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Ma D, Li Y, Li L, Yang L. Risk factors for endoscopic postoperative recurrence in patients with Crohn's Disease: a protocol for systematic review and meta-analysis. BMC Gastroenterol 2024; 24:211. [PMID: 38918740 PMCID: PMC11197377 DOI: 10.1186/s12876-024-03301-z] [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: 01/15/2024] [Accepted: 06/20/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Crohn's disease (CD) is a chronic condition characterized by a high recurrence rate after surgery, which seriously affects the quality of life of patients. Many studies have explored the risk factors for the recurrence of CD after surgery, there is a lack of meta-analysis focusing on endoscopic postoperative recurrence (ePOR) as a clinical outcome. Therefore, this paper aims to identify the risk factors for ePOR in CD patients through systematic review and meta-analysis. METHODS PubMed, Embase, Cochrane Library, and Web of Science databases were searched for related literature from inception to 17th October 2023. Two researchers independently screened the literature and extracted information. Data analysis was performed using Stata18.0. RESULTS Twenty-three papers were included, with 5 case-control studies and 18 cohort studies. The National Institutes of Health quality assessment tool rated 17 studies as good and 6 studies as fair. The sample size of the 23 studies ranged from 40 to 346, and the number of patients with ePOR ranged from 23 to 169. The results of multivariate meta-analysis showed that smoking [OR = 2.06, 95% CI (1.65, 2.57), P = 0.0001], previous ileocolonic resection [OR = 1.71, 95% CI (1.23, 2.38), P = 0.002], disease localization at ileocolic resection [OR = 2.68, 95% CI (1.38, 5.22), P = 0.004], perianal disease [OR = 1.47, 95% CI (1.07, 2.03), P = 0.017], and anastomotic scattered ulcer [OR = 3.39, 95% CI (1.83, 6.28), P = 0.001] were risk factors for ePOR in CD patients. Postoperative prophylactic medication [OR = 0.53, 95% CI (0.38,0.75), P = 0.0001] was a protective factor for ePOR in CD patients. CONCLUSIONS This systematic review identified multiple factors for ePOR in CD patients, as well as a protective factor. However, the number of articles included was limited. More high-quality clinical studies are required to further validate the conclusions. TRIAL REGISTRATION This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023483671).
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Affiliation(s)
- Dongchi Ma
- School of nursing, Zhejiang Chinese Medical University, 548 Bin-wen Road, Hangzhou, Zhejiang, 310053, PR China
| | - Yu Li
- School of nursing, Zhejiang Chinese Medical University, 548 Bin-wen Road, Hangzhou, Zhejiang, 310053, PR China
| | - Ling Li
- School of nursing, Zhejiang Shuren University, 8 Shuren Road, Hangzhou, Zhejiang, 310015, PR China
| | - Lili Yang
- School of nursing, Zhejiang Chinese Medical University, 548 Bin-wen Road, Hangzhou, Zhejiang, 310053, PR China.
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Hammoudi N, Sachar D, D'Haens G, Reinisch W, Kotze PG, Vermeire S, Schölmerich J, Kamm MA, Griffiths A, Panes J, Ghosh S, Siegel CA, Bemelman W, O'Morain C, Steinwurz F, Fleshner P, Mantzaris GJ, Sands B, Abreu MT, Dotan I, Turner D, Dignass A, Allez M. Outcomes and Endpoints of Postoperative Recurrence in Crohn's Disease: Systematic Review and Consensus Conference. J Crohns Colitis 2024; 18:943-957. [PMID: 38112601 DOI: 10.1093/ecco-jcc/jjad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/24/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Outcomes after ileocolonic resection in Crohn's disease [CD] are heterogeneous, and a clear definition of postoperative recurrence remains to be determined. Our Endpoints Working Group of the International Organization for the study of Inflammatory Bowel Disease [IOIBD] aimed to standardise postoperative outcomes, to discuss which endpoints should be used for postoperative clinical trials, and to define those which could be used in trials or registries. METHODS Based on a systematic review of the literature, recommendations and statements were drafted and sent to all IOIBD members for a first round of voting. Recommendations and statements were revised based on the voters' comments during a consensus hybrid conference open to all IOIBD members. If no agreement was reached after two rounds of voting, the statement was excluded. RESULTS In the systematic review, 3071 manuscripts were screened of which 434 were included. Sixteen recommendations were identified, of which 11 were endorsed. Recommendations and statements include that endoscopy remains the gold standard and should be used as a short-term primary endpoint in both observational cohorts and randomised controlled trials. Clinical symptoms classically used in clinical trials for luminal CD are not reliable in this specific situation. For that reason, longer-term endpoints should be based on the evidence of macroscopic inflammation assessed by imaging techniques, endoscopy, or as reflected by the presence of complications. CONCLUSIONS Agencies recommend the use of clinical evaluations, as in the case of luminal CD, and do not recognise primary endpoints based solely on endoscopy. This consensus has led to agreement on the need to define postoperative endoscopy-based and/or imaging-based endpoints.
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Affiliation(s)
- Nassim Hammoudi
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - David Sachar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Geert D'Haens
- Department of Gastroenterology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Walter Reinisch
- Department Internal Medicine III, Division Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Severine Vermeire
- Department of Gastroenterology & Hepatology, University Hospital Leuven, Leuven, Belgium
| | | | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anne Griffiths
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Julian Panes
- Formerly Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Corey A Siegel
- IBD Center, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, USA
| | - Willem Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Colm O'Morain
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Flavio Steinwurz
- Department of Gastroenterology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Bruce Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria T Abreu
- Department of Medicine, Division of Gastroenterology, Crohn's and Colitis Center, Leonard M. Miller School of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medica Center, Petah-Tikva, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt Am Main, Germany
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
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Shen B. Endoscopic Evaluation of the Ileal Pouch. Dis Colon Rectum 2024; 67:S52-S69. [PMID: 38276962 DOI: 10.1097/dcr.0000000000003269] [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: 01/27/2024]
Abstract
BACKGROUND Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described. DATA SOURCES PubMed, Google Scholar, and Cochrane databases. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES Accurate characterization of the ileal pouch in healthy or diseased states. RESULTS The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series. CONCLUSIONS Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.
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Affiliation(s)
- Bo Shen
- The Global Integrated Center for Colorectal Surgery and Interventional Endoscopy and Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
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Bak MT, ten Bokkel Huinink S, Erler NS, Bodelier AG, Dijkstra G, Romberg-Camps M, de Boer NK, Hoentjen F, Stassen LP, van der Meulen–de Jong AE, West RL, van Ruler O, van der Woude CJ, de Vries AC. Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease. Am J Gastroenterol 2024; 119:306-312. [PMID: 37737675 PMCID: PMC10833187 DOI: 10.14309/ajg.0000000000002509] [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: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD. METHODS Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes. RESULTS Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence. DISCUSSION The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.
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Affiliation(s)
- Michiel T.J. Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastiaan ten Bokkel Huinink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicole S. Erler
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Heerlen-Sittard-Geleen, the Netherlands
| | - Nanne K.H. de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada;
| | - Laurents P.S. Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Rachel L. West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Ziekenhuis, Cappelle aan den IJssel, the Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annemarie C. de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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Bachour SP, Click BH. Clinical Update on the Prevention and Management of Postoperative Crohn's Disease Recurrence. Curr Gastroenterol Rep 2024; 26:41-52. [PMID: 38227128 DOI: 10.1007/s11894-023-00911-7] [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] [Accepted: 12/27/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE OF REVIEW Despite advances in therapeutics, a significant portion of patients with Crohn's disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn's disease recurrence. RECENT FINDINGS Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and "-omic" risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy. Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn's disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.
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Affiliation(s)
- Salam P Bachour
- Brigham and Women's Hospital, Department of Medicine, Boston, MA, 02115, USA
| | - Benjamin H Click
- University of Colorado Anschutz Medical Campus, Division of Gastroenterology and Hepatology, 13001 E 17th Pl, Aurora, CO, 80045, USA.
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Ueda T, Koyama F, Sugita A, Ikeuchi H, Futami K, Fukushima K, Nezu R, Iijima H, Mizushima T, Itabashi M, Watanabe K, Hata K, Shinagawa T, Matsuoka K, Takenaka K, Sasaki M, Nagayama M, Yamamoto H, Shinozaki M, Fujiya M, Kato J, Ueno Y, Tanaka S, Okita Y, Hashimoto Y, Kobayashi T, Koganei K, Uchino M, Fujii H, Suzuki Y, Hisamatsu T. Endoscopic Lesions of Postoperative Anastomotic Area in Patients With Crohn's Disease in the Biologic Era: A Japanese Multi-Centre Nationwide Cohort Study. J Crohns Colitis 2023; 17:1968-1979. [PMID: 37450892 DOI: 10.1093/ecco-jcc/jjad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND AIMS Many patients have endoscopic evidence of recurrent Crohn's disease [CD] at 1 year after intestinal resection. These lesions predict future clinical recurrence. We endoscopically evaluated postoperative anastomotic lesions in CD patients from a large cohort of postoperative CD patients. METHODS We retrospectively enrolled CD patients who underwent surgical resection between 2008 and 2013 at 19 inflammatory bowel disease [IBD]-specialist institutions. The initial analyses included patients who underwent ileocolonoscopy ~1 year after intestinal resection. Follow-up analyses assessed any changes in the endoscopic findings over time. We evaluated the postoperative endoscopic findings, which were classified into four categories [no lesion, mild, intermediate, severe] at the sites of the anastomotic line and peri-anastomosis. RESULTS In total, 267 CD patients underwent postoperative ileocolonoscopy. Postoperative anastomotic lesions were widely detected in index ileocolonoscopy [61.0%] and were more frequently detected in follow-up ileocolonoscopy [74.9%]. Endoscopic severity also increased. Patients with intermediate or severe peri-anastomotic or anastomotic line lesions at the index ileocolonoscopy required significantly more interventions, including endoscopic dilatation or surgery, than patients with mild lesions or no lesions. CONCLUSIONS Frequent anastomotic lesions were observed at the postoperative index ileocolonoscopy. These gradually increased for subsequent ileocolonoscopy, even in the biologic era. Regarding lesions on the anastomotic line, intermediate lesions on the anastomotic line [e.g. irregular or deep ulcers] might be considered recurrent disease, and mild lesions [e.g. linear superficial ulcers] might be considered non-recurrent disease. Prospective studies are needed to resolve this issue, including treatment enhancement.
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Affiliation(s)
- Takeshi Ueda
- Department of Surgery, Nara Medical University, Kashihara, Japan
- Sai Gastroenterology and Proctology Clinic, Fujiidera, Japan
| | - Fumikazu Koyama
- Department of Surgery, Nara Medical University, Kashihara, Japan
- Division of Endoscopy, Nara Medical University Hospital, Kashihara, Japan
| | - Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Hiroki Ikeuchi
- Department of Gastroenterological Surgery, Division of Inflammatory Bowel Disease Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kitaro Futami
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | | | - Riichiro Nezu
- Department of Surgery, Osaka Central Hospital, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, and Department of Gastroenterology, Department of Gastroenterology, Osaka Police Hospital, Osaka, Japan
| | - Tsunekazu Mizushima
- Department of Therapeutics for Inflammatory Bowel Diseases, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
- Nihonbashi Muromachi Mitsui Tower Midtown Clinic, Tokyo, Japan
| | | | - Katsuyoshi Matsuoka
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Makoto Sasaki
- Division of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Manabu Nagayama
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Masaru Shinozaki
- Department of Surgery, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan, and Saitama Gastroenterological Clinic, Saitama, Japan
| | - Mikihiro Fujiya
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Kato
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshitaka Ueno
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | | | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kazutaka Koganei
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Motoi Uchino
- Department of Gastroenterological Surgery, Division of Inflammatory Bowel Disease Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hisao Fujii
- Gastrointestinal Endoscopy and IBD Center, Yoshida Hospital, Nara, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
- Ginza Central Clinic, Tokyo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
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Hussan E, Kroemer A, Elsabbagh AM, Khan KM, Yazigi NA, Ekong UD, Subramanian S, Ghobrial SS, Guerra JF, Fishbein TM, Matsumoto CS, Kaufman SS. Idiopathic Ileal Ulceration After Intestinal Transplantation. Transplant Direct 2023; 9:e1529. [PMID: 37899780 PMCID: PMC10602531 DOI: 10.1097/txd.0000000000001529] [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: 05/11/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 10/31/2023] Open
Abstract
Background Idiopathic ileal ulceration after intestinal transplantation (ITx) has been discussed infrequently and has an uncertain natural history and relation to graft rejection. Herein, we review our experience with this pathology. Methods We retrospectively reviewed 225 ITx in 217 patients with minimum 1 y graft survival. Routine graft endoscopy was conducted up to twice weekly within the first 90 d after ITx, gradually decreasing to once yearly. Risks for ulceration over time were evaluated using Cox regression. Results Of 93 (41%) patients with ulcers, 50 were found within 90 d after ITx mostly via ileoscopy; delayed healing after biopsy appeared causal in the majority. Of the remaining 43 patients with ulcers found >90 d after ITx, 36 were after ileostomy closure. Multivariable modeling demonstrated within 90-d ulcer associations with increasing patient age (hazard ratio [HR], 1.027; P < 0.001) and loop ileostomy (versus Santulli ileostomy; HR, 0.271; P < 0.001). For ulcers appearing after ileostomy closure, their sole association was with absence of graft colon (HR, 7.232; P < 0.001). For ulcers requiring extended anti-microbial and anti-inflammatory therapy, associations included de novo donor-specific antibodies (HR, 3.222; P < 0.007) and nucleotide oligomerization domain mutations (HR, 2.772; P < 0.016). Whole-cohort post-ITx ulceration was not associated with either graft rejection (P = 0.161) or graft failure (P = 0.410). Conclusions Idiopathic ulceration after ITx is relatively common but has little independent influence on outcome; risks include ileostomy construction, colon-free ITx, immunologic mutation, and donor sensitization.
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Affiliation(s)
- Elsadig Hussan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Ahmed M. Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Udeme D. Ekong
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | | | - Juan-Francisco Guerra
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
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8
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Dragoni G, Allocca M, Myrelid P, Noor NM, Hammoudi N, Rivière P, Panis Y, Ferrante M. Results of the Eighth Scientific Workshop of ECCO: Diagnosing Postoperative Recurrence of Crohn's Disease After an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis 2023; 17:1373-1386. [PMID: 37070339 DOI: 10.1093/ecco-jcc/jjad055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Despite the introduction of potent biologic therapies, many patients with Crohn's disease [CD] still require an ileocolonic resection [ICR] during the course of their disease. Furthermore, the need of redo ICR has not decreased over the past few decades, highlighting the need for better strategies to prevent and treat postoperative recurrence [POR]. The first step to develop such a strategy would be to define and standardise the description of POR with adequate diagnostic instruments. In this article, we will describe the different methodologies used to report POR [endoscopic, histological, radiological, biochemical, clinical, and surgical], and review their potential benefits and limitations, as well as the optimal timing of evaluation.
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Affiliation(s)
- Gabriele Dragoni
- IBD Referral Center, Department of Gastroenterology, Careggi University Hospital, Florence, Italy
- Gastroenterology Research Unit, Department of Experimental and Clinical Biochemical Sciences 'Mario Serio', University of Florence, Florence, Italy
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin M Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nassim Hammoudi
- Gastroenterology Department, Hôpital Saint-Louis - APHP, Université Paris Cité, INSERM U1160, Paris, France
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases and Metabolism [CHROMETA], KU Leuven, Leuven, Belgium
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9
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Xiong S, He J, Chen B, He Y, Zeng Z, Chen M, Chen Z, Qiu Y, Mao R. A nomogram incorporating ileal and anastomotic lesions separately to predict the long-term outcome of Crohn's disease after ileocolonic resection. Therap Adv Gastroenterol 2023; 16:17562848231198933. [PMID: 37720355 PMCID: PMC10503285 DOI: 10.1177/17562848231198933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Background The Rutgeerts score (RS) is widely used to predict postoperative recurrence after ileocolonic resection for Crohn's disease (CD) based on the severity of lesions at the neoterminal ileum and anastomosis (RS i0-i4). However, the value of anastomotic ulcers remains controversial. Objectives Our aim was to establish a nomogram model incorporating ileal and anastomotic lesions separately to predict the long-term outcomes of CD after ileal or ileocolonic resection. Design A total of 136 patients with CD were included in this retrospective cohort study. Methods Consecutive CD patients who underwent ileal or ileocolonic resections with postoperative ileocolonoscopy evaluation within 1 year after the surgery were included. The primary endpoint was postoperative clinical relapse (CR). An endoscopic classification separating ileal and anastomotic lesions was applied (Ix for neoterminal ileum lesions; Ax for anastomotic lesions). A nomogram was constructed to predict CR. The performance of the model was evaluated by the receiver-operating characteristic (ROC) curve and decision curve analysis (DCA). Results CR was observed in 47.1% (n = 64) of patients within a median follow-up of 26.9 (interquartile range, 11.4-55.2) months. The risk of CR was significantly higher in patients with an RS ⩾ i2 assessed by the first postoperative endoscopy compared with patients with an RS ⩽ i1 (p < 0.001). Moreover, the cumulative rate of CR was significantly higher in patients with ileal lesions (I1-4) compared with patients without (I0) (p < 0.001). Besides, patients with anastomotic lesions (A1-3) had significantly higher rates of CR than patients without (A0) (p = 0.002). A nomogram, incorporating scores of postoperative ileal or anastomotic lesions, sex, L2-subtype and perianal disease, was established. The DCA analysis indicated that the nomogram had a higher benefit for CR, especially at the timeframe of 24-60 months after index endoscopy, compared to the traditional RS score. Conclusion A nomogram incorporating postoperative ileal and anastomotic lesions separately was developed to predict CR in CD patients, which may serve as a practical tool to identify high-risk patients who need timely postoperative intervention.
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Affiliation(s)
- Shanshan Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jinshen He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhihui Chen
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, China
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10
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Bachour SP, Shah RS, Lyu R, Rieder F, Qazi T, Lashner B, Achkar JP, Philpott J, Barnes EL, Axelrad J, Holubar SD, Lightner AL, Regueiro M, Cohen BL, Click BH. Mild neoterminal ileal post-operative recurrence of Crohn's disease conveys higher risk for severe endoscopic disease progression than isolated anastomotic lesions. Aliment Pharmacol Ther 2022; 55:1139-1150. [PMID: 35285534 PMCID: PMC9677520 DOI: 10.1111/apt.16804] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 12/15/2022]
Abstract
There are conflicting data assessing the impact of isolated post-operative anastomotic inflammation on future disease progression. The aim of this study was to determine the relative risk of severe disease progression in post-operative Crohn's disease (CD) patients with isolated anastomotic disease. METHODS Retrospective cohort study of adult CD patients undergoing ileocolonic resection between 2009 and 2020. Patients with a post-operative ileocolonoscopy ≤18 months from surgery and ≥1 subsequent ileocolonoscopy were included. Disease activity was assessed using the modified Rutgeerts' score (RS). Primary outcome was severe endoscopic progression, defined as i3 or i4 disease, on immediate subsequent ileocolonoscopy and during entire post-operative follow-up. Secondary outcome was surgical recurrence. RESULTS One hundred and ninety-nine CD patients had an ileocolonoscopy ≤18 months from surgery, index RS of i0-i2b and ≥1 subsequent ileocolonoscopy. At index ileocolonoscopy, 34.7% had i0 disease, 16.1% i1, 24.6% i2a and 24.6% i2b. On multivariable logistic regression, i2b disease was associated with severe endoscopic progression compared to i0 or i1 (aOR 5.53; P < 0.001) and i2a disease patients (aOR 2.63; P = 0.03). However, i2a disease did not confer increased risk compared to i0 or i1 disease (P = 0.09). Furthermore, i2b patients experienced severe endoscopic progression significantly earlier than i0 or i1 disease (aHR 4.68; P < 0.001), whereas i2a disease did not differ from i0 or i1 disease (P = 0.25). Surgical recurrence was not associated with index RS i0-i2b (P = 0.86). CONCLUSION Post-operative ileal disease recurrence, not isolated anastomotic inflammation, confers increased risk for severe endoscopic disease progression. Location of CD recurrence may impact optimal management strategies.
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Affiliation(s)
- Salam P. Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Ravi S. Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Ruishen Lyu
- Cleveland Clinic Department of Quantitative Health Sciences
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition,Department of Inflammation and Immunity, Lerner Research Institute
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Edward L. Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology
| | | | | | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin L. Cohen
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin H. Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
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