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Sun Z, Cao L, Chen Y, Zhu W, Li Y. Long-term outcomes of intestinal penetrating Crohn's disease following successful nonoperative management. Eur J Gastroenterol Hepatol 2024; 36:867-874. [PMID: 38625818 DOI: 10.1097/meg.0000000000002775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
There is a paucity of data on the surgical or medical treatment for abscess/fistula complicating Crohn's disease after successful nonsurgical management. We conducted a cohort study to investigate the long-term outcomes and the risk factors for the requirement of subsequent surgical intervention in Crohn's disease patients with complicating fistulas/abscess following successful nonsurgical management. Data were collected on penetrating Crohn's disease experiencing successful nonsurgical treatment between December 2012 and December 2021. Long-term outcomes and risk factors of surgery were assessed by univariate and multivariate analysis, and subgroup analysis was performed based on penetrating phenotype including abscess, fistula, and phlegmon. A total of 523 penetrating Crohn's disease patients; there were 390, 125, and 60 patients complicated with fistulas, abscess, and phlegmon, respectively. Long-term outcomes showed that BMI < 18.5 (kg/m 2 ), the recurrent abscess, and stricture were independent risk factors of surgery. Biologics and resolution of abscess were independent protective factors of surgery. Furthermore, in 399 patients undergoing early surgery, stricture and BMI < 18.5 (kg/m 2 ) were independent risk factors, and biologics and abscess resolution were protective of the early surgery. Subgroup analysis based on fistula, abscess, and phlegmon phenotype also demonstrated that concomitant stricture was an independent risk factor and the use of biologics was protective of surgical resection. Our data indicate that biologics can delay the requirement of surgery and may be given to patients with penetrating complicating Crohn's disease who have been successfully treated nonoperatively, but surgical resection should be considered in the setting of malnutrition and stenosis formation.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| | - Yusheng Chen
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| | - Weiming Zhu
- Department of Anorectal Surgery, IBD Therapeutic Center, Nanjing University of Chinese Medicine, Nanjing, PR China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
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Adamina M, Minozzi S, Warusavitarne J, Buskens C, Chaparro M, Verstockt B, Kopylov U, Agrawal M, Allocca M, Atreya R, Battat R, Bettenworth D, Bislenghi G, Brown SR, Burisch J, Casanova MJ, Czuber-Dochan W, de Groof J, El-Hussuna A, Ellul P, Fidalgo C, Fiorino G, Gisbert J, Sabino JG, Hanzel J, Holubar S, Iacucci M, Iqbal N, Kapizioni C, Karmiris K, Kobayashi T, Kotze PG, Luglio G, Maaser C, Moran G, Noor N, Papamichael K, Peros G, Reenaers C, Sica G, Sigall-Boneh R, Vavricka SR, Yanai H, Raine T, Gordon H, Myrelid P. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2024:jjae089. [PMID: 38878002 DOI: 10.1093/ecco-jcc/jjae089] [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: 05/21/2024] [Indexed: 07/28/2024]
Abstract
This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital of Fribourg & Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Visceral and Thoracic Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Christianne Buskens
- Department of Surgery, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Maria Chaparro
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid; Spain
| | - Bram Verstockt
- Department Gastroenterology & Hepatology, University Hospitals Leuven, KU Leuven and Dpt. Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Manasi Agrawal
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva; Faculty of Medicine, Tel Aviv University, Tel Aviv; Israel
| | - Mariangela Allocca
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Raja Atreya
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert Battat
- Department of Surgery, Università Tor Vergata, Roma, Italy
| | | | - Gabriele Bislenghi
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Steven Ross Brown
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Johan Burisch
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - María José Casanova
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham
- Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham. NG7 2UH. United Kingdom
| | | | - Joline de Groof
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Alaa El-Hussuna
- Health Sciences Postgraduate Program, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Pierre Ellul
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Catarina Fidalgo
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - Gionata Fiorino
- Department of Gastroenterology, Attikon University Hospital, Athens, Greece
| | - Javier Gisbert
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - João Guedelha Sabino
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Jurij Hanzel
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana; Chair of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marietta Iacucci
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Nusrat Iqbal
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Konstantinos Karmiris
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal
| | | | | | - Gaetano Luglio
- Colorectal Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Christian Maaser
- Florence Nightingale Faculty of Nursing- Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Gordon Moran
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid. Spain
| | - Nurulamin Noor
- Gastrounit, Medical Division, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | | | - Georgios Peros
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
| | - Catherine Reenaers
- CED Schwerpunktpraxis, Münster and Medical Faculty of the University of Münster, Münster, NRW, Germany
| | - Giuseppe Sica
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Rotem Sigall-Boneh
- First Department of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan R Vavricka
- IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Gastroenterology and Endoscopy, Milan, Italy
| | - Henit Yanai
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Hannah Gordon
- Translational Gastroenterology and Liver Unit, University of Oxford, Oxford, UK
| | - Pär Myrelid
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Sun Z, Cao L, Chen Y, Song T, Guo Z, Zhu W, Li Y. Impact of total parenteral nutrition v. exclusive enteral nutrition on postoperative adverse outcomes in patients with penetrating Crohn's disease undergoing surgical resection: a retrospective cohort study. Br J Nutr 2024:1-10. [PMID: 38832664 DOI: 10.1017/s0007114524001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Achieving optimal nutritional status in patients with penetrating Crohn's disease is crucial in preparing for surgical resection. However, there is a dearth of literature comparing the efficacy of total parenteral nutrition (TPN) v. exclusive enteral nutrition (EEN) in optimising postoperative outcomes. Hence, we conducted a case-matched study to assess the impact of preoperative EEN v. TPN on the incidence of postoperative adverse outcomes, encompassing overall postoperative morbidity and stoma formation, among penetrating Crohn's disease patients undergoing bowel surgery. From 1 December 2012 to 1 December 2021, a retrospective study was conducted at a tertiary centre to enrol consecutive patients with penetrating Crohn's disease who underwent surgical resection. Propensity score matching was utilised to compare the incidence of postoperative adverse outcomes. Furthermore, univariate and multivariate logistic regression analyses were conducted to identify the risk factors associated with adverse outcomes. The study included 510 patients meeting the criteria. Among them, 101 patients in the TPN group showed significant improvements in laboratory indicators at the time of surgery compared with pre-optimisation levels. After matching, TPN increased the occurrence of postoperative adverse outcomes (92·2 % v. 64·1 %, P = 0·001) when compared with the EEN group. In the multivariate analysis, TPN showed a significantly higher OR for adverse outcomes than EEN (OR = 4·241; 95 % CI 1·567-11·478; P = 0·004). The study revealed that penetrating Crohn's disease patients who were able to fulfil their nutritional requirements through EEN exhibited superior nutritional and surgical outcomes in comparison with those who received TPN.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, People's Republic of China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, People's Republic of China
| | - Yusheng Chen
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, People's Republic of China
| | - Tianrun Song
- Department of General Surgery, Jinling Clinical School of Medicine (Eastern Theater General Hospital), Nanjing Medical University, Nanjing 210002, People's Republic of China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, People's Republic of China
| | - Weiming Zhu
- IBD Therapeutic Center, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, People's Republic of China
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Sun Z, Cao L, Guo Z, Zhou Y, Zhu W, Li Y. A nomogram to predict stoma creation in elective surgical resection for penetrating Crohn's disease. ANZ J Surg 2024; 94:923-930. [PMID: 38290990 DOI: 10.1111/ans.18872] [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: 11/07/2023] [Revised: 12/14/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUNDS The decision to perform a stoma during surgical resection of penetrating Crohn's disease (CD) is a critical consideration. The objective of this study was to identify factors that influence stoma creation and develop a predictive nomogram model to assist surgeons in making optimal surgical decisions. METHODS A retrospective study was conducted at a tertiary center from December 1, 2012, to December 1, 2021, involving consecutive patients with penetrating CD who underwent elective surgical resection. The LASSO regression method was used to select preoperative predictors, and a nomogram was constructed using multivariate logistic regression. The performance of the nomogram was validated in an internal cohort by assessing its discrimination, calibration, and clinical usefulness. RESULTS The study included 405 cases in the training group and 135 cases in the validation group. Nine risk factors for stoma formation were identified, including disease location, fistula resulted from previous anastomosis, absence of preoperative exclusive enteral nutrition support, albumin levels below 35 g/L, C-reactive protein levels above 10 mg/L, hemoglobin levels below 100 g/L, perianal disease, internal fistula, and surgical approach. These risk factors were selected using the LASSO regression method, and a nomogram was developed based on them. The area under the curve and the coefficient of determination (R2) of the nomogram were 0.821 and 0.394, respectively. And the nomogram demonstrated good performance in the validation cohort. CONCLUSIONS The nomogram exhibited good predictive ability for stoma formation during elective surgical resection for penetrating CD, which can assist surgeons in making informed clinical decisions.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yan Zhou
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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