results A total of 18 studies were included in the paper, covering 13 countries. The study sample consisted of 9669 cases. Ileal CD (OR = 1.46, 95 % CI = 1.21-1.76), smoking at the time of diagnosis (OR = 1.19, 95 % CI = 1.02-1.38), and use of NSAIDs (OR = 1.34, 95 % CI = 1.04-1.72) were significantly associated with a delay in CD diagnosis. However, no significant associations were observed between diagnostic delay and sex, age, endoscopic ileocolonoscopy, or diarrhea. Funnel plot analysis, indicating potential risks of publication bias, suggested the existence of unpublished or unreported study findings. Conclusion The findings suggest that ileal CD, use of NSAIDs, and smoking are risk factors for the delayed diagnosis of CD. Enhancing education of patients and primary care providers about these factors is warranted.
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Affiliation(s)
| | | | - Wenrui Wang
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, 211198, China
| | - Rong Shao
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, 211198, China
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16
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Kim WJ, Iskandarani M, Manzo CA, Pellino G, Gallostra MM, Tekkis PP, Celentano V, Kontovounisios C. Patient-reported outcome measures and surgery for Crohn's disease: systematic review. BJS Open 2023; 7:zrad098. [PMID: 37882628 PMCID: PMC10601451 DOI: 10.1093/bjsopen/zrad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND/AIMS Crohn's disease is an inflammatory bowel disease with up to 50 per cent of patients requiring surgery within 10 years of diagnosis. Patient-reported outcome measures (PROMs) are vital to monitor and assess patient health-related quality of life (HRQoL). This systematic review aims to evaluate PROMs within studies for perioperative Crohn's disease patients. METHODS Articles from MEDLINE, Embase, Emcare and CINAHL databases were searched to find studies relating to the assessment of HRQoL in perioperative Crohn's disease patients using PROMs and patient-reported experience measures (PREMs) from 1st January 2015 to 22nd October 2023. Bias was assessed using the ROBINS-I tool was used for non-randomized interventional studies and the Cochrane RoB2 tool was used for randomized trials. RESULTS 1714 journal articles were filtered down to eight studies. Six studies focused on ileocaecal resection, one on perianal fistulas and one on the effects of cholecystectomy on patients with Crohn's disease. Within these articles, ten different PROM tools were identified (8 measures of HRQoL and 2 measures of functional outcome). Overall improvements in patient HRQoL pre- to postoperative for ileocaecal Crohn's disease were found in both paediatric and adult patients. Outcomes were comparable in patients in remission, with or without stoma, but were worse in patients with a stoma and active disease. CONCLUSION There are significant variations in how PROMs are used to evaluate perioperative Crohn's disease outcomes and a need for consensus on how tools are used. Routine assessments using an internationally accepted online platform can be used to monitor patients and support areas of treatment pathways that require further support to ensure high standards of care. They also enable future statistical comparisons in quantitative reviews and meta-analyses.
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Affiliation(s)
- Whei J Kim
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Carlo A Manzo
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Gianluca Pellino
- Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autonoma de Barcelona, UAB, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Marc Martí Gallostra
- Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autonoma de Barcelona, UAB, Barcelona, Spain
| | - Paris P Tekkis
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Valerio Celentano
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
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17
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Schwandner O. [Stem Cell Therapy for Complex Anal Fistula in Crohn`s Disease: Current Evidence and Future Perspectives]. Zentralbl Chir 2023; 148:220-227. [PMID: 37267976 DOI: 10.1055/a-2063-3673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Despite progress in multidisciplinary diagnostic and therapeutic strategies, complex anal fistulas associated with Crohn's disease remain a challenge for both medical and surgical management. Conventional surgical techniques such as flap procedures or LIFT are still associated with considerable persistence and recurrence rates. Based on this background, results of stem cell therapy for Crohn's anal fistula have shown promising results and are a sphincter-preserving technique. In particular, adipose-derived, allogeneic stem cell therapy (Darvadstrocel) has shown encouraging healing rates within the randomised controlled ADMIRE-CD trial, which were reproducible in "real world" data of limited clinical studies. The current evidence has led to the integration of allogeneic stem cell therapy into international guidelines. To date, the definitive status of allogeneic stem cells in the multidisciplinary treatment algorithm for complex anal fistulas associated with Crohn's disease cannot be evaluated.
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Affiliation(s)
- Oliver Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland
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18
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Fu Y, Waghray N, Fass R, Song G. Diagnostic Implications of Irritable Bowel Syndrome Is an Independent Risk Factor for Undergoing Surgical Interventions in Patients with Inflammatory Bowel Disease. Diagnostics (Basel) 2023; 13:diagnostics13111901. [PMID: 37296752 DOI: 10.3390/diagnostics13111901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/18/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) can present with overlapping symptoms, making diagnosis and management challenging. Patients with IBD in remission may continue to experience IBS symptoms. Patients with IBS were found to have a disproportionately higher prevalence of abdominal and pelvic surgeries than the general population. AIMS The aim of this study was to determine whether IBS is a risk factor for undergoing surgical interventions in patients with IBD and explore the diagnostic implications of these findings. METHODS A population-based cohort analysis was performed using TriNetX. Patients with Crohn's disease + IBS (CD + IBS) and ulcerative colitis + IBS (UC + IBS) were identified. The control groups consisted of patients with CD or UC alone without IBS. The main outcome was to compare the risks of undergoing surgical interventions between the cohorts. The secondary outcomes were to compare the risks of developing gastrointestinal symptoms and IBD-related complications between the cohorts. RESULTS Patients with IBD who subsequently developed IBS were more likely to experience gastrointestinal symptoms than those without IBS (p < 0.0001). Patients with concomitant IBD and IBS were more likely to develop IBD-related complications, including perforation of the intestine, gastrointestinal bleeding, colon cancer, and abdominal abscess (p < 0.05). Patients with concomitant IBD and IBS were more likely to undergo surgical interventions than patients without IBS, including colectomy, appendectomy, cholecystectomy, exploratory laparotomy, and hysterectomy (p < 0.05). CONCLUSIONS IBS appears to be an independent risk factor for patients with IBD to develop IBD-related complications and undergo surgical interventions. Patients with concomitant IBD and IBS could represent a unique subgroup of IBD patients with more severe symptoms, highlighting the importance of accurate diagnosis and management in this population.
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Affiliation(s)
- Yuhan Fu
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Nisheet Waghray
- Department of Gastroenterology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Ronnie Fass
- Department of Gastroenterology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Gengqing Song
- Department of Gastroenterology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA
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19
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Classification of surgical causes of and approaches to the chronically failing ileoanal pouch. Tech Coloproctol 2023; 27:271-279. [PMID: 36040574 PMCID: PMC10008244 DOI: 10.1007/s10151-022-02688-9] [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: 04/22/2022] [Accepted: 08/14/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Although there are various surgical causes of and therapeutic approaches to the chronically failing ileoanal pouch (PF), cases are often detailed without distinguishing the exact cause and corresponding treatment. The aim of our study was to classify causes of PF and corresponding surgical treatment options, and to establish efficacy of surgical approach per cause. METHODS This retrospective study included all consecutive adult patients with chronic PF surgically treated at our tertiary hospital between July 2014 and March 2021. Patients were classified according to a proposed sub-classification for surgical related chronic PF. Results were reported accordingly. RESULTS A total of 59 procedures were completed in 50 patients (64% male, median age 45 years [IQR 34.5-54.3]) for chronic PF. Most patients had refractory ulcerative colitis as indication for their restorative proctocolectomy (68%). All patients could be categorized according to the sub-classification. Reasons for chronic PF were septic complications (n = 25), pouch body complications (n = 12), outlet problems (n = 11), cuff problems (n = 8), retained rectum (n = 2), and inlet problems (n = 1). For these indications, 17 pouches were excised, 10 pouch reconstructions were performed, and 32 pouch revision procedures were performed. The various procedures had different complication rates. Technical success rates of redo surgery for the different causes varied from 0 to 100%, with a 75% success rate for septic causes. CONCLUSIONS Our sub-classification for chronic PF and corresponding treatments is suitable for all included patients. Outcomes varied between causes and subsequent management. Chronic PF was predominantly caused by septic complications with redo surgery achieving a 75% technical success rate.
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20
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Fousekis FS, Mitselos IV, Tepelenis K, Pappas-Gogos G, Katsanos KH, Lianos GD, Frattini F, Vlachos K, Christodoulou DK. Medical, Endoscopic and Surgical Management of Stricturing Crohn's Disease: Current Clinical Practice. J Clin Med 2022; 11:2366. [PMID: 35566492 PMCID: PMC9104530 DOI: 10.3390/jcm11092366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 12/10/2022] Open
Abstract
The development of fibrostenotic intestinal disease occurs in approximately one-third of patients with Crohn's disease and is associated with increased morbidity. Despite introducing new biologic agents, stricturing Crohn's disease remains a significant clinical challenge. Medical treatment is considered the first-line treatment for inflammatory strictures, and anti-TNF agents appear to provide the most considerable benefit among the available medical treatments. However, medical therapy is ineffective on strictures with a mainly fibrotic component, and a high proportion of patients under anti-TNF will require surgery. In fibrotic strictures or cases refractory to medical treatment, an endoscopic or surgical approach should be considered depending on the location, length, and severity of the stricture. Both endoscopic balloon dilatation and endoscopic stricturoplasty are minimally invasive and safe, associated with a small risk of complications. On the other hand, the surgical approach is indicated in patients not suitable for endoscopic therapy. This review aimed to present and analyze the currently available medical, endoscopic, and surgical management of stricturing Crohn's disease.
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Affiliation(s)
- Fotios S. Fousekis
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (F.S.F.); (I.V.M.); (K.H.K.)
| | - Ioannis V. Mitselos
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (F.S.F.); (I.V.M.); (K.H.K.)
| | - Kostas Tepelenis
- Department of Surgery, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (K.T.); (G.P.-G.); (G.D.L.); (K.V.)
| | - George Pappas-Gogos
- Department of Surgery, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (K.T.); (G.P.-G.); (G.D.L.); (K.V.)
| | - Konstantinos H. Katsanos
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (F.S.F.); (I.V.M.); (K.H.K.)
| | - Georgios D. Lianos
- Department of Surgery, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (K.T.); (G.P.-G.); (G.D.L.); (K.V.)
| | | | - Konstantinos Vlachos
- Department of Surgery, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (K.T.); (G.P.-G.); (G.D.L.); (K.V.)
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (F.S.F.); (I.V.M.); (K.H.K.)
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21
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Chandrasinghe P. Surgical Management of Small Bowel Crohn's Disease. Front Surg 2022; 9:759668. [PMID: 35495760 PMCID: PMC9051431 DOI: 10.3389/fsurg.2022.759668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.
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22
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Dietary Management of Chronic Kidney Disease and Secondary Hyperoxaluria in Patients with Short Bowel Syndrome and Type 3 Intestinal Failure. Nutrients 2022; 14:nu14081646. [PMID: 35458207 PMCID: PMC9030588 DOI: 10.3390/nu14081646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/09/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Abstract
Short gut syndrome can lead to type 3 intestinal failure, and nutrition and hydration can only be achieved with parenteral nutrition (PN). While this is a lifesaving intervention, it carries short- and long-term complications leading to complex comorbidities, including chronic kidney disease. Through a patient with devastating inflammatory bowel disease’s journey, this review article illustrates the effect of short gut and PN on kidney function, focusing on secondary hyperoxaluria and acute precipitants of glomerular filtration. In extensive small bowel resections colon in continuity promotes fluid reabsorption and hydration but predisposes to hyperoxaluria and stone disease through the impaired gut permeability and fat absorption. It is fundamental, therefore, for dietary intervention to maintain nutrition and prevent clinical deterioration (i.e., sarcopenia) but also to limit the progression of renal stone disease. Adaptation of both enteral and parenteral nutrition needs to be individualised, keeping in consideration not only patient comorbidities (short gut and jejunostomy, cirrhosis secondary to PN) but also patients’ wishes and lifestyle. A balanced multidisciplinary team (renal physician, gastroenterologist, dietician, clinical biochemist, pharmacist, etc.) plays a core role in managing complex patients, such as the one described in this review, to improve care and overall outcomes.
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Therapeutic Drug Monitoring in Perianal Fistulizing Crohn’s Disease. J Clin Med 2022; 11:jcm11071813. [PMID: 35407421 PMCID: PMC8999746 DOI: 10.3390/jcm11071813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 12/15/2022] Open
Abstract
Perianal fistulas are a common complication of Crohn’s disease (CD) that has, historically, been challenging to manage. Despite the strong available evidence that anti-tumor necrosis factor (anti-TNF) agents are useful in the treatment of perianal fistulizing Crohn’s disease (PFCD), a significant number of these patients do not respond to therapy. The use of therapeutic drug monitoring (TDM) in patients with CD receiving biologic agents has evolved and is currently positioned as an important tool to optimize and guide biologic treatment. Considering the treatment of PFCD can represent a challenge; identifying novel tools to improve the efficacy of current treatments is an important unmet need. Given its emerging role in other phenotypes of Crohn’s disease, the use of TDM could also offer an opportunity to enhance the effectiveness of available therapies and improve outcomes in the subset of patients with PFCD receiving biologics. Overall, there is mounting evidence that higher anti-TNF drug levels are associated with better rates of “fistula healing”. However, studies have been limited by their use of subjective outcomes and observational designs. Ultimately, further interventional, randomized controlled trials looking into the relationship between drug exposure and fistula outcomes are needed.
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Schardey J, Zehl S, Kappenberger AS, Zimmermann P, Beigel F, Schiergens TS, Kasparek MS, Kühn F, Werner J, Wirth U. It is not NOD2 - genetic and clinical risk factors for postoperative complications following ileocolic resection in Crohn's disease. Int J Colorectal Dis 2022; 37:1901-1908. [PMID: 35913516 PMCID: PMC9388399 DOI: 10.1007/s00384-022-04223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the role of the nucleotide oligomerization domain 2 (NOD2) mutation status and other risk factors for the incidence of postoperative complications after ileocolic resection for Crohn's disease (CD). METHODS Data of 138 patients consecutively undergoing ileocolic resection for CD at a tertiary academic referral center were retrospectively analyzed including single nucleotide polymorphism (SNP) data of the NOD2 gene. Uni- and multivariate regression analysis was performed to identify factors associated with increased risk of severe postoperative complications. RESULTS From 114 patients (83%), the NOD2 mutation status was available. Of these, 60 (53%) had a NOD2 wildtype, whereas eleven (10%) were homozygous for the high risk p.Leu1007fsX1008 (rs2066847) variant. Major postoperative complications occurred in 28 patients (20%). Twenty-seven of these (96%) were intraabdominal septic complications such as anastomotic leakage or abscess. Male gender (P = 0.029; OR 3.052, the duration of CD (time [months] from initial diagnosis of CD to surgery; P = 0.001; OR 1.009), previous abdominal surgery for CD (P = 0.017; OR 3.49), and the presence of enteric fistulas (P = 0.023; OR 3.21) were identified as independent risk factors for major postoperative complications. Homozygosity for the NOD2 high-risk variant p.Leu1007fsX1008 did not show increased postoperative morbidity in the short and long-term outcome. CONCLUSIONS We could detect independent risk factors for major postoperative complications after ileocolic resection for Crohn's disease. However, patients with the high-risk variant p.Leu1007fsX1008 of the NOD2 gene did not show increased postoperative morbidity.
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Affiliation(s)
- Josefine Schardey
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Sophie Zehl
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Alina S. Kappenberger
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Petra Zimmermann
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Florian Beigel
- grid.5252.00000 0004 1936 973XDepartment of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Tobias S. Schiergens
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael S. Kasparek
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany ,Department of Visceral Surgery, Josephinum, Munich, Germany
| | - Florian Kühn
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Jens Werner
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Ulrich Wirth
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
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Snyder EF, Davis S, Aldrich K, Veerabagu M, Larussa T, Abenavoli L, Boccuto L. Crohn disease: Identification, diagnosis, and clinical management. Nurse Pract 2021; 46:22-30. [PMID: 34808643 DOI: 10.1097/01.npr.0000798212.61425.4f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT Crohn disease is an inflammatory bowel disorder affecting children and adults. With its increasing prevalence, healthcare providers need adequate resources to assist with diagnosis and management. This article discusses early diagnosis, disease severity and classification, familial predisposition and genomics, and clinical management in the primary care setting.
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The Revival of Surgery in Crohn's Disease-Early Intestinal Resection as a Reasonable Alternative in Localized Ileitis. Biomedicines 2021; 9:biomedicines9101317. [PMID: 34680434 PMCID: PMC8533348 DOI: 10.3390/biomedicines9101317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 12/20/2022] Open
Abstract
Crohn's disease (CD) represents a heterogeneous and complex disease with no curative therapeutic option available to date. Current therapy is mainly antibody-based focusing on the immune system while other treatment alternatives such as surgery are considered to be "last options". However, medical therapy for CD results in mild to severe side effects in a relevant amount of patients and some patients do not respond to the medication. Following that, quality of life is often significantly reduced in this patient cohort, thus, therapeutic alternatives are urgently needed. Updated evidence has revealed that surgery such as ileocecal resection (ICR) might be a potential therapeutic option in case of localized terminal ileitis since resection at early time points improves quality of life and significantly reduces the postoperative need for immunosuppressive medication with low rates of morbidity. In addition, new surgical approaches such as Kono-S anastomosis or inclusion of the mesentery result in significantly reduced rates of disease recurrence and reoperation. Based on the new evidence, the goal of this review is to provide an update on the role of surgery as a reasonable alternative to medical therapy in the interdisciplinary treatment of patients with CD.
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Antunes JC, Seabra CL, Domingues JM, Teixeira MO, Nunes C, Costa-Lima SA, Homem NC, Reis S, Amorim MTP, Felgueiras HP. Drug Targeting of Inflammatory Bowel Diseases by Biomolecules. NANOMATERIALS 2021; 11:nano11082035. [PMID: 34443866 PMCID: PMC8401460 DOI: 10.3390/nano11082035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a group of disabling, destructive and incurable immune-mediated inflammatory diseases comprising Crohn’s disease (CD) and ulcerative colitis (UC), disorders that are highly prevalent worldwide and demand a large investment in healthcare. A persistent inflammatory state enables the dysfunction and destruction of healthy tissue, hindering the initiation and endurance of wound healing. Current treatments are ineffective at counteracting disease progression. Further, increased risk of serious side effects, other comorbidities and/or opportunistic infections highlight the need for effective treatment options. Gut microbiota, the key to preserving a healthy state, may, alternatively, increase a patient’s susceptibility to IBD onset and development given a relevant bacterial dysbiosis. Hence, the main goal of this review is to showcase the main conventional and emerging therapies for IBD, including microbiota-inspired untargeted and targeted approaches (such as phage therapy) to infection control. Special recognition is given to existing targeted strategies with biologics (via monoclonal antibodies, small molecules and nucleic acids) and stimuli-responsive (pH-, enzyme- and reactive oxygen species-triggered release), polymer-based nanomedicine that is specifically directed towards the regulation of inflammation overload (with some nanosystems additionally functionalized with carbohydrates or peptides directed towards M1-macrophages). The overall goal is to restore gut balance and decrease IBD’s societal impact.
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Affiliation(s)
- Joana Costa Antunes
- Centre for Textile Science and Technology (2C2T), Campus de Azurém, University of Minho, 4800-058 Guimarães, Portugal; (J.M.D.); (M.O.T.); (N.C.H.); (M.T.P.A.); (H.P.F.)
- Correspondence: ; Tel.: +351-253-510-289
| | - Catarina Leal Seabra
- Laboratório Associado para a Química Verde (LAQV), Network of Chemistry and Technology (REQUIMTE), Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, 4050-313 Porto, Portugal; (C.L.S.); (C.N.); (S.A.C.-L.); (S.R.)
| | - Joana Margarida Domingues
- Centre for Textile Science and Technology (2C2T), Campus de Azurém, University of Minho, 4800-058 Guimarães, Portugal; (J.M.D.); (M.O.T.); (N.C.H.); (M.T.P.A.); (H.P.F.)
| | - Marta Oliveira Teixeira
- Centre for Textile Science and Technology (2C2T), Campus de Azurém, University of Minho, 4800-058 Guimarães, Portugal; (J.M.D.); (M.O.T.); (N.C.H.); (M.T.P.A.); (H.P.F.)
| | - Cláudia Nunes
- Laboratório Associado para a Química Verde (LAQV), Network of Chemistry and Technology (REQUIMTE), Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, 4050-313 Porto, Portugal; (C.L.S.); (C.N.); (S.A.C.-L.); (S.R.)
| | - Sofia Antunes Costa-Lima
- Laboratório Associado para a Química Verde (LAQV), Network of Chemistry and Technology (REQUIMTE), Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, 4050-313 Porto, Portugal; (C.L.S.); (C.N.); (S.A.C.-L.); (S.R.)
| | - Natália Cândido Homem
- Centre for Textile Science and Technology (2C2T), Campus de Azurém, University of Minho, 4800-058 Guimarães, Portugal; (J.M.D.); (M.O.T.); (N.C.H.); (M.T.P.A.); (H.P.F.)
| | - Salette Reis
- Laboratório Associado para a Química Verde (LAQV), Network of Chemistry and Technology (REQUIMTE), Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, 4050-313 Porto, Portugal; (C.L.S.); (C.N.); (S.A.C.-L.); (S.R.)
| | - Maria Teresa Pessoa Amorim
- Centre for Textile Science and Technology (2C2T), Campus de Azurém, University of Minho, 4800-058 Guimarães, Portugal; (J.M.D.); (M.O.T.); (N.C.H.); (M.T.P.A.); (H.P.F.)
| | - Helena Prado Felgueiras
- Centre for Textile Science and Technology (2C2T), Campus de Azurém, University of Minho, 4800-058 Guimarães, Portugal; (J.M.D.); (M.O.T.); (N.C.H.); (M.T.P.A.); (H.P.F.)
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