ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

Impact of Seton Use on Clinical, Patient-Reported, and Healthcare Resource Utilization Outcomes in Complex Crohn's Perianal Fistulas: A Systematic Literature Review

BACKGROUND

Optimal treatment strategies for seton use in patients with Crohn's perianal fistulas (CPF) remain elusive. This systematic literature review aimed to summarize clinical, patient-reported, and healthcare resource utilization (HCRU) outcomes associated with seton use for symptomatic relief and treatment of complex CPF.

METHODS

Electronic databases (MEDLINE, Embase, EBM Reviews, EconLit) were searched. Titles, abstracts, and relevant full texts were screened by 2 reviewers for inclusion using prespecified PICOS-T criteria. Articles published in English between January 1, 1980 and September 6, 2021 were included; animal/in vitro studies and case reports with <5 patients were excluded. Outcomes of interest included rates of complete response/remission and fistula recurrence in patients receiving seton with/without infliximab or biologics. Data were summarized using descriptive statistics.

RESULTS

Overall, 56 studies were included (full texts: n = 43; congress abstracts: n = 13). CPF and clinical outcome definitions were heterogeneous. Rates (range) of complete response/remission varied widely (seton: 13%-75%; seton + infliximab: 23%-100%; seton + biologics: 23%-59%) as did rates for fistula recurrence (seton: 4%-68%; seton + infliximab: 0%-50%; seton + biologics: 0%-17%). Rates of fistula-related reintervention, new fistula or abscess formation, and abscess recurrence were also varied; more consistency was observed regarding the use of patient-reported outcomes. Few studies reported outcomes from pediatric/adolescent patients or HCRU.

CONCLUSIONS

Optimal use of seton in patients with CPF remains unclear. International standardization of definitions for CPF and related clinical outcomes are required to permit data comparability and identify the most effective treatment strategies involving seton use in CPF.

Elastographic Histogram Analysis as a Non-Invasive Tool for Detecting Early Intestinal Remodeling in Experimental IBD

Background/Objectives: Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, is characterized by cycles of inflammation and tissue remodeling that can culminate in fibrosis. Differentiating between early inflammatory and fibrotic bowel wall changes remains a diagnostic challenge due to overlapping imaging features. This study aimed to assess the potential of elastography, specifically pixel histogram analysis, as a non-invasive method to identify acute inflammatory changes in a rat model of 2,4,6-trinitrobenzenesulfonic (TNBS)-induced colitis. Methods: Female CRL:Wi rats were randomized into control and experimental groups, with the latter receiving intracolonic TNBS to induce acute colitis. On day 7 post-induction, all animals underwent ultrasonographic and strain elastographic assessment of the distal colon using a standardized protocol. Histogram-based analysis of red, green, and blue pixel distributions was performed on elastographic video frames. Results were compared with histologic grading of inflammation and fibrosis using hematoxylin-eosin and Masson's trichrome staining. Results: Rats with TNBS-induced colitis exhibited significant weight loss, increased bowel wall thickness (31.5% vs. controls, p < 0.01), and elevated elastographic pixel intensity across all color channels (p < 0.05). Histologically, experimental animals showed severe inflammation and early submucosal fibrosis. A strong positive correlation was found between elastographic histogram values and histologic fibrosis scores (r = 0.86, p < 0.01), confirming the technique's diagnostic relevance. Conclusions: Elastographic pixel histogram analysis is a reproducible, non-invasive approach capable of distinguishing acute inflammatory changes and early fibrotic remodeling in experimental colitis. These findings support its potential application as a diagnostic adjunct in the early assessment and monitoring of IBD-related bowel wall changes.

Information Needs of Patients with Inflammatory Bowel Disease in the Digital Era: A 20-Year Longitudinal Study

Background: Chronic inflammatory bowel disease significantly impacts patients' everyday lives. Despite receiving regular medical care in gastroenterological or family medicine consultations, patients with inflammatory bowel disease (IBD) still experience a lack of information. To evaluate these deficits, we analyzed the main points of interest raised in an online consultation forum offered as a supplementary resource for patients. Methods: We analyzed 20 years of online consultation data at three time points, 2003 (launch of the forum), 2013, and 2024, and compared them against each other. A total of 681 patients participated in the consultations during these years. The clinical profiles of the participants included Crohn's disease (CD, n = 209), ulcerative colitis (UC, n = 140), unclassified colitis (IBDU, n = 30), and individuals with no specified diagnosis (NSD, n = 303). Results: Patients with ulcerative colitis demonstrated interest in topics such as diet and nutrition, as well as treatment with biologics. Patients with Crohn's disease expressed interest in diet, nutritional management, and treatment with biologics. Additionally, they showed interest in pain management, diagnostic imaging, and stress management. In the case of patients with unclassified colitis, a broad range of topics was addressed, with no single area emerging as particularly prominent. Patients with no specified diagnosis exhibited interest in diet and nutrition, laboratory diagnostics, and pain therapy. Conclusions: For patients with inflammatory bowel disease, online consultations represent a valuable complement to standard medical care. They provide additional support and contribute to enhancing patients' confidence in managing their condition. A broad spectrum of disease-related topics was addressed during the consultations. Identified information gaps can be systematically discussed and subsequently reduced.

Comparative analysis of natural language processing methodologies for classifying computed tomography enterography reports in Crohn's disease patients

Imaging is crucial to assess disease extent, activity, and outcomes in inflammatory bowel disease (IBD). Artificial intelligence (AI) image interpretation requires automated exploitation of studies at scale as an initial step. Here we evaluate natural language processing to classify Crohn's disease (CD) on CTE. From our population representative IBD registry a sample of CD patients (male: 44.6%, median age: 50 IQR37-60) and controls (n = 981 each) CTE reports were extracted and split into training- (n = 1568), development- (n = 196), and testing (n = 198) datasets each with around 200 words and balanced numbers of labels, respectively. Predictive classification was evaluated with CNN, Bi-LSTM, BERT-110M, LLaMA-3.3-70B-Instruct and DeepSeek-R1-Distill-LLaMA-70B. While our custom IBDBERT finetuned on expert IBD knowledge (i.e. ACG, AGA, ECCO guidelines), outperformed rule- and rationale extraction-based classifiers (accuracy 88.6% with pre-tuning learning rate 0.00001, AUC 0.945) in predictive performance, LLaMA, but not DeepSeek achieved overall superior results (accuracy 91.2% vs. 88.9%, F1 0.907 vs. 0.874).

Impact of preoperative use of biologics on 30-day surgical morbidity and mortality in patients with Crohn's disease undergoing ileocolectomy: National Surgical Quality Improvement Program database analysis

Preoperative use of biologics has been inconsistently reported to be associated with increased frequency of infectious and surgical anastomotic complications in inflammatory bowel disease patients. We aimed to evaluate the rates of 30-day postoperative morbidity and mortality in Crohn's disease patients exposed preoperatively to biologics. Data were collected from the NSQIP (National Surgical Quality Improvement Program). Crohn's disease patients undergoing open or laparoscopic ileocolectomy were identified using corresponding ICD 10 and CPT Codes from the NSQIP Participant Use Data File (PUF) for 2021. Patients were divided based on the preoperative use of biologics (group 1) and (group 2) for whom no biologics were used. A total of 910 patients (female n = 473; 52%, mean age of 42.3 ± 16.1) were included. The group 1 patients were significantly younger (40.30 years ± 15.33) than group 2 (43.58 years ± 16.8, p = 0.002) and had significantly slightly higher ASA III and IV scores (97.4% vs. 97.2%, p = 0.004). On the other hand, group 2 had a significantly higher prevalence of hypertension (20.2% vs. 12.8%, p = 0.003) and chronic obstructive pulmonary disease (2.6% vs. 0%, p = 0.001). No significant difference in remaining preoperative variables, surgical approach (laparoscopic vs. open), and comorbidities were found between the two groups. Only a significant prevalence of deep vein thrombosis and thromboembolism was found in patients exposed to biologics (1.1% vs. 0%, p = 0.027). Crohn's disease patients undergoing ileocolectomy and exposed preoperatively to biologics did not show a significant increase in 30-day postoperative morbidity and mortality. The outcomes did not support the concept that biological agents increase septic complications.

Overcoming the challenges of overtreating and undertreating inflammatory bowel disease

Several therapeutic advances have been achieved over the past two decades for inflammatory bowel disease (IBD). The expanding therapeutic armamentarium and the increasingly ambitious treatment targets have led to an increased use of advanced therapies and better outcomes. Nevertheless, many patients remain suboptimally treated and are at risk of disease progression, hospital admission, and surgery, even when advanced therapies are cycled, escalated, or combined. Conversely, IBD can also be characterised by an indolent disease course. Top-down and treat-to-target strategies, although beneficial in a substantial proportion of patients, might not be advantageous in patients with mild disease and might risk overtreatment. Identifying patients with mild activity and a benign disease trajectory in the long-term is important; unnecessary exposure to advanced therapies increases the risk of adverse events and increases financial costs and health-care resource utilisation. This Review details the importance of adopting clinical strategies to avoid the pitfalls of undertreating and overtreating IBD.

Efficacy and Safety of Upadacitinib for Perianal Fistulizing Crohn's Disease: A Post Hoc Analysis of 3 Phase 3 Trials

BACKGROUND & AIMS

Efficacy of upadacitinib, an oral Janus kinase inhibitor, for moderate-to-severe Crohn's disease was demonstrated in phase 3 induction (U-EXCEL, U-EXCEED) and maintenance (U-ENDURE) trials; this post hoc analysis evaluated upadacitinib outcomes in patients with fistulizing disease in these studies.

METHODS

Patients were randomized (2:1) to once daily upadacitinib 45 mg or placebo for 12 weeks. Upadacitinib 45 mg clinical responders were rerandomized (1:1:1) to upadacitinib 15 mg, upadacitinib 30 mg, or placebo for 52 weeks. In patients with fistulas (any and perianal), resolution of drainage, closure of external openings, clinical remission, endoscopic response, and safety were assessed.

RESULTS

Of 1021 patients in U-EXCEL and U-EXCEED, 143 (14.0%) had any fistulas at baseline (66 draining); of these, most (n = 128) had perianal fistulas (56 draining). Greater proportions of patients receiving upadacitinib vs placebo achieved resolution of drainage of perianal fistulas at the end of induction (placebo: 5.6%, n/n = 1/18; upadacitinib 45 mg: 44.7%, n/n = 17/38; P = .003) and maintenance (placebo: 0%, n/n = 0/11; upadacitinib 15 mg: 28.6%, n/n = 4/14; P = .105; upadacitinib 30 mg: 23.1%, n/n = 3/13; P = .223) and closure of perianal fistula external openings (for induction, placebo: 4.8%, n/n = 2/42; upadacitinib 45 mg: 22.1%, n/n = 19/86; P = .013; for maintenance, placebo: 0%, n/n = 0/30; upadacitinib 15 mg: 18.8%, n/n = 6/32; P = .024; upadacitinib 30 mg: 16.0%, n/n = 4/25; P = .037).

CONCLUSION

Patients with fistulizing disease (primarily perianal) treated with upadacitinib achieved higher rates of resolution of drainage, closure of external openings, clinical remission, and endoscopic response vs placebo.

CLINICALTRIALS

gov, Numbers: NCT03345849 (U-EXCEL), NCT03345836 (U-EXCEED), NCT03345823 (U-ENDURE).

Predicting conversion to tailor patient expectations and perioperative pain management in ileocecal resection for Crohn's disease

This study aims to identify risk factors of conversion to open surgery for patients undergoing minimally invasive surgery for their CD and to develop a predictive scoring system. Data from patients undergoing minimally invasive resection for their CD were collected in two European referral centers. The scoring system was developed from a logistic regression model including clinical and operative variables and its performance was evaluated using receiver operating characteristics (ROC) area under the curve (AUC). The study included 309 patients including surgery for recurrence. Conversion to open surgery occurred in 21% (65/309) of patients. The logistic regression analysis identified male sex, BMI, preoperative evidence of multiple disease localizations and abscess or perforation, and previous surgery for CD as independent risk factors for conversion. The risk score values in the converted group were significantly higher compared to non-converted group (MD = - 20.40; 95%CI - 14.12 to - 26.69; p < 0.0001). In the ROC analysis, the score achieved an AUC of 0.80 (SE = 0.03; 95%CI 0.74-0.86; p < 0.0001). Male sex, BMI, preoperative evidence of multiple disease localizations and abscess or perforation, and previous surgery for CD were associated with an increased risk of conversion to open surgical approach in patients undergoing minimally invasive surgery and were used to develop a predictive score. The results of this study might be useful to tailor patient expectations and perioperative pain management in ileocecal resection for Crohn's disease.

Nationwide study on clinical impact of early tumor necrosis factor-α inhibitors following first intestinal resection in biologics-naïve Crohn's disease patients

In Crohn's disease (CD) patients who have undergone surgery, postoperative recurrence remains a challenge, and there is a lack of investigation into the impact of early anti-tumor necrosis factor (TNF) therapy following surgery on clinical outcomes compared to late use of anti-TNF agents. Utilizing the Health Insurance Review and Assessment database, we conducted a retrospective cohort study comprising 481 CD patients who underwent their first intestinal resection and were naïve to preoperative biological therapy from 2010 to 2018. Patients initiating anti-TNF agents early (within one year post-surgery) were compared to those starting later for prognosis. Clinical outcomes, including biologics switching and surgical recurrence, were assessed. The late start group (n = 290) exhibited a higher surgical recurrence rate (27.9% vs. 18.3%, p-value = 0.021), while biologics switching rates did not significantly differ (8.3% vs. 12.6%, p-value = 0.167) compared to the early start group (n = 191). Kaplan-Meier curves revealed no significant differences in the risk of biologics switching (p-value = 0.319) or surgical recurrence (p-value = 0.380) between the early and late start groups. This study investigated the potential role of early anti-TNF therapy after first intestinal resection in biologics-naïve CD patients compared to late initiation. Further refined prospective research is warranted to validate these comparisons.

Invasive Therapeutic Strategies for Stricturing Crohn's Disease in Childhood: A Systematic Review and Meta-Analysis

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract. Current drugs are not effective for treating the primary fibrotic component of CD. Recommended invasive treatments include endoscopic balloon dilation, surgery with resection, or strictureplasty. This meta-analysis compared invasive treatment techniques for CD-related strictures in the pediatric population.

METHODS

The MEDLINE, EMBASE, and LILACS databases were searched from inception to December 2023. This meta-analysis was performed as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome was measured by the rate of stenosis recurrence and the adverse events of the techniques. Eligibility criteria were studies that involved the analysis of the recurrence rate of stenosis in pediatric patients with CD requiring surgical intervention after undergoing any of the previously proposed therapies. Additionally, adverse events were analyzed.

RESULTS

Three studies comprising a total of 106 endoscopic balloon dilations demonstrated a combined rate of stricture recurrence in patients with CD requiring surgical intervention of 0.171 (95% confidence interval [CI], 0.110-0.255). Three studies comprising a total of 49 surgical resections demonstrated a pooled event rate of 0.100 (95% CI, 0.038-0.240). Finally, 2 studies comprising a total of 38 strictureplasties demonstrated a pooled event rate of 0.347 (95% CI, 0.070-0.789). Concerning adverse events, the most common occurrences were found after surgical resection.

CONCLUSIONS

Surgical resection is the best option for treating strictures in pediatric CD patients in terms of recurrence rate, compared with endoscopic balloon dilation and strictureplasty. Nevertheless, surgical resection is associated with more adverse events.

TOpClass Class 4 Perineal Crohn's Disease: A Systematic Review and Meta-analysis of Perineal Wound Complication After Proctectomy in Crohn's Patients

BACKGROUND

Nonhealing perineal wounds have been reported to be common after proctectomy for Crohn's disease (CD). We performed a systematic review and meta-analysis of perineal wound healing after proctectomy for CD and assessed the risk factors for nonhealing.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, and Scopus databases from 2010 to 2023, and articles reporting perineal wound healing rates after proctectomy for CD were included. Data on study characteristics and proportion of healed wounds, and risk factors, were extracted. Random-effects meta-analysis was performed to estimate the pooled proportion and 95% CIs using the "meta" package in R. Heterogeneity was assessed using the I2 statistic.

RESULTS

We identified 501 articles, of which 252 remained after de-duplication. After screening, 4 retrospective cohort studies involving 333 patients were included. Across the 4 studies, the pooled proportion of completely healed perineal wounds at 6 months was 65% (95% CI 52%-80%), and 70% (95% CI 60%-83%) at 12 months. Significant heterogeneity was found between studies (I2 = 86% at 6 months). Three studies examined risk factors for impaired healing after proctectomy. One study identified preoperative perineal sepsis as the only independent factor associated with impaired healing (P = .001) on multivariable analysis. In 1 study, male sex, shorter time from diversion to proctectomy, and higher preoperative C-reactive protein levels were all associated with delayed healing in univariate analysis. Another study found that close rectal dissection was associated with significantly lower healing rates than total mesorectal excision (P = .01). Prior use of tumor necrosis factor inhibitors was not associated with wound healing outcomes.

CONCLUSIONS

This meta-analysis revealed complete perineal healing in only 70% of patients 12 months after proctectomy for CD. This highlights knowledge gaps, including the identification of modifiable risk factors and methods for preventing or as rescue therapy, such as vacuum-assisted closure and flap reconstruction, for nonhealing perineal wounds after proctectomy for CD. Poor perineal wound healing outcomes are likely related to imperfectly understood underlying inflammatory dysregulation and systemically impaired wound healing in patients with CD.

Definitions, diagnosis, and management of postoperative recurrence in Crohn's disease patients with permanent ileostomy-a systematic review and meta-analysis

BACKGROUND AND AIMS

Over 10% of patients with Crohn's disease require permanent ileostomy. We aimed to summarize the existing data on diagnosis, definitions of recurrence, and management of Crohn's disease patients with permanent ileostomy.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched from inception to February 6, 2024. Randomized controlled trials, cohort and cross-sectional studies, and case series of more than 5 patients reporting on postoperative recurrence or the need for surgery in patients with Crohn's disease and permanent ileostomy were included. Search results were independently screened, and full text of all titles meeting eligibility criteria was obtained. Outcomes of interest included diagnostic techniques, recurrence definitions, and management approaches. We estimated pooled rates (with 95% confidence interval [CI]) of recurrence.

RESULTS

Thirty cohort studies including 2055 Crohn's patients with permanent ileostomy were included (53% female, median age at the time of ileostomy creation 32 years, the most common reason for ileostomy was refractory disease). The postoperative recurrence rate was 27% (95% CI, 21.3-33.3, 26 studies, 451/1805 patients). Modalities for diagnosis of Crohn's disease recurrence were symptoms (15 studies), endoscopy (4 studies), histology from endoscopic biopsies (2 studies), imaging (5 studies), and surgery (22 studies). The reported definitions of recurrence for each modality were heterogeneous.

CONCLUSIONS

There is a lack of standardized monitoring tools and criteria for diagnosing recurrence in patients with Crohn's disease and permanent ileostomy. The results of this systematic review will form the basis of a global expert recommendation exercise focused on developing management standards and trial endpoints for this condition.

Case series of small bowel adenocarcinoma associated with Crohn's disease

Long-standing Crohn's disease (CD) is well known to be associated with gastrointestinal malignancies. Patients with CD have a higher risk of developing small bowel adenocarcinoma (SBA) compared to healthy individuals. However, CD-associated SBA is not as common as colorectal cancer. While patients with CD often present with complicated stricture lesions in the small intestine, it is difficult to confirm all lesions by endoscopy. There is still no consensus on the surgical treatment of small bowel strictures with suspected CD-associated SBA. We report a case of small bowel high-grade dysplasia and two cases with advanced SBA. Case 1 involved a 53-year-old man whose high-grade dysplastic lesion of the small intestine was discovered incidentally postoperatively and successfully resected curatively. Case 2 was that of a 60-year-old man and Case 3 involved a 69-year-old man. Both patients had multiple small bowel stenotic lesions and were diagnosed with advanced small bowel cancer during follow-up. In conclusion, for patients with long-standing Crohn's disease who are refractory to treatment or have stenotic lesions, surgical resection should be considered as a treatment option with CD-associated SBA in consideration.

A modified totally stapled KONO-S anastomosis for ileal and ileo-colic Crohn's disease: technical aspects and case series

Crohn's disease (CD) is a chronic immune-mediated disorder affecting the gastrointestinal tract. While medical therapies have advanced, approximately 80% of CD patients will require surgery due to disease recurrence. A significant debate exists regarding the primary site of post-operative recurrence. This discrepancy in recurrence patterns underscores the complexity of CD management and the ongoing need for tailored surgical approaches. It has been recently demonstrated that the Kono-S anastomosis is safe and efficient in reducing endoscopic and surgical recurrence. Newer versions of the Kono-S anastomosis using staplers have been reported to further simplify the procedure and decrease operative time. The aim of this paper was to describe a distinct version of a totally stapled Kono-S anastomosis and provide preliminary results from our center. The technical procedure of a totally stapled Kono-S anastomosis is illustrated. A consecutive series of patients undergoing ileal or ileo-colic resection followed by totally stapled Kono-S anastomosis was identified from a prospectively collated database. Data included patient demographics and baseline characteristics, intraoperative details, short- and long-term post-operative outcomes. Between January and November 2023, 41 patients (mean age 36.4 years, 61% males) underwent ileal or ileo-colic resection followed by totally stapled Kono-S anastomosis for Crohn's disease. Mean operative time was 150.76 ± 43.22 min, and mean time of anastomotic construction was 19.71 ± 4.24. Time to flatus and stool were 2.73 ± 0.70 and 3.51 ± 1.16 days, respectively, and the length of post-operative stay was 6.80 ± 2.13 days. Only two patients (4.8%) presented complications following surgery, namely anastomotic bleeding. At a mean follow-up of 17.0 ± 2.1 months, no patient needed re-do surgery for disease recurrence at anastomotic site. The endoscopic recurrence rate was 14.4% (4/28). Our fully stapled version of the Kono-S anastomosis is safe and feasible, and short construction time and low technical complexity may help its diffusion among colorectal surgeons. Long-term outcomes on disease recurrence are still to be defined.

Medical Management of Ulcerative Colitis and Crohn's Disease-Strategies for Inducing and Maintaining Remission

Medical management of ulcerative colitis (UC) and crohn's sisease (CD) is complex. While there is significant overlap in medical therapies used for UC and CD, there remain few distinct differences in their management. The overall goals of therapy are to achieve disease remission, prevent complications, decrease the need for surgical interventions, and restore patients' quality of life. In the current article, we discuss currently available therapies and their mechanisms, limitations and side effects, followed by a comprehensive discussion of key consideration points in regards to the medical management.

Extended versus limited mesenteric excision in bowel resection for Crohn's disease: a meta-analysis and systematic review

BACKGROUND

There is ongoing debate regarding the benefits of extended mesenteric excision (EME) versus limited mesenteric excision (LME) in intestinal resection for Crohn's disease (CD). Some studies suggest that EME may reduce surgical recurrence, which is defined as the need for reoperation due to disease complications or insufficient response to therapy, when compared with LME. This systematic review and meta-analysis aims to compare postoperative complications, surgical recurrence, and endoscopic recurrence in patients undergoing EME versus LME for CD.

METHODS

MEDLINE, Cochrane, the Central Register of Clinical Trials, Scopus and Web of Science databases were searched for studies published through April 2024. Odds ratios (OR) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed with Cochran's Q test and I2 statistics, with p-values < 0.10 and I2 > 25% considered significant. Statistical analyses were performed using R software, version 4.4.1.

RESULTS

One randomized controlled trial (RCT) and five observational studies were included, totaling 4498 patients, of whom 1059 (23.5%) underwent EME and 3439 (76.5%) LME. EME was associated with a lower surgical recurrence rate (5% versus 15%; OR 0.31; 95% CI 0.12-0.84; p = 0.021; I2 = 47%). No significant differences were observed between EME and LME for overall complications, Clavien-Dindo ≥ 3 events, bleeding requiring transfusion, anastomotic leaks, intraabdominal abscesses, surgical site infections (SSIs), reoperations, readmissions, ileus, endoscopic recurrences, operative times, or hospital stays.

CONCLUSIONS

EME was associated with a significant reduction in surgical recurrence compared with LME, without differences in endoscopic recurrence or postoperative complication rates.

To cut or not to cut? Extended mesenteric excision during intestinal resection does not impact the postoperative recurrence nor the postoperative complications in Crohn's disease: a systematic review and meta-analysis

BACKGROUND

The mesentery might be involved in the pathogenesis of Crohn's disease (CD). As a result of scarce and conflicting data, it is debatable whether removal during intestinal resections could influence postsurgical outcome. We aimed to investigate the association between the extent of mesenteric excision during intestinal resections and postoperative complications and recurrence.

METHODS

We conducted a systematic search in five databases on 29 July 2024 for studies reporting outcomes in patients with CD who underwent intestinal resections with extended mesenteric excision (EME) compared with limited mesenteric excision (LME). Pooled odds ratios (ORs) with 95% confidence intervals (CI) were calculated using the random-effects model. We assessed the risk of bias using the ROBINS-I and RoB2 tool and evaluated the certainty of evidence according to the GRADE Working Group recommendations.

RESULTS

We retrieved data from six studies, covering 4590 patients. The pooled data showed no significant difference between EME and LME patients regarding surgical recurrence (OR 0.3; 95% CI 0.02-3.73; p = 0.176), overall postoperative complications (OR 0.78; 95% CI 0.33-1.82, p = 0.329), anastomotic leak (OR 0.76, 95% CI 0.09-6.85, p = 0.722), surgical site infection (OR 0.84, 95% CI 0.3-2.36, p = 0.539), reoperation rate (OR 1.09, 95% CI 0.33-3.58, p = 0.783), or hospitalization (MD - 0.33 (95% CI - 1.8 to 1.15, p = 0.53). Individual studies reported similar results regarding 6 months follow-up endoscopic recurrence. The certainty of evidence was very low and low, respectively.

CONCLUSION

Extended mesenteric excision is not statistically associated with improved postoperative complications or postoperative recurrence. Results should be interpreted cautiously because of the small number of studies; hence, randomized, long-term, controlled trials are needed.

Orally Deliverable Iron-Ceria Nanotablets for Treatment of Inflammatory Bowel Disease

Ceria-based nanoparticles are versatile in treating various inflammatory diseases, but their feasibility in clinical translation is undermined by safety concerns and a limited delivery system. Meanwhile, the idiopathic nature of inflammatory bowel disease (IBD) calls for a wider variety of therapeutics via moderation of the intestinal immune system. In this regard, the synthesis and oral formulation of iron-ceria nanoparticles (CF NPs) with enhanced nanozymic activity and lower toxicity risk than conventional ceria-based nanoparticles are reported. CF NPs are clustered in calcium phosphate (CaP) and coated with a pH-responsive polymer to provide the enteric formulation of iron-ceria nanotablets (CFNT). CFNT exhibits a marked alleviative efficacy in the dextran sodium sulfate (DSS)-induced enterocolitis model in vivo by modulating the pro-inflammatory behavior of innate immune cells including macrophages and neutrophils, promoting anti-inflammatory cytokine profiles, and downregulating key transcription factors of inflammatory pathways.

Global trends in surgically based treatment of anal fistula in Crohn's disease: a bibliometric and visualization analysis

BACKGROUND

Crohn's disease (CD) is a chronic, recurrent gastrointestinal disorder characterized by a complex etiology. Among its perianal complications, anal fistulas represent a challenging comorbidity. With the increase of surgical options, a comprehensive bibliometric analysis was deemed necessary to consolidate the vast array of research in this field.

METHODS

We extracted 1608 articles spanning from 1 January 1994, to 1 May 2024, from the Web of Science Core Collection. Using VOSviewer, CiteSpace, and Scimago Graphica for visual analytics, we synthesized key trends across multiple bibliometric indicators, encompassing geographic and institutional contributions, individual authorship, journal prominence, citation metrics, and thematic prevalence.

RESULTS

From the delineated corpus, we identified publications from 325 countries and 5110 research institutions, with the US and UK at the forefront of publication volume and academic impact. The data indicated a leading role for institutions like the Cleveland Clinic and Imperial College London. "Diseases of the Colon and Rectum" emerged as a central journal due to its high publication and citation frequency. Distinctly, the analysis uncovered trending keywords, signifying the field's prioritization on surgical intervention, biologic therapy, imaging modalities, and emerging biological treatments.

CONCLUSION

Our findings elucidate a trajectory toward prominent advancements in CD fistula research. This analysis underscores the field's shift towards integrative treatment strategies, spotlighting the pressing need for comprehensive comparative studies of surgical approaches. It underscores the imperative for robust clinical trials to standardize treatments and extend care to a broader CD patient population.

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Is stapled Kono-S anastomosis a protective factor against postoperative endoscopic recurrence in Crohn disease? A single-center, retrospective cohort study

BACKGROUND

Handsewn Kono-S anastomosis is safe and associated with a reduction in postoperative recurrence (POR) in Crohn disease (CD). This study aimed to investigate the advantages of stapled Kono-S anastomosis in patients with CD who underwent intestinal anastomosis.

METHODS

Patients with CD who underwent intestinal anastomosis were reviewed via a prospectively maintained database. Patients who underwent conventional stapled side-to-side anastomosis were classified into the conventional group, and those who underwent stapled Kono-S anastomosis were classified into the Kono-S group. The primary endpoint was modified endoscopic recurrence (mER; ≥i2b). Other endpoints were endoscopic recurrence (ER; ≥i2); severe ER (i3 and i4); intra- and postoperative outcomes, including morbidity and hospital stay; and cross-sectional parameters. Multivariate logistic regression analysis was performed to assess the independent risk factors for mER.

RESULTS

Between 2020 and 2023, 199 patients (63 in the Kono-S group) were included in this study. After matching the 63 patients in each group, the overall rates of mER, ER, and severe ER were 19.0%, 24.6%, and 8.7%, respectively. The mER, ER, and severe ER rates were lower in the Kono-S group than in the conventional group (12.7% vs 25.4% [P =.07], 20.6% vs 28.6% [P =.30], and 6.3% vs 11.1% [P =.34], respectively). Multivariate analysis indicated that stapled Kono-S anastomosis (odds ratio [OR], 0.35; 95% CI, 0.12-0.98; P =.047) was an independent protective factor for mER, whereas male gender (OR, 7.75; 95% CI, 1.50-40.00; P =.01) and BMI of <18.5 kg/m2 (OR, 3.27; 95% CI, 1.11-9.67; P =.03) were independent risk factors for mER.

CONCLUSION

Stapled Kono-S anastomosis is safe for patients with CD. However, stapled Kono-S anastomosis may not be a protective factor against POR compared with conventional stapled side-to-side anastomosis.

Total fistula volume predicts surgical outcomes in complex perianal fistulizing Crohn's disease following fistula-tract laser closure: a single-center retrospective study

BACKGROUNDS

This study aimed to identify risk factors influencing long-term treatment outcomes in patients with complex perianal fistulizing Crohn's disease (pfCD) following fistula-tract laser closure (FiLaC™).

METHODS

A retrospective analysis was conducted on data from patients with complex pfCD who underwent FiLaC™ from January 2019 to December 2020, including demographics, pharmacological regimens, and preoperative MRI assessments. Follow-up monitored fistula outcomes such as healing, remission, failure, and recurrence.

RESULTS

Among 49 patients followed for an average of 60.0 months, 31 (63.3%) achieved fistula healing, 3 (6.1%) showed improvement, 3 (6.1%) had non-healing, and 12 (24.5%) experienced recurrence. Significant differences were found between healed and unhealed groups in total fistula volume (TFV), number of fistula tracts, and perianal Crohn's disease activity index (PDAI) (P = 0.036, P = 0.020, and P = 0.041, respectively). Multivariate regression analysis indicated TFV as a significant predictor of healing outcomes (P = 0.013). ROC analysis confirmed its predictive value for fistula healing in complex pfCD, with an area under the curve (AUC) of 0.729 (P = 0.008). The optimal threshold for TFV was 4.81 cm3, with a sensitivity of 61.1% and a specificity of 83.9%. The AUC for recurrence rates was 0.883 (P < 0.001), with sensitivity and specificity at 83.3% and 83.8%, respectively, using the same threshold for TFV. The Kaplan-Meier survival curve highlighted the predictive potential of TFV for fistula recurrence (P < 0.0001).

CONCLUSIONS

TFV is an effective predictor of long-term outcomes in patients with complex pfCD following FiLaC™.

New Insights into the Pathogenesis of Intestinal Fibrosis in Inflammatory Bowel Diseases: Focusing on Intestinal Smooth Muscle Cells

Strictures in inflammatory bowel disease, especially Crohn's disease (CD), are characterized by increased intestinal wall thickness, which, according to recent accumulating data, is mainly attributed to the expansion of the intestinal smooth muscle layers and to a lesser extent to collagen deposition. In this review, we will discuss the role of intestinal smooth muscle cells (SMCs) as crucial orchestrators of stricture formation. Activated SMCs can synthesize extracellular matrix (ECM), thus contributing to intestinal fibrosis, as well as growth factors and cytokines that can further enhance ECM production, stimulate other surrounding mesenchymal and immune cells, and increase SMC proliferation via paracrine or autocrine signaling. There is also evidence that, in stricturing CD, a phenotypic modulation of SMC toward a myofibroblast-like synthetic phenotype takes place. Moreover, the molecular mechanisms and signaling pathways that regulate SMC hyperplasia/hypertrophy will be extensively reviewed. The understanding of the cellular network and the molecular background behind stricture formation is essential for the design of effective anti-fibrotic strategies, and SMCs might be a promising therapeutic target in the future.

Patterns and predictors of postoperative complications and recurrence after ileocecal resection for Crohn's disease: a national multicenter longitudinal study

BACKGROUND

Crohn's disease (CD) negatively impacts quality of life, and a high percentage of patients will need surgery. Ileocecal resection (ICR) is the most common abdominal procedure performed in CD. Postoperative complications are frequent, and recurrence is common. The main objectives of this study were to analyze risk factors (RF) for anastomotic leakage (AL) and recurrence after ICR, as well as quality of life (QoL) in CD in a sample of the Spanish population.

METHODS

A prospective, multicenter, observational study was designed, including all types of hospitals in Spain from 2018 to 2021. Demographic and medical-surgical characteristics, postoperative complications, hospital types by annual ICR volume, and quality of life (IBDQ-9) up to 1 year follow-up (OYF) were recorded and analyzed.

RESULTS

A total of 386 ICRs were recorded. At 60 days, there were 134 (36.4%) complications, 46 (11.91%) of which were major. A total of 23 (5.9%) AL were registered, and RF were Montreal A3 [OR 14.2, 95% CI (2.70-126), p = 0.005], Montreal p [OR 7.29, 95% CI (1.14-44.4), p = 0.029], and intensified adalimumab treatment [3.8, 95% CI (1.2-13.1), p = 0.026]. Recurrences at OYF were 67 (19%), and RF were history of neoplasia [OR 7.14, p = 0.01], Montreal B3 [OR 2.12, p = 0.02], and minimally invasive surgery (MIS) [OR 2.63, p = 0.02]. The mean difference in IBDQ-9 from baseline to 60 days was +1.72 (n = 177, p < 0.001) and to OYF +2.12 (n = 140, p < 0.001).

CONCLUSIONS

The AL rate was 5.9%. Montreal A3, perianal disease, and intensified adalimumab were associated with a higher rate of AL. The recurrence rate was 17.6% (OYF). Prior neoplasia, Montreal B3, and MIS were associated with higher risk of recurrence. ICR improves quality of life at 60 days and is maintained 1 year after surgery.

UNEXPECTED FINDINGS DURING LAPAROTOMY SURGERY AND URGENT SURGICAL INDICATIONS ARE ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN'S DISEASE

BACKGROUND

Patients undergoing Crohn's disease (CD) surgery may develop a higher rate of postoperative complications (POC) than other patients.

AIMS

The aim of this study was to investigate factors determining POC in patients with CD undergoing urgent laparotomy.

METHODS

This is a retrospective cohort study conducted on adult patients undergoing urgent laparotomy for CD. Clinical and surgical variables, medication history, American Society of Anesthesiologists classification, and POC were investigated. Data collection and management were carried out using the REDCap software (REDCap electronic data capture tools) hosted at the hospital institution. For statistical analysis, the χ2 (or Fisher's exact) test, Student's t-test, Mann-Whitney test, and simple and multiple multilevel logistic regression analyses were used.

RESULTS

There was an association regarding the history of adalimumab use (p=0.04, OR 2.8, 95%CI 1.03-7.65), previous use of prednisone (p<0.01, OR 2.03, 95%CI 2.00-2.05), urgent surgery indications (p<0.01, OR=4.32, 95% CI=1.58-11.82), mechanical anastomosis (p=0.02, OR=0.22, 95%CI 0.06-0.80), unexpected intraoperative findings (p=0.02, OR 10.46, 95%CI 1.50-72.99), length of hospital stay greater than 10 days (p<0.01, OR 16.86, 95%CI 2.99-94.96), unplanned intensive care unit (ICU) admission (p=0.01, OR 15.06, 95%CI 1.96-115.70), and planned ICU admission (p<0.01, OR 18.46, 95%CI 3.60-94.51). On multivariate analysis, there was an association between the indication of urgent surgery (or emergency) (p=0.01, OR 4.38, 95%CI 1.43-13.37) and unexpected intraoperative findings (p=0.03, OR 8.11, 95%CI 1.21-54.50).

CONCLUSIONS

Unexpected changes and urgent surgical indications are considered risk factors for POC in patients with CD.

The challenges of implementing earlier surgery for terminal ileal Crohn's disease-A qualitative study of the clinician's perspective

AIM

Evidence suggests that earlier bowel resection may offer more stable remission in localized luminal terminal ileal (TI) Crohn's disease compared with ongoing medical therapy. Surgery is still considered late in the treatment pathway. The aim of this study was to understand the clinician's perspective on 'early' surgery by qualitatively exploring how clinicians make treatment-related decisions.

METHOD

Semistructured interviews with clinicians across the UK with an interest in inflammatory bowel disease (IBD) were undertaken using videoconferencing (February-November 2022). Inductive thematic analysis of interview transcripts was performed; 10% of the data were double-coded. Data saturation was confirmed before stopping recruitment.

RESULTS

Participants included nine consultant surgeons, seven consultant gastroenterologists and seven specialist nurses (n = 23) from secondary care and tertiary referral centres. Five key themes were identified: timing of surgery in practice, barriers to timely surgery, factors influencing decision-making, offering choice and the patient's perspective. A practice of exhausting medical options before considering surgery was commonly described. A lack of IBD specialists (especially surgeons), inadequate opportunities for multidisciplinary teamwork and long waiting lists for surgical clinics and theatre were cited as barriers to timely surgery. According to interviewees, patients prefer medical therapy over surgery; the most dreaded risk is thought to be that of a stoma.

CONCLUSION

This study provides new insights into the barriers to earlier surgery for TI disease. Organizational barriers should be considered when designing local services. Collaborative multidisciplinary teamwork may allow clinicians to consider surgery sooner. A study investigating the patient perspective is warranted.

Variation in nutritional therapy practices: results of a survey on nutritional management of severe inflammatory bowel disease

OBJECTIVES

The optimal nutritional management during a severe flare of inflammatory bowel disease is uncertain. The goal of this study was to describe variations in nutritional practices between different countries, professions and types of hospitals, as well as between ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

In this cross-sectional study, a novel questionnaire was distributed in the ECCO Congress 2022 and via ECCO country representatives.

RESULTS

The survey was completed by 313 participants. In total, 68% of the respondents were physicians. No specific nutritional screening tool was used by 45% of respondents. Almost a quarter of respondents reported less than 25% of patients being assessed by a dietitian in the first 3 days of a flare. The most common form of nutritional therapy was oral nutritional supplements (ONS) with easy-to-digest food. Total parenteral nutrition (TPN) was used by 10% of respondents for UC patients and 7% for CD. Energy intake, stool frequency and inflammatory biomarkers were the most common factors in determining when to change nutritional therapy. There were significant differences between different countries and health care professions for all the outcomes ( P  < 0.05). Nutritional management did not generally vary according to hospital type (university vs. general). During the first 3 days of a flare, a diet consisting exclusively of ONS was significantly more frequently used for CD than UC ( P  = 0.018). Otherwise, similar nutritional therapy strategies were reported for CD and UC, including using TPN to a similar extent.

CONCLUSION

There is significant variation in nutritional management practices. Country is the main determinant of differences in practice.

Profiling the patient with inflammatory bowel disease in the relationship between physical activity and partner/social network status: A post hoc patient-tailored analysis of the "BE-FIT-IBD" study

INTRODUCTION

Normal quality of life is an ultimate target in the therapeutic approach to inflammatory bowel diseases (IBD), encompassing Crohn's disease (CD) and ulcerative colitis (UC) in the context of which regular physical activity (PA) is often a chimeric parameter that is not standardized in terms of quality/quantity. The study aimed to profile a sample of IBD patients about the relationship between PA-partner status and social network support.

PATIENTS AND METHODS

A post hoc analysis of the "BE-FIT-IBD" study was set up by stratifying the data of PA with that of partner status and the support that the patient's social network (i.e., relatives, friends) provided in inciting the patient to practice regular PA.

RESULTS

In the 219 patients included, there was a greater tendency for patients with stable partners to view the risk of reactivation/worsening of IBD as a barrier to conducting regular PA (p<0.0001). Single patients considered PA more as a protective factor (p=0.045). Patients without a PA-supporting social network retained IBD-related treatment as a PA barrier (p=0.016) and PA as a risk for IBD complications (p=0.01), with less confidence that PA could improve the course of IBD (p<0.001). Rectal syndrome was an IBD-related barrier more represented in patients with PA-deterring social network (p<0.0001).

CONCLUSIONS

These factors are potential targets for recovering the IBD patient's adherence to regular PA.

Incidence and Risk Factors for Nonreversal of Stoma in Patients With Crohn's Disease: A Single-Center Study

BACKGROUND

Even in the biological era, permanent stoma is not uncommon in patients with Crohn's Disease.

OBJECTIVE

This study aimed to investigate the incidence and risk factors of permanent stoma in Crohn's disease patients and provide clinical evidence for reducing this disabling outcome.

DESIGN

Consecutive patients with Crohn's disease who underwent ostomies in the past decade were reviewed.

SETTINGS

The study was conducted in a tertiary referral hospital.

PATIENTS

Four hundred fifty-seven patients with Crohn's disease were divided into temporary stoma and permanent stoma groups based on stoma reversal or not. A permanent stoma was defined as a stoma that had not been reversed or closed for at least 2 years.

MAIN OUTCOME MEASURES

The incidence, risk factors, and long-term outcomes of permanent stomas were reported.

RESULTS

The rate of permanent stoma was 4.0% in our surgical cohort. The mean age at the time of permanent stoma creation was 36.0 (28.0-45.0) years. The annual incidence of permanent stoma had declined significantly in the past 10 years (p = 0.033). Our study showed that the independent risk factors for permanent stoma formation included female sex, previous operation for Crohn's disease, the presence of rectal disease, subtotal colectomy, and rectal resection. Interestingly, long-term follow-up found that the active distal colorectal lesion was independently associated with the requirement of subsequent surgery.

LIMITATIONS

The study was limited by its retrospective nature.

CONCLUSIONS

Although the incidence of permanent stoma in patients with Crohn's disease showed a downward trend in the past 10 years, effective treatments based on relevant risk factors should be used to prevent permanent stoma and control subsequent surgical recurrence. See Video Abstract.

INCIDENCIA Y FACTORES DE RIESGO DE NO REVERSIN DEL ESTOMA EN PACIENTES CON ENFERMEDAD DE CROHN ESTUDIO DE UN SOLO CENTRO

ANTECEDENTES:Incluso en la era biológica, el estoma permanente no es poco común en pacientes con enfermedad de Crohn.OBJETIVO:Este estudio tuvo como objetivo investigar la incidencia y los factores de riesgo del estoma permanente en pacientes con enfermedad de Crohn y proporcionar evidencia clínica para reducir este resultado discapacitante.DISEÑO:Se revisaron pacientes consecutivos con enfermedad de Crohn que se sometieron a ostomías en la última década.ESCENARIO:El estudio se realizó en un hospital de referencia terciario.PACIENTES:457 pacientes con enfermedad de Crohn se dividieron en los grupos de estoma temporal y estoma permanente según si se había revertido o no el estoma. Un estoma permanente se definió como un estoma que no se había revertido o cerrado durante al menos dos años.PRINCIPALES MEDIDAS DE RESULTADOS:Se informó la incidencia, los factores de riesgo y los resultados a largo plazo de los estomas permanentes.RESULTADOS:La tasa de estoma permanente fue del 4,0 % en nuestra cohorte quirúrgica. La edad media en el momento de la creación del estoma permanente fue de 36,0 (28,0-45,0) años. La incidencia anual de estomas permanentes había disminuido significativamente en los últimos 10 años (p = 0,033). Nuestro estudio mostró que los factores de riesgo independientes para la formación de estomas permanentes incluían el sexo femenino, la cirugía previa para la enfermedad de Crohn, la presencia de enfermedad rectal, la colectomía subtotal y la resección rectal. Curiosamente, el seguimiento a largo plazo encontró que la enfermedad colorrectal distal activa se asoció de forma independiente con la necesidad de una cirugía posterior.LIMITACIONES:El estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES:Aunque la incidencia de estomas permanentes en pacientes con enfermedad de Crohn mostró una tendencia descendente en los últimos 10 años, se deben utilizar tratamientos efectivos basados en factores de riesgo relevantes para prevenir el estoma permanente y controlar la recurrencia quirúrgica posterior. (Traducción-Dr. Felipe Bellolio).

Curing cryptoglandular anal fistulas-Is it possible without surgery?

BACKGROUND

Empirical reviews suggested that cryptoglandular anal fistulas require surgical resolution. However, some reports have indicated the possibility of nonsurgical and conservative treatment, which is discussed in this review.

METHODS

This review explores the potential of nonsurgical approaches for curing anal fistulas through bacterial inhibition and immunomodulation. The longstanding cryptoglandular theory has been a subject of controversy, prompting the reevaluation of conventional surgical interventions for anal fistulas. The review was conducted through database searches, including Medline, EMBASE, PubMed, and the Cochrane Library.

RESULTS

Emerging evidence suggests that targeting the anaerobic environments present in anal fistulas and perianal abscesses and eradicating bacteria and their by-products may be critical for successful treatment. Immunomodulatory strategies show promise as a potential avenue for the nonsurgical management of anal fistulas.

CONCLUSIONS

Ongoing developments in pharmacological research offer opportunities for alternative treatment options, shedding light on the prospects of noninvasive anal fistula management.

Durable remission after ileocolic resection for Crohn's disease is achievable in selected patients. Long-term results of a prospective multicentric cohort study of the GETAID Chirurgie

BACKGROUND AND AIMS

Postoperative recurrence requiring medical treatment intensification or redo surgery is common after ileocolic resection (ICR) for Crohn's disease (CD). This study aimed to identify a subgroup of CD patients for whom ICR could achieve durable remission.

METHODS

This retrospective follow-up study analyzed 592 CD patients who underwent ICR (2013-2015) in a nationwide prospective cohort. Patients with >36 months follow-up were included. Primary outcome was durable remission, defined as the absence of endoscopic recurrence and/or medical treatment intensification. Uni- and multivariate analyses identified predictive factors for durable remission.

RESULTS

Among 268 included patients, 59% had B2 phenotype, 70% had a first ICR, and 66% had postoperative medical treatment. After a median follow-up of 85 (36-104) months, 52 patients (19%) experienced durable remission, of whom 24 (46%) didn't require medical treatment and 28 (54%) maintained the same postoperative treatment, including anti-tumor necrosis factor in 15/28 patients (54%). Surgery could stabilize the disease course in 112 patients (41.7%), including 22.4% endoscopic recurrence that didn't require CD treatment initiation or intensification. Durable remission rate was significantly increased in B1 phenotype vs B2/B3 (n = 7/18;39% vs n = 45/250;18%, P = .030) and in first ICR vs redo ICR (n = 43/184;23% vs n = 9/80;11%, P = .023). In multivariate analysis, B1 phenotype was the only independent predictive factor for durable remission (odds ratio = 3.59, IC 95%, 1.13-11.37, P = .030).

CONCLUSIONS

Surgery for CD achieved durable remission in 20%, rising to 40% in those with a B1 phenotype. These results support surgery as a viable alternative to medical treatment, offering treatment-free durable remission and preserving medical treatment options.

Early Surgical Resection in Pediatric Patients with Localized Ileo-Cecal Crohn's Disease: Results of a Retrospective Multicenter Study

Background: Crohn's disease (CD) is an inflammatory bowel disease (IBD) that also affects pediatric patients. It frequently presents as a localized disease, affecting the ileocecal area, ileum, or colon. It requires targeted therapy to achieve a good quality of life and long-term control of disease activity. Despite multiple medical therapies available, several patients benefit from surgical treatment. The aim of our study is to demonstrate how an early surgical approach can bring an improvement in disease activity, evaluating the Simple Endoscopic Score for Crohn's Disease (SES-CD) and the Pediatric Crohn's Disease Activity Index (PCDAI). Methods: A retrospective multicenter study was carried out from 2008 to 2023, including 29 patients, affected by localized CD. These data were analyzed: demographics, SES-CD, and PCDAI, before and after surgery. The differences between groups were analyzed using Student's t-test for continuous variables, and Pearson's Chi-squared test or Fisher's exact test for categorical variables. Results: The SES-CD significantly decreased from 12 (median, range 1-15) to 0 (median, range 0-6) (p < 0.0001) and the PCDAI decreased from 30 (median, range 10-50) to 0 (median, range 0-15) (p < 0.0001). The rate of patients receiving enteral nutrition decreased from 51.7% preoperatively to 0% postoperatively (p = 0.0001). The rate of antibiotic use decreased from 13.8% to 0% (p = 0.0001). The rate of patients receiving ≥2 drugs decreased from 10.3% to 0% (p = 0.0001). Conclusions: The early surgical approach can be considered an excellent therapeutic strategy in patients with localized CD. Both parameters examined, SES-CD and PCDAI, demonstrated a clear improvement in the endoscopic images and in disease activity.

Current approaches to the surgical management of Crohn's disease in Australia and New Zealand

PURPOSE

Given the evolving literature regarding the optimal surgical approach to mitigate post-operative recurrence of Crohn's disease (CD), this survey study aimed to elucidate the practices and preferences of colorectal surgeons in Australia and New Zealand (ANZ) in their surgical management of CD.

METHODS

Colorectal surgical consultants and fellows (n = 337) registered with the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) were invited by email in April 2022 to participate in a cross-sectional survey consisting of basic demographics and 12 questions relating to their usual surgical practice and preferred operative strategy.

RESULTS

A total of 135 responses were received (39.9%). Regarding anastomotic configuration, 47% (n = 68) preferred the side-to-side anastomosis (STSA), 19% (n = 28) the end-to-end anastomosis (ETEA), and 15% (n = 21) the Kono S anastomosis. Most respondents preferred to resect at the proximal junction of the abnormal mesentery (75%, n = 97), while radical resection of the mesentery was preferred in 10% (n = 13) and close intestinal resection through abnormal mesentery in 15% (n = 20). The preferred surgical approach was by far laparoscopic (93%, n = 125) with extraction from the midline peri-umbilical port (80%, n = 108).

CONCLUSION

Amongst participating colorectal surgeons, there was a clear consensus on the approach, where the dominant practice was laparoscopy with a midline peri-umbilical extraction. Similarly, most respondents preferred some degree of mesenteric resection. However, anastomotic configuration and technique were domains of resection in CD lacking unanimity despite clear guidelines, highlighting an area requiring further attention.

Microbiome and Mucosal Immunity in the Intestinal Tract

The human bowel is exposed to numerous biotic and abiotic external noxious agents. Accordingly, the digestive tract is frequently involved in malfunctions within the organism. Together with the commensal intestinal flora, it regulates the immunological balance between inflammatory defense processes and immune tolerance. Pathological changes in this system often cause chronic inflammatory bowel diseases including Crohn's disease and ulcerative colitis. This review article highlights the complex interaction between commensal microorganisms, the intestinal microbiome, and the intestinal epithelium-localized local immune system. The main functions of the human intestinal microbiome include (i) protection against pathogenic microbial colonization, (ii) maintenance of the barrier function of the intestinal epithelium, (iii) degradation and absorption of nutrients and (iv) active regulation of the intestinal immunity. The local intestinal immune system consists primarily of macrophages, antigen-presenting cells, and natural killer cells. These cells regulate the commensal intestinal microbiome and are in turn regulated by signaling factors of the epithelial cells and the microbiome. Deregulated immune responses play an important role and can lead to both reduced activity of the commensal microbiome and pathologically increased activity of harmful microorganisms. These aspects of chronic inflammatory bowel disease have become the focus of attention in recent years. It is therefore important to consider the immunological-microbial context in both the diagnosis and treatment of inflammatory bowel diseases. A promising holistic approach would include the most comprehensive possible diagnosis of the immune and microbiome status of the patient, both at the time of diagnostics and during therapy.

Suboptimal disease control and contributing factors in Italian IBD patients: The IBD-PODCAST Study

BACKGROUND AND AIM

Suboptimal disease control (SDC) and its contributing factors in IBD according to STRIDE-II criteria is unclear. IBD-PODCAST was a non-interventional, international, multicenter real-world study to assess this.

METHODS

Data from the Italian IBD cohort (N=220) are presented here. Participants aged ≥19 with confirmed IBD diagnosis of ≥1 year were consecutively enrolled. A retrospective chart review and cross-sectional assessment by physicians and patients within the past 12 months were performed. SDC or optimal disease control was assessed using adapted STRIDE-II criteria.

RESULTS

At the index date, 53.4 % of 116 CD patients and 49.0 % of 104 UC patients had SDC, mainly attributed to a Short Inflammatory Bowel Disease Questionnaire score <50, failure to achieve endoscopic remission, and the presence of active extra-intestinal manifestations in both diseases. Disease monitoring with imaging and/or endoscopy during the previous year was conducted in ∼50 % of patients, with endoscopy performed in ∼40 %. Potential therapeutic adjustments were reported for half of the patients.

CONCLUSIONS

This study highlights SDC in a significant portion of IBD Italian patients. These results emphasize the need for more proactive management strategies in both CD and UC patients.

Intravenous Steroids Do Not Improve Short-Term Outcomes of Patients With Crohn's Disease Presenting With an Acute Small Bowel Obstruction

BACKGROUND

Intravenous (IV) steroids are commonly used to treat acute flares of Crohn's disease (CD). However, it is unclear if they are beneficial in the setting of uncomplicated small bowel obstruction (SBO). We sought to examine if IV steroid administration improved short-term outcomes in patients with CD hospitalized for acute, uncomplicated SBO across three New York City hospital systems.

METHODS

This retrospective study included patients ≥ 18 years old admitted between January 1, 2011, and December 31, 2019, with Crohn's disease and an admission diagnosis of uncomplicated acute SBO, defined as cases without adhesions, fistula, phlegmon, and sepsis. Primary endpoints (length of stay and frequency of surgery) were compared between patients who received IV steroids upon admission and those who did not.

RESULTS

Our analysis included 674 unique patients. Ninety-two (14%) received IV steroids, and 582 (86%) did not. IV steroid use did not result in shorter hospital stays (median days [IQR]: 3.0 (2.0-5.5) days vs 3.0 (2.0-6.0) days in the no-steroid group, P = .65) or reduce the need for surgery (4 patients (4.4%) vs 28 patients (4.8%) in the no-steroid group, P = .85). Sex, age, disease duration, concomitant biologic therapy, and NG tube placement did not independently contribute to either outcome.

CONCLUSIONS

These findings suggest that IV steroid administration for uncomplicated SBO in CD patients does not decrease hospital length of stay or need for surgery. Further research may help identify specific obstruction patterns or other therapies associated with different outcomes.

Evaluation of the Effectiveness and Safety of Mesenchymal Stem Cell Treatment in Fistulising Crohn's Disease: An International Real-Life Retrospective Multicentre Cohort Study

BACKGROUND

Perianal fistulas of Crohn's disease (CD) create a significant burden on patients' lives. However, the efficacy and safety of adipose-derived mesenchymal stem cell treatment are contradicting, and real-world evidence is lacking.

AIMS

To examine the usability of darvadstrocel therapy in managing perianal CD.

METHODS

We enrolled patients with CD and perianal fistulas in this retrospective multicenter study. The primary outcome was perianal clinical remission (defined as all treated fistulas closed) at weeks 26 and 52. Secondary outcomes were clinical response rates (≥ 1 fistulas closed), perianal activity (PDAI), patient satisfaction, and adverse events. Data were recorded at baseline and weeks 12, 26 and 52. Prediction of primary outcomes was performed by logistic regression.

RESULTS

Overall, among 223 patients (male/female ratio: 0.48), perianal clinical remission was achieved in 78.2% and 62.3% until weeks 26 and 52. Baseline PDAI score (OR 0.75), number of fistulas (OR 0.28) and the number of weeks after preparation for surgery (OR 0.98) were associated with treatment failure. The clinical response rates were 84.8% and 79.8% at weeks 26 and 52. Improvement of subjective perianal symptoms was achieved in 77.8% and 78.4% of patients, respectively. Adverse events occurred in 13.5% of patients; perianal abscesses and proctalgia were the most frequently reported.

CONCLUSION

Effectiveness data were higher than in clinical trials. The safety profile was reassuring, and patients' satisfaction was high. Appropriate patient selection, fistula preparation and expertise may help to achieve treatment success.

Device-Assisted Enteroscopy in Inflammatory Bowel Disease: From Balloon Enteroscopy to Motorized Spiral Enteroscopy

Careful patient selection is a key factor in optimizing the use of device-assisted enteroscopy (DAE) in Crohn's disease (CD). Current technologies include double-balloon enteroscopy and single-balloon enteroscopy which have similar efficiency and safety. DAE allows a variety of therapeutic interventions in the small bowel (SB). These include dilation of SB strictures which achieves promising results and should be preferred to surgery that can still be performed in the event of failure. DAE has developed into an indispensable part of clinical practice in the management of CD patients.

The Role of Diet in Inflammatory Bowel Disease Onset, Disease Management, and Surgical Optimization

The concept of using diet as therapy in inflammatory bowel disease is of interest to clinicians and patients. Once considered to play a minor role, diet is now known to not only affect disease onset but may also serve as a therapeutic tool for inducing and maintaining remission and improving surgical outcomes. Further research is needed to fully elucidate how, when, and in whom diet therapies may be best applied to improve clinical and disease outcomes. The aim of this review was to summarize current research findings and serve as a tool to help facilitate patient-clinician conversations.

Discordance between MR enterography and endoscopic detection of Crohn's disease ileal strictures: evidence to inform recommendations

PURPOSE

To evaluate correlation between terminal ileal (TI) stricture diagnosis at MR enterography (MRE) and ileocolonoscopy (IC) in patients with Crohn's disease (CD).

METHODS

One hundred and four patients with CD (51% females; 41 ± 15 years) underwent IC and MRE within 3 months in this retrospective case-control study. Positive cases had TI strictures diagnosed by endoscopy (n = 35); or MRE (threshold small bowel dilation ≥ 3cm; n = 34). Negative controls did not have stricture by either modality (n = 35). Three radiologists examined MRE exams, with per-patient stricture diagnosis based on majority agreement. Sensitivity for stricture diagnosis using threshold dilation of 2.5 cm at MRE was also evaluated.

RESULTS

There were 69 CD TI strictures (57 by endoscopy; 43 by MRE). Sensitivity by endoscopy and MRE criteria were 82.6% (57/69) and 62.3% (43/69), respectively, with additional 20.3% (14/69) of MRE exams classified as "probable stricture" by SAR/AGA/SPR criteria. Lowering MRE small bowel dilation threshold to 2.5 cm increased MRE sensitivity for endoscopically-diagnosed strictures to 71.9% (41/57; up from 56.1% [32/57]), without sacrificing interobserver agreement (κ = 0.684 vs. κ = 0.587). Of 25 new patients diagnosed with a TI stricture using a 2.5 cm threshold by 2 or more readers, 96% (24/25) had hospitalization, small bowel obstruction, endoscopic dilation, and/or surgical resection during clinical follow-up. Nine false negative MRE exams had short strictures with bowel dilation ≥ 2.5 cm.

CONCLUSION

Either IC or MRE alone is insufficient to diagnose Crohn's small bowel strictures. Diagnostic criteria should incorporate endoscopic and MRE findings. Lowering threshold dilation to 2.5 cm increases sensitivity in stricture diagnosis and identifies clinically significant strictures.

Appraisal of current surgical guidelines for inflammatory bowel disease using the AGREE-S instrument: A scoping review

AIM

Guidelines play a crucial role in improving patient care by providing clinicians with up to date evidence-based recommendations. A vast number of guidelines exist on the surgical management of inflammatory bowel disease (IBD). The aim of this scoping review was to identify current surgical IBD guidelines, assess their quality and identify areas of variation between the existing guidelines.

METHOD

A systematic search of the literature from January 2008 to September 2023 was conducted. After identifying eligible guidelines, they were assessed for quality using the Appraisal of Guidelines for Research and Evaluation for Surgical Interventions (AGREE-S) instrument. Data were extracted on descriptive guideline characteristics and recommendations.

RESULTS

Fifteen guidelines were identified globally. Most guidelines were published between 2011 and 2023, with six focusing solely on Crohn's disease, five on ulcerative colitis and four on both. Six guidelines focused exclusively on surgical management, while nine contained both medical and surgical recommendations. The overall mean AGREE-S score was 59%, with more recent guidelines scoring higher.

CONCLUSIONS

The quality of IBD surgical guidelines varies considerably. High-quality, collaborative, international guidelines are needed to reduce duplication and ensure consistent, evidence-based surgical care for IBD patients worldwide. Future guideline development should adhere to the AGREE-S criteria to enhance methodological rigour and transparency.

Reversal Surgery for Split Stoma with Peristomal Incision is Associated with Improved Postoperative Outcome in Patients with Crohn's Disease

BACKGROUND

Temporary stoma formation is common in Crohn's disease (CD), while stoma reversal is associated with postoperative morbidity. This study aimed to evaluate the postoperative outcomes of split stoma reversal, SSR (i.e., exteriorization of proximal and distal ends of the stoma through a small common opening) and end stoma closure, ESC (i.e., the proximal stump externalized, and distal end localized abdominally.

METHODS

Patients with CD who underwent stoma reversal surgeries between January 2017 and December 2021 were included. Demographic, clinical, and postoperative data were collected and analyzed to evaluate outcomes of reversal surgery.

RESULTS

A total of 255 patients who underwent stoma reversal surgeries met the inclusion criteria. SSR was superior to ESC in terms of operative time (80.0 vs. 120.0, p = 0.0004), intraoperative blood loss volume (20.0 vs. 100.0, p = 0.0002), incision length (3.0 vs. 15.0, p < 0.0001), surgical wound classification (0 vs. 8.3%, p = 0.04), postoperative hospital stay (7.0 vs. 9.0, p = 0.0007), hospital expense (45.6 vs. 54.2, p = 0.0003), and postoperative complications (23.8% vs. 44.3%, p = 0.0040). Although patients in the ESC group experienced more surgical recurrence than those in the SSR group (8.3% vs. 3.2%) during the follow-up, the Kaplan-Meier curve analysis revealed no statistical difference (p = 0.29).

CONCLUSIONS

The split stoma can be recommended when stoma construction is indicated in patients with Crohn's disease.

Navigating the complexities of perianal Crohn's disease: Diagnostic strategies, treatment approaches, and future perspectives

This article discusses the literature review article by Pacheco et al published in July 2024; the authors provided good reviews of perianal Crohn's disease (CD), and challenges faced by clinicians in the management. CD, characterized by its chronic and relapsing nature, is an idiopathic condition that can involve any segment of the gastrointestinal tract. Perianal disease impacts up to 40% of patients with CD, with perianal fistulas constituting up to 80% of perianal lesions. Perianal CD can be highly incapacitating and profoundly diminish the overall well-being of patients. The management focuses on controlling the perianal sepsis and treating luminal CD. Biologics are crucial to the treatment approach, and results have been encouraging. The surgery focuses on controlling the sepsis, with more definitive treatments being fistula surgery, fecal diversion, and proctectomy as the last resort. This manuscript briefly describes the burden of CD, the challenges posed by perianal CD, and the role of different treatment modalities from colorectal surgeon's perspective.

Prediction of the Short-Term Effectiveness of Ustekinumab in Patients with Moderate to Severe Crohn's Disease

Background

Ustekinumab (UST) is recommended as the first-line treatment for patients with moderate to severe Crohn's disease (CD). However, the efficacy of certain patients may be suboptimal and necessitate intensive treatment or modification of the treatment regimen. We sought to establish a nomogram model to predict the short-term effectiveness of UST in moderate to severe CD patients.

Methods

We established a derivation cohort comprising patients diagnosed with CD and treated with UST at the Sixth Affiliated Hospital of Sun Yat-sen University from May 2020 to July 2023. The patient data, including demographic and clinical characteristics as well as treatment details, were systematically collected. The achievement of clinical remission (defined as Crohn's Disease Activity Index, CDAI < 150, without corticosteroid usage) after induction therapy was the endpoint observed during follow-up. Potential predictors were identified through the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis. Subsequently, a multivariate logistic regression analysis was conducted to construct a nomogram model. The predictive accuracy and discriminative power of the model were assessed by Receiver Operating Characteristics (ROC) curves and calibration curves. Decision curve analysis (DCA) was employed to assess the clinical application value of the model.

Results

162 patients were included in the derivation cohort. The predictor's selection was according to the minimum criteria. Prognostic factors, including duration, body mass index (BMI), smoking, extraintestinal manifestations (EIMs), perianal lesions (P), history of Vedolizumab therapy, and albumin levels (ALB), were identified and included in the nomogram. The model showed good discrimination and calibration on internal validation based on the bootstrap method (C-index: 0.843, 95% confidence interval: 0.768-0.903). Moreover, DCA demonstrated that the nomogram was clinically beneficial.

Conclusion

We constructed a practical tool to assist clinicians in identifying moderate to severe CD patients who are expected to have a good clinical response to UST, promoting personalized treatment and the development of precision medicine.

Recurrence rates after strictureplasty for small bowel Crohn's disease remain high in the era of biologics

AIM

Despite advancements in therapeutic options for Crohn's disease (CD), strictureplasty is a mainstay bowel-preserving technique for small bowel CD. We sought to audit international practice across three high-volume centres since the widespread use of biologic medication.

METHODS

A retrospective audit was performed for all strictureplasties undertaken for small bowel CD, over a 15-year period (2006-2021), in three high-volume centres in the United Kingdom and Italy. Primary endpoints were clinical recurrence and reoperation for recurrence.

RESULTS

In all, 123 patients were included; 58% were men, 25% smoked and 60% had previous abdominal surgery for CD. Median age was 40 years (interquartile range 30-52 years), mean body mass index 22 (15-31) and median disease duration 138 months (81-255 months). 42% had been treated with biologics preoperatively. In total 338 strictureplasties were performed in 123 patients, with a median of two per patient (interquartile range 1-3). Complications occurred in 35%, with 8% scoring Clavien-Dindo Grade 3. There were no Grade 4/5 complications. Postoperative biologic treatment was administered to 84/123 patients (68.3%). Median follow-up was 54 months. 41/123 patients (33.3%) developed clinical recurrence. Reoperation for recurrent stricturing was performed in 26/123 patients (21%). Clinical recurrence and reoperation rates were significantly higher in patients who continued to smoke after their index surgery.

CONCLUSION

Strictureplasty remains a safe and effective surgical treatment for small bowel CD. Recurrence and reoperation rates remain high, regardless of postoperative biologic therapy. Smoking significantly increases the risk of recurrence.

Computerized tomography features acting as predictors for invasive therapy in the management of Crohn's disease-related spontaneous intra-abdominal abscess: experience from long-term follow-up

BACKGROUND

Decision-making in the management of Crohn's disease (CD)-related spontaneous intra-abdominal abscess (IAA) is challenging. This study aims to reveal predictive factors for percutaneous drainage and/or surgery in the treatment of CD-related spontaneous IAA through long-term follow-up.

METHODS

Data were collected, including clinical manifestations, radiography and treatment strategies, in Chinese patients with CD-related IAA in a tertiary medical center. Univariate and Multivariate Cox analysis were conducted to identify predictors for invasive therapy.

RESULTS

Altogether, 48 CD patients were identified as having IAA through enhanced CT scans. The median follow-up time was 45.0 (23.3, 58.0) months. 23 (47.9%) patients underwent conservative medical treatment, and 25 (52.1%) patients underwent percutaneous drainage and/or surgical intervention (invasive treatment group). The 1-, 2-, and 5-year overall survival rates without invasive treatment were 75.0%, 56.1%, and 46.1%, respectively. On univariate Cox analysis, the computerized tomography (CT) features including nonperienteric abscess (HR: 4.22, 95% CI: 1.81-9.86, p = 0.001), max abscess diameter (HR: 1.01, 95% CI: 1.00-1.02, p<0.001) and width of sinus (HR: 1.27, 95% CI: 1.10-1.46, p = 0.001) were significantly associated with invasive treatment. Nonperienteric abscess was significantly associated with invasive treatment on multivariate Cox analysis (HR: 3.11, 95% CI: 1.25-7.71, p = 0.015). A score model was built by width of sinus, location of abscess and max abscess diameter to predict invasive treatment. The AUC of ROC, sensitivity and specificity were 0.892, 80.0% and 90.9% respectively.

CONCLUSIONS

More than half of CD-related IAA patients needed invasive therapy within 5-year follow-up. The CT features including nonperienteric abscess, larger maximum abscess diameter and width of sinus suggested a more aggressive approach to invasive treatment.

Preoperative Exclusive Enteral Nutrition Is Associated With Reduced Skin and Soft Tissue and Intra-abdominal Infections in Patients With Crohn's Disease Undergoing Intestinal Surgery: Results from a Meta-Analysis

BACKGROUND

Malnutrition is an independent risk factor for adverse postoperative outcomes and is common among patients with Crohn's disease (CD). The objective of this meta-analysis was to precisely quantify the association of preoperative exclusive enteral nutrition (EEN) and total parenteral nutrition (TPN) with surgical outcomes in patients undergoing intestinal surgery for CD.

METHODS

PubMed, Embase, and Scopus were queried for comparative studies evaluating the impact of preoperative nutritional support on postoperative outcomes in patients undergoing surgery for CD. Random effects modeling was used to compute pooled estimates of risk difference. Heterogeneity was assessed using I2.

RESULTS

Fourteen studies, all nonrandomized cohort studies, met inclusion criteria for studying EEN. After pooling data from 14 studies (874 EEN treated and 1044 control patients), the relative risk of intra-abdominal septic complications was decreased 2.1-fold in patients receiving preoperative EEN (relative risk 0.47, 95% confidence interval [CI], 0.35-0.63, I2 = 0.0%). After pooling data from 9 studies (638 EEN treated and 819 control patients), the risk of skin and soft tissue infection was decreased 1.6-fold (relative risk 0.63; 95% CI, 0.42-0.94, I2 = 42.7%). No significant differences were identified in duration of surgery, length of bowel resected, or operative blood loss. Among the 9 studies investigating TPN, no significant differences were identified in infectious outcomes.

CONCLUSIONS

Preoperative nutritional optimization with EEN was associated with reduced risk of infectious complications in CD patients undergoing intestinal surgery. Preoperative nutritional support with EEN should be considered for optimizing outcomes in CD patients requiring bowel resection surgery.

Inflammatory Bowel Disease and Endometriosis: Diagnosis and Clinical Characteristics

Background/Objectives: Endometriosis and inflammatory bowel disease (IBD) share some epidemiological, clinical and pathogenetic features. A differential diagnosis between pelvic endometriosis and IBD may be challenging, even for expert clinicians. In the present review, we aimed to summarize the currently available data regarding the relationship between endometriosis and IBD and their possible association. Methods: The PubMed and Scopus database were considered, by searching the following terms: "Crohn's Disease", "Ulcerative Colitis", "Endometriosis", "Adenomyosis", and "Inflammatory Bowel Disease", individually or combined. Full-text papers published in English with no date restriction were considered. Results: Few studies have researched the possible association between endometriosis and IBD. Both conditions are characterized by chronic recurrent symptoms, which may be shared (abdominal pain, fatigue, infertility, menstrual irregularities, diarrhea, constipation). Deep infiltrating endometriosis (DIE) can cause bowel symptoms. In a large Danish study, a 50% increased risk of IBD was observed in women with endometriosis. A missed diagnosis of endometriosis and an increased risk of endometriosis has been reported in IBD. Current evidence does not support an association between endometriosis and IBD characteristics. However, IBD may be associated with DIE, characterized by pelvic symptoms (dyschezia, dyspareunia). Preliminary observations suggest an increased IBD risk in patients with endometriosis treated with hormonal therapy. Conclusions: Current findings suggest that a careful search is needed for concomitant endometriosis in subgroups of patients with IBD showing compatible symptoms and vice versa. A multidisciplinary approach including dedicated gastroenterologists and gynecologists is required for a proper search for IBD and endometriosis in subgroups of patients. This approach may avoid diagnostic delays or overtreatments for these conditions.

Characteristics of Interventional Trials for Patients Living With Intestinal Stoma Registered in ClinicalTrials.gov With a Focus on Inflammatory Bowel Disease

BACKGROUND

This systematic review was performed to characterize the landscape of research conducted in patients with intestinal stoma (IS) and highlight unmet needs for clinical research in Crohn's disease (CD) and IS.

METHODS

We searched ClinicalTrials.gov from inception to May 25, 2022, to identify clinical trials assessing interventions in patients with an IS, as well as those with an IS and CD. Studies were grouped according to type of intervention. We excluded observational studies with no treatment arm.

RESULTS

A total of 253 studies were included in the final analysis. Most studies investigated devices (n = 122 [48.2%]), or surgical procedures (n = 63 [24.9%]), followed by behavioral interventions (n = 30 [11.8%]), drugs (n = 20 [7.9%]), dietary interventions (n = 2 [0.8%]), skin care products (n = 2 0.8%]), and others (n = 14 [5.5%]). A total of 50.9% (n = 129) of studies had completed recruitment, enrolling 11 116 participants. Only 6 studies (surgery: n = 3; physiological studies: n = 2; drugs: n = 1) exclusively included patients with inflammatory bowel disease (IBD), and 16 studies commented that patients with IBD were excluded in their eligibility criteria. No study assessed efficacy of drugs in patients with CD and IS. Approximately one-quarter of studies (n = 65 of 253) included quality of life as an outcome measure.

CONCLUSION

There is a paucity of research in IBD patients with IS, with the majority focusing on devices and surgical procedures. There have been no drug trials evaluating efficacy in patients with CD and IS. There is an urgent need to identify barriers to enrollment and develop eligibility and outcome measures that enable the inclusion of patients with CD with stoma into clinical trials.