Early versus late surgery in patients with intestinal Behçet disease

Intestinal Behçet's disease: A review of clinical diagnosis and treatment

Behçet's disease (BD) is a chronic inflammatory disorder prone to frequent recurrences, with a high predilection for intestinal involvement. However, the efficacy and long-term effects of surgical treatment for intestinal BD are unknown. In the current issue of World J Gastrointest Surg, Park et al conducted a retrospective analysis of 31 patients with intestinal BD who received surgical treatment. They found that elevated C-reactive protein levels and emergency surgery were poor prognostic factors for postoperative recurrence, emphasizing the adverse impact of severe inflammation on the prognosis of patients with intestinal BD. This work has clinical significance for evaluating the postoperative condition of intestinal BD. The editorial attempts to summarize the clinical diagnosis and treatment of intestinal BD, focusing on the impact of adverse factors on surgical outcomes. We hope this review will facilitate more precise postoperative management of patients with intestinal BD by clinicians.

Short- and long-term outcomes of surgical treatment in patients with intestinal Behcet's disease

BACKGROUND

Behcet's disease (BD), a chronic vasculitic disorder affecting multiple organs, is characterized by recurrent oral and genital ulcers, arthritis, vasculitis, and intestinal ulcers. Although intestinal involvement of BD is common in East Asia, the efficacy and long-term outcomes of surgical treatment of intestinal BD still remain to be established.

AIM

To evaluate the postoperative clinical course of intestinal BD and determine factors associated with its recurrence.

METHODS

Data from patients who underwent surgical treatment for intestinal BD between January 2010 and August 2021 were retrospectively reviewed. Patients' demographics, clinical features, postoperative course, complications, and follow-up data were evaluated.

RESULTS

We analyzed 39 surgeries in 31 patients. The mean patient age was 45.1 years, and the mean interval between the diagnosis of intestinal BD and surgical treatment was 4.9 years (range 1.0-8.0 years). The most common indication for surgery was medical intractability (n = 16, 41.0%), followed by fistula or abscess (n = 11, 28.2%). Laparoscopic approaches were used in 19 patients (48.7%), and 5 patients (12.8%) underwent emergency surgeries. The most common surgical procedure was ileocecal resection (n = 18, 46.2%), followed by right colectomy (n = 11, 28.2%). A diverting stoma was created in only one patient (2.6%). During a mean follow-up period of 45 (range 8-72) months, eight cases (20.5%) of recurrence in five patients required reoperation. The interval between operations was 12.1 months (range 6.3-17.8 mo). Four patients (10.3%) experienced recurrence within 1 year postoperatively, and all eight recurrences occurred within 2 years of the initial surgery. The reoperation rates at 1 and 3 years were 10.3% and 20.5%, respectively. A redo ileocolic anastomosis was performed in all recurrent cases. In multivariate Cox regression analysis, emergency surgery [hazard ratio (HR) 9.357, 95% confidence interval (CI): 1.608-54.453, P = 0.013] and elevated C-reactive protein (CRP) levels (HR 1.154, 95%CI: 1.002-1.328, P = 0.047), but not medication use, were predictors of recurrence.

CONCLUSION

Surgical resection is a feasible treatment option for complicated BD. Reoperation is associated with severe inflammatory conditions, reflected by increased CRP levels and the requirement for emergency surgery.

C-reactive protein is associated with postoperative outcomes in patients with intestinal Behçet's disease

BACKGROUND

Patients with intestinal Behçet's disease (BD) frequently undergo intestinal resections, which significantly affects postoperative morbidity and mortality. The aim of this study was to identify the association between C-reactive protein (CRP) levels and postoperative outcomes in patients with intestinal BD who underwent surgical bowel resection.

METHODS

Patients who were diagnosed with intestinal BD and underwent intestinal surgery due to BD at Severance Hospital between November 2005 and April 2018 were retrospectively investigated. Clinical relapse was defined as a disease activity index of BD (DAIBD) > 40, existence of newly added medications, re-hospitalization, or re-operation related to intestinal BD. The relationship between CRP level and postoperative outcomes was analyzed, and a receiver operating characteristic (ROC) curve was drawn to specify a cut-off value.

RESULTS

Ninety patients with intestinal BD were included. Among them, 44 were male (48.9%), and the median age at diagnosis was 38 years (range, 11-69 years). The median total disease follow-up duration was 130 months (range, 3-460 months). Forty patients (44.4%) underwent laparoscopic surgery. A higher CRP level immediately after surgery was significantly associated with postoperative complications (OR 1.01, 95% CI 1.004-1.018, p < 0.01), re-operation (hazard ratio [HR] 1.01, 95% CI 1.005-1.020, p < 0.01), and re-admission (HR 1.01, 95% CI 1.006-1.017 p < 0.01). The ROC curve showed that CRP predicts the risk of postoperative complications (p < 0.01) at a cut-off value of 41.9% with a sensitivity of 60.0% and specificity of 67.7%.

CONCLUSIONS

Postoperative CRP levels in patients with intestinal BD undergoing surgical resection were associated with postoperative outcomes.

Long-term outcome after surgery in a patient with intestinal Behçet's disease complicated by myelodysplastic syndrome and trisomy 8

Behçet's disease (BD) is a multisystem inflammatory disease of unknown origin. Rarely, BD occurs together with myelodysplastic syndrome (MDS). Interestingly, it is speculated that these are not simple coexistence but that the etiology of intestinal BD is at least partly derived from MDS itself. Furthermore, there is a relationship between MDS in patients with intestinal BD and trisomy 8. Immunosuppressive agents alone are insufficient to control MDS-associated BD, and many of these patients die of infection or hemorrhage. Surgery is considered for intestinal BD patients who are unresponsive to medical treatment or those with bowel complications such as perforation or persistent bleeding. We report a case of intestinal BD associated with MDS and trisomy 8. The patient was unresponsive to oral steroids and immunosuppressive treatment; the patient improved by surgical repair of a bowel perforation. Five years after the surgery, the patient is free of recurrence and not on medication. Our experience suggests that surgery may provide an effective therapeutic option for the treatment of MDS-related BD.

Incidence and clinical outcomes of intestinal Behçet's disease in Korea, 2011-2014: a nationwide population-based study

BACKGROUND

Intestinal Behçet's disease (BD) is very rare, and epidemiologic data regarding BD are scarce. Moreover, there have been no population-based studies focusing on intestinal BD. We conducted a nationwide population-based study to examine the incidence and clinical course of Korean patients with intestinal BD.

METHODS

We collected data on 365 patients diagnosed with intestinal BD from 2011 to 2014 using the Health Insurance Review and Assessment Services claims database. We analyzed the incidence and clinical outcomes, including cumulative rates of bowel resection, hospitalization, and medication use.

RESULTS

During the study period, the average annual incidence for intestinal BD was 0.18 per 10⁵ population, and the proportion of cases with intestinal involvement was 3.9%. At 1 and 4 years after diagnosis, the cumulative rates of surgery were 5.0 and 10.9%, respectively, whereas those of hospitalization were 27.8 and 32.4%, respectively. The 1- and 4-year cumulative rates of requirements for medications were 39.8 and 49.1% for moderate- to high-dose corticosteroids, 33.6 and 42.1% for immunomodulators, and 3.5 and 6.8% for biologics, respectively. The cumulative probability of corticosteroid and immunomodulator use was higher in male than in female patients and in younger (<40 years) than in older (≥40 years) patients. However, there were no significant differences in the cumulative probabilities of surgery, hospitalization, and biologics use according to sex and age group.

CONCLUSIONS

The incidence of intestinal BD in Korea is quite low and has been stable in recent years.

The outcomes and risk factors of early reoperation after initial intestinal resective surgery in patients with intestinal Behçet's disease

PURPOSE

Patients with intestinal Behçet's disease who underwent intestinal resective surgery often require reoperation. However, there have been no studies on the risk factors and outcomes of early reoperation in these patients.

METHODS

We retrospectively evaluated 41 patients with intestinal Behçet's disease who received repeated intestinal resective surgeries between 2006 and 2016. We analyzed two different patient groups-those who required early reoperation within 6 months and those who underwent reoperation >6 months after the initial surgery-and determined the risk factors for early reoperation.

RESULTS

Eleven patients (26.8%) underwent reoperation within 6 months and 30 patients (73.2%) after 6 months. Emergency surgery at the initial operation and higher initial perioperative erythrocyte sedimentation rate and C-reactive protein levels were significantly associated with early reoperation in the univariate analysis. After the multivariate analysis, initial emergency operation (P = 0.020; hazard ratio [HR], 42.625; 95% confidence interval [CI], 1.817-1000.088) and high erythrocyte sedimentation rate (P = 0.039; HR, 1.049; 95% CI, 1.002-1.097) were determined to be the independent factors for early reoperation.

CONCLUSIONS

Emergency surgery and high perioperative erythrocyte sedimentation rate levels were the prognostic factors for early reoperation (within 6 months) in patients with intestinal Behçet's disease after initial bowel resective surgery.

An update on the diagnosis, treatment, and prognosis of intestinal Behçet's disease

PURPOSE OF REVIEW

This review discusses recent scientific developments in the diagnosis, treatment, and prognosis of intestinal Behçet's disease.

RECENT FINDINGS

Gastrointestinal involvement is a major cause of morbidity and mortality in Behçet's disease. Patient clinical data are scarce because of the rarity of the disease; however, novel diagnostic criteria and disease activity indices have been developed recently to aid treatment of Behçet's disease patients. Current therapies include 5-aminosalicylic acids, corticosteroids, immunomodulators, or antitumor necrosis factor alpha agents. Antitumor necrosis factor alpha agents can achieve clinical responses and remission in patients that were previously nonresponsive to corticosteroids or immunomodulators. Clinical variables, including young age and higher disease activity at the time of diagnosis, volcano-type ulcers, absence of mucosal healing, higher C-reactive protein levels, prior history of surgery, and lack of initial response to medical therapy, can be regarded as poor prognostic factors.

SUMMARY

Previously, the diagnosis and management of intestinal Behçet's disease depended upon the expertise of individual clinicians; however, more standardized medical assessments and improved treatment regimens for Behçet's disease patients are evolving.

Management of Behçet's syndrome

PURPOSE OF REVIEW

There is agreement that the management of Behçet's syndrome has recently improved, especially with the wider use of biologics. The aim of this review is to summarize the current management strategies in Behçet's syndrome.

RECENT FINDINGS

There is growing experience with tumor necrosis factor-alpha antagonists in the management of eye gastrointestinal and nervous disease in Behçet's syndrome. Interferon-alpha at lower doses may increase its tolerability. Other biologics such as interleukin 1-blocking agents and tocilizumab were used in a small number of patients and also seem to be effective.

SUMMARY

Although experiences with biologics have expanded and looks promising, this is mostly observational or retrospective. There still is a lack of controlled trials with these agents, especially in patients with major organ involvement.

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Behcet's disease with multiple spontaneous intestinal perforations: A case report

Behcet's disease may lead to perforation of the intestine, which is often misdiagnosed. Surgical operation is the main treatment, but intestinal fistula is an important postoperative complication. Therefore, surgical treatment of Behcet's disease requires reasonable operation planning, unobstructed drainage and effective postoperative treatment.