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Valvano M, Vinci A, Cesaro N, Frassino S, Ingravalle F, Ameli M, Viscido A, Necozione S, Latella G. The long-term effect on surgery-free survival of biological compared to conventional therapy in Crohn's disease in real world-data: a retrospective study. BMC Gastroenterol 2023; 23:438. [PMID: 38097975 PMCID: PMC10720171 DOI: 10.1186/s12876-023-03074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and, in particular, that it could lead to a significant reduction in surgery in the short and long term. This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn's disease (CD) who were never with the surgical option. METHODS This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L'Aquila. Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group. Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population. RESULTS Two hundred three CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Meier survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p = 0.03). However, after propensity matching analysis, conducted on 143 patients, no significant difference was found in surgery-free survival (p = 0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p = 0.02; Hazard Ratio 2.9; CI 1.01-8.54) while no significant difference was found between the biologic and conventional post-biologic groups (p = 0.15; Hazard Ratio 2.1; CI 0.69-6.44). CONCLUSION This study shows that the introduction of biological therapy has only a slight impact on the eventual occurrence of surgery in CD patients over a long observation period. Nevertheless, biological therapy appears to delay the first intestinal resection.
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Affiliation(s)
- M Valvano
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy.
| | - A Vinci
- Hospital Health Management Area, Local Health Authority "Roma 1", 00193, Rome, Italy
- University of Rome "Tor Vergata", 00133, Rome, Italy
| | - N Cesaro
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - S Frassino
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - F Ingravalle
- Hospital Health Management Area, Local Health Authority "Roma 6", 00041, Albano Laziale, Italy
| | - M Ameli
- Area Vasta (ASUR) 5; Ascoli Piceno - San Benedetto del Tronto, San Benedetto del Tronto, Italy
| | - A Viscido
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - S Necozione
- Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - G Latella
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
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2
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Frieri G, Valvano M, Frassino S, Faenza S, Cesaro N, Amicucci G, Manetta R, Viscido A, Latella G. Prophylactic Treatment with Vedolizumab in the Prevention of Postoperative Recurrence (POR) in High-Risk Crohn's Patients. J Clin Med 2023; 12:jcm12093130. [PMID: 37176570 PMCID: PMC10179568 DOI: 10.3390/jcm12093130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
About 50% of Crohn's Disease (CD) patients undergo an intestinal resection during their lifetime. Although the patients experience a fairly long period of well-being after the intestinal resection, they presented a postoperative recurrence (POR) in 40% of cases within 5 years. In this case series, we aimed to evaluate the incidence of POR in CD patients with high risk for early POR, prophylactically treated with Vedolizumab. All consecutive CD patients (followed from 2017 to 2020) who underwent ileocolonic resection after the loss of response at anti-Tumor Necrosis Factor α (anti-TNFα) and with one or more risk factors for early POR were included. POR was defined as a Rutgeerts score (Ri) > 1 at the colonoscopic evaluation. All the included patients underwent a Magnetic resonance enterography (MRE) at least one year after the surgical resection. Six patients (4 Female; 2 Males) were included. At the first endoscopic evaluation, all patients were in endoscopic remission (5 patients Ri 0; 1 patient Ri 1). No stenosis nor other intestinal wall changes or complications were observed at MRE. Five patients underwent colonoscopy over two years of follow-up (median: 32 months; range 25-33). The Ri score was 0 in four patients, while the fifth patient showed severe endoscopic relapse. The same patient presented a clinical relapse (Harvey-Bradshaw index = 10) with a flare of disease in the colonic mucosa. These data suggest that early post-operative treatment with Vedolizumab could be a valuable strategy to be submitted to a prospective controlled trial for preventing POR.
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Affiliation(s)
- Giuseppe Frieri
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
| | - Marco Valvano
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
| | - Sara Frassino
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
| | - Susanna Faenza
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
| | - Nicola Cesaro
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
| | | | - Rosa Manetta
- Division of Radiology, S. Salvatore Hospital, 67100 L'Aquila, Italy
| | - Angelo Viscido
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology Unit, Division of Gastroenterology, Hepatology and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100 L'Aquila, Italy
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3
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Pellino G, Sampietro GM. Defining the role of abdominal surgery and its impact on the disease course in patients with Crohn's disease: Unsolved issues and novel insights. Dig Liver Dis 2023; 55:587-588. [PMID: 36774220 DOI: 10.1016/j.dld.2023.01.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/13/2023]
Affiliation(s)
- Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Gianluca M Sampietro
- Division of General and HPB Surgery, ASST Rhodense, Rho Memorial Hospital, Milano, Italy.
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4
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D'Alessio S, Ungaro F, Noviello D, Lovisa S, Peyrin-Biroulet L, Danese S. Revisiting fibrosis in inflammatory bowel disease: the gut thickens. Nat Rev Gastroenterol Hepatol 2022; 19:169-184. [PMID: 34876680 DOI: 10.1038/s41575-021-00543-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
Intestinal fibrosis, which is usually the consequence of chronic inflammation, is a common complication of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. In the past few years, substantial advances have been made in the areas of pathogenesis, diagnosis and management of intestinal fibrosis. Of particular interest have been inflammation-independent mechanisms behind the gut fibrotic process, genetic and environmental risk factors (such as the role of the microbiota), and the generation of new in vitro and in vivo systems to study fibrogenesis in the gut. A huge amount of work has also been done in the area of biomarkers to predict or detect intestinal fibrosis, including novel cross-sectional imaging techniques. In parallel, researchers are embarking on developing and validating clinical trial end points and protocols to test novel antifibrotic agents, although no antifibrotic therapies are currently available. This Review presents the state of the art on the most recently identified pathogenic mechanisms of this serious IBD-related complication, focusing on possible targets of antifibrotic therapies, management strategies, and factors that might predict fibrosis progression or response to treatment.
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Affiliation(s)
| | - Federica Ungaro
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Noviello
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sara Lovisa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Centre, Laboratory of Gastrointestinal Immunopathology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- INSERM NGERE, University of Lorraine, Vandoeuvre-les-Nancy, Nancy, France.,Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, France
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy. .,University Vita-Salute San Raffaele, Milan, Italy.
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5
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Carvello M, Danese S, Spinelli A. Surgery versus Medical Therapy in Luminal Ileocecal Crohn's Disease. Clin Colon Rectal Surg 2022; 35:72-77. [PMID: 35069033 PMCID: PMC8763452 DOI: 10.1055/s-0041-1740031] [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: 01/19/2023]
Abstract
The deeper understanding of the inflammatory process which gradually evolves into irreversible fibrosis and tissue damage has provided a precise picture of the disease course of luminal ileocecal Crohn's disease. According to the model of progressive structural damage, ideal time windows for medical and surgical treatment have been identified. While complicated disease clearly profits from surgical treatment, uncomplicated disease has become, in the last years, the most debatable setting in terms of different approaches including early surgery. On one hand, the rationale of traditional escalating medical therapy (step-up approach) has been undermined by the top-down medical approach. Indeed, the step-up approach has the possible drawback of delaying, up to a later disease stage, the use of more effective agents such as anti-tumor necrosis factors. Conversely, the top-down approach might expose patients to an overtreatment along with side effects including hypersensitivity to biologic agents. More recently, it has been shown how early surgery could be a valid option in this subset of patients being more cost-effective than medical therapy. Involving the surgeon at an early stage is considered now a good clinical practice and, in this scenario full of possibilities, the surgeon should be included into the decision-making process from the very beginning of patient management.
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Affiliation(s)
- Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy,Department of Gastroenterology, IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy,Address for correspondence Antonino Spinelli, MD, PhD Via Alessandro Manzoni, 56, Rozzano, 20089, MilanItaly
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6
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Broide E, Eindor-Abarbanel A, Naftali T, Shirin H, Shalem T, Richter V, Matalon S, Leshno M. Early Surgery Versus Biologic Therapy in Limited Nonstricturing Ileocecal Crohn's Disease-A Decision-making Analysis. Inflamm Bowel Dis 2020; 26:1648-1657. [PMID: 31909420 DOI: 10.1093/ibd/izz282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Surgery is the preferred option for patients with symptomatic localized fibrostenotic ileocecal Crohn's disease (CD) but not for those with predominantly active inflammation without obstruction. The benefit of early surgery in patients with a limited nonstricturing ileocecal CD over biologic treatment is still a debate. OBJECTIVE Our objective is to formulate a decision analysis model based on recently published data to explore whether early surgery in patients with limited nonstricturing CD is preferred over biologic treatment. METHODS We constructed a Markov model comparing 2 strategies of treatment: (1) early surgery vs (2) biologic treatment. To estimate the quality-adjusted life years (QALYs) and the costs in each strategy, we simulated 10,000 virtual patients with the Markov model using a Monte Carlo simulation 100 times. Sensitivity analyses were performed to evaluate the robustness of the model and address uncertainties in the estimation of model parameters. RESULTS The costs were $29,457 ± $407 and $50,382 ± $525 (mean ± SD) for early surgery strategy and biologic treatment strategy, respectively. The QALY was 6.24 ± 0.01 and 5.81 ± 0.01 for early surgery strategy and biologic treatment strategy, respectively. CONCLUSION The strategy of early surgery dominates (higher QALY value [efficacy] and less cost) compared with the strategy of biologic treatment in patients with limited ileocecal CD.
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Affiliation(s)
- Efrat Broide
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Eindor-Abarbanel
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Timna Naftali
- Department of Gastroenterology and Hepatology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Shirin
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tzippora Shalem
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Richter
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Matalon
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Faculty of Management, Tel Aviv University, Tel Aviv, Israel
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7
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Dotimas J, Das M, Martin D. Cutaneous T-cell lymphoma in the setting of anti-tumor necrosis factor and immunomodulator therapy: A case report and literature review. SAGE Open Med Case Rep 2020; 8:2050313X20937223. [PMID: 32655868 PMCID: PMC7328350 DOI: 10.1177/2050313x20937223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/31/2020] [Indexed: 01/23/2023] Open
Abstract
Immunosuppressive therapy is well recognized as increasing the risk of lymphoma. Mycosis fungoides is a rare cutaneous form of T-cell lymphoma with a largely unknown etiology and not typically associated with immunosuppression. In this article, we describe our encounter with a 24-year-old male with Crohn’s disease in remission on immunotherapy, specifically dual therapy with azathioprine and infliximab, presenting with a facial rash found to be consistent with mycosis fungoides on biopsy. The patient’s rash resolved with treatment of topical steroids. In addition, the decision was made to discontinue his azathioprine to minimize his risks of developing future malignancies.
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Affiliation(s)
- James Dotimas
- The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Manjusha Das
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Daniel Martin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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8
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Butt WT, Ryan ÉJ, Boland MR, McCarthy EM, Omorogbe J, Hazel K, Bass GA, Neary PC, Kavanagh DO, McNamara D, O'Riordan JM. Strictureplasty versus bowel resection for the surgical management of fibrostenotic Crohn's disease: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:705-717. [PMID: 32048011 DOI: 10.1007/s00384-020-03507-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Strictureplasty (SPX) conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease (CD). However, SPX may be associated with a higher risk of recurrence compared with bowel resection (BR). AIM We sought to compare morbidity and recurrence following SPX and BR in patients with fibrostenotic CD. METHODS A systematic review was performed according to PRISMA and MOOSE guidelines. Observational studies that compared outcomes of CD patients undergoing either SPX or BR were identified. Log hazard ratios (InHR) for recurrence-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots or Cox regression models and pooled using the inverse variance method. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Continuous variables were pooled as weighted mean differences. RESULTS Twelve studies of 1026 CD patients (SPX n = 444, 43.27%; BR with or without SPX n = 582, 56.72%) were eligible for inclusion. There was an increased likelihood of disease recurrence with SPX than with BR (OR 1.61; 95% CI, 1.03, 2.52; p = 0.04; I2 = 0%). Patients who had a SPX alone had a significantly reduced RFS than those who underwent BR (HR 1.47; 95% CI, 1.08, 2.01; p = 0.02; I2 = 0%). There was no difference in morbidity between the groups (OR 0.58; 95% CI, 0.26, 1.28; p = 0.18; I2 = 0%). CONCLUSION SPX should only be performed in those patients with Crohn's strictures that are at high risk for short bowel syndrome and intestinal failure; otherwise, BR is the favored surgical technique for the management of fibrostenotic CD.
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Affiliation(s)
- Waqas T Butt
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
| | - Eilis M McCarthy
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Joseph Omorogbe
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Karl Hazel
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Gary A Bass
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - James M O'Riordan
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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9
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Sarker SK. Legal & ethical dilemmas in incidental findings during surgery: Review article. Int J Surg 2020; 75:107-113. [DOI: 10.1016/j.ijsu.2020.01.141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/21/2020] [Accepted: 01/26/2020] [Indexed: 12/25/2022]
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10
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Ryan ÉJ, Orsi G, Boland MR, Syed AZ, Creavin B, Kelly ME, Sheahan K, Neary PC, Kavanagh DO, McNamara D, Winter DC, O'Riordan JM. Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease. Int J Colorectal Dis 2020; 35:501-512. [PMID: 31915984 DOI: 10.1007/s00384-019-03479-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early bowel resection (EBR) in ileocolonic Crohn's disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included. AIM To compare the efficacy of EBR versus IMT for ileocolonic CD METHODS: A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales. RESULTS A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7-9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups. CONCLUSION EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. 'Upfront' or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.
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Affiliation(s)
- Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland. .,School of Medicine, University College Dublin, Dublin, Ireland.
| | - Gabriel Orsi
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Adeel Zafar Syed
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Ben Creavin
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Michael E Kelly
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Kieran Sheahan
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Histopathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - James M O'Riordan
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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11
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Yun SM, Kim SH, Kim EH. The Molecular Mechanism of Transforming Growth Factor-β Signaling for Intestinal Fibrosis: A Mini-Review. Front Pharmacol 2019; 10:162. [PMID: 30873033 PMCID: PMC6400889 DOI: 10.3389/fphar.2019.00162] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/11/2019] [Indexed: 01/01/2023] Open
Abstract
Inflammatory bowel disease is known as the most chronic inflammatory disorder in colon, which subsequently progresses to intestinal obstruction and fistula formation. Many studies to date for the treatment of IBD have been focused on inflammation. However, most of the anti-inflammatory agents do not have anti-fibrotic effects and could not relieve intestinal stricture in IBD patients. Because preventing or reversing intestinal fibrosis in IBD is a major therapeutic target, we analyzed the papers focusing on TGF-β signaling in intestinal fibrosis. TGF-β is a good candidate to treat the intestinal fibrosis in IBD which involves TGF-β signaling pathway, EMT, EndMT, ECM, and other regulators. Understanding the mechanism involved in TGF-β signaling will contribute to the treatment and diagnosis of intestinal fibrosis occurring in IBD as well as the understanding of the molecular mechanisms underlying the pathogenesis.
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Affiliation(s)
- Sun-Mi Yun
- College of Pharmacy and Institute of Pharmaceutical Sciences, CHA University, Seongnam, South Korea
| | - Seok-Ho Kim
- College of Pharmacy and Institute of Pharmaceutical Sciences, CHA University, Seongnam, South Korea
| | - Eun-Hee Kim
- College of Pharmacy and Institute of Pharmaceutical Sciences, CHA University, Seongnam, South Korea
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Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease. Gastroenterol Res Pract 2018; 2018:3159543. [PMID: 30584421 PMCID: PMC6280273 DOI: 10.1155/2018/3159543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/17/2018] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.
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Zhang HJ, Zhang YN, Zhou H, Guan L, Li Y, Sun MJ. IL-17A Promotes Initiation and Development of Intestinal Fibrosis Through EMT. Dig Dis Sci 2018; 63:2898-2909. [PMID: 30097894 DOI: 10.1007/s10620-018-5234-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 07/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intestinal fibrosis is a common complication of Crohn's disease (CD). Its exact mechanism is still unclear, and effective treatments to control or reverse the fibrosis process are unavailable. Epithelial-mesenchymal transition (EMT) may promote intestinal fibrosis by increasing deposition of extracellular matrix protein. IL-17A is a pro-inflammatory cytokine, and it has been shown as a profibrotic factor as its association with fibrosis of multiple organs was reported. AIMS To assess the roles of IL-17A and EMT in the initiation and development of intestinal fibrosis and to verify the potential inductive effect of IL-17A on EMT. METHODS In this study, we evaluated the expression of IL-17A and EMT-related genes in colonic mucosal biopsy tissues of CD patients and control individuals. Then, we examined the changes of EMT-related genes and fibrosis-related genes of IEC-6 cells which cultured for 72 h under increasing concentrations of IL-17A or with TGF-β1, to verify the potential inductive effect of IL-17A on EMT in vitro. We blocked the IL-17A of the mouse model of TNBS-induced experimental intestinal colitis and fibrosis to further verify the potential inductive effect of IL-17A on EMT in vivo. RESULTS We found the occurrence of EMT and high-level expression of IL-17A in intestinal mucosa of CD patients. Using IEC-6 cells, we showed that IL-17A may induce EMT in intestinal epithelial cells that come with reduced E-cadherin expression and increased expression of vimentin, snail, and α-SMA. We further found that anti-IL-17A treatment alleviated intestinal fibrosis through reducing EMT in mouse intestine. CONCLUSIONS Our study confirmed the involvement of IL-17A in the development of intestinal fibrosis through inducing EMT.
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Affiliation(s)
- Hui-Jing Zhang
- Department of Endoscopy, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yi-Ning Zhang
- Department of Endoscopy, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Huan Zhou
- Department of Endoscopy, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Lin Guan
- Department of Endoscopy, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yue Li
- Department of Endoscopy, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ming-Jun Sun
- Department of Endoscopy, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
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Improved Biochemical Parameters in Patients Who Undergo Early Resection in Isolated Ileocaecal Crohn's Disease. Surg Res Pract 2017; 2017:4396573. [PMID: 28776001 PMCID: PMC5523538 DOI: 10.1155/2017/4396573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/11/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of this study is to evaluate the outcome of introduction of early surgery in the course of isolated ileocecal Crohn's disease, where there is no absolute indication of surgery. METHODS Observational study involving patients with isolated ileocecal Crohn's disease who underwent early surgical resection (within one year of the presentation of the hospital). A complete blood count, ESR, and CRP were done and compared between the preoperative value, 1st postoperative visit (3-4 weeks), and last follow-up visit. Statistical analysis was done using Analysis of Variance (ANOVA) to compare the different figures. RESULTS There was a statistically significant increase in the hemoglobin levels between preoperative, postoperative, and long-term follow-up and a significant decrease in leukocyte count between the pre- and postoperative values (F = 19.8, p < 0.001 and F = 8.9, p = 0.002, resp.). Similarly, the ESR and CRP values were decreased significantly at long-term follow-up (F = 8.5, p = 0.019 and F = 8.3, p = 0.013, resp.). CONCLUSION Early surgical resection in isolated ileocaecal Crohn's disease achieved significant biochemical improvements. These successful results in this small number of patients indicate that early surgical intervention may provide better outcomes. These initial results encourage larger and comparative studies of long-term results versus long-term use of biological agents.
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Latella G, Di Gregorio J, Flati V, Rieder F, Lawrance IC. Mechanisms of initiation and progression of intestinal fibrosis in IBD. Scand J Gastroenterol 2015; 50:53-65. [PMID: 25523556 DOI: 10.3109/00365521.2014.968863] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal fibrosis is a common complication of the inflammatory bowel diseases (IBDs). It becomes clinically apparent in >30% of patients with Crohn's disease (CD) and in about 5% with ulcerative colitis (UC). Fibrosis is a consequence of local chronic inflammation and is characterized by excessive extracellular matrix (ECM) protein deposition. ECM is produced by activated myofibroblasts, which are modulated by both, profibrotic and antifibrotic factors. Fibrosis depends on the balance between the production and degradation of ECM proteins. This equilibrium can be impacted by a complex and dynamic interaction between profibrotic and antifibrotic mediators. Despite the major therapeutic advances in the treatment of active inflammation in IBD over the past two decades, the incidence of intestinal strictures in CD has not significantly changed as the current anti-inflammatory therapies neither prevent nor reverse the established fibrosis and strictures. This implies that control of intestinal inflammation does not necessarily affect the associated fibrotic process. The conventional view that intestinal fibrosis is an inevitable and irreversible process in patients with IBD is also gradually changing in light of an improved understanding of the cellular and molecular mechanisms that underline the pathogenesis of fibrosis. Comprehension of the mechanisms of intestinal fibrosis is thus vital and may pave the way for the developments of antifibrotic agents and new therapeutic approaches in IBD.
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Affiliation(s)
- Giovanni Latella
- Department of Life, Health and Environmental Sciences, Gastroenterology Unit, University of L'Aquila , L'Aquila , Italy
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Botti F, Caprioli F, Pettinari D, Carrara A, Magarotto A, Contessini Avesani E. Surgery and diagnostic imaging in abdominal Crohn's disease. J Ultrasound 2013; 18:3-17. [PMID: 25767635 DOI: 10.1007/s40477-013-0037-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 08/26/2013] [Indexed: 02/06/2023] Open
Abstract
Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.
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Affiliation(s)
- Fiorenzo Botti
- Unità Operativa di Chirurgia Generale e d'Urgenza, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy ; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Flavio Caprioli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy ; Unità Operativa di Gastroenterologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Diego Pettinari
- Unità Operativa di Chirurgia Generale e d'Urgenza, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Alberto Carrara
- Unità Operativa di Chirurgia Generale e d'Urgenza, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy ; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Andrea Magarotto
- Scuola di Specializzazione in Gastroenterologia ed Endoscopia Digestiva, Università degli Studi di Milano, Milan, Italy
| | - Ettore Contessini Avesani
- Unità Operativa di Chirurgia Generale e d'Urgenza, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy ; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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Latella G, Papi C. Crucial steps in the natural history of inflammatory bowel disease. World J Gastroenterol 2012; 18:3790-9. [PMID: 22876029 PMCID: PMC3413049 DOI: 10.3748/wjg.v18.i29.3790] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/18/2012] [Accepted: 05/05/2012] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic, progressive and disabling disorders. Over the last few decades, new therapeutic approaches have been introduced which have led not only to a reduction in the mortality rate but also offered the possibility of a favorable modification in the natural history of IBD. The identification of clinical, genetic and serological prognostic factors has permitted a better stratification of the disease, thus allowing the opportunity to indicate the most appropriate therapy. Early treatment with immunosuppressive drugs and biologics has offered the opportunity to change, at least in the short term, the course of the disease by reducing, in a subset of patients with IBD, hospitalization and the need for surgery. In this review, the crucial steps in the natural history of both UC and CD will be discussed, as well as the factors that may change their clinical course. The methodological requirements for high quality studies on the course and prognosis of IBD, the true impact of environmental and dietary factors on the clinical course of IBD, the clinical, serological and genetic predictors of the IBD course (in particular, which of these are relevant and appropriate for use in clinical practice), the impact of the various forms of medical treatment on the IBD complication rate, the role of surgery for IBD in the biologic era, the true magnitude of risk of colorectal cancer associated with IBD, as well as the mortality rate related to IBD will be stressed; all topics that are extensively discussed in separate reviews included in this issue of World Journal of Gastroenterology.
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Caprilli R, Latella G, Frieri G. Treatment of inflammatory bowel diseases: to heal the wound or to heal the sick? J Crohns Colitis 2012; 6:621-5. [PMID: 22425510 DOI: 10.1016/j.crohns.2012.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 02/11/2012] [Indexed: 02/08/2023]
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