Postoperative therapy with infliximab prevents long-term Crohn's disease recurrence

Clinical Predictors of Early and Late Endoscopic Recurrence Following Ileocolonic Resection in Crohn's Disease

BACKGROUND AND AIMS

Multiple factors are suggested to place Crohn's disease patients at risk of recurrence after ileocolic resection with conflicting associations. We aimed to identify clinical predictors of recurrence at first [early] and further [late] postoperative colonoscopy.

METHODS

Crohn's disease patients undergoing ileocolic resection were prospectively recruited at six North American centres. Clinical data were collected and endoscopic recurrence was defined as Rutgeerts score ≥i2. A multivariable model was fitted to analyse variables independently associated with recurrence.

RESULTS

A total of 365 patients undergoing 674 postoperative colonoscopies were included with a median age of 32 years, 189 [51.8%] were male, and 37 [10.1%] were non-Whites. Postoperatively, 133 [36.4%] used anti-tumour necrosis factor [anti-TNF] and 30 [8.2%] were smokers. At first colonoscopy, 109 [29.9%] had recurrence. Male gender (odds ratio [OR] = 1.95, 95% confidence interval [CI] 1.12-3.40), non-White ethnicity [OR = 2.48, 95% CI 1.09-5.63], longer interval between surgery and colonoscopy [OR = 1.09, 95% CI 1.002-1.18], and postoperative smoking [OR = 2.78, 95% CI 1.16-6.67] were associated with recurrence, while prophylactic anti-TNF reduced the risk [OR = 0.28, 95% CI 0.14-0.55]. Postoperative anti-TNF prophylaxis had a protective effect on anti-TNF experienced patients but not on anti-TNF naïve patients. Among patients without recurrence at first colonoscopy, Rutgeerts score i1 was associated with subsequent recurrence [OR = 4.43, 95% CI 1.73-11.35].

CONCLUSIONS

We identified independent clinical predictors of early and late Crohn's disease postoperative endoscopic recurrence. Clinical factors traditionally used for risk stratification failed to predict recurrence and need to be revised.

Positioning risankizumab in the treatment algorithm of moderate-to-severe Crohn's disease

Risankizumab is a humanized monoclonal antibody that inhibits the p19 subunit of IL-23 cytokine. Recently it has been approved for the treatment of patients with moderate-to-severe Crohn's disease (CD). We conducted a scoping review to summarize the available data on risankizumab and to define its positioning in the treatment algorithm of CD. Pubmed, Embase and Scopus databases were searched up to Oct 31, 2023 to identify studies reporting efficacy and safety data of risankizumab in patients with CD. Risankizumab is an effective and safe drug for the management of patients with moderate-to-severe CD. It could be used as first-line therapy in biologic-naive patients and in patients who have previously failed other biological therapies.

Are the New Biologics Effective in the Management of Postoperative Crohn's Disease?

BACKGROUND

Despite the growing therapeutic armamentarium, at least half of the patients with Crohn's disease will require surgery during their lifetime. Current evidence for the prevention and treatment of postoperative Crohn's disease supports the use of anti-tumor necrosis factor agents with limited data about the use of the newer biologics, vedolizumab and ustekinumab.

METHODS

We performed a systematic review of available data to determine the efficacy of the newer biologics in the management of postoperative Crohn's disease. We included noncomparative and comparative studies. The main outcomes of interest were clinical and endoscopic postoperative recurrence rates.

RESULTS

The search strategy identified 1231 citations, with 32 eligible for review. Several studies showed that the postoperative Crohn's disease recurrence rates with the use of the newer biologics were comparable to previously published results with the use of anti-tumor necrosis factor agents, while other studies failed to show their efficacy. It is important to note that the studies were heterogeneous and included a relatively small sample size, making it difficult to draw a definite conclusion about the efficacy of the newer biologics in the management of postoperative Crohn's disease.

CONCLUSION

The newer biologics do play a role in the management of postoperative Crohn's disease. After our review, we proposed an updated algorithm on the role of newer biologics in the approach to patients with postoperative Crohn's disease. Yet, until we have better-designed studies, their definite positioning remains to be determined.

Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis

Despite the introduction of biological therapies, an ileocolonic resection is often required in patients with Crohn's disease [CD]. Unfortunately, surgery is not curative, as many patients will develop postoperative recurrence [POR], eventually leading to further bowel damage and a decreased quality of life. The 8th Scientific Workshop of ECCO reviewed the available scientific data on both prevention and treatment of POR in patients with CD undergoing an ileocolonic resection, dealing with conventional and biological therapies, as well as non-medical interventions, including endoscopic and surgical approaches in case of POR. Based on the available data, an algorithm for the postoperative management in daily clinical practice was developed.

Anti-TNF Agents and New Biological Agents (Vedolizumab and Ustekinumab) in the Prevention and Treatment of Postoperative Recurrence After Surgery in Crohn's Disease

Surgery for Crohn's disease (CD) is not curative, as postoperative recurrence (POR) after ileocolonic resection is the rule in the absence of prophylactic treatment. In the present article, we critically review available data on the role of anti-tumour necrosis factor (TNF) agents and new biologics (including vedolizumab and ustekinumab) in the prevention and treatment of POR after surgery in CD. Several studies (summarised in various meta-analyses) have confirmed the efficacy of anti-TNFs in the prevention of POR. We identified 37 studies, including 1863 CD patients, with mean endoscopic POR at 6-12 months of 29%. Only few randomised controlled trials (RCTs) have directly compared thiopurines and anti-TNFs, with controversial results, although the superiority of the latter is supported by several meta-analyses. Infliximab and adalimumab seem equally effective. The combination of anti-TNFs and immunosuppressives should be considered in patients previously exposed to anti-TNFs. Several studies have shown that anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. In fact, the use of the same anti-TNF before and after surgery might be effective for the prevention of POR. Prophylactic anti-TNF treatment, once started, should be continued long term. Anti-TNFs are also effective for the treatment of established POR. Retreatment with anti-TNFs for POR is a valid strategy even after their preoperative failure. In six studies (including 156 patients) evaluating vedolizumab, mean endoscopic POR at 6-12 months was 41%. The non-randomised comparison of anti-TNFs and vedolizumab has provided controversial results. One placebo-controlled RCT confirmed that vedolizumab is quite effective in preventing POR in CD patients with increased risk of recurrence. Seven studies (including 162 patients) evaluated ustekinumab, with a mean endoscopic POR at 6-12 months of 41%. The comparative efficacy of ustekinumab and anti-TNFs is still unclear. Ustekinumab and vedolizumab seem to be equally effective, although the experience is very limited. In conclusion, to date, anti-TNFs are the most effective agents in preventing and treating POR in CD. Anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. Vedolizumab seems to be quite effective in the prevention of POR in patients with increased risk of recurrence. Ustekinumab is probably also effective in the postoperative setting, although the comparative efficacy with anti-TNFs or vedolizumab is still unclear.

Long-term Outcomes and Factors Predicting Outcome of IPAA When Used Intentionally for Well-Defined Crohn's Disease

BACKGROUND

Crohn's disease is considered a contraindication for IPAA. In our prior study, when IPAA was used intentionally for well-defined Crohn's disease, we found a high incidence of recurrent disease with a low incidence of pouch failure.

OBJECTIVE

This study aimed to replicate these findings in a larger cohort over a longer period.

DESIGN

Retrospective review of a prospective IBD registry.

SETTINGS

Large IBD referral center.

PATIENTS

Patients with preoperative colorectal Crohn's disease requiring surgery were included in the study.

INTERVENTION

IPAA.

MAIN OUTCOME MEASURES

Long-term Crohn's disease recurrence, pouch failure, and pouch function.

RESULTS

Forty-six patients were identified. Crohn's disease was diagnosed on the basis of perianal disease (n = 18; 39%), small-bowel disease (n = 16; 35%), noncaseating granuloma (n = 10; 22%), and discontinuous inflammation (colorectal skip lesions) (n = 11; 24%). After a median follow-up of 93 (7-291) months, 22 patients (48%) developed recurrent Crohn's disease based on afferent limb disease (n = 14; 30%) or pouch fistulizing disease (n = 8; 18%). Only 4 patients (9%) developed pouch failure. No clinical factor was associated with Crohn's disease recurrence. Young age at the time of surgery and short duration of disease before IPAA were associated with pouch fistula recurrence ( p = 0.003 and p = 0.03, respectively). Most patients (86%) reported excellent continence, with no urgency (67%) and median stool frequency of 6 (range, 3-9) per day.

LIMITATION

Retrospective nature and relatively small sample size.

CONCLUSION

This largest reported series examining the intentional use of IPAA in Crohn's disease showed a high (48%) incidence of postoperative Crohn's disease with a low (9%) incidence of pouch failure. Young age and short disease course before surgery were risk factors for poor outcomes. Highly motivated patients with colorectal Crohn's disease may consider IPAA and avoid a definitive ileostomy. See Video Abstract at http://links.lww.com/DCR/C171 .

RESULTADOS A LARGO PLAZO Y FACTORES PREDICTORES DE RESULTADOS DE LA ANASTOMOSIS ILEOANAL CON RESERVORIO CUANDO SE USA INTENCIONALMENTE PARA LA ENFERMEDAD DE CROHN BIEN DEFINIDA

ANTECEDENTES: La enfermedad de Crohn (EC) se considera una contraindicación para la anastomosis ileoanal con reservorio (IPAA). Nuestro estudio previo de IPAA cuando fue usada intencionalmente para EC bien definida mostró una alta incidencia de enfermedad recurrente con una baja incidencia de falla del reservorio.OBJETIVO: Replicar estos hallazgos en una cohorte más grande durante un período más largo.DISEÑO: Revisión retrospectiva de una base de datos prospectiva de enfermedad inflamatoria intestinal.ESCENARIO: Un centro grande de referencia de EII.PACIENTES: EC colorrectal preoperatoria con necesidad de tratamiento quirúrgico.INTERVENCIÓN: Anastomosis ileoanal con reservorio.RESULTADOS PRINCIPALES: Recurrencia de EC a largo plazo, falla del reservorio y función del reservorio.RESULTADOS: Cuarenta y seis pacientes fueron identificados. El diagnóstico de EC se basó en enfermedad perianal (n = 18; 39%), enfermedad del intestino delgado (n = 16; 35%), granuloma no caseificante (n = 10; 22%) e inflamación discontinua (lesiones salteadas colorrectales) (n = 11; 24%). Después de una mediana de seguimiento de 93 (7-291) meses, 22 (48 %) pacientes desarrollaron EC recurrente debido a enfermedad del asa aferente (n = 14; 30%) o enfermedad fistulizante del reservorio (n = 8; 18%). Solo 4 (9%) pacientes desarrollaron falla del reservorio. Ningún factor clínico se asoció con la recurrencia de EC. La edad joven en el momento de la cirugía y la corta duración de la enfermedad antes de IPAA se asociaron con la recurrencia de la fístula del reservorio ( p = 0.003 y p = 0.03, respectivamente). El recuento de plaquetas preoperatorio más alto fue la única característica clínica significativamente asociada con el fracaso del reservorio ( p = 0.02). La mayoría de los pacientes (86%) reportaron una continencia excelente, sin urgencia (67%) y una mediana de frecuencia evacuatoria de 6 (rango, 3-9) por día.LIMITACIONES: Naturaleza retrospectiva y tamaño de muestra relativamente pequeño.CONCLUSIÓN: Esta serie, la más grande reportada que examina el uso intencional de IPAA en la EC mostró una incidencia alta (48Rectal Cancer: Clinical and Molecular Predictors of a Complete Response to Total Neoadjuvant Therapy%) de EC posoperatoria con una incidencia baja (9%) de falla del reservorio. La edad joven y el curso corto de la enfermedad antes de la cirugía fueron factores de riesgo para pobres resultados. Pacientes altamente motivados con EC colorrectal pueden considerar una IPAA y evitar una ileostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/C171 . (Traducción-Dr. Jorge Silva Velazco ).

Clinical Evaluation of Risankizumab in the Treatment of Adults with Moderately to Severely Active Crohn's Disease: Patient Selection and Reported Outcomes

This article will review risankizumab, a monoclonal antibody targeting interleukin 23 (IL-23) for the treatment of moderate-to-severe Crohn's disease. The article will detail the mechanism of action and dosing strategies. Efficacy in induction and maintenances will be reviewed from available clinical trials as well as an evaluation of safety of the medication for use in Crohn's disease and other immune mediated diseases. Finally, a discussion of when to use this medication for treatment in Crohn's disease as well as how to monitor patients after medication initiation will be discussed.

Biologic and Small-Molecule Therapies for Moderate-to-Severe Psoriasis: Focus on Psoriasis Comorbidities

Psoriasis is a systemic immune-mediated disease associated with an increased risk of comorbidities, such as psoriatic arthritis, cardiovascular disease, metabolic syndrome, inflammatory bowel disease, psychiatric disorders, and malignancy. In recent years, with the advent of biological agents, the efficacy and safety of psoriasis treatments have dramatically improved. Presently, tumor necrosis factor-α inhibitors, interleukin-17 inhibitors, interleukin-12/23 inhibitors, and interleukin-23 inhibitors are approved to treat moderate-to-severe psoriasis. Small-molecule inhibitors, such as apremilast and deucravacitinib, are also approved for the treatment of psoriasis. Although it is still unclear, systemic agents used to treat psoriasis also have a significant impact on its comorbidities by altering the systemic inflammatory state. Data from clinical trials and studies on the safety and efficacy of biologics and small-molecule inhibitors provide important information for the personalized care and treatment for patients with psoriasis. Notably, treatment with interleukin-17 inhibitors is associated with new-onset or exacerbations of inflammatory bowel disease. In addition, great caution needs to be taken when using tumor necrosis factor-α inhibitors in patients with psoriasis with concomitant congestive heart failure, multiple sclerosis, and malignancy. Apremilast may induce weight loss as an adverse effect, presenting also with some beneficial metabolic actions. A better understanding of the characteristics of biologics and small-molecule inhibitors in the treatment of psoriasis comorbidities can provide more definitive guidance for patients with distinct comorbidities.

Perioperative Management of Ulcerative Colitis: A Systematic Review

BACKGROUND

Patients with ulcerative colitis may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. Managing ulcerative colitis is complicated because there are many factors at play, including patient optimization and treatment, as the guidance varies on the ideal perioperative use of corticosteroids, immunomodulators, biologics, and small molecule agents.

OBJECTIVE

A systematic literature review was performed to describe the current status of perioperative management of ulcerative colitis.

DATA SOURCES

PubMed and Cochrane databases were used.

STUDY SELECTION

Studies published between January 2000 and January 2022, in any language, were included. Articles regarding pediatric or endoscopic management were excluded.

INTERVENTIONS

Perioperative management of ulcerative colitis was included.

MAIN OUTCOME MEASURES

Successful management, including reducing surgical complication rates, was measured.

RESULTS

A total of 121 studies were included in this review, including 23 meta-analyses or systematic reviews, 25 reviews, and 51 cohort studies.

LIMITATIONS

Qualitative review including all study types. The varied nature of study types precludes quantitative comparison.

CONCLUSION

Indications for colectomy in ulcerative colitis include severe disease unresponsive to medical treatment and colitis-associated neoplasia. Urgent colectomy has a higher mortality rate than elective colectomy. Corticosteroids are associated with postsurgical infectious complications and should be stopped or weaned before surgery. Biologics are not associated with adverse postoperative effects and do not necessarily need to be stopped preoperatively. Additionally, the clinician must assess individuals' comorbidities, nutrition status, and risk of venous thromboembolism. Nutritional imbalance should be corrected, ideally at the preoperative period. Postoperatively, corticosteroids can be tapered on the basis of the length of preoperative corticosteroid use.

Post-operative prevention and monitoring of Crohn's disease recurrence

Crohn's disease (CD) and ulcerative colitis (UC) are relapsing and remitting chronic inflammatory diseases of the gastrointestinal tract. Although surgery for UC can provide a cure, surgery for CD is rarely curative. In the past few decades, research has identified risk factors for postsurgical CD recurrence, enabling patient risk stratification to guide monitoring and prophylactic treatment to prevent CD recurrence. A MEDLINE literature review identified articles regarding post-operative monitoring of CD recurrence after resection surgery. In this review, we discuss the evidence on risk factors for post-operative CD recurrence as well as suggestions on post-operative management.

Early Post-Operative Endoscopy Is Associated with Lower Surgical Recurrence of Crohn's Disease: A Retrospective Study of Three Successive Cohorts

BACKGROUND

The severity of endoscopic recurrence during the first year after intestinal resection for Crohn's disease is predictive of clinical recurrence. The aim of our study was to assess the impact of the implementation of an ileocolonoscopy during the first year after surgery on surgical recurrence.

METHODS

All patients who underwent a first intestinal resection for Crohn's disease between 1992 and 2018 at the University Hospital of Liège were retrospectively included. The time to surgical recurrence was compared in three successive groups of patients operated on in the period 1992-2001 (group A), 2002-2011 (group B), and 2012-2020 (group C) using the Kaplan-Meier method and the Log-Rank test. To identify independent prognostic factors, a multivariate analysis was used via the Cox model.

RESULTS

223 patients (group A = 69, group B = 94, group C = 60) were included. Probabilities of surgical recurrence were significantly lower in group C (2.2% and 4.7% at 3 and 5 years, respectively) compared with group B (4.2% and 7.6% at 3 and 5 years, respectively) and with group A (9% and 18.2% at 3 and 5 years, respectively) (p = 0.0089). Ileocolonoscopy during the year after surgery was associated with a significantly reduced surgical recurrence rate in univariate and multivariate analysis (HR = 0.31, p = 0.0049).

CONCLUSION

The implementation of an early ileocolonoscopy after surgery for Crohn's disease since early 2000 has been associated with a reduced surgical recurrence over the last 30 years.

Early Initiation of Antitumor Necrosis Factor Therapy Reduces Postoperative Recurrence of Crohn's Disease Following Ileocecal Resection

BACKGROUND

Postoperative recurrence (POR) of Crohn's disease (CD) is common after surgical resection. We aimed to compare biologic type and timing for preventing POR in adult CD patients after ileocecal resection (ICR).

METHODS

We performed a retrospective cohort study of CD patients who underwent an ICR at 2 medical centers. Recurrence was defined by endoscopy (≥ i2b Rutgeerts score) or radiography (active inflammation in neoterminal ileum) and stratified by type and timing of postoperative prophylactic biologic within 12 weeks following an ICR (none, tumor necrosis factor antagonists [anti-TNF], vedolizumab, and ustekinumab).

RESULTS

We identified 1037 patients with CD who underwent an ICR. Of 278 (26%) who received postoperative prophylaxis, 80% were placed on an anti-TNF agent (n = 223) followed by ustekinumab (n = 28, 10%) and vedolizumab (n = 27, 10%). Prophylaxis was initiated in 35% within 4 weeks following an ICR and in 65% within 4 to 12 weeks. After adjusting for factors associated with POR, compared with no biologic prophylaxis, the initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR (adjusted hazard ratio, 0.61; 95% CI, 0.40-0.93). Prophylaxis after 4 weeks following an ICR or with vedolizumab or ustekinumab was not associated with a reduction in POR compared with those who did not receive prophylaxis.

CONCLUSION

Early initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR. Vedolizumab or ustekinumab, at any time following surgery, was not associated with a reduction in POR, although sample size was limited.

Advances in the Comprehensive Management of Postoperative Crohn's Disease

Patients with postoperative Crohn's disease are difficult to manage because of their risk of experiencing a more severe course, multiple symptom confounders, and poor sensitivity of symptomatic remission to rule out intestinal inflammation. In this group, data are lacking on biologic therapeutic efficacy, and recommendations are lacking for those with multiple medication failures. Novel noninvasive testing can simultaneously exclude alternate causes of symptoms (serum C4, fecal fat, small intestinal bowel overgrowth breath testing) and assess intestinal inflammation (fecal calprotectin, endoscopic healing index). In addition, endoscopy-based disease activity assessment and management are required. Endoscopy should be performed within 6 months of surgery, and aggressive disease activity monitoring can be considered with colonoscopy every 1-2 years subsequently to ensure late recurrence is detected. Patients with multiple resections should be screened for short bowel syndrome. Predictive biomarkers are needed to guide medication selection in this high-risk population. Postoperative prophylactic biologic therapy is prudent for patients with preoperative biologic failure. However, there are no high-quality data to guide which agent should be selected. Selecting biologics with an alternative mechanism of action in those who had failed a biologic with adequate drug concentrations and selection of different agents in those with previous intolerance are reasonable. Significantly more study is required to assess the efficacy of therapies in this setting.

Secondary Indicators for an Evaluation and Guidance System for Quality of Care in Inflammatory Bowel Disease Centers: A Critical Review of the Inflammatory Bowel Disease Quality of Care Center

The number of patients with inflammatory bowel disease (IBD) has increased remarkably in recent years. However, the level of health care for IBD patients varies greatly among regions of China. Standardization of health care for IBD patients is essential to improve quality of care (QoC). The mission of the IBD Quality Care Evaluation Center (IBDQCC) is to establish indicators for QoC. Since 2017, the IBDQCC has developed structure, process, and outcome indicators with the steering committee of IBD specialists and methodologists; 28 core and 13 secondary IBD QoC indicators were selected using a Delphi method. Applications for certification of IBD quality care units were made voluntarily and preliminarily screened through the IBDQCC committee. Regional units had to meet all core indicators, and units of excellence were required to meet all core indicators together with an additional 50% of secondary indicators. As of 2019 and 2020, 69 IBD units (all from tertiary referral hospitals) have been certified as regional IBD units in China. The certification of excellence of the IBD units is currently undergoing auditing. The awareness of and appreciation for QoC in IBD is increasing in China, especially through the quality control evaluation program initiated by the IBDQCC, with a higher number of IBD units applying for the next round of certification. Although secondary indicators seem to play relatively minor roles in QoC, they suggest additional requirements for high-level centers.

Fecal Diversion for Perianal Crohn Disease in the Era of Biologic Therapies: A Multicenter Study

BACKGROUND

The natural history of perianal Crohn disease (PCD) after fecal diversion in the era of biologics is poorly understood. We assessed clinical and surgical outcomes after fecal diversion for medically refractory PCD and determined the impact of biologics.

METHODS

We performed a retrospective, multicenter study from 1999 to 2020. Patients who underwent fecal diversion for refractory PCD were stratified by diversion type (ostomy with or without proctectomy). Times to clinical and surgical outcomes were estimated using Kaplan-Meier methods, and the association with biologics was assessed using multivariable Cox proportional hazards models.

RESULTS

Eighty-two patients, from 3 academic institutions, underwent a total of 97 fecal diversions: 68 diversions without proctectomy and 29 diversions with proctectomy. Perianal healing occurred more commonly after diversion with proctectomy than after diversion without proctectomy (83% vs 53%; P = 0.021). Among the patients who had 68 diversions without proctectomy, with a median follow-up of 4.9 years post-diversion (interquartile range, 1.66-10.19), 37% had sustained healing, 31% underwent surgery to restore bowel continuity, and 22% underwent proctectomy. Ostomy-free survival occurred in 21% of patients. Biologics were independently associated with avoidance of proctectomy (hazard ratio, 0.32; 95% confidence interval, 0.11-0.98) and surgery to restore bowel continuity (hazard ratio, 3.10; 95% confidence interval, 1.02-9.37), but not fistula healing.

CONCLUSIONS

In this multicenter study, biologics were associated with bowel restoration and avoidance of proctectomy after fecal diversion without proctectomy for PCD; however, a minority of patients achieved sustained fistula healing after initial fecal diversion or after bowel restoration. These results highlight the refractory nature of PCD.

Predictability of simple endoscopic score for Crohn's disease for postoperative outcomes in Crohn's disease

BACKGROUND AND AIM

Approximately half of patients with Crohn's disease (CD) who have surgery will experience clinical recurrence within 10 years of their surgery. This study aimed to assess the postoperative outcomes according to disease location and validated the simple endoscopic score for CD (SES-CD) to predict disease-related outcomes.

METHODS

We retrospectively assessed medical records of CD patients who underwent ileocolonoscopy within 12 months after surgery at the University of Chicago between 2005 and 2016. We defined patients with postoperative colonic inflammation at the first postoperative ileocolonoscopy or had Montreal classification L2 as colon-dominant disease and patients without colonic involvement or who had L1 as small intestine (SI)-dominant disease. The outcomes included clinical and surgical recurrence.

RESULTS

Among 207 CD patients, 51 (24.6%) and 156 (75.4%) patients had colon-dominant and SI-dominant disease, respectively. Patients with colon-dominant disease had a greater risk of postoperative clinical recurrence compared with those with SI-dominant disease (P = 0.018). Colon-dominant disease was a risk of earlier surgical recurrence compared with SI-dominant disease, although there were no significant differences in the recurrence-free survivals. SES-CD > 2 at the first postoperative ileocolonoscopy was a significant risk of clinical recurrence on log-rank test (P < 0.001) and Cox proportional hazards model (hazard ratio = 2.25; 95% confidence interval = 1.14-4.47; P = 0.020). An SES-CD of 1 was an appropriate cut-off to predict the clinical recurrence of SI-dominant disease, but a higher SES-CD cut-off value of 5 was required for colon-dominant disease.

CONCLUSIONS

We demonstrated that SES-CD predicts postoperative clinical recurrence of CD, regardless of disease location.

Informed consent in inflammatory bowel disease: a necessity in real-world clinical practice

In modern medicine, any medical intervention has to be supported by a patient's informed consent. Challenges to this process include the specificity and complexity of medical information being provided, the patient's ability to comprehend the information, the medical uncertainty of the outcomes, and the physician's legal concerns. Important elements of the consent process are respect for the patient's autonomy and self-determination, appropriate disclosure and verification of their understanding, and voluntariness. In inflammatory bowel disease (IBD), pharmaceutical treatment carries significant risks, making discussion and illustration of the treatment critical for decision making. This review aims to emphasize the importance of the informed consent process in routine IBD clinical practice, and suggests an appropriate way of informing patients about the medical treatment on offer. The information that has to be comprehensively presented before consent includes: i) treatment goal; ii) basic characteristics of treatment (route and timetable of drug administration, drug efficacy, adverse events); and iii) consequences of staying untreated. The IBD physician's main concerns must include ensuring not only that the information being provided is detailed and objective, but also that the decision-making process is shared with the patient. Ultimately, the process of obtaining informed consent in real-world clinical practice is undoubtedly of great importance, for both upholding the principles of medical ethics and avoiding legal conflicts.

Risk of Late Postoperative Recurrence of Crohn's Disease in Patients in Endoscopic Remission After Ileocecal Resection, Over 10 Years at Multiple Centers

BACKGROUND & AIMS

The risk of recurrence of Crohn's disease (CD) from 1 to 10 years after surgery despite initial endoscopic remission (late post-operative recurrence) is not clear.

METHODS

We performed a retrospective study, at 3 inflammatory bowel disease (IBD) centers in France and Belgium, of all patients with CD (n = 86) undergoing an ileocecal resection with curative intent from 2006 through 2016 who did not have endoscopic evidence for recurrence (Rutgeerts score less than i2) at their baseline assessment. Postoperative recurrence after baseline endoscopy was defined as a composite endpoint of at least 1 of the following: clinical recurrence, IBD-related hospitalization, occurrence of bowel damage, need for endoscopic balloon dilatation of the anastomosis, and need to repeat the surgery. Risk of mucosal disease progression was studied as a secondary outcome.

RESULTS

The median time between surgery and baseline endoscopy was 7 months (IQR, 5.7-9.5 months); 40 patients (46.5%) received medical prophylaxis in this period. The median follow-up time was 3.5 years (IQR, 1.6-5.3 years). Thirty-five patients (40.7%) had a late post-operative recurrence of CD, with a median time to disease recurrence after baseline endoscopy of 14.2 months (IQR, 6.3-26.1 months). Recurrence status did not differ significantly between patients with Rutgeerts scores of i0 (20/55) or i1 (15/31) at baseline (P = .28) and was independent of medical prophylaxis (16/40 with prophylactic therapy vs 19/46 without prophylactic therapy; P = .90). Mucosal disease progressed in 29 of the 71 patients (40.8%) with available data. We did not identify risk factors for late post-operative recurrence of CD or mucosal disease progression.

CONCLUSIONS

Among patients with CD treated by ileocecal resection, 40% of patients had a late recurrence, despite initial endoscopic remission, after a median follow-up time of 3.5 years. Tight monitoring of these patients is recommended beyond 18 months.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review

BACKGROUND

Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure.

OBJECTIVE

This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease.

DATA SOURCES

A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews.

STUDY SELECTION

The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected.

INTERVENTION

Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology.

MAIN OUTCOMES MEASURES

The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate.

RESULTS

Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified.

LIMITATIONS

This investigation was limited by the small number of studies with significant study heterogeneity.

CONCLUSION

In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

Active Margins, Plexitis, and Granulomas Increase Postoperative Crohn's Recurrence: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Rates of postoperative Crohn's disease recurrence remain high, although the ability to predict this risk of recurrence remains limited. As such, we aimed to determine the association of histologic features at the time of resection with postoperative recurrence.

METHODS

Electronic databases were searched through February 2020 for studies that reported risk of clinical, endoscopic, or surgical postoperative recurrence in patients with positive resection margins, plexitis, or granulomas in the index specimen. Pooled risk ratios (RRs) with 95% CIs were calculated for this risk in patients with and without these histologic features.

RESULTS

Twenty-one studies (2481 patients) assessed positive resection margins, 10 studies (808 patients) assessed plexitis, and 19 studies (1777 patients) assessed granulomas. Positive resection margins increased the risk of clinical (RR, 1.26; 95% CI, 1.06-1.49; I² = 41%) and surgical (RR, 1.87; 95% CI, 1.14-3.08; I² = 71%) recurrence, with a trend toward endoscopic recurrence (RR, 1.56; 95% CI, 0.79-3.05; I² = 85%). Granulomas increased the risk of clinical (RR, 1.31; 95% CI, 1.05-1.64; I² = 36%) and endoscopic (RR, 1.37; 95% CI, 1.00-1.87; I² = 49%) recurrence, with a trend toward surgical recurrence (RR, 1.58; 95% CI, 0.89-2.80; I² = 75%). Plexitis increased the risk of endoscopic recurrence (RR, 1.31; 95% CI, 1.00-1.72; I² = 20%), with a trend toward clinical recurrence (RR, 1.34; 95% CI, 0.95-1.91; I² = 46%).

CONCLUSIONS

Positive resection margins, granulomas, and plexitis are predictive of postoperative Crohn's disease recurrence and should be recorded at the time of index resection.

Medical therapies for postoperative Crohn's disease

Postoperative recurrence of Crohn's disease is common and requires a multidisciplinary approach between surgeons and gastroenterologists in the perioperative and postoperative period to improve outcomes in this patient population. Endoscopic recurrence precedes clinical and surgical recurrence and endoscopic monitoring is crucial to guide postoperative management. Risk stratification of patients is recommended to guide early prophylactic management, and follow-up endoscopic monitoring can guide intensification of therapy. This review summarizes evidence behind postoperative recurrence rates, disease monitoring techniques, nonbiologic and biologic therapies available to prevent and treat postoperative recurrence, risk factors associated with recurrence, and postoperative management strategies guided by endoscopic monitoring.

Prophylaxis of Crohn's disease recurrence: A surgeon's perspective

Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.

Prevention of Postoperative Recurrence in CD: Tailoring Treatment to Patient Profile

Crohn's disease (CD) is an immune-mediated condition characterized by the transmural inflammation of the gut tissue, associated with progressive bowel damage often leading to surgical intervention. As operative resection of the damaged segment is not curative, a majority of patients undergoing intestinal resections for complicated CD present disease recurrence within 3 years after the intervention. Postoperative recurrence can be defined as endoscopic, clinical, radiological or surgical. Endoscopic recurrence rates within 1 year exceed 60% and the severity, according to the Rutgeerts' score, is associated with worse prognosis and can predict clinical recurrence (in up to 1/3 of the patients). Most importantly, about 50% of patients will undergo a reoperation after 10 years of their first intestinal resection. Therefore, the prevention of postoperative recurrence in CD remains a challenge in clinical practice and should be properly managed. We aim to summarize the most recent data on the definition, risk factors, assessment and treatment of postoperative CD recurrence.

First-Line Biologics or Small Molecules in Inflammatory Bowel Disease: a Practical Guide for the Clinician

PURPOSE OF REVIEW

Treating moderate-to-severe inflammatory bowel disease has become increasingly complex as the array of available biologics increases. Moreover, tofacitinib, the first small molecule approved for IBD, is available for use in ulcerative colitis. Choosing the right biologic, for the right patient, at the right time, can be a confusing and daunting task for clinicians.

RECENT FINDINGS

In this review, we summarize the evidence for first-line use of the available biologics by disease state. Special circumstances for consideration including rapidity of action, safety, comparative effectiveness, postoperative Crohn's disease, fertility and pregnancy, and extraintestinal manifestations are discussed. In the moderate-to-severe UC patient, vedolizumab and infliximab are preferred first-line options. In the moderate-to-severe CD patient with a penetrating phenotype or with multiple EIMs, infliximab or adalimumab are the preferred first-line agents. In the moderate-to-severe CD patient with an inflammatory phenotype, anti-TNF, vedolizumab, and ustekinumab are all reasonable options.

Pharmacological Prevention and Management of Postoperative Relapse in Pediatric Crohn's Disease

Pediatric Crohn's disease (CD) is characterized by an aggressive course that commonly requires more intensive pharmacological and surgical treatments. In spite of the therapeutic advances in monitoring and management, including the widespread use of biologic therapy, the cumulative incidence of surgery in children with CD is still high. However, surgery is usually not curative and disease recurrence after small bowel resection is common. Gastrointestinal endoscopy is currently the gold standard to evaluate disease progression after surgery, but other non-invasive methods have been suggested. Although the efficacy of several drugs as medical prophylaxis to reduce the rate of disease recurrence following intestinal resection has been evaluated, selecting the most appropriate preventive therapeutic intervention remains a challenge. The current recommendations, mostly based on adult studies due to limited pediatric data, state that treatment should be guided by risk for recurrence. Low-risk patients may be given no prophylaxis or only 5-ASA. Maintenance enteral nutrition may also be considered. Thiopurines may be used in moderate risk of CD recurrence. In high risk patients for postoperative recurrence (extensive disease, short disease duration from diagnosis to surgery, recurrent surgery, long resected segment, surgery for fistulizing disease, disease complications, perianal disease, smoking), prophylactic treatment with anti-TNFα is recommended. subsequently, therapy should be guided by repeated measurement of objective measures including endoscopic re-evaluation at 6-12 months following surgery.

Interventions for maintenance of surgically induced remission in Crohn's disease: a network meta-analysis

BACKGROUND

Crohn's disease (CD) is a chronic disease of the gut. About 75% of people with CD undergo surgery at least once in their lifetime to induce remission. However, as there is no known cure for the disease, patients usually experience a recurrence even after surgery. Different interventions are routinely used in maintaining postsurgical remission. There is currently no consensus on which treatment is the most effective.

OBJECTIVES

To assess the effects and harms of interventions for the maintenance of surgically induced remission in Crohn's disease and rank the treatments in order of effectiveness.

SEARCH METHODS

We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, and Embase from inception to 15 January 2019. We also searched reference lists of relevant articles, abstracts from major gastroenterology meetings, ClinicalTrials.gov, and the WHO ICTRP. There was no restriction on language, date, or publication status.

SELECTION CRITERIA

We considered for inclusion randomised controlled trials (RCTs) that compared different interventions used for maintaining surgically induced remission in people with CD who were in postsurgical remission. Participants had to have received maintenance treatment for at least three months. We excluded studies assessing enteral diet, diet manipulation, herbal medicine, and nutritional supplementation.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected relevant studies, extracted data, and assessed the risk of bias. Any disagreements were resolved by discussion or by arbitration of a third review author when necessary. We conducted a network meta-analysis (NMA) using a Bayesian approach through Markov Chain Monte Carlo (MCMC) simulation. For the pairwise comparisons carried out in Review Manager 5, we calculated risk ratios (RR) with their corresponding 95% confidence intervals (95% CI). For the NMA, we presented hazard ratios (HR) with corresponding 95% credible intervals (95% CrI) and reported ranking probabilities for each intervention. For the NMA, we focused on three main outcomes: clinical relapse, endoscopic relapse, and withdrawals due to adverse events. Data were insufficient to assess time to relapse and histologic relapse. Adverse events and serious adverse events were not sufficiently or objectively reported to permit an NMA. We used CINeMA (Confidence in Network Meta-Analysis) methods to evaluate our confidence in the findings within networks, and GRADE for entire networks.

MAIN RESULTS

We included 35 RCTs (3249 participants) in the review. The average age of study participants ranged between 33.6 and 38.8 years. Risk of bias was high in 18 studies, low in four studies, and unclear in 13 studies. Of the 35 included RCTs, 26 studies (2581 participants; 9 interventions) were considered eligible for inclusion in the NMA. The interventions studied included 5-aminosalicylic acid (5-ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone. This resulted in 30 direct contrasts, which informed 102 mixed-treatment contrasts.The evidence for the clinical relapse network (21 studies; 2245 participants) and endoscopic relapse (12 studies; 1128 participants) were of low certainty while the evidence for withdrawal due to adverse events (15 studies; 1498 participants) was of very low certainty. This assessment was due to high risk of bias in most of the studies, inconsistency, and imprecision across networks. We mainly judged individual contrasts as of low or very low certainty, except 5-ASA versus placebo, the evidence for which was judged as of moderate certainty.We ranked the treatments based on effectiveness and the certainty of the evidence. For clinical relapse, the five most highly ranked treatments were adalimumab, infliximab, budesonide, 5-ASA, and purine analogues. We found some evidence that adalimumab (HR 0.11, 95% Crl 0.02 to 0.33; low-certainty evidence) and 5-ASA may reduce the probability of clinical relapse compared to placebo (HR 0.69, 95% Crl 0.53 to 0.87; moderate-certainty evidence). However, budesonide may not be effective in preventing clinical relapse (HR 0.66, 95% CrI 0.27 to 1.34; low-certainty evidence). We are less confident about the effectiveness of infliximab (HR 0.36, 95% CrI 0.02 to 1.74; very low-certainty evidence) and purine analogues (HR 0.75, 95% CrI 0.55 to 1.00; low-certainty evidence). It was unclear whether the other interventions reduced the probability of a clinical relapse, as the certainty of the evidence was very low.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing endoscopic relapse. Whilst there might be some evidence of prevention of endoscopic relapse with adalimumab (HR 0.10, 95% CrI 0.01 to 0.32; low-certainty evidence), no other intervention studied appeared to be effective.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing withdrawal due to adverse events. Withdrawal due to adverse events appeared to be least likely with sulfasalazine (HR 1.96, 95% Crl 0.00 to 8.90; very low-certainty evidence) and most likely with antibiotics (HR 53.92, 95% Crl 0.43 to 259.80; very low-certainty evidence). When considering the network as a whole, two adverse events leading to study withdrawal (i.e. pancreatitis and leukopenia) occurred in more than 1% of participants treated with an intervention. Pancreatitis occurred in 2.8% (11/399) of purine analogue participants compared to 0.17% (2/1210) of all other groups studied. Leukopenia occurred in 2.5% (10/399) of purine analogue participants compared to 0.08% (1/1210) of all other groups studied.

AUTHORS' CONCLUSIONS

Due to low-certainty evidence in the networks, we are unable to draw conclusions on which treatment is most effective for preventing clinical relapse and endoscopic relapse. Evidence on the safety of the interventions was inconclusive, however cases of pancreatitis and leukopenia from purine analogues were evident in the studies. Larger trials are needed to further understand the effect of the interventions on endoscopic relapse.

Diagnostic pathways in Crohn's disease

The management of Crohn's disease (CD) is shifting from a stepwise, incremental approach based on symptom control to more aggressive early combined immunosuppression in an attempt to induce remission more rapidly and avoid long-term bowel damage. Accurately defining disease activity is a major challenge, as there is often a disconnect between symptomatology and underlying disease status. The role of imaging in CD has evolved such that it now plays a central role establishing the initial diagnosis, characterising disease phenotype, activity assessment, disease surveillance, and assessing response to therapy. Furthermore, the "treat-to-target" approach is being investigated in CD, with resolution of transmural inflammation on cross-sectional imaging being the treatment goal. In this review, we summarise the principal imaging techniques available to the radiologist, the key findings, and provide some guidance on the preferred imaging option in the diagnostic pathway. We consider the relative merits and drawbacks of each imaging technique before offering a brief discussion of some current developments and research avenues in CD imaging. We discuss how imaging may be useful in a "treat-to-target" approach. Finally, we highlight some practical considerations around service configuration and delivery to optimise imaging in CD in an accurate, cost-effective manner.

Early Postoperative Anti-TNF Therapy Does Not Increase Complications Following Abdominal Surgery in Crohn's Disease

BACKGROUND

The impact of postoperative anti-TNF therapy on infectious complications following Crohn's disease surgery remains controversial. Use of anti-TNF therapy 2-4 weeks postoperatively appears safe, but safety of use within 2 weeks is unknown.

AIMS

We sought to evaluate the effect of anti-TNF therapy initiated within 2 weeks of abdominal surgery in patients with Crohn's disease.

METHODS

We conducted a retrospective review of adult Crohn's disease patients undergoing abdominal surgery between 2004 and 2011. Infectious and non-infectious complications were compared between patients exposed to anti-TNF therapy within 2 weeks or between 2 and 4 weeks postoperatively and to those without exposure using chi-squared and regression analysis.

RESULTS

Three hundred thirty-one abdominal surgeries were included; 241 were without anti-TNF exposure, 46 received postoperative anti-TNF within 2 weeks of surgery, and 44 received anti-TNF therapy 2-4 weeks after surgery. Patients who received anti-TNF therapy within 2 weeks of surgery, those initiated between 2 and 4 weeks of surgery, and those who did not receive anti-TNF therapy within 4 weeks of surgery had no significant difference in rates of infectious complications (22%, 32%, 33%, p = 0.332). Rates of non-infectious complications (4%, 9%, 14%, p = 0.143), mortality (0%, 0%, 3%, p = 0.105), hospital readmission (17%, 16%, 15%, p = 0.940), and reoperation (11%, 11%, 16%, p = 0.563) were also similar between groups.

CONCLUSIONS

Use of early anti-TNF therapy within 2 weeks or between 2 and 4 weeks following abdominal surgery did not increase risk of postoperative surgical infections in Crohn's patients.

Systematic Review and Network Meta-Analysis of Medical Therapies to Prevent Recurrence of Post-Operative Crohn's Disease

BACKGROUND AND AIMS

Surgery is an important treatment for Crohn's disease [CD], but recurrence occurs in up to 80% of individuals post-operatively. The efficacy of several drugs to prevent post-operative recurrence has been studied in previous meta-analyses, but a number of randomized controlled trials [RCTs] have recently been published. We therefore performed an updated systematic review and network meta-analysis to investigate this issue.

METHODS

We performed a comprehensive literature search through to July 2018 to identify RCTs investigating the endoscopic and clinical recurrence of CD at 12 months post-operatively. We performed a random-effects network meta-analysis to produce a pooled relative risk [RR] with 95% confidence intervals [CIs]. We ranked the treatments according to their P-score.

RESULTS

We included 10 RCTs, containing 751 patients, in our primary analysis of endoscopic recurrence of CD at 12 months. Anti-tumour necrosis factor [TNF]-α therapies were significantly better than placebo, either alone [P-score 0.98, RR 0.13; 95% CI 0.04-0.39] or in combination with 5-aminosalicylates [5-ASAs] [P-score 0.81, RR 0.30; 95% CI 0.12-0.75], or 5-nitroimidazoles [P-score 0.75, RR 0.40; 95% CI 0.23-0.69]. Combination therapy with a thiopurine and 5-nitroimidazole was also more effective than placebo [P-score 0.59, RR 0.56; 95% CI 0.40-0.80], as was thiopurine monotherapy [P-score 0.31, RR 0.84; 95% CI 0.74-0.94]. However, neither 5-nitroimidazoles nor 5-ASAs alone were superior to placebo.

CONCLUSIONS

In network meta-analysis, anti-TNF-α therapies alone, or in combination, appear to be the best medications for preventing endoscopic post-operative recurrence of CD.

Infliximab in inflammatory bowel disease

Anti-tumor necrosis factor (TNF) therapy has revolutionized the medical treatment of the inflammatory bowel diseases (IBD), Crohn’s disease (CD), and ulcerative colitis. Twenty years ago, infliximab became the first anti-TNF agent approved for IBD. Data from randomized controlled trials, large observational cohort studies, postmarketing registries, and meta-analyses show that infliximab is a very effective treatment for moderate to severe IBD with a good safety profile. Infliximab has been also used to treat pouchitis following an ileal pouch–anal anastomosis (IPAA) after restorative proctocolectomy and to prevent postoperative recurrence following an ileocolonic resection for CD with good results. Nevertheless, up to 30% of patients show no clinical benefit following induction and up to 50% lose response over time. Both these unwanted outcomes can be largely explained by inadequate drug concentrations and frequently by the development of antibodies to infliximab. Loss of response can be managed efficiently and often prevented by applying therapeutic drug monitoring. Recently, the first biosimilars of infliximab have been approved and are utilized in clinical practice with comparable efficacy and safety with the originator. This review will mainly focus on the efficacy of infliximab in IBD.

Surgery in the age of biologics

Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.

Risk of surgery in patients with stricturing type of Crohn's disease at the initial diagnosis: a single center experience

BACKGROUND/AIMS

It remains uncertain which patients with stricturing-type Crohn's disease (CD) require early small bowel surgery after the initial diagnosis. We aimed to clarify clinical characteristics associated with the intervention in such condition of CD.

METHODS

We retrospectively evaluated the clinical course of 53 patients with CD and small bowel strictures who were initially treated with medications after the initial diagnosis. We investigated possible associations between small bowel surgery and the following: clinical factors and radiologic findings at initial diagnosis and the types of medications administered during follow-up.

RESULTS

Twenty-eight patients (53%) required small bowel resection during a median follow-up period of 5.0 years (range, 0.5-14.3 years). The cumulative incidence rates of small bowel surgery at 2, 5, and 10 years were 26.4%, 41.0%, and 63.2%, respectively. Univariate analysis indicated that obstructive symptoms (P=0.036), long-segment stricture (P<0.0001), and prestenotic dilation (P<0.0001) on radiography were associated with small bowel surgery, and immunomodulatory (P=0.037) and biological therapy (P=0.008) were significant factors during follow-up. Multivariate analysis revealed that long-segment stricture (hazard ratio [HR], 4.25; 95% confidence interval [CI], 1.78-10.53; P=0.001) and prestenotic dilation (HR, 3.41; 95% CI, 1.24-9.62; P=0.018) on radiography showed a positive correlation with small bowel surgery, and biological therapy (HR, 0.40; 95% CI, 0.15-0.99; P=0.048) showed a negative correlation.

CONCLUSIONS

CD patients with long-segment stricture and prestenotic dilation on radiography seem to be at a higher risk of needing small bowel surgery. For such patients, early surgical intervention might be appropriate, even at initial diagnosis.

Effectiveness of Mesalazine, Thiopurines and Tumour Necrosis Factor Antagonists in Preventing Post-Operative Crohn's Disease Recurrence in a Real-Life Setting

BACKGROUND

Most Crohn's disease (CD) patients develop endoscopic recurrence within one year of intestinal resection. The best treatment method to prevent post-operative CD recurrence remains uncertain.

METHODS

A total of 155 CD patients from 2 referral centres, who were undergoing intestinal resection with ileo-colonic anastomosis (January 2004-January 2015), were included. All subjects received preventive therapy with tumour necrosis factor antagonists (anti-TNFs), thiopurinesor mesalazine. The primary outcome was the rate of endoscopic recurrence (Rutgeerts score ≥i2) in the 3 treatment groups.

RESULTS

Patients treated with anti-TNFs were at significantly lower risk of endoscopic recurrence during the follow-up than those receiving thiopurines or mesalazine (incidence rates of 2.2, 3.0 and 4.8 per 100 person-months, respectively, log-rank, p = 0.011). The median time to recurrence was significantly longer in patients treated with anti-TNFs than in those who received thiopurines or mesalazine (37.0, 13.7, and 16.8 months, respectively, log-rank, p = 0.011). Anti-TNFs were more effective than mesalazine (univariable analysis, hazard ratio [HR] 0.45, 95% CI 0.26-0.77, p = 0.004; multivariable analysis, HR 0.45, 95% CI 0.26-0.77, p = 0.004), and non-significantly superior over thiopurines.

CONCLUSION

Anti-TNF therapy was the most effective strategy for the prevention of endoscopic CD recurrence.

Risk factors for recurrence of Crohn's disease requiring surgery in patients receiving post-operative anti-tumor necrosis factor maintenance therapy

OBJECTIVES

Anti-tumor necrosis factor (TNF) antibodies have shown efficacy in the prevention of recurrence of Crohn's disease after intestinal resection. However, some patients develop surgical recurrence despite this therapy. We aimed to evaluate the risk factors for recurrence of Crohn's disease requiring surgery while receiving post-operative anti-TNF therapy.

METHODS

We performed a retrospective evaluation of 164 patients who had received post-operative anti-TNF maintenance therapy between 2002 and 2016. We classified Crohn's disease-related re-operation as surgical recurrence and analyzed its risk factors using the Cox proportional hazard model.

RESULTS

Of the 164 participants, 128 had received infliximab and 36 had received adalimumab maintenance therapy. We obtained follow-up data over a mean of 60.2 months. The proportion of patients with surgical recurrence at 5 years was 14.9%. The only independent risk factor for surgical recurrence, which we identified was post-operative smoking habit (odds ratio, 5.03; 95% CI, 1.14-12.8; P=0.033).

CONCLUSIONS

Post-operative smoking may be a significant risk factor for post-operative surgical recurrence of Crohn's disease while receiving anti-TNF maintenance therapy.

The Presence of Postoperative Infectious Complications is Associated with the Risk of Early Postoperative Clinical Recurrence of Crohn's Disease

BACKGROUND

The purpose of the study was to identify risk factors for early clinical and surgical recurrence in Crohn's disease (CD) patients who underwent intestinal resection.

METHOD

This was a retrospective study. Consecutive patients who underwent intestinal resection with a primary anastomosis from January 2011-December 2014 were enrolled. Gender, age at surgery, clinical phenotypes of CD, serum albumin and C-reactive protein level the day before surgery, smoking status at surgery, anastomosis technique, number of anastomoses, details of postoperative complications, the postoperative prophylactic treatment were assessed to figure out risk factors for postoperative clinical and surgical recurrence within 1 year after the initial resection by univariate and then multivariate analysis.

RESULTS

Two hundred and thirty-seven patients were analyzed. The risk of early postoperative clinical recurrence was 2.99 times higher in patients suffered postoperative infectious complications [odds ratio (OR) 2.99; 95% CIs, 1.42-6.32; p = 0.004], while never-smoking was found to be a protective factor for early clinical recurrence (OR 0.326; 95% CIs, 0.18-0.59; p < 0.0001). For surgical recurrence within 1 year after resection, the presence of postoperative intra-abdominal septic complications might be a risk factor (OR 6.77; 95% CIs, 1.61-28.5; p = 0.009). Smoker at surgery was also a risk factor for early surgical recurrence (OR 5.41; 95% CIs, 1.36-21.5; p = 0.017).

CONCLUSION

The presence of postoperative infectious complications was identified as a possible risk factor for early postoperative clinical recurrence after resection in CD patients.

European Crohn's and Colitis Organisation Topical Review on Treatment Withdrawal ['Exit Strategies'] in Inflammatory Bowel Disease

Clinically effective therapies now exist for remission maintenance in both ulcerative colitis [UC] and Crohn's Disease [CD]. For each major class of IBD medications [5-aminosalicyclates, immunomodulators, and biologic agents], used alone or in combination, there is a risk of relapse following reduction or cessation of treatment. A consensus expert panel convened by the European Crohn's and Colitis Organisation [ECCO] reviewed the published literature and agreed a series of consensus practice points. The objective of the expert consensus is to provide evidence-based guidance for clinical practice so that physicians can make informed decisions in partnership with their patients. The likelihood of relapse with stopping each class of IBD medication is reviewed. Factors associated with an altered risk of relapse with withdrawal are evaluated, and strategies to monitor and allow early identification of relapse are considered. In general, patients in clinical, biochemical, and endoscopic remission are more likely to remain well when treatments are stopped. Reintroduction of the same treatment is usually, but not always, successful. The decision to stop a treatment needs to be individualized, and shared decision making with the patient should take place.

Treatment With Biologic Agents Has Not Reduced Surgeries Among Patients With Crohn's Disease With Short Bowel Syndrome

BACKGROUND & AIMS

Little is known about the effects of biologic agents used to treat Crohn's disease (CD) on its long-term complications, such as short bowel syndrome and intestinal failure (SBS-IF). We evaluated trends in small bowel resections and health care utilization among patients with CD with and without SBS-IF.

METHODS

We collected data on the National Inpatient Sample on 2,989,185 patients hospitalized with CD in the United States before the time period in which CD was treated with biologic agents (1993-1997) and after biologic therapy became widespread (1998-2014). We used Poisson and linear regression analyses to evaluate trends for small bowel resections and health care utilization among patients with CD with and without SBS-IF. Multivariable models were adjusted for age, sex, Charlson-Deyo comorbidity index, payer source, hospital size, region, and teaching status.

RESULTS

The proportions of patients who underwent resection did not significantly change during the period before biologic therapy (121.8 per 1000 hospitalizations in 1993 to 110.1 per 1000 hospitalizations in 1997; P trend =.14) but decreased significantly during the period after biologic therapy began (99.0 per 1000 hospitalizations in 1998 to 64.6 per 1000 hospitalizations in 2014; P trend < .01). However, among patients with SBS-IF, similar proportions of patients underwent resection during the period before biologic therapy (0.7 per 1000 hospitalizations in 1993 to 0.7 per 1000 hospitalizations in 1997; P trend = .92) and during the period after biologic therapy (0.6 per 1000 hospitalizations in 1998 to 0.7 per 1000 hospitalizations in 2014; P trend = .06). Rates of hospitalization for patients with SBS-IF increased from 16.5 per 1000 hospitalizations in 1998 to 19.5 per 1000 hospitalizations in 2014 (P trend < .01). SBS-IF hospitalizations were associated with longer lengths of stay (P < .01) and greater total charges (P < .01).

CONCLUSIONS

In a study of the United States population, we found that the use of biologic agents to treat CD reduced the proportion of patients undergoing resection, but not among patients with SBS-IF. These findings indicate that biologic agents reduce some but not all features of CD. Studies are needed to identify patients at risk for SBS-IF, prevent and treat this complication, and identify new treatments.

Long-term outcomes of pediatric inflammatory bowel disease

The incidence and prevalence of childhood-onset inflammatory bowel diseases (IBD), including subtypes Crohn's disease and ulcerative colitis, have risen dramatically in recent years, and have emerged globally as important pediatric chronic diseases. Therefore, health care providers are more frequently encountering very young children with IBD, a chronic and incurable condition requiring life-long therapy. These children are living long lives with IBD and therefore knowledge of long-term outcomes is increasingly important to better counsel families and determine the best course of treatment. This review summarizes the current knowledge and literature surrounding long-term outcomes of pediatric IBD, with emphasis on the following areas: need for surgery due to complicated disease behavior, risk of disease remission and recurrence, mental health and psychosocial well-being, educational outcomes, linear growth impairment, cancer risk, and mortality. In addition, we review recent research about predicting negative long-term outcomes in children with IBD.

NASPGHAN Clinical Report on Postoperative Recurrence in Pediatric Crohn Disease

Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.

Management of Crohn's Disease After Surgical Resection

Approximately 25% to 35% of patients with Crohn's disease (CD) who undergo surgery require repeat surgery. Active smoking, multiple prior surgeries, and penetrating or perianal disease are risk factors for recurrence of CD after surgical resection. Early initiation of prophylactic therapy is effective in decreasing the risk of recurrence. Active colonoscopic surveillance for the early detection of endoscopic recurrence within 6 to 12 months of surgery is recommended. In symptomatic patients without evidence of endoscopic recurrence, noninflammatory causes should be sought.

Endoscopic Recurrence 6 Months After Ileocecal Resection in Children With Crohn Disease Treated With Azathioprine

OBJECTIVES

Intestinal surgery is an important part of Crohn disease (CD) treatment in children. The aim of the present study was to compare the rate of endoscopic recurrence at the sixth month after ileocecal resection (ICR) in children with CD treated with azathioprine between patients who received prior antitumor necrosis factor alpha (anti-TNF-α) therapy and those who were not administered this therapy. Moreover, we tried to identify the potential risk factors for disease recurrence and describe the schedule of long-term follow-up after surgery.

METHODS

We prospectively collected data from pediatric patients with CD, who underwent ICR between October 2011 and June 2015 at our hospital and were treated with azathioprine monotherapy after ICR. We evaluated the endoscopic recurrence (Rutgeerts score) at the sixth month after ICR in all included patients.

RESULTS

Among 21 included patients, 13 achieved endoscopic remission (Rutgeerts score < i2) at the sixth month after ICR. No difference was found between patients who received prior anti-TNF-α therapy and those who did not. We did not find any clinically relevant factors associated with endoscopic recurrence rate at the sixth month.

CONCLUSIONS

Prior anti-TNF-α therapy does not seem to be a strong risk factor for endoscopic recurrence within 6 months after ICR. Further studies on large sample of patients are needed to identify potential predictors of disease recurrence.

Postoperative prophylaxis in Crohn's disease after intestinal resection: a retrospective analysis

INTRODUCTION

Up to 80% of patients with Crohn's disease (CD) may require surgery at some point in their lives, and it is estimated that as many as 40% may require several surgeries. It has been suggested that prophylactic medication decreases the rate of clinical and endoscopic recurrence following intestinal resection. This study aims to describe real-world clinical outcomes observed from a pragmatic, individualised strategy in postoperative CD.

METHODS

All patients undergoing intestinal resection for CD between 2009 and 2013 were identified. The endpoint of the study, treatment success, was defined as glucocorticosteroid-free, resection-free survival, at the last point of follow-up, without requiring an escalation or change of therapy during this time. Clinical information was extracted from chart reviews, endoscopy and radiology reports, and from prescribing databases. Patients were followed from the date of surgery, and the last point of follow-up was 31 January 2015.

RESULTS

149 patients were analysed. Median duration of follow-up was 32 months (range 1-69 months). 101 patients received postoperative prophylactic therapy, and 48 did not. In 77 (51.7%) patients, thiopurines were used as first-line therapy, with treatment success occurring in 32 (41.6%) with a median follow-up of 25 months. 11 patients (7.4%) received anti-tumour necrosis factor (TNF)-α monotherapy, with treatment success occurring in 5 patients (45.5%) with a median follow-up of 35 months. 13 (8.7%) patients received first-line combination therapy, with 11 (84.6%) patients achieving treatment success with a median follow-up of 21 months.

CONCLUSIONS

In our study, combination therapy with anti-TNF-α and immunomodulator therapy was well tolerated, efficacious (efficacy appeared durable for patients with postoperative CD) and superior to monotherapy with either thiopurines or anti-TNF-α drugs. Several limitations notwithstanding, our data suggest that there may be merit in the use of combination therapy in carefully selected postoperative patients whose care has been individualised via a multidisciplinary team meeting format. Prospective, controlled studies are therefore required to further assess the efficacy and safety of combination therapy for postoperative prophylaxis in CD.

Previous Exposure to Multiple Anti-TNF Is Associated with Decreased Efficiency in Preventing Postoperative Crohn's Disease Recurrence

BACKGROUND AND AIMS

Infliximab and adalimumab are increasingly used to prevent postoperative recurrence in Crohn's disease patients. The impact of previous exposure to one or more anti-tumour necrosis factor [TNF] agents before surgery on the efficacy of anti-TNF therapy on postoperative recurrence is unknown.

METHODS

We performed a retrospective analysis of Crohn's disease patients who underwent surgical bowel resection with anastomosis and prophylactic treatment with anti-TNF therapy between January 2005 and June 2013.

RESULTS

A total of 57 consecutive Crohn's disease patients with bowel resection and anastomosis followed by prophylactic treatment with anti-TNF were included; 21 [37%] and 24 [42%] patients had a previous exposure to one and more than one anti-TNF agents, respectively; 39 patients [68%] had a surveillance colonoscopy. Cumulative rates of postoperative endoscopic recurrence at 2 years were 45.5% [26.6-69.6%] in patients exposed to two or more anti-TNFα as compared with 29.1% [11.5-48.1%] in patients exposed to one or to zero anti-TNFα before surgery [p = 0.07]. Cumulative rates of clinical recurrence at 1 year were 21.6% [9.6-44.4%] in patients exposed to two or more anti-TNFα as compared with 6.9% [1.8-25.1%] in patients exposed to zero or one anti-TNFα before surgery [p = 0.02]. Multivariable analysis identified smoking and previous exposure to two or more anti-TNFα as risk factors for Crohn's disease clinical or endoscopic postoperative recurrence (hazard ratio [HR] = 3.17; 95% confidence interval [CI]: 1.3-7.8, p = 0.01 and HR = 4.2; 95% CI: 1.8-10.2, p = 0.001, respectively).

CONCLUSIONS

Previous exposure to two or more anti-TNF agents was associated with a higher risk of postoperative recurrence in Crohn's disease patients.

Top-down approach to biological therapy of Crohn's disease

INTRODUCTION

Crohn's disease (CD) is a chronic, immune-mediated condition with a potentially disabling and destructive course. Despite growing data on when to use a therapeutic 'top-down' strategy, clinical management of this complex disorder is still challenging. Currently, the discussion of 'top-down' strategy in CD mostly includes biological therapy alone or in combination. Areas covered: This article is based on a review of existing literature regarding the use of biological therapy in a 'top-down' approach for the treatment of Crohn's disease. The authors reviewed all the major databases including MEDLINE as well as DDW and ECCO abstracts, respectively. Expert opinion: A 'top-down' therapeutic approach in Crohn's disease is strongly supported by existing data in patients with several risk factors for a severe course of disease. Moreover, there is an increasing amount of published data recommending a more individualised therapeutic strategy to identify candidates for 'top-down' treatment, based on enhanced diagnostics using biomarkers. Emerging therapeutic approaches besides existing therapy concepts using biologicals may possibly redefine the 'top-down' therapeutic strategy for Crohn's disease in the future.

Surgical Considerations in the Treatment of Small Bowel Crohn's Disease

Surgery remains a cornerstone of the management of Crohn's disease (CD). Despite the rise of biologic therapy, most CD patients require surgery for penetrating, obstructing, or malignant complications. Optimal surgical therapy requires sophisticated operative judgment and medical optimization. Intraoperatively, surgeons must balance treatment of CD complications against bowel preservation and functional outcome. This demands mastery of multiple techniques for anastomosis and strictureplasty, accurate assessment of bowel integrity for margin minimization, and a comprehensive skillset for navigating adhesions and altered anatomy, controlling thickened mesentery, and safely managing the hostile abdomen. Outside of the operating room, a multi-disciplinary team is critical for pre-operative optimization, patient support, and medical management. Postoperatively, prevention and surveillance of recurrence remain a matter of research and debate, and medical options include older drugs with limited efficacy and tolerability versus biologic agents with greater effect sizes and shorter track records. The evidence base for current management is limited by the inherent challenges of studying a chronic disease marked by heterogeneity and recurrence, but also by a lack of prospective trials incorporating both medical and surgical therapies.

Anti-TNF therapy is able to stabilize bowel damage progression in patients with Crohn's disease. A study performed using the Lémann Index

AIMS

The Lémann Index (LI) was developed to assess the cumulative structural damage of the intestinal tract in patients with Crohn's Disease (CD) independently of clinical and biochemical activity. Recently, the goal of CD focused on obtaining mucosal healing and deep remission rather than simple symptom control. These new therapeutic aims emphasize the need to prevent progression of bowel damage. In this study we aimed to evaluate the influence of different treatments on structural damage progression, assessed by means of LI in a series of CD patients consistently treated with various drugs.

METHODS

The LI was calculated at inclusion and at the end of follow-up in 104 CD patients subdivided according to treatments received: biological drugs (n=40, 38.4%), azathioprine (n=19, 18.3%), and mesalazine (n=45, 43.3%).

RESULTS

The median follow-up was 29 months, with no difference among groups. During follow-up, the median LI was stable in the biological group [from 6.3 (range, 0.6-37.3) to 6.4 (range, 0.6-37.6), P=0.543], whereas it significantly increased from 4.1 (range, 0.6-30) to 8.3 (range, 0.6-31.8) in the azathioprine group (P=0.0006), and from 2.4 (range, 0.6-25.8) to 4.1 (range, 0.6-28.8) in the mesalazine group (P<0.0001). Also during follow-up the LI increased significantly (P=0.004) in the azathioprine (68.4%) and mesalazine (60.0%) groups as compared with the biological therapy group (30.0%).

CONCLUSIONS

In CD patients the LI tends to increase over time, although the use of biological drugs rather than azathioprine or mesalazine seems to be able to reduce the progressive bowel damage.