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Aras OA, Patel AS, Satchell EK, Serniak NJ, Byrne RM, Cagir B. Comparison of outcomes in small bowel surgery for Crohn's disease: a retrospective NSQIP review. Int J Colorectal Dis 2024; 39:119. [PMID: 39073495 PMCID: PMC11286688 DOI: 10.1007/s00384-024-04661-4] [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] [Accepted: 05/28/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Despite advances in medical therapy, approximately 33% of Crohn's disease (CD) patients will need surgery within 5 years after initial diagnosis. Several surgical approaches to CD have been proposed including small bowel resection, strictureplasty, and combined surgery with resection plus strictureplasty. Here, we utilize the American College of Surgeons (ACS) national surgical quality registry (NSQIP) to perform a comprehensive analysis of 30-day outcomes between these three surgical approaches for CD. METHODS The authors queried the ACS-NSQIP database between 2015 and 2020 for all patients undergoing open or laparoscopic resection of small bowel or strictureplasty for CD using CPT and IC-CM 10. Outcomes of interest included length of stay, discharge disposition, wound complications, 30-day related readmission, and reoperation. RESULTS A total of 2578 patients were identified; 87% of patients underwent small bowel resection, 5% resection with strictureplasty, and 8% strictureplasty alone. Resection plus strictureplasty (combined surgery) was associated with the longest operative time (p = 0.002). Patients undergoing small bowel resection had the longest length of hospital stay (p = 0.030) and the highest incidence of superficial/deep wound infection (44%, p = 0.003) as well as the highest incidence of sepsis (3.5%, p = 0.03). Small bowel resection was found to be associated with higher odds of wound complication compared to combined surgery (OR 2.09, p = 0.024) and strictureplasty (1.9, p = 0.005). CONCLUSION Our study shows that various surgical approaches for CD are associated with comparable outcomes in 30-day related reoperation and readmission, or disposition following surgery between all three surgical approaches. However, small bowel resection displayed higher odds of developing post-operative wound complications.
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Affiliation(s)
- Oguz Az Aras
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA.
- Department of Internal Medicine, TriStar Centennial Medical Center, Nashville, TN, USA.
| | - Apar S Patel
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
- Department of Surgery, Geisinger Health System, Danville, PA, USA
| | - Emma K Satchell
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Nicholas J Serniak
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Raphael M Byrne
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Burt Cagir
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
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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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3
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Van Eaton J, Hatch QM. Surgical Emergencies in Inflammatory Bowel Disease. Surg Clin North Am 2024; 104:685-699. [PMID: 38677830 DOI: 10.1016/j.suc.2023.11.012] [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: 04/29/2024]
Abstract
Inflammatory bowel disease (IBD) patients are at risk for undergoing emergency surgery for fulminant disease, toxic megacolon, bowel perforation, intestinal obstruction, or uncontrolled gastrointestinal hemorrhage. Unfortunately, medical advancements have failed to significantly decrease rates of emergency surgery for IBD. It is therefore important for all acute care and colorectal surgeons to understand the unique considerations owed to this often-challenging patient population.
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Affiliation(s)
- John Van Eaton
- Department of General Surgery, Madigan Army Medical Center, 9040A Jackson Avenue, JBLM, Tacoma, WA 98413, USA.
| | - Quinton M Hatch
- Department of General Surgery, Madigan Army Medical Center, 9040A Jackson Avenue, JBLM, Tacoma, WA 98413, USA
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Scow JS. Modern surgery for Crohn's disease: When to divert, impact of biologics on infectious complications, and surgical techniques to decrease post-operative recurrence of Crohn's disease. Surg Open Sci 2024; 19:20-23. [PMID: 38585036 PMCID: PMC10995856 DOI: 10.1016/j.sopen.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/14/2024] [Indexed: 04/09/2024] Open
Abstract
Crohn's disease is a complex condition that confers a significant risk of requiring multiple surgeries. Questions that surgeons must frequently answer include: which patients benefit from diversion? Does monoclonal antibody therapy increase post-operative complications? And, are there surgical techniques that can prevent the recurrence of Crohn's disease? This review examines current data to answer these questions.
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Affiliation(s)
- Jeffrey S. Scow
- Division of Colorectal Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, United States of America
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Jha DK, Mishra S, Dutta U, Sharma V. Antibiotics for inflammatory bowel disease: Current status. Indian J Gastroenterol 2024; 43:145-159. [PMID: 38376725 DOI: 10.1007/s12664-024-01537-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/17/2024] [Indexed: 02/21/2024]
Abstract
There is abundant literature reporting about the use of antibiotics in inflammatory bowel disease (IBD), but their role in the management of IBD is not entirely clear. Diverse infectious organisms have been implicated in the pathogenesis of Crohn's disease. Also, infections are believed to be a trigger for flares of ulcerative colitis. The benefit of the routine use of antibiotics in IBD is equivocal. However, there are certain situations, where antibiotics have a clear role and evidence of benefit: perianal fistula, intra-abdominal abscesses in Crohn's disease, acute pouchitis and infection-related flares. However, there is a lack of supportive evidence for the routine use of antibiotics in all disease-related flares. Evidence indicates a lack of benefit of intravenous antibiotics in acute severe ulcerative colitis and only limited benefit in active ulcerative colitis. Limited evidence suggests the role of a combination of oral antibiotics in pediatric ulcerative colitis. Certain targeted antibiotic regimens have been used in IBD. In ulcerative colitis, limited evidence suggests the benefit of the use of an antibiotic cocktail directed against Fusobacterium varium. Therapy directed against Escherichia coli does not seem to have a benefit in inflammatory Crohn's disease. In Crohn's disease, antimycobacterial therapy may result in symptomatic improvement but no durable benefit. Antitubercular therapy (ATT), on the contrary, may result in fibrotic transformation, suggesting a need to avoid misdiagnosis and limit the duration of ATT in Crohn's disease. This review assesses the published literature with respect to antibiotic use and provides guidance to clinicians in appropriate antibiotic use in various situations in the setting of IBD.
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Affiliation(s)
- Daya K Jha
- Indian Navy, Visakhapatnam, 530 014, India
| | | | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
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Fansiwala K, Rusher A, Shore B, Herfarth HH, Barnes E, Kochar B, Chang S. Oral vs Intravenous Discharge Antibiotic Regimens in the Management of Intra-abdominal Abscesses in Penetrating Crohn's Disease. Inflamm Bowel Dis 2023:izad299. [PMID: 38150318 DOI: 10.1093/ibd/izad299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Antibiotics are a cornerstone in management of intra-abdominal abscesses in Crohn's disease (CD). Yet, the optimal route of antibiotic administration is poorly studied. We aimed to compare surgical and nonsurgical readmission outcomes for patients hospitalized for intra-abdominal abscesses from CD discharged on oral (PO) or intravenous (IV) antibiotics. METHODS Data for patients with CD hospitalized for an intra-abdominal abscess were obtained from 3 institutions from January 2010 to December 2020. Baseline patient characteristics were obtained. Primary outcomes of interest included need for surgery and hospital readmission within 1 year from hospital discharge. We used multivariable logistic regression models and Cox regression analysis to adjust for abscess size, history of prior surgery, history of penetrating disease, and age. RESULTS We identified 99 patients discharged on antibiotics (PO = 74, IV = 25). Readmissions related to CD at 12 months were less likely in the IV group (40% vs 77% PO, P = .01), with the IV group demonstrating a decreased risk for nonsurgical readmissions over time (hazard ratio, 0.376; 95% confidence interval, 0.176-0.802). Requirement for surgery was similar between the groups. There were no differences in time to surgery between groups. CONCLUSIONS In this retrospective, multicenter cohort of CD patients with intra-abdominal abscess, surgical outcomes were similar between patients receiving PO vs IV antibiotics at discharge. Patients treated with IV antibiotics demonstrated a decreased risk for nonsurgical readmission. Further prospective trials are needed to better delineate optimal route of antibiotic administration in patients with penetrating CD.
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Affiliation(s)
- Kush Fansiwala
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alison Rusher
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Shore
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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7
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Constant BD, de Zoeten EF, Weinman JP, Albenberg L, Scott FI. Early Anti-Tumor-Necrosis-Factor Therapy for Crohn's Disease-Related Abdominal Abscesses and Phlegmon in Children. Dig Dis Sci 2023; 68:877-888. [PMID: 35790702 DOI: 10.1007/s10620-022-07604-7] [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: 02/16/2022] [Accepted: 06/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Internally penetrating Crohn's Disease complications, including abscesses and phlegmon, represent a high-risk Crohn's Disease phenotype. Anti-tumor-necrosis-factor-α (Anti-TNF) therapies are effective in treating penetrating Crohn's Disease and early initiation has shown unique benefits. However, timing of anti-TNF initiation in the setting of internally penetrating Crohn's Disease complications is typically heterogenous due to concern over precipitating serious infections. Recent studies demonstrate such an association may not exist. AIMS We aimed to describe the multidisciplinary management of pediatric patients with internally penetrating Crohn's Disease complications, focusing on the utilization and timing of anti-TNF therapy relative to complication resolution and adverse events. METHODS We performed a single-center retrospective cohort study of pediatric patients with internally penetrating Crohn's Disease complications from 2007 to 2021. The safety and effectiveness of anti-TNF therapy initiation prior to complication resolution was assessed by comparing rates of infectious and Crohn's Disease-related adverse events between those who received anti-TNF therapy prior to complication resolution, versus those who did not. RESULTS Twenty-one patients with internally penetrating Crohn's Disease complications were identified. 7/21 received anti-TNF therapy prior to complication resolution. Infectious adverse events within 90 days of complication occurred in 0/7 patients initiating anti-TNF therapy prior to complication resolution and 10/14 patients who did not (p = 0.004). Crohn's Disease-related surgeries and hospitalizations within 1 year of complication occurred in 12/20 patients, with similar frequency between groups. CONCLUSIONS Initiating anti-TNF therapy prior to internally penetrating Crohn's Disease complication resolution may be a safe and effective strategy to improve clinical outcomes.
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Affiliation(s)
- Brad D Constant
- Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA.
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Edwin F de Zoeten
- Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA
| | - Jason P Weinman
- Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave. B158, Aurora, CO, 80045, USA
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8
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A rare case report of high-grade primary B-cell intestinal lymphoma in young adult, with a focus on radiological role in the diagnosis and management. Radiol Case Rep 2023; 18:647-650. [DOI: 10.1016/j.radcr.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 12/03/2022] Open
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9
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Yoon S, Park SH, Kim JS. Radiologic images of complications of Crohn's disease. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2023. [DOI: 10.18528/ijgii220003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sungjin Yoon
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - So Hyun Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jun Seong Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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10
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Yu S, Zhang M, Ye Z, Wang Y, Wang X, Chen YG. Development of a 32-gene signature using machine learning for accurate prediction of inflammatory bowel disease. CELL REGENERATION (LONDON, ENGLAND) 2023; 12:8. [PMID: 36600111 PMCID: PMC9813306 DOI: 10.1186/s13619-022-00143-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/09/2022] [Indexed: 01/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory condition caused by multiple genetic and environmental factors. Numerous genes are implicated in the etiology of IBD, but the diagnosis of IBD is challenging. Here, XGBoost, a machine learning prediction model, has been used to distinguish IBD from healthy cases following elaborative feature selection. Using combined unsupervised clustering analysis and the XGBoost feature selection method, we successfully identified a 32-gene signature that can predict IBD occurrence in new cohorts with 0.8651 accuracy. The signature shows enrichment in neutrophil extracellular trap formation and cytokine signaling in the immune system. The probability threshold of the XGBoost-based classification model can be adjusted to fit personalized lifestyle and health status. Therefore, this study reveals potential IBD-related biomarkers that facilitate an effective personalized diagnosis of IBD.
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Affiliation(s)
- Shicheng Yu
- grid.9227.e0000000119573309Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Guangzhou Science Park, Luogang District, Guangzhou, 510530 China ,Guangzhou Laboratory, Guangzhou, 510700 China
| | - Mengxian Zhang
- grid.12527.330000 0001 0662 3178The State Key Laboratory of Membrane Biology, Tsinghua-Peking Center for Life Sciences, School of Life Sciences, Tsinghua University, Beijing, 100084 China
| | - Zhaofeng Ye
- grid.12527.330000 0001 0662 3178School of Medicine, Tsinghua University, Beijing, 100084 China
| | - Yalong Wang
- grid.9227.e0000000119573309Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Guangzhou Science Park, Luogang District, Guangzhou, 510530 China ,Guangzhou Laboratory, Guangzhou, 510700 China
| | - Xu Wang
- Guangzhou Laboratory, Guangzhou, 510700 China
| | - Ye-Guang Chen
- Guangzhou Laboratory, Guangzhou, 510700 China ,grid.12527.330000 0001 0662 3178The State Key Laboratory of Membrane Biology, Tsinghua-Peking Center for Life Sciences, School of Life Sciences, Tsinghua University, Beijing, 100084 China ,grid.260463.50000 0001 2182 8825School of Basic Medicine, Nanchang University, Nanchang, 330031 China
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Xia K, Gao RY, Wu XC, Yin L, Chen CQ. Timing of individualized surgical intervention in Crohn’s disease. World J Gastrointest Surg 2022; 14:1320-1328. [PMID: 36632120 PMCID: PMC9827570 DOI: 10.4240/wjgs.v14.i12.1320] [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: 09/01/2022] [Revised: 10/24/2022] [Accepted: 12/01/2022] [Indexed: 12/27/2022] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with an increasing incidence worldwide. Comprehensive therapy for CD focuses on symptom control and healing the intestinal mucosa to improve the quality of life and prevent complications. Surgical intervention plays a vital role in comprehensive therapy. However, deciding the optimal timing for surgical intervention has long been a focus of controversy. This review provides insights into the timing of surgery for CD and guides clinicians in daily treatment.
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Affiliation(s)
- Kai Xia
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Ren-Yuan Gao
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Xiao-Cai Wu
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Lu Yin
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Chun-Qiu Chen
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
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Kusan S, Surat G, Kelm M, Anger F, Kim M, Germer CT, Schlegel N, Flemming S. Microbial Spectrum and Antibiotic Resistance in Patients Suffering from Penetrating Crohn's Disease. J Clin Med 2022; 11:jcm11154343. [PMID: 35893433 PMCID: PMC9330589 DOI: 10.3390/jcm11154343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 01/27/2023] Open
Abstract
Intraabdominal abscess formation occurs in up to 30% of patients suffering from Crohn´s disease (CD). While international guidelines recommend a step-up approach with a combination of empiric antibiotic therapy and percutaneous drainage to delay or even avoid surgery, evidence about microbial spectrum in penetrating ileitis is sparse. We retrospectively assessed outcomes of 46 patients with terminal penetrating Ileitis where microbial diagnostics have been performed and compared microbial spectrum and antibiotic resistance profile of CD patients with patients suffering from diverticulitis with intraabdominal abscess formation. In both groups, the most frequently isolated pathogen was the gram-negative bacterium E. coli belonging to the family of Enterobacterales. However, overall Enterobacterales were significantly more often verifiable in the control group than in CD patients. Furthermore, microbial analysis showed significant differences regarding isolation of anaerobic pathogens with decreased frequency in patients with CD. Subgroup analysis of CD patients to evaluate a potential influence of immunosuppressive therapy on microbial spectrum only revealed that Enterobacterales was less frequently detected in patients treated with steroids. Immunosuppressive therapy did not show any impact on all other groups of pathogens and did not change antibiotic resistance profile of CD patients. In conclusion, we were able to demonstrate that the microbial spectrum of CD patients does differ only for some pathogen species without increased rate of antibiotic resistance. However, the empiric antibiotic therapy for CD-associated intra-abdominal abscess remains challenging since different points such as local epidemiological and microbiological data, individual patient risk factors, severity of infection, and therapy algorithm including non-surgical and surgical therapy options should be considered before therapeutical decisions are made.
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Affiliation(s)
- Simon Kusan
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Güzin Surat
- Unit for Infection Control and Antimicrobial Stewardship, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany;
| | - Matthias Kelm
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Mia Kim
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (S.K.); (M.K.); (F.A.); (M.K.); (C.-T.G.); (N.S.)
- Correspondence:
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Kucharzik T, Atreya R, Bachmann O, Baumgart DC, Daebritz J, Helwig U, Janschek J, Kienle P, Langhorst J, Mudter J, Schmidt C, Schreyer AG, Vieth M, Wessling J, Maaser C. [Position paper on reporting of intestinal ultrasound findings in patients with inflammatory bowel disease]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:978-990. [PMID: 35671995 DOI: 10.1055/a-1801-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intestinal ultrasound is increasingly used for primary diagnosis, detection of complications and monitoring of patients with Crohn's disease and ulcerative colitis. Standardization of reporting is relevant to ensure quality of the methodology and to improve communication between different specialties. The current manuscript describes the features required for optimized reporting of intestinal ultrasound findings in inflammatory bowel disease (IBD). METHODS An expert consensus panel of gastroenterologists, radiologists, pathologists, paediatric gastroenterologists and surgeons conducted a systematic literature search. In a Delphi- process members of the Kompetenznetz Darmerkrankungen in collaboration with members of the German Society for Radiology (DRG) voted on relevant criteria for reporting of findings in intestinal ultrasound. Based on the voting results statements were agreed by expert consensus. RESULTS Clinically relevant aspects of intestinal ultrasound (IUS) findings have been defined to optimize reporting and to standardize terminology. Minimal requirements for standardized reporting are suggested. The statements focus on description of disease activity as well as on complications of IBD. Attributes of intestinal inflammation are described and illustrated by exemplary images. CONCLUSION The current manuscript provides practical recommendations on how to standardize documentation and reporting from intestinal ultrasound findings in patients with IBD.
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Affiliation(s)
- Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Germany
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Bachmann
- Klinik für Innere Medizin 1, Siloah St. Trudpert Klinikum, Pforzheim, Germany
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Jan Daebritz
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Ulf Helwig
- Internistische Praxengemeinschaft Oldenburg, Oldenburg, Germany.,1. Med. Klinik, Universität Kiel, UKSH Kiel, Kiel, Germany
| | | | - Peter Kienle
- Allgemein-und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik GmbH, Mannheim, Germany
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg, Germany
| | - Jonas Mudter
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Carsten Schmidt
- Medizinische Klinik II, Universitätsmedizin Marburg-Campus Fulda, Klinikum Fulda AG, Fulda, Germany
| | - Andreas G Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg, Universitätsklinikum Brandenburg a.d. Havel, Brandenburg an der Havel, Germany
| | - Michael Vieth
- Institut für Pathologie, Klinikum Bayreuth, Friedrich-Alexander Universität Erlangen-Nürnberg, Bayreuth, Germany
| | - Johannes Wessling
- Zentrum für Radiologie, Neuroradiologie und Nuklearmedizin, Clemenshospital Münster, Münster, Germany
| | - Christian Maaser
- Ambulanzzentrum Gastroenterologie, Klinik für Geriatrie, Klinikum Lüneburg, Lüneburg, Germany
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14
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Kucharzik T, Tielbeek J, Carter D, Taylor SA, Tolan D, Wilkens R, Bryant RV, Hoeffel C, De Kock I, Maaser C, Maconi G, Novak K, Rafaelsen SR, Scharitzer M, Spinelli A, Rimola J. ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:523-543. [PMID: 34628504 DOI: 10.1093/ecco-jcc/jjab180] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The diagnosis and follow up of patients with inflammatory bowel disease [IBD] requires cross-sectional imaging modalities, such as intestinal ultrasound [IUS], magnetic resonance imaging [MRI] and computed tomography [CT]. The quality and homogeneity of medical reporting are crucial to ensure effective communication between specialists and to improve patient care. The current topical review addresses optimized reporting requirements for cross-sectional imaging in IBD. METHODS An expert consensus panel consisting of gastroenterologists, radiologists and surgeons convened by the ECCO in collaboration with ESGAR performed a systematic literature review covering the reporting aspects of MRI, CT, IUS, endoanal ultrasonography and transperineal ultrasonography in IBD. Practice position statements were developed utilizing a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥80% of the participants agreed on a recommendation. RESULTS Twenty-five practice positions were developed, establishing standard terminology for optimal reporting in cross-sectional imaging. Assessment of inflammation, complications and imaging of perianal CD are outlined. The minimum requirements of a standardized report, including a list of essential reporting items, have been defined. CONCLUSIONS This topical review offers practice recommendations to optimize and homogenize reporting in cross-sectional imaging in IBD.
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Affiliation(s)
- Torsten Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Jeroen Tielbeek
- Department of Radiology, Spaarne Gasthuis, Boerhaavelaan 22, Haarlem, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hasomher, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Radiology Department, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, UK
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Hvidovre University Hospital, Copenhagen, Denmark; Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - Christine Hoeffel
- Department of Abdominal Radiology, CHU Reims and CRESTIC, URCA, 51100 Reims, France
| | - Isabelle De Kock
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Giovanni Maconi
- Gastroenterology Unit, 'Luigi Sacco' University Hospital, Milan, Italy
| | - Kerri Novak
- Department of Radiology and Medicine, Division of Gastroenterology, University of Calgary, Alberta, Canada
| | - Søren R Rafaelsen
- Department of Radiology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Jordi Rimola
- IBD unit, Radiology Department, Hospital Clínic Barcelona, Barcelona, Catalonia, Spain
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15
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Myrelid P, Soop M, George BD. Surgical Planning in Penetrating Abdominal Crohn's Disease. Front Surg 2022; 9:867830. [PMID: 35592128 PMCID: PMC9110798 DOI: 10.3389/fsurg.2022.867830] [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: 02/01/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mattias Soop
- Department of Surgery, Ersta Hospital, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Bruce D. George
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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16
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Ferrari L, Fichera A. Operative indications and options in intestinal Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Celentano V, Giglio MC, Pellino G, Rottoli M, Sampietro G, Spinelli A, Selvaggi F, Pellino G, Rottoli M, Poggioli G, Sica G, Giglio MC, Campanelli M, Coco C, Rizzo G, Sionne F, Colombo F, Sampietro G, Lamperti G, Foschi D, Ficari F, Vacca L, Cricchio M, Giudici F, Selvaggi L, Sciaudone G, Peltrini R, Manfreda A, Bucci L, Galleano R, Ghazouani O, Zorcolo L, Deidda S, Restivo A, Braini A, Di Candido F, Sacchi M, Carvello M, Martorana S, Bordignon G, Angriman I, Variola A, Di Ruscio M, Barugola G, Geccherle A, Tropeano FP, Luglio G, Tanzanu M, Sasia D, Migliore M, Giuffrida MC, Marrano E, Moretto G, Impellizzeri H, Gallo G, Vescio G, Sammarco G, Terrosu G, Calini G, Bondurri A, Maffioli MD A, Zaffaroni G, Resegotti A, Mistrangelo M, Allaix ME, Botti F, Prati M, Boni L, Perotti S, Mineccia M, Giuliani A, Romano L, Graziano GMP, Pugliese L, Pietrabissa A, Delaini GG, Spinelli A, Selvaggi F. High complication rate in Crohn's disease surgery following percutaneous drainage of intra-abdominal abscess: a multicentre study. Int J Colorectal Dis 2022; 37:1421-1428. [PMID: 35599268 PMCID: PMC9167187 DOI: 10.1007/s00384-022-04183-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Intra-abdominal abscesses complicating Crohn's disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD. METHODS This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing ileocolic resection for primary or recurrent CD from June 2018 to May 2019. The outcomes of patients who underwent radiological guided drainage prior to ileocolonic resection were compared to the patients who did not require preoperative drainage. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. RESULTS Amongst a group of 575 included patients who had an ileocolic resection for CD, there were 36 patients (6.2%) who underwent abscess drainage prior to surgery. Postoperative morbidity (44.4%) and anastomotic leak (11.1%) were significantly higher in the group of patients who underwent preoperative drainage. CONCLUSIONS Patients with Crohn's disease who require preoperative radiological guided drainage of intra-abdominal abscesses are at increased risk of postoperative morbidity and septic complications following ileocaecal or re-do ileocolic resection.
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Affiliation(s)
- Valerio Celentano
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster Hospital NHS Foundation Trust, London, UK ,grid.4701.20000 0001 0728 6636University of Portsmouth, Portsmouth, UK ,grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College, London, UK
| | - Mariano Cesare Giglio
- grid.4691.a0000 0001 0790 385XDepartment of Clinical Medical and Surgery, Federico II University, Naples, Italy
| | - Gianluca Pellino
- grid.9841.40000 0001 2200 8888Department of Advanced Medical and Surgical Science, Universita’ Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
| | - Matteo Rottoli
- grid.6292.f0000 0004 1757 1758Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Alma Mater, Studiorum University of Bologna, Bologna, Italy
| | - Gianluca Sampietro
- Division of General and HPB Surgery, ASST Rhodense, Rho Memorial Hospital, Milan, Italy
| | - Antonino Spinelli
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy ,grid.417728.f0000 0004 1756 8807IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Francesco Selvaggi
- grid.9841.40000 0001 2200 8888Department of Advanced Medical and Surgical Science, Universita’ Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
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18
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Raine T, Verstockt B, Kopylov U, Karmiris K, Goldberg R, Atreya R, Burisch J, Burke J, Ellul P, Hedin C, Holubar SD, Katsanos K, Lobaton T, Schmidt C, Cullen G. ECCO Topical Review: Refractory Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:1605-1620. [PMID: 34160593 DOI: 10.1093/ecco-jcc/jjab112] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammatory bowel disease is a chronic disease with variable degrees of extent, severity, and activity. A proportion of patients will have disease that is refractory to licensed therapies, resulting in significant impairment in quality of life. The treatment of these patients involves a systematic approach by the entire multidisciplinary team, with particular consideration given to medical options including unlicensed therapies, surgical interventions, and dietetic and psychological support. The purpose of this review is to guide clinicians through this process and provide an accurate summary of the available evidence for different strategies.
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Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Rimma Goldberg
- Department of Gastroenterology, Monash Health and School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Raja Atreya
- Department of Medicine 1, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Burke
- Colorectal and General Surgery, Beaumont Hospital, Dublin, Ireland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
- Karolinska University Hospital, Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Triana Lobaton
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Carsten Schmidt
- Medical Faculty of the Friedrich Schiller University, Jena, Germany
| | - Garret Cullen
- Centre for Colorectal Disease, St Vincent's University Hospital and School of Medicine, University College Dublin, Gastroenterology, Dublin, Ireland
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19
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Sninsky J, Barnes EL. Medical Management of Aggressive Inflammatory Bowel Disease: When Is the Time to Cut Your (and the Patient's) Losses? J Laparoendosc Adv Surg Tech A 2021; 31:905-910. [PMID: 34171979 DOI: 10.1089/lap.2021.0338] [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: 11/13/2022] Open
Abstract
Despite a treatment armamentarium that continues to increase in terms of medical options for the therapy of Crohn's disease (CD) and ulcerative colitis (UC), a significant proportion of patients will require surgical intervention over their disease course. Surgery does not represent a failure of medical therapy in the treatment of patients with inflammatory bowel disease (IBD); rather, surgery represents an integral feature of the multidisciplinary approach to an individual patient. The timing, factors, and potential outcomes of each therapeutic decision in the pre-, peri- and postoperative periods must be weighed by each member of a multidisciplinary team with the goal of improving the quality of life for patients with IBD. In this article, we review the current evidence underlying approaches to the medical and surgical management of complications of CD and UC. We also outline opportunities for tailored decision-making and potentially earlier surgical intervention with the aim of improving long-term outcomes among patients with IBD.
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Affiliation(s)
- Jared Sninsky
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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20
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Chinese consensus on diagnosis and treatment in inflammatory bowel disease (2018, Beijing). J Dig Dis 2021; 22:298-317. [PMID: 33905603 DOI: 10.1111/1751-2980.12994] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/22/2021] [Indexed: 12/11/2022]
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21
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Abstract
Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.
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Affiliation(s)
- Dakota T Thompson
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
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22
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De Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, Sartelli M, Biffl WL, Ansaloni L, Coccolini F, Chiarugi M, De’Angelis N, Moore EE, Kluger Y, Abu-Zidan F, Sakakushev B, Coimbra R, Celentano V, Wani I, Pintar T, Sganga G, Di Carlo I, Tartaglia D, Pikoulis M, Cardi M, De Moya MA, Leppaniemi A, Kirkpatrick A, Agnoletti V, Poggioli G, Carcoforo P, Baiocchi GL, Catena F. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg 2021; 16:23. [PMID: 33971899 PMCID: PMC8111988 DOI: 10.1186/s13017-021-00362-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. METHOD A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. CONCLUSIONS Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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Affiliation(s)
- Belinda De Simone
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elie Chouillard
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
| | - Frank Hoentjen
- RIMLS - Radboud Institute for Molecular Life Sciences, Radboud University-Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Antonio Tarasconi
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Walter L. Biffl
- Scripps Memorial Hospital La Jolla, San Diego, California USA
| | - Luca Ansaloni
- Department of Surgery, University Hospital of Pavia, Pavia, Italy
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Nicola De’Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Acquaviva delle Fonti (Bari), Italy
| | - Ernest E. Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | - Valerio Celentano
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Hampshire, UK
| | - Imtiaz Wani
- Government Gousia Hospital-Srinagar, Directorate of Health Services-Kashmir, Srinagar, Kashmir India
| | - Tadeja Pintar
- Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Gabriele Sganga
- Department of Emergency Surgery, “A. Gemelli Hospital”, Catholic University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Dario Tartaglia
- Emergency Surgery Unit & Trauma Center, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National & Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Maurizio Cardi
- Department of Oncological Surgery “P.Valdoni”, Sapienza University, Rome, Italy
| | - Marc A. De Moya
- Trauma/Acute Care Surgery Department, Medical College of Wisconsin/Froedtert Trauma Center, Wauwatosa, Wisconsin USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Gilberto Poggioli
- Department of Surgical Sciences, Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Paolo Carcoforo
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | | | - Fausto Catena
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
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23
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Alharbi O, Almadi MA, Azzam N, Aljebreen AM, AlAmeel T, Schreiber S, Mosli MH. Clinical characteristics, natural history, and outcomes of Crohn's-related intra-abdominal collections. Saudi J Gastroenterol 2021; 27:79-84. [PMID: 33723092 PMCID: PMC8183360 DOI: 10.4103/sjg.sjg_89_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Intra-abdominal collections in the form of abscesses or matted bowel loops, called phlegmons, might occur in patients with Crohn's disease (CD). The clinical characteristics and management of such conditions are not well described. We aim to characterize CD-related intra-abdominal collections clinically, and identify predictors of need for surgical interventions and the time to surgery. METHODS We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify all patients treated for radiologically proven intra-abdominal abscesses or phlegmons since inception. Demographics, clinical data, clinical course, and treatment outcomes were recorded. Logistic regression analysis and survival analysis were used to identify predictors of surgical resection and differences in time to surgery between patient subgroups, respectively. RESULTS A total of 734 patients with a diagnosis of CD were screened and 75 patients were identified. The mean age was 25.6 ± 9.9 years and 51% were males. Nearly 60% of patients had abscesses larger than 3 cm while 13% had smaller abscesses and 36% had phlegmons. On presentation, the most commonly reported symptom was abdominal pain (99%) followed by weight loss (27%). About 89% of patients were treated with antibiotics during hospitalization for an average of 2.7 weeks. Steroids were prescribed for 52% of patients and tumor necrosis factor alpha (TNF-alpha) antagonists for 17%. Surgical resection was required for 33 patients (44% of the cohort) while 51% were managed with antibiotics and/or percutaneous drainage. The most common surgical intervention was ileocecal resection (45%). Although patients who underwent follow-up imaging were more likely to require early surgical intervention (P = 0.04), no statistically significant predictor of surgery could be identified from this cohort. Time to surgery varied numerically according to abscess size (HR = 1.18, 95% CI = 0.62-2.27, P = 0.61). CONCLUSIONS Although the majority of patients with CD-related intra-abdominal collections underwent surgical resection in this cohort, no obvious predictors of surgical intervention could be identified. The decision to perform early surgery appeared to be influenced by the findings observed on cross-sectional imaging during the follow-up of these collections.
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Affiliation(s)
- Othman Alharbi
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia,Address for correspondence: Dr. Othman Alharbi, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail:
| | - Majid A. Almadi
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Nahla Azzam
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman M. Aljebreen
- Department of Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
| | - Stefan Schreiber
- Department of Internal Medicine, Institute of Clinical Molecular Biology, Christian-Albrechts-University, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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Grajo JR, Huang C, Dillman JR, Gee MS, Jaffe TA, Soto JA, Baker ME. MR Enterography of Complicated Crohn Disease: Stricturing and Penetrating Disease. Top Magn Reson Imaging 2021; 30:23-30. [PMID: 33528209 DOI: 10.1097/rmr.0000000000000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Stricturing and penetrating disease are complications of Crohn disease (CD) that significantly affect patient outcomes. Careful evaluation for such complications is critical to the interpretation of magnetic resonance enterography. This manuscript outlines the key findings related to stricturing and penetrating CD and discusses current understanding of the pathophysiology and prognosis of complicated CD based on the literature.
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Affiliation(s)
- Joseph R Grajo
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tracy A Jaffe
- Department of Radiology, Duke University School of Medicine, Durham, NC
| | - Jorge A Soto
- Department of Radiology, Boston University School of Medicine, Boston, MA
| | - Mark E Baker
- Department of Radiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH
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25
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Papa A, Lopetuso LR, Minordi LM, Di Veronica A, Neri M, Rapaccini G, Gasbarrini A, Papa V. A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn's disease patients. Expert Rev Gastroenterol Hepatol 2020; 14:857-865. [PMID: 32673498 DOI: 10.1080/17474124.2020.1797484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn's disease (CD) that is challenging to treat and has considerable morbidity and mortality rates. AREAS COVERED This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients. EXPERT OPINION Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.
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Affiliation(s)
- Alfredo Papa
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Loris Riccardo Lopetuso
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy.,Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy
| | - Laura Maria Minordi
- Dipartimento di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| | - Alessandra Di Veronica
- Dipartimento di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| | - Matteo Neri
- Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy.,Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy
| | - Gianludovico Rapaccini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Antonio Gasbarrini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Valerio Papa
- Università Cattolica del Sacro Cuore , Roma, Italia.,Dipartimento di Chirurgia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
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Gecse KB, Buskens CJ. Implication of Medical Treatment for Surgical Strategies in IBD. Curr Drug Targets 2020; 20:1363-1368. [PMID: 31113342 DOI: 10.2174/1389450120666190515095520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 04/15/2019] [Accepted: 04/19/2019] [Indexed: 01/14/2023]
Abstract
Despite changing medical paradigm, still a significant proportion of patients with IBD require surgery. The patient's general condition, including nutritional status and the use of immunosuppressive medications is of great importance with regard to surgical complications, as well as the choice of optimal surgical strategy. The indication and the timing of surgery are key factors for the multidisciplinary management of IBD patients. The purpose of this review is to provide an overview on the impact of medical treatment on surgical strategies in IBD.
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Affiliation(s)
- Krisztina B Gecse
- Departement of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Christianne J Buskens
- Departement of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
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27
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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28
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Soop M. Challenges in Crohn's disease: Intestinal failure and short bowel syndrome in Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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29
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Di Candido F, Moggia E, Spinelli A. Pre-operative optimisation in Crohn's Disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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30
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Scharitzer M, Koizar B, Vogelsang H, Bergmann M, Primas C, Weber M, Schima W, Mang T. Crohn's disease: prevalence, MR features, and clinical significance of enteric and colonic sinus tracts. Eur Radiol 2020; 30:5358-5366. [PMID: 32458171 PMCID: PMC7476978 DOI: 10.1007/s00330-020-06935-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/15/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Objectives Enteric and colonic sinus tracts are inflammatory complications that precede intestinal fistulas in patients with Crohn’s disease (CD). The aim of this study was to retrospectively determine the prevalence, morphologic features, and outcome of sinus tracts using MR imaging. Methods A consecutive cohort of 642 patients with known CD, referred for MR enterography or MR enteroclysis (study period 01/2014–09/2019), was evaluated retrospectively for the presence of sinus tracts, their locations, presence and length of coexisting strictures, bowel wall thickness, CDMI score, upstream dilation, and bowel distension. Clinical outcome was assessed using medical records. For metric data, means and standard deviation, as well as one-way ANOVA and Pearson’s correlation coefficient, were calculated. Results In 36/642 patients with CD undergoing MRE, 49 sinus tracts (forty in small intestine, nine in left-sided colon) were detected with a prevalence of 6.9% in patients with MR-visible signs of CD (n = 519, overall prevalence of 5.6%). Mean segmental bowel wall thickness was 8.9 mm, and mean CDMI score was 9.3. All sinus tracts were located within a stenotic segment, showing mesenteric orientation within the small bowel and upstream dilation in 13 patients. Of 36 patients, 19 underwent immediate surgery and seven developed clinical progression within the segment containing the sinus tract. Conclusions Sinus tracts occur in 6.9% of patients with visible signs of CD. They are located within stenotic, severely thickened bowel segments with high MR inflammation scores. Their detection is clinically important, because they indicate a more aggressive phenotype and, if left untreated, may show severe progression. Key Points • Sinus tracts occur in 6.9% of patients with MR-visible signs of Crohn’s disease. • Sinus tracts are a radiological indicator of early penetrating Crohn’s disease, with a high risk of progression, and require dedicated treatment. • Sinus tracts can be recognized by characteristic findings and typically occur in stenotic, severely thickened bowel segments with high MR inflammation scores.
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Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernd Koizar
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Grieskirchner Straße 42, 4600, Wels, Austria
| | - Harald Vogelsang
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Michael Bergmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Primas
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Wolfgang Schima
- Department of Diagnostic and Interventional Radiology, KH Goettlicher Heiland, KH der Barmherzigen Schwestern, St. Josef-KH, Dornbacher Straße 20-30, 1170, Vienna, Austria
| | - Thomas Mang
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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31
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Kaur M, Dalal RL, Shaffer S, Schwartz DA, Rubin DT. Inpatient Management of Inflammatory Bowel Disease-Related Complications. Clin Gastroenterol Hepatol 2020; 18:1346-1355. [PMID: 31927105 DOI: 10.1016/j.cgh.2019.12.040] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023]
Abstract
Despite advances in therapeutic options, a sizeable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. While current treatment guidelines for the management of ulcerative colitis and Crohn's disease cover the spectrum of disease severity and behavior, management of acute complications of inflammatory bowel disease can present unique challenges that are not always addressed in these guidelines. In this review, the authors provide a comprehensive summary of the existing literature focused on management of patients hospitalized with complications of inflammatory bowel disease. Proposed management algorithms are provided to guide clinicians through common scenarios to determine the most appropriate interventions - escalation of medical therapies, non-surgical therapeutic interventions (drainage of intra-abdominal abscess or endoscopic balloon dilation) or surgery. Prevention of complications is proposed through a multi-disciplinary approach that involves surgeons, dieticians, radiologists, pathologists and infectious disease consultants.
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Affiliation(s)
- Manreet Kaur
- Section of Gastroenterology, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas.
| | - Robin L Dalal
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Seth Shaffer
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
| | - David A Schwartz
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
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32
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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Abstract
Inflammatory bowel diseases (IBD), including Crohn's disease, ulcerative colitis, and pouchitis, are chronic, relapsing intestinal inflammatory disorders mediated by dysregulated immune responses to resident microbiota. Current standard therapies that block immune activation with oral immunosuppressives or biologic agents are generally effective, but each therapy induces a sustained remission in only a minority of patients. Furthermore, these approaches can have severe adverse events. Recent compelling evidence of a role of unbalanced microbiota (dysbiosis) driving immune dysfunction and inflammation in IBD supports the therapeutic rationale for manipulating the dysbiotic microbiota. Traditional approaches using currently available antibiotics, probiotics, prebiotics, and synbiotics have not produced optimal results, but promising outcomes with fecal microbiota transplant provide a proof of principle for targeting the resident microbiota. Rationally designed oral biotherapeutic products (LBPs) composed of mixtures of protective commensal bacterial strains demonstrate impressive preclinical results. Resident microbial-based and microbial-targeted therapies are currently being studied with increasing intensity for IBD primary therapy with favorable early results. This review presents current evidence and therapeutic mechanisms of microbiota modulation, emphasizing clinical studies, and outlines prospects for future IBD treatment using new approaches, such as LBPs, bacteriophages, bacterial function-editing substrates, and engineered bacteria. We believe that the optimal clinical use of microbial manipulation may be as adjuvants to immunosuppressive for accelerated and improved induction of deep remission and as potential safer solo approaches to sustained remission using personalized regimens based on an individual patient's microbial profile.
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Affiliation(s)
- Akihiko Oka
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 111 Mason Farm Road, Chapel Hill, NC, 27599, USA
| | - R Balfour Sartor
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 111 Mason Farm Road, Chapel Hill, NC, 27599, USA.
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, NC, 27599, USA.
- National Gnotobiotic Rodent Resource Center, University of North Carolina at Chapel Hill, 120 Mason Farm Road, Chapel Hill, NC, 27514, USA.
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Gao D, Medina MG, Alameer E, Nitz J, Tsoraides S. A case report on delayed diagnosis of perforated Crohn's disease with recurrent intra-psoas abscess requiring omental patch. Int J Surg Case Rep 2019; 65:325-328. [PMID: 31770708 PMCID: PMC6879988 DOI: 10.1016/j.ijscr.2019.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 11/07/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Intra-abdominal abscesses associated with Crohn's disease (CD) can rarely occur in the psoas muscle. An intra-psoas abscess is prone to misdiagnosis because its location mimics other diseases, like appendicitis and diverticulitis [1]. PRESENTATION OF CASE We present the case of a 25-year-old female with an 11-year history of CD, previously well-controlled on Remicade, who presented with right lower quadrant (RLQ) pain and CT findings of a right psoas abscess initially attributed to perforated appendicitis. Two percutaneous drainages pre-ileocecectomy, laparoscopic ileocecectomy, three percutaneous drainages post-ileocolectomy, and evidence of a recurrent abscess prompted diagnostic laparoscopy. The abscess was unroofed and debrided. A flap of omentum was used to fill the abscess cavity. A comprehensive literature search was performed using the terms 'Crohn's abscess', 'intra-psoas abscess', and 'omental patches' in Medline and on PubMed. DISCUSSION We attribute the abscess' recurrence to possible epithelialization of the abscess cavity. Intra-psoas abscesses, albeit rare, are a known manifestation of CD. Percutaneous drainage is the initial standard of care, although diagnosis can be difficult given its association with several diseases, which can delay definitive treatment. We summarize a recently proposed and agreed upon treatment scheme for the management of the Crohn's patient with an abdominal abscess. We also propose the novel technique of omental packing in abscess management. CONCLUSION Clinician awareness must be heightened for perforating CD in the setting of abscess refractory to either multiple drainage procedures, although care should be taken to individualize treatment to each CD patient who presents with an abdominal abscess.
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Affiliation(s)
- David Gao
- Department of Surgery, University of Illinois College of Medicine Peoria, 624 NE Glen Oak, Peoria, IL 61603, United States
| | - Melissa G Medina
- Department of Surgery, University of Illinois College of Medicine Peoria, 624 NE Glen Oak, Peoria, IL 61603, United States
| | - Ehab Alameer
- Department of Surgery, University of Illinois College of Medicine Peoria, 624 NE Glen Oak, Peoria, IL 61603, United States
| | - Jonathan Nitz
- Department of Surgery, University of Illinois College of Medicine Peoria, 624 NE Glen Oak, Peoria, IL 61603, United States.
| | - Steven Tsoraides
- Department of Surgery, University of Illinois College of Medicine Peoria, 624 NE Glen Oak, Peoria, IL 61603, United States
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Elshazzly M, Bashjawish F, Shahid MA, Marrero DA, Horowitz J. A Challenging Case of Retroperitoneal Abscess in a Post-Partum Crohn's Disease Patient. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:773-777. [PMID: 29961750 PMCID: PMC6061711 DOI: 10.12659/ajcr.909545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patient: Female, 29 Final Diagnosis: Retroperitoneal abscess Symptoms: Flank bruising • flank pain Medication: — Clinical Procedure: Incision • drainage • debridement of the necrotizing soft-tissue infection Specialty: Infectious Diseases
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Affiliation(s)
- Mohamed Elshazzly
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Fuad Bashjawish
- Department of Internal Medicine, Cape Fear Valley Hospital, Fayetteville, NC, USA
| | - Muhammad A Shahid
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Dana A Marrero
- Department of Internal Medicine, Cape Fear Valley Hospital, Fayetteville, NC, USA
| | - Joel Horowitz
- Department of General Surgery, Cape Fear Valley Hospital, Fayetteville, NC, USA
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36
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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37
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Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, Kato J, Kobayashi K, Kobayashi K, Koganei K, Kunisaki R, Motoya S, Nagahori M, Nakase H, Omata F, Saruta M, Watanabe T, Tanaka T, Kanai T, Noguchi Y, Takahashi KI, Watanabe K, Hibi T, Suzuki Y, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol 2018; 53:305-353. [PMID: 29429045 PMCID: PMC5847182 DOI: 10.1007/s00535-018-1439-1] [Citation(s) in RCA: 330] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.
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Affiliation(s)
- Katsuyoshi Matsuoka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Taku Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumiaki Ueno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
- Ofuna Central Hospital, 6-2-24 Ofuna, Kamakura-shi, Kanagawa, 247-0056, Japan.
| | - Toshiyuki Matsui
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumihito Hirai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Nagamu Inoue
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Jun Kato
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kiyonori Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazutaka Koganei
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Reiko Kunisaki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Satoshi Motoya
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masakazu Nagahori
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroshi Nakase
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumio Omata
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masayuki Saruta
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Tanaka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takanori Kanai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshinori Noguchi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Ken-Ichi Takahashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshifumi Hibi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yasuo Suzuki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kentaro Sugano
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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Safety and Efficacy of Exclusive Enteral Nutrition for Percutaneously Undrainable Abdominal Abscesses in Crohn's Disease. Gastroenterol Res Pract 2017; 2017:6360319. [PMID: 28947899 PMCID: PMC5602481 DOI: 10.1155/2017/6360319] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/27/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022] Open
Abstract
Background The percutaneously undrainable abdominal abscesses in Crohn's disease (CD) are not uncommon. The treatment protocol is still under debate. This study was conducted to assess the safety and efficacy of exclusive enteral nutrition (EEN) for percutaneously undrainable abscesses in CD. Methods A consecutive cohort of 83 CD patients with percutaneously undrainable abdominal abscesses between January 2011 and June 2015 was retrospectively analyzed. They were divided into the EEN group and the non-EEN group. Results The cumulative surgical rate was significantly lower in the EEN group than in the non-EEN group (P = 0.001). Fifteen percent patients treated with EEN avoided surgery. EEN (P = 0.002) was associated with a decreased need for surgery. Previous abdominal surgery (P = 0.009) and abscess diameter > 3 cm (P = 0.022) were associated with an increased need for operation. EEN increased the albumin level, while decreased ESR and CRP significantly for patients requiring surgery. The risk of postoperative intra-abdominal septic complications (P = 0.036) was significantly lower in the EEN group compared with the non-EEN group. Conclusions EEN is feasible in CD patients presenting with percutaneously undrainable abdominal abscesses. It is associated with a reduction in surgical rate, optimized preoperative condition, and improved postoperative outcomes in these specific groups of patients.
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Multiple fresh fecal microbiota transplants induces and maintains clinical remission in Crohn's disease complicated with inflammatory mass. Sci Rep 2017; 7:4753. [PMID: 28684845 PMCID: PMC5500501 DOI: 10.1038/s41598-017-04984-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/23/2017] [Indexed: 02/08/2023] Open
Abstract
The ancient Chinese medical literature, as well as our prior clinical experience, suggests that fecal microbiota transplantation (FMT) could treat the inflammatory mass. We aimed to evaluate the efficacy and safety of multiple fresh FMTs for Crohn’s disease (CD) complicated with intraabdominal inflammatory mass. The "one-hour FMT protocol" was followed in all patients. Twenty-five patients were diagnosed with CD and related inflammatory mass by CT or MRI. All patients received the initial FMT followed by repeated FMTs every 3 months. The primary endpoint was clinical response (improvement and remission) and sustained clinical remission at 12 months. Secondary endpoints were improvement in size of phegmon/abscess based upon cross-sectional imaging and safety of FMT. 68.0% (17/25) and 52.0% (13/25) of patients achieved clinical response and clinical remission at 3 months post the initial FMT, respectively. The proportion of patients at 6 months, 12 months and 18 months achieving sustained clinical remission with sequential FMTs was 48.0% (12/25), 32.0% (8/25) and 22.7% (5/22), respectively. 9.5% (2/21) of patients achieved radiological healing and 71.4% (15/21) achieved radiological improvement. No severe adverse events related to FMT were observed. This pragmatic study suggested that sequential fresh FMTs might be a promising, safe and effective therapy to induce and maintain clinical remission in CD with intraabdominal inflammatory mass.
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40
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Wei SC, Chang TA, Chao TH, Chen JS, Chou JW, Chou YH, Chuang CH, Hsu WH, Huang TY, Hsu TC, Lin CC, Lin HH, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsang YM, Wang CY, Wang HY, Weng MT, Wu DC, Wu WC, Yen HH, Wong JM. Management of Crohn's disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease. Intest Res 2017; 15:285-310. [PMID: 28670226 PMCID: PMC5478754 DOI: 10.5217/ir.2017.15.3.285] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 12/12/2022] Open
Abstract
Crohn's disease (CD) is a chronic relapsing and remitting inflammatory disease of the gastrointestinal tract. CD is rare in Taiwan and other Asian countries, but its prevalence and incidence have been steadily increasing. A steering committee was established by the Taiwan Society of Inflammatory Bowel Disease to formulate statements on the diagnosis and management of CD taking into account currently available evidence and the expert opinion of the committee. Thorough clinical, endoscopic, and histological assessments are required for accurate diagnosis of CD. Computed tomography and magnetic resonance imaging are complementary to endoscopic evaluation for disease staging and detecting complications. The goals of CD management are to induce and maintain remission, reduce the risk of complications, and improve quality of life. Corticosteroids are the mainstay for inducing re-mission. Immunomodulating and biologic therapies should be used to maintain remission. Patients should be evaluated for hepatitis B virus and tuberculosis infection prior to treatment and receive regular surveillance for cancer. These consensus statements are based on current local evidence with consideration of factors, and could be serve as concise and practical guidelines for supporting clinicians in the management of patients with CD in Taiwan.
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Affiliation(s)
- Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jinn-Shiun Chen
- Division of Colorectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Hsin Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Chen Lin
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Pathology and Forensic Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yuk-Ming Tsang
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan.,MacKay Medical College, New Taipei City, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Wen-Chieh Wu
- Division of Gastroenterology, Department of Medicine, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Hsu-Heng Yen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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41
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Park JJ, Yang SK, Ye BD, Kim JW, Park DI, Yoon H, Im JP, Lee KM, Yoon SN, Lee H. [Second Korean Guidelines for the Management of Crohn's Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:29-54. [PMID: 28135790 DOI: 10.4166/kjg.2017.69.1.29] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of the Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kang Moon Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Nam Yoon
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
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Graham E, Rao K, Cinti S. Medical Versus Interventional Treatment of Intra-Abdominal Abscess in Patients With Crohn Disease. Infect Dis (Lond) 2017; 10:1179916117701736. [PMID: 28469460 PMCID: PMC5398645 DOI: 10.1177/1179916117701736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/01/2017] [Indexed: 12/26/2022] Open
Abstract
Background: Few studies exist to guide the treatment approach to intra-abdominal abscesses in Crohn disease, which can include antimicrobials alone or in conjunction with percutaneous drainage or surgery. The primary aim of this study is to review outcomes from different treatment approaches to intra-abdominal abscess in Crohn disease. Methods: Medical records were reviewed for patients admitted to the University of Michigan health care system with Crohn disease and intra-abdominal abscess over a 4-year period. Outcomes were compared among medical and interventional approaches. The χ2 test was used to test for statistical significance. Results: Of the 33 patients included, 13 were in the medical group and 20 were in the interventional group. Abscess recurrence/nonresolution occurred in 31% of patients in the medical group and 25% of patients in the interventional group (P = .7). Conclusions: In this study, there was no significant difference in outcome between medical and interventional therapy for intra-abdominal abscess in Crohn disease.
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Affiliation(s)
- Emily Graham
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sandro Cinti
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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43
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Soop M, Carlson GL. Recent developments in the surgical management of complex intra-abdominal infection. Br J Surg 2017; 104:e65-e74. [PMID: 28121035 DOI: 10.1002/bjs.10437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Current guidance on the management of sepsis often applies to infection originating from abdominal or pelvic sources, which presents specific challenges and opportunities for efficient and rapid source control. Advances made in the past decade are presented in this article. METHODS A qualitative systematic review was undertaken by searching standard literature databases for English-language studies presenting original data on the clinical management of abdominal and pelvic complex infection in adults over the past 10 years. High-quality studies relevant to five topical themes that emerged during review were included. RESULTS Important developments and promising preliminary work are presented, relating to: imaging and other diagnostic modalities; antimicrobial therapy and the importance of antimicrobial stewardship; the particular challenges posed by fungal sepsis; novel techniques in percutaneous and endoscopic source control; and current issues relating to surgical source control and managing the abdominal wound. Logistical challenges relating to rapid access to cross-sectional imaging, interventional radiology and operating theatres need to be addressed so that international benchmarks can be met. CONCLUSION Important advances have been made in the diagnosis, non-operative and surgical control of abdominal or pelvic sources, which may improve outcomes in the future. Important areas for continued research include the diagnosis and therapy of fungal infection and the challenges of managing the open abdomen.
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Affiliation(s)
- M Soop
- Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - G L Carlson
- Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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44
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Park JJ, Yang SK, Ye BD, Kim JW, Park DI, Yoon H, Im JP, Lee KM, Yoon SN, Lee H. Second Korean guidelines for the management of Crohn's disease. Intest Res 2017; 15:38-67. [PMID: 28239314 PMCID: PMC5323307 DOI: 10.5217/ir.2017.15.1.38] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 01/15/2017] [Accepted: 01/16/2017] [Indexed: 02/07/2023] Open
Abstract
Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kang Moon Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Nam Yoon
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
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45
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Yaari S, Benson A, Aviran E, Lev Cohain N, Oren R, Sosna J, Israeli E. Factors associated with surgery in patients with intra-abdominal fistulizing Crohn's disease. World J Gastroenterol 2016; 22:10380-10387. [PMID: 28058018 PMCID: PMC5175250 DOI: 10.3748/wjg.v22.i47.10380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 10/03/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize radiological and clinical factors associated with subsequent surgical intervention in Crohn’s disease (CD) patients with intra-abdominal fistulae.
METHODS From a cohort of 1244 CD patients seen over an eight year period (2006 to 2014), 126 patients were identified as having intra-abdominal fistulae, and included in the study. Baseline patient information was collected from the medical records. Imaging studies were assessed for: anatomic type and number of fistulae; diameter of the inflammatory conglomerate; length of diseased bowel; presence of a stricture with pre-stenotic dilatation; presence of an abscess; lymphadenopathy; and the degree of bowel enhancement. Multivariate analysis for the prediction of abdominal surgery was calculated via Generalized Linear Models.
RESULTS In total, there were 193 fistulae in 132 patients, the majority (52%) being entero-enteric. Fifty-nine (47%) patients underwent surgery within one year of the imaging study, of which 36 (29%) underwent surgery within one month. Radiologic features that were associated with subsequent surgery included: multiple fistulae (P = 0.009), presence of stricture (P = 0.02), and an entero-vesical fistula (P = 0.01). Evidence of an abscess, lymphadenopathy, or intense bowel enhancement as well as C-reactive protein levels was not associated with an increased rate of surgery. Patients who were treated after the imaging study with combination immunomodulatory and anti-TNF therapy had significantly lower rates of surgery (P = 0.01). In the multivariate analysis, presence of a stricture [RR 4.5 (1.23-16.3), P = 0.02] was the only factor that increased surgery rate.
CONCLUSION A bowel stricture is the only factor predicting an increased rate of surgery. Radiological parameters may guide in selecting treatment options in patients with fistulizing CD.
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Abstract
The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.
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47
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Efficacy of fibrin glue therapy for abscess-associated enteric fistulas. Tech Coloproctol 2016; 20:641-6. [PMID: 27522598 DOI: 10.1007/s10151-016-1512-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Abdominal abscess that result from bowel injury may require treatment with percutaneous drainage. In some cases, an abscess-associated fistula develops between the injured bowel and the drainage catheter. Fistulas that fail to resolve may require surgery; however, fibrin glue therapy (FGT) may be a suitable alternative. METHODS We retrospectively identified patients undergoing FGT for an abscess-associated enteric fistula between 2004 and 2015. Success was defined as closure of the fistula tract without need for additional intervention. A multivariable logistic regression analysis was utilized to identify factors associated with success. RESULTS We identified 34 patients with a median age of 54 (23-87) years and 24 (71 %) males. FGT was successful in 23 (67 %) patients. On multivariate analysis, a tract width less than 5 mm (OR 19.2, 95 % CI 1.7-214.5) and removal of the drain (OR 13.8, 95 % CI 1.2-157.6) predicted FGT success. The time from initial FGT to resolution was significantly decreased for the patients who were successfully treated compared to those who failed 24 (14-38) days vs. 99 (71-175) days, respectively (p < 0.001). CONCLUSIONS Fibrin glue therapy for abscess-associated enteric fistula results in successful and accelerated healing in the majority of cases. Factors associated with successful fibrin glue therapy were identified.
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Role of percutaneous abscess drainage in the management of young patients with Crohn disease. Pediatr Radiol 2016; 46:653-9. [PMID: 26833482 DOI: 10.1007/s00247-015-3533-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/31/2015] [Accepted: 12/18/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intra-abdominal abscess is a common complication of Crohn disease in children. Prior studies, primarily in adults, have shown that percutaneous abscess drainage is a safe and effective treatment for this condition; however, the data regarding this procedure and indications in pediatric patients is limited. OBJECTIVE Our aim was to determine the success rate of percutaneous abscess drainage for abscesses related to Crohn disease in pediatric patients with a focus on treatment endpoints that are relevant in the era of biological medical therapy. MATERIALS AND METHODS We retrospectively reviewed 25 cases of patients ages ≤20 years with Crohn disease who underwent percutaneous abscess drainage. Technical success was defined as catheter placement within the abscess with reduction in abscess size on post-treatment imaging. Clinical success was defined as (1) no surgery within 1 year of drainage or (2) surgical resection following drainage with no residual abscess at surgery or on preoperative imaging. Multiple clinical parameters were analyzed for association with treatment success or failure. RESULTS All cases were classified as technical successes. Nineteen cases were classified as clinical successes (76%), including 7 patients (28%) who required no surgery within 1 year of percutaneous drainage and 12 patients (48%) who had elective bowel resection within 1 year. There was a statistically significant association between resumption of immunosuppressive therapy within 8 weeks of drainage and both clinical success (P < 0.01) and avoidance of surgery after 1 year (P < 0.01). CONCLUSION Percutaneous abscess drainage is an effective treatment for Crohn disease-related abscesses in pediatric patients. Early resumption of immunosuppressive therapy is statistically associated with both clinical success and avoidance of bowel resection, suggesting a role for percutaneous drainage in facilitating prompt initiation of medical therapy and preventing surgical bowel resection.
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Strong S, Steele SR, Boutrous M, Bordineau L, Chun J, Stewart DB, Vogel J, Rafferty JF. Clinical Practice Guideline for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2015; 58:1021-36. [PMID: 26445174 DOI: 10.1097/dcr.0000000000000450] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Preoperative Percutaneous Drainage of Spontaneous Intra-Abdominal Abscess in Patients With Crohn's Disease: A Meta-Analysis. J Clin Gastroenterol 2015; 49:e82-90. [PMID: 25216386 DOI: 10.1097/mcg.0000000000000219] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
GOALS We aimed to compare clinical outcomes between percutaneous drainage (PD) with or without further elective surgery and initial surgery for patients with Crohn's disease (CD)-related spontaneous intra-abdominal abscess. BACKGROUND Intra-abdominal abscess is common in patients with CD leading to significant morbidity. The role of PD before abdominal surgery in patients with CD remains controversial. STUDY We performed a meta-analysis comparing PD and surgery as the initial approach to CD-related spontaneous intra-abdominal abscess. Overall complication and recurrent abscess were assessed. Subgroup analyses on initial PD were performed including preoperative PD and PD alone. RESULTS A total of 9 studies including 513 patients with CD-related spontaneous intra-abdominal abscesses were included. The overall complication rate was significantly higher in patients undergoing initial surgery compared with those undergoing initial PD [odds ratio (OR)=0.58; 95% confidence interval (CI), 0.35-0.96; P=0.03]. In a subgroup analysis, preoperative PD was associated with a significant reduction in overall complication (OR=0.44; 95% CI, 0.23-0.83; P=0.01) as compared with initial surgery. The risk for recurrent abscess was higher in patients who underwent PD alone than those who underwent initial surgery (OR=2.16; 95% CI, 1.03-4.54; P=0.04). No significance difference in postoperative recurrent abscess was found between preoperative PD group and initial surgery group. CONCLUSION Although abdominal surgery appeared to be inevitable in the majority of the patients with CD who develop intra-abdominal abscess, preoperative PD may decrease overall complication after surgery.
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