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Levin A, Risto A, Myrelid P. The changing landscape of surgery for Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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D'Ugo S, Romano F, Sibio S, Bagaglini G, Sensi B, Biancone L, Monteleone G, Sica GS. Impact of surgery on quality of life in Crohn's disease: short- and mid-term follow-up. Updates Surg 2020; 72:773-780. [PMID: 32185677 DOI: 10.1007/s13304-020-00738-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 03/04/2020] [Indexed: 02/06/2023]
Abstract
Active Crohn's disease has a substantial impact on Quality of Life (QoL). Medical management could be associated to side effects, hospitalization, long treatment period and requires patient's compliance, impacting QoL. Ileocecal resection (ICR) is often required, open or laparoscopic. Aim of the study was to assess Health-Related (HR) QoL changes following ICR, and to identify factors impacting on QoL in the short and mid-term. From a single institution, we created a prospective database of patients undergoing ICR from 01/2009 to 12/2015. HRQoL was analysed with Cleveland Global Quality of Life (CGQL) score, Overall Quality of Happiness (OQH), and asking patients if they would have surgery again. QoL scores were recorded at 30 days, 6, 12 and 36 months postoperatively and compared according to follow-up timing, technique, medical treatment and demographics. Statistical analysis included 187 patients. Mean follow-up was 3.8 ± 2.9 years. Both at 30 days and 6 months postoperatively, CGQL, its items and OQH increased significantly (p < 0.001). Increased values were also recorded at 1 and 3 years; 88% of patients would undergo surgery again. Laparoscopy was associated with improved CGQL scores, while preoperative steroids with worsen data. Young female patients, with penetrating pattern, experienced greater HRQoL improvements. Surgery is associated with improvements of HRQoL and patients' happiness in the short and mid-term. Laparoscopy, steroid-free and young patients showed the best results. ICR should be considered a reasonable alternative to non-operative strategies in selected cases.
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Affiliation(s)
- Stefano D'Ugo
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy.
- Department of Surgery, "Vito Fazzi" Hospital, Piazza F. Muratore, 73100, Lecce, Italy.
| | - Francesca Romano
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Simone Sibio
- Department of Surgery, La Sapienza University, P.le A. Moro, Rome, Italy
| | - Giulia Bagaglini
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Bruno Sensi
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Livia Biancone
- Gastroenterology Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Giovanni Monteleone
- Gastroenterology Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Giuseppe S Sica
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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Gerdin L, Eriksson AS, Olaison G, Sjödahl R, Ström M, Söderholm JD, Myrelid P. The Swedish Crohn Trial: A Prematurely Terminated Randomized Controlled Trial of Thiopurines or Open Surgery for Primary Treatment of Ileocaecal Crohn's Disease. J Crohns Colitis 2016; 10:50-4. [PMID: 26507858 DOI: 10.1093/ecco-jcc/jjv184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/02/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The importance of efficient and safe treatment of Crohn's disease is highlighted by its chronicity. Both medical and surgical treatments have shown good results in the symptomatic control of limited ileocaecal Crohn's disease. The aim of this study was to compare medical treatment with surgical treatment of ileocaecal Crohn's disease. METHODS Thirty-six patients from seven hospitals with primary ileocaecal Crohn's disease were randomized to either medical or surgical treatment. The medical treatment was induction of remission with budesonide and thereafter maintenance treatment with azathioprine. The surgical treatment was open ileocaecal resection. Crohn's disease activity index over time, expressed as area under the curve at 1, 3 and 5 years, was the primary endpoint. Subjective health measured with the 36-item Short Form Survey Instrument (SF36) and a visual analogue scale (VAS) were secondary endpoints. RESULTS There were no differences between the treatment groups in Crohn's disease activity index over time. General health, measured as SF36 score, was higher in patients receiving surgical treatment than in those receiving medical treatment at 1 year, but there was no corresponding difference in VAS. Due to the slow inclusion rate and changes in clinical practice, the study was t=erminated prematurely. CONCLUSION The study ended up being underpowered and should be interpreted with caution, but there was no clinically significant difference between the two treatment arms. Further studies are needed to address this important clinical question.
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Affiliation(s)
- Linda Gerdin
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden, Department of Surgery, Höglandssjukhuset, Eksjö, Sweden
| | - Anders S Eriksson
- Department of Gastroenterology Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Gunnar Olaison
- Department of Surgery, Northern Hospital Zeeland, Copenhagen, Denmark
| | - Rune Sjödahl
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Magnus Ström
- Department of Gastroenterology, County Council of Östergötland, Linköping, Sweden
| | - Johan D Söderholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden,
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Myrelid P, Svärm S, Andersson P, Almer S, Bodemar G, Olaison G. Azathioprine as a postoperative prophylaxis reduces symptoms in aggressive Crohn's disease. Scand J Gastroenterol 2006; 41:1190-5. [PMID: 16990204 DOI: 10.1080/00365520600587378] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Recurrence of Crohn's disease (CD) after surgery is common. Azathioprine/6-mercaptopurine (Aza/6-MP) is effective in controlling medically induced remission but, so far, has only been sparsely investigated after surgically induced remission. This study comprises a subset of CD patients considered to have an aggressive disease course and chosen for treatment with Aza postoperatively. MATERIAL AND METHODS In 1989-2000, a total of 100 patients with CD were given Aza/6-MP as a postoperative prophylaxis. Fourteen Aza/6-MP-intolerant patients were compared with 28 Aza-tolerant patients, matched for gender, age, and duration of disease. Patients were prospectively registered for symptoms using a modified Crohn's disease activity index (CDAI) and perceived health was assessed on a visual analogue scale (VAS). The primary outcome variable was the modified CDAI postoperatively integrated over time; other variables were time to first relapse (modified CDAI >or= 150), time to first repeated surgery, number of courses of steroids, and repeated surgery per year of follow-up. Patients were followed for a median of 84.7 months (23.2-140). RESULTS The modified CDAI integrated over time was 93 for Aza-treated patients compared with 184 for controls (p=0.01) and time to first relapse was 53 and 24 months, respectively (p<0.05). Aza-treated patients needed fewer courses of corticosteroids (p=0.05) compared with controls. Perceived health did not differ between the groups, nor did need of repeated surgery. Time to first repeat operation was 53 and 37 months, respectively. CONCLUSIONS In CD patients considered to have an aggressive disease course, Aza reduced symptoms after surgery and prolonged the time to symptomatic relapse. The findings support a role for Aza as a postoperative maintenance treatment in CD.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery, Unit of Colorectal Surgery, Linköping University Hospital, Sweden.
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Abstract
BACKGROUND & AIMS The aim of this study was to quantify temporal changes in health care utilization by a population-based cohort of IBD. METHODS By using the University of Manitoba IBD Epidemiology Database we assessed utilization of outpatient and hospital services, estimating relative risk (RR) of utilization for IBD cases compared with a matched cohort of non-IBD controls and for CD versus UC. We tested differences in utilization between prevalence cohorts 1990-1991 and 2000-2001. Also, utilization of the 1987-1988 incidence cohort was followed forward 15 years from diagnosis. The probability, intensity, and volume of utilization were estimated. RESULTS In 2000-2001, IBD patients compared with controls were more likely to have an outpatient visit (RR, 1.18; 95% confidence interval [CI], 1.17-1.19) and an overnight hospital stay (RR, 2.32; 95% CI, 2.16-2.49). CD cases were more likely than UC cases to be hospitalized (RR, 1.26; 95% CI, 1.11-1.43) and had a greater number of outpatient visits. From 1990-1991 to 2000-2001, IBD cases experienced a significant decrease in the likelihood of an outpatient surgical visit relative to non-IBD controls (P < .05), and for those cases who were hospitalized, CD cases tended to be less likely than UC cases to experience IBD-specific inpatient surgery (P < .07). Of the 1987-1988 incidence cohort, 80% of admissions that occurred during the follow-up period were during the first 5 years after diagnosis. CONCLUSIONS In 2000-2001, health care utilization continued to be higher in IBD versus controls and CD versus UC; however, the gap in costly service utilization appeared to narrow between the latter pair.
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Affiliation(s)
- Teresa Longobardi
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre and Department of Medicine, Winnipeg, Manitoba, Canada
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Abstract
Inflammatory bowel disease (IBD) has the propensity to affect patients who are in their late teens and early 20s, an age when most people decide on their educational and career directions. This review describes the effects that IBD has on the continuum of education and employment. Patients with Crohn's disease and ulcerative colitis attain a similar level of education as that of the general population. The quality of life of such patients in school, as measured by both patients' and teachers' perceptions, indicates that, despite the difficulties that students face in terms of missed school time and physical inconveniences, teachers are generally perceived by students to have favorable attitudes toward helping them. Even though earlier work in the area of employment has suggested that the occurrence of IBD is clustered among people in white-collar positions, recent data have suggested that certain environmental risks for IBD (i.e., sedentary or indoor jobs) may be associated with jobs classified as being white-collar, and therefore having a white-collar job may in itself not be a risk factor for the development of IBD. Patients with IBD have a higher rate of nonparticipation in the labor force, and the participation rate seems to maintain steady levels over time. A majority of patients with IBD continue in the same employment positions over a period of years. Patients with IBD, especially those who have undergone surgery, took more sick leave than their counterparts without IBD. A majority of patients with IBD favored the disclosure of their diagnosis to their employers and perceived little discrimination in the workplace. Furthermore, most employers were perceived by their employees with IBD as having fair attitudes toward the compensation provided for their employees with IBD.
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Affiliation(s)
- Sheetal R Marri
- Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
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Longobardi T, Jacobs P, Bernstein CN. Utilization of health care resources by individuals with inflammatory bowel disease in the United States: a profile of time since diagnosis. Am J Gastroenterol 2004; 99:650-5. [PMID: 15089897 DOI: 10.1111/j.1572-0241.2004.04132.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are no cost studies of inflammatory bowel disease (IBD) that describe its impact on resource utilization or treatment costs over long periods of time. Our aim was to determine if there are observable trends in health-care resource utilization by adults with IBD depending on disease duration. METHODS The 1999 U.S. National Health Interview Survey (n = 30,801; N = 195,398,057) included 256 adult cases with IBD who indicated the number of years since the onset of disease. Cases were grouped according to the "number of years with IBD" to distinguish between recent diagnosis (0-5 yr with IBD), long-standing IBD (6-15 yr with IBD), and very long-standing IBD (16-62 yr). A group of non-IBD controls was established and age and gender were controlled for through logistic regression analysis. Odds ratios were computed for resource use including hospitalization, health provider contact, and prescription medication. Population estimates were computed, while accounting for the complex survey design. RESULTS When compared with the general population, IBD patients were more likely to visit a specialist and to use prescription medication regardless of disease duration. GP visits were more likely until 15 yr with diagnosed IBD [0-5 yr with IBD: OR = 2.26; 95% CI = (1.21-4.21); 6-15 yr with IBD: OR = 2.73; 95% CI = (1.17-6.37)]. Home care was more likely in the IBD population with long-standing disease [OR = 3.21; 95% CI = (1.22-8.40)]. An emergency room visit [OR = 2.41; 95% CI = (1.49-3.88)] and hospitalization [OR = 2.34; 95% CI = (1.38-3.96)] were more likely in the first 5 yr since diagnosis as was hospitalization and surgical intervention [OR = 2.14; 95% CI = (1.09-4.19)]. CONCLUSION Specialist physicians are visited by IBD patients, and prescription medications are provided to treat IBD patients throughout their lives. This is a statistically significant trend that is viewed from onset of the disease to up to 62 yr with IBD. Our results also suggest, at least tentatively, that patients within the first 5 yr after the onset of the disease have a stronger tendency than the general population to visit an emergency room, to be hospitalized, and to have been both hospitalized and to have had surgery. If these results were borne out by further studies, then this would indicate that we can measure the greatest proportion of treatment effects on these resources within a relatively short period.
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Affiliation(s)
- Teresa Longobardi
- University of Manitoba Department of Internal Medicine, Winnipeg, MB, Canada
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Affiliation(s)
- S B Hanauer
- University of Chicago Pritzker School of Medicine, Illinois 60637, USA
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Abstract
The past year's literature pertaining to the medical treatment of Crohn's disease was highlighted by the US Food and Drug Administration's approval of infliximab. Other developments of interest include more evolutionary (in contrast to revolutionary) clinical data regarding aminosalicylates, antibiotics, and steroids as inductive agents and use of immunomodulatory agents as maintenance therapies. Comparative trials continue to demonstrate that steroids, including budesonide, have a greater acute benefit than aminosalicylates, but this benefit does not translate into long-term efficacy. Azathioprine and 6-mercaptopurine are the standard maintenance therapies for steroid-dependent Crohn's disease, and long-term safety data continue to accumulate regarding these agents in adults and children. Several novel approaches have been reported in preliminary fashion that will require much more extensive clinical experience and controlled-trial evidence.
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Affiliation(s)
- S B Hanauer
- University of Chicago Hospital, Chicago, Illinois 60637, USA
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