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Wall CL, Bensley R, Glyn T, Haines M, Rowbotham D, Bissett I, Eglinton T, Gearry RB. Preoperative Crohn's Disease Exclusion Diet and Exclusive Enteral Nutrition in Adults with Crohn's Disease: A Feasibility Randomised Controlled Trial. Nutrients 2024; 16:2105. [PMID: 38999853 PMCID: PMC11243368 DOI: 10.3390/nu16132105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
Preoperative exclusive enteral nutrition (EEN) improves nutritional status, reduces intestinal inflammation, and likely improves surgical outcomes. Crohn's disease exclusion diet with partial enteral nutrition (CDED) also reduces intestinal inflammation but its safety preoperatively is unknown. This single-blinded, multicentre, randomised controlled trial of three preoperative nutritional therapies aimed to assess the feasibility of recruiting and retaining patients and collecting primary and secondary effectiveness outcomes. Adults undergoing elective Crohn's disease surgery with a body mass index (BMI) > 18.5 kg/m2 and without significant weight loss were eligible to participate. Patients were randomly assigned to six weeks of preoperative EEN, CDED, or standard care. Feasibility, nutritional, radiological, and surgical outcomes were recorded. Over 18 months, 48 patients were screened, 17 (35%) were randomised, and 13/17 (76%) patients were retained in the intervention phase. It was feasible to collect primary and secondary effectiveness data; at day 30, three patients had Clavien Dindo Grade 2 complications, and 10 had no complications. Nutritional therapy adherence of patients retained in the study was high. Recruitment and retention of patients who need elective Crohn's disease surgery for preoperative nutritional therapy is possible, although a shorter duration may improve EEN completion. The impact on surgical outcomes should be assessed in a larger study.
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Affiliation(s)
- Catherine L. Wall
- Department of Medicine, University of Otago, Christchurch 8011, New Zealand
| | - Rachael Bensley
- Department of Medicine, University of Otago, Christchurch 8011, New Zealand
| | - Tamara Glyn
- Department of Surgery and Critical Care, University of Otago, Christchurch 8011, New Zealand
- Christchurch Hospital, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch 8011, New Zealand
| | - Melissa Haines
- Waikato Hospital, Te Whatu Ora Health New Zealand Waikato, Hamilton 3240, New Zealand
| | - David Rowbotham
- Auckland City Hospital, Te Whatu Ora Health New Zealand Te Toka Tumai, Auckland 1023, New Zealand
| | - Ian Bissett
- Auckland City Hospital, Te Whatu Ora Health New Zealand Te Toka Tumai, Auckland 1023, New Zealand
- Department of Surgery, The University of Auckland, Auckland 1023, New Zealand
| | - Timothy Eglinton
- Department of Surgery and Critical Care, University of Otago, Christchurch 8011, New Zealand
- Christchurch Hospital, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch 8011, New Zealand
| | - Richard B. Gearry
- Department of Medicine, University of Otago, Christchurch 8011, New Zealand
- Christchurch Hospital, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch 8011, New Zealand
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Fiorindi C, Giudici F, Testa GD, Foti L, Romanazzo S, Tognozzi C, Mansueto G, Scaringi S, Cuffaro F, Nannoni A, Soop M, Baldini G. Multimodal Prehabilitation for Patients with Crohn's Disease Scheduled for Major Surgery: A Narrative Review. Nutrients 2024; 16:1783. [PMID: 38892714 PMCID: PMC11174506 DOI: 10.3390/nu16111783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/25/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.
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Affiliation(s)
- Camilla Fiorindi
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Francesco Giudici
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 6, 50135 Florence, Italy; (F.G.); (S.S.)
| | - Giuseppe Dario Testa
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Division of Geriatric and Intensive Care Medicine, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Lorenzo Foti
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Section of Anesthesiology and Intensive Care, University of Florence, Largo Brambilla 3, 50139 Florence, Italy
| | - Sara Romanazzo
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Cristina Tognozzi
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Giovanni Mansueto
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Stefano Scaringi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 6, 50135 Florence, Italy; (F.G.); (S.S.)
| | - Francesca Cuffaro
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
| | - Anita Nannoni
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
| | - Mattias Soop
- Department for IBD and Intestinal Failure Surgery, Karolinska University Hospital, SE 177 76 Stockholm, Sweden;
| | - Gabriele Baldini
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Section of Anesthesiology and Intensive Care, University of Florence, Largo Brambilla 3, 50139 Florence, Italy
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3
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Ullrich SJ, Frischer JS. Surgical management of complicated Crohn's disease. Semin Pediatr Surg 2024; 33:151399. [PMID: 38642531 DOI: 10.1016/j.sempedsurg.2024.151399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2024]
Abstract
Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population - notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.
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Affiliation(s)
- Sarah J Ullrich
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA
| | - Jason S Frischer
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA.
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Duan M, Cao L, Lu M, Zhang T, Ji Q, Guo X, Guo Z, Wu Q, Liu Y, Gong J, Zhu W, Li Y. Prophylactic Intra-abdominal Drainage is Associated With Lower Postoperative Complications in Patients With Crohn's Disease: A Randomized Controlled Trial. Surg Innov 2024; 31:157-166. [PMID: 38339842 DOI: 10.1177/15533506241232598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Prophylactic intraoperative drains have been shown not superior for patients underwent intestinal surgery. However, for patients with Crohn's disease (CD), this needs further exploration. METHODS In this pilot study, CD patients were randomly assigned to drain (n = 50) and no-drain (n = 50) groups. The primary endpoint was the rate of postoperative prolonged ileus (PPOI). The secondary endpoints were postoperative abdominal ascites, postoperative systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) levels. RESULTS The incidences of PPOI and postoperative abdominal ascites were significantly lower in the drain group (12% vs 44%; 0% vs 24%, both P < .05). Postoperative SIRS incidence and CRP levels were significantly increased in the no-drain group [36% vs 10%; 54.9 vs 34.3 mg/L, both P < .05]. In multivariate analysis, prophylactic drainage was the independent protective factor for PPOI and postoperative LOS. CONCLUSIONS Prophylactic drainage may be associated with improved clinical outcomes in CD patients.
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Affiliation(s)
- Ming Duan
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Mengjie Lu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qing Ji
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Xian Guo
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qiong Wu
- Department of Scientific Research and Training, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Yuxiu Liu
- Data and Statistics Division, Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Krasnovsky L, Weber AT, Gershuni V, Pettke E, Lewis JD. 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. Inflamm Bowel Dis 2024:izad304. [PMID: 38262631 DOI: 10.1093/ibd/izad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Indexed: 01/25/2024]
Abstract
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.
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Affiliation(s)
- Lev Krasnovsky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew T Weber
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Gershuni
- Division of Gastrointestinal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erica Pettke
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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6
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Chen Y, Cao L, Qiu J, Li Z, Guo Z, Zhu Z, Xu Y, Qian W, Zhu W, Li Y. Surgical Management and Outcome of Entero-Urinary Fistula Complicating Crohn's Disease: A Single Center Study. World J Surg 2023; 47:3365-3372. [PMID: 37775571 DOI: 10.1007/s00268-023-07196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Entero-urinary fistulas (EUF) are a rare complication of Crohn's disease (CD), observed in 1.6 to 7.7%. The management of EUF complicating CD is challenging. We aimed to report the outcome and surgical management of EUF in CD. METHODS A retrospective chart review was performed in all CD patients with EUF who underwent surgery in our center between January 2012 and December 2021. Patient demographics, preoperative optimization, surgical management, postoperative complications, and follow-up information were collected from a prospectively maintained database. RESULTS A total of 74 eligible patients were identified. The median interval between CD diagnosis and EUF diagnosis was 2 (0.08-6.29) years. Patients with EUF presented with pneumaturia (75.68%), urinary tract infections (72.97%), fecaluria (66.22%), and hematuria (6.76%). Fistulae originated most commonly from the ileum (63.51%), followed by the colon (14.86%), the rectum (9.46%), the cecum (2.70%), and multiple sites (9.46%). The EUF symptoms, weight, nutritional status, laboratory results were significantly improved after preoperative optimization. The absence of EUF symptoms was observed in 42 patients after the optimization and only 9 of which required bladder repair. However, 19 of 32 patients whose symptoms did not resolve required bladder repair (P = 0.001). Only 1 patient developed a bladder leakage in the early postoperative period and 3 patients experienced recurrent bladder fistula. CONCLUSIONS Surgical management of EUF complicating CD is effective and safe, with a low rate of postoperative complication and EUF recurrence. Preoperative optimization, which is associated with the resolution of urinary symptoms and improved surgical outcomes, should be recommended.
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Affiliation(s)
- Yusheng Chen
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Jiayin Qiu
- Department of Neurosurgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
| | - Zhun Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Zhenxing Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Yihan Xu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Wenwei Qian
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, People's Republic of China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
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Fansiwala K, Shah ND, McNulty KA, Kwaan MR, Limketkai BN. Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease. Nutr Clin Pract 2023; 38:1282-1295. [PMID: 37667524 DOI: 10.1002/ncp.11068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/25/2023] [Accepted: 08/06/2023] [Indexed: 09/06/2023] Open
Abstract
Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.
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Affiliation(s)
- Kush Fansiwala
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California, San Francisco, San Francisco, California, USA
| | - Kelly A McNulty
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Mary R Kwaan
- Division of Colon and Rectal Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Berkeley N Limketkai
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Hlaing HH, Sharkey LM. Let food be thy medicine…. Saudi J Gastroenterol 2023; Publish Ahead of Print:377484. [PMID: 37282443 DOI: 10.4103/sjg.sjg_180_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Affiliation(s)
- Htar Htar Hlaing
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Lisa Mary Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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9
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Howk AA, Smith SR, Polireddy K, Sauer CG, Kugathasan S, Glasson J, Chahine AA. The Use of the Perioperative Nutrition Score in Postoperative Pediatric Inflammatory Bowel Disease Patients. J Pediatr Surg 2023; 58:1195-1199. [PMID: 36914462 DOI: 10.1016/j.jpedsurg.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Preoperative malnutrition is associated with increased postoperative morbidity. The perioperative nutrition score (PONS) was developed to identify patients at risk of malnutrition. We sought to assess the correlation between preoperative PONS and postoperative outcomes in pediatric inflammatory bowel disease (IBD) patients. METHODS We performed a retrospective cohort study of IBD patients, less than 21 years of age, who underwent elective bowel resection between June 2018 and November 2021. Patients were divided based upon whether they met PONS criteria. The primary outcome was postoperative surgical site infections. RESULTS 96 patients were included. Sixty-one patients (64%) met at least one PONS criteria, while 35 patients (36%) met none. PONS positive patients more frequently received preoperative TPN supplementation (p < .001). There was no difference in preoperative oral nutritional supplementation between groups. Patients that screened positive for PONS had a longer hospital stay (p = .002), more readmissions (p = .029), and more surgical site infections (p = .002). CONCLUSIONS Our data highlight the prevalence of malnutrition in the pediatric IBD population. Patients who screened positive had worse postoperative outcomes. Further, very few of these patients received preoperative optimization with oral nutritional supplementation. There is a need for standardization of nutritional evaluation to improve preoperative nutritional status and postoperative outcomes. LEVEL OF EVIDENCE III. TYPE OF STUDY Retrospective Cohort.
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Affiliation(s)
- Amy A Howk
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University, Atlanta, GA, USA; Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA.
| | - Savannah R Smith
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Karunesh Polireddy
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Cary G Sauer
- Emory-Children's Pediatric Institute, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, And Nutrition, Emory University, Atlanta, GA, USA
| | - Subra Kugathasan
- Emory-Children's Pediatric Institute, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, And Nutrition, Emory University, Atlanta, GA, USA
| | - Julie Glasson
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A Alfred Chahine
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University, Atlanta, GA, USA; Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
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10
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Lomer MCE, Wilson B, Wall CL. British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease. J Hum Nutr Diet 2023; 36:336-377. [PMID: 35735908 PMCID: PMC10084145 DOI: 10.1111/jhn.13054] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/07/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Despite increased awareness of diet and nutrition being integral to the management of patients with inflammatory bowel disease (IBD), there are gaps in the knowledge of IBD healthcare providers regarding nutrition. Furthermore, high quality evidence on nutritional assessment and dietary management of IBD is limited. A Delphi consensus from a panel of experts allows for best-practice guidelines to be developed, especially where high quality evidence is limited. The aim was to develop guidelines for the nutritional assessment and dietary management of IBD using an eDelphi online consensus agreement platform. METHODS Seventeen research topics related to IBD and nutrition were systematically reviewed. Searches in Cochrane, Embase®, Medline® and Scopus® electronic databases were performed. GRADE was used to develop recommendations. Experts from the IBD community (healthcare professionals and patients with IBD) were invited to vote anonymously on the recommendations in a custom-built online platform. Three rounds of voting were carried out with updated iterations of the recommendations and evaluative text based on feedback from the previous round. RESULTS From 23,824 non-duplicated papers, 167 were critically appraised. Fifty-five participants completed three rounds of voting and 14 GRADE statements and 42 practice statements achieved 80% consensus. Comprehensive guidance related to nutrition assessment, nutrition screening and dietary management is provided. CONCLUSIONS Guidelines on the nutritional assessment and dietary management of IBD have been developed using evidence-based consensus to improve equality of care. The statements and practice statements developed demonstrate the level of agreement and the quality and strength of the guidelines.
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Affiliation(s)
- Miranda C E Lomer
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Bridgette Wilson
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Catherine L Wall
- Department of Nutritional Sciences, King's College London, London, UK.,Department of Medicine, University of Otago, Christchurch, New Zealand
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Modified Primary Anastomosis Using an Intestinal Internal Drainage Tube for Crohn's Disease: A Pilot Study. J Clin Med 2023; 12:jcm12010364. [PMID: 36615164 PMCID: PMC9821564 DOI: 10.3390/jcm12010364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/24/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Surgical treatment is an important part of the management of Crohn's disease (CD). However, the current recommended staged procedures require two operations, with long hospital stays and high costs, while traditional primary anastomosis has a high risk of complications. Therefore, the aim of this study was to compare the clinical efficacy and safety of modified primary anastomosis using intestinal internal drainage tubes for CD. METHODS In this study, emergency and nonemergency CD patients were included separately. Then, the patients were divided into three subgroups: patients with intestinal internal drainage tubes (modified primary anastomosis), staged procedures, and traditional primary anastomosis. The main outcomes were the number of hospitalizations, length and cost of the first hospital stay, length and cost of total hospital stays, and complications. RESULTS The outcomes of the three subgroups of emergency CD patients were not significantly different. For nonemergency CD patients, patients with intestinal internal drainage tubes had shorter total hospital stays and fewer hospitalizations compared with the staged procedures subgroup, while no significant differences in any outcomes were observed between the modified and traditional primary anastomosis subgroups. CONCLUSIONS For emergency CD patients, no significant advantage in terms of the main outcomes was observed for modified primary anastomosis. For nonemergency CD patients, modified primary anastomosis reduced the length of total hospital stays and hospitalizations compared with staged procedures. The placement of intestinal internal drainage tubes allows some patients who cannot undergo primary anastomosis to undergo it, which is a modification of traditional primary anastomosis.
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12
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Traiki TAB, Alshammari SA, Aljomah NA, Alsalouli MM, Altawil ES, Abdulla MH, Alhassan NS, Alkhayal KA. The impact of preoperative total parenteral nutrition on the surgical complications of Crohn's disease: A retrospective cohort study. Saudi J Gastroenterol 2022:366286. [PMID: 36588367 DOI: 10.4103/sjg.sjg_425_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Crohn's disease (CD) is associated with malnutrition, an independent risk factor for surgical morbidity and mortality in more than 65% of patients, with a significant impact on disease outcomes. In this single-center retrospective cohort study, we aimed to investigate the impact of total parenteral nutrition (TPN) on the surgical outcomes of patients with CD. METHODS This study included patients with CD who underwent abdominal surgery. We compared patients who received preoperative total parenteral nutrition (TPN group) to those who did not (non-TPN group). Prolonged oral intolerance, albumin level <30 g/L, and body mass index <18.5 were the main indications for TPN. We evaluated postoperative surgical complications in both groups. RESULTS Between January 2010 and October 2018, 169 eligible patients underwent abdominal surgery. The TPN and non-TPN groups included 40 and 129 patients, respectively. The mean albumin level was significantly lower in the TPN group (P = 0.013). Laparoscopic surgery was performed in 76.9% of the patients, with a conversion rate of 11.6%. Infectious and non-infectious complications developed in 8.9% and 16% of patients, respectively. Surgical complications were comparable between the groups (P >0.05). CONCLUSIONS Despite oral intake intolerance and severe disease in the TPN group, the surgical complications were comparable between the groups.
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Affiliation(s)
- Thamer A Bin Traiki
- Department of Surgery, Colorectal Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sulaiman A Alshammari
- Department of Surgery, Colorectal Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Nadia A Aljomah
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Monirah M Alsalouli
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Esraa S Altawil
- Pharmacy Department, Clinical Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Maha-Hamadien Abdulla
- Department of Surgery, Colorectal Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Noura S Alhassan
- Department of Surgery, Colorectal Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khayal A Alkhayal
- Department of Surgery, Colorectal Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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13
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Fitzpatrick JA, Melton SL, Yao CK, Gibson PR, Halmos EP. Dietary management of adults with IBD - the emerging role of dietary therapy. Nat Rev Gastroenterol Hepatol 2022; 19:652-669. [PMID: 35577903 DOI: 10.1038/s41575-022-00619-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 02/08/2023]
Abstract
Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.
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Affiliation(s)
- Jessica A Fitzpatrick
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Sarah L Melton
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Chu Kion Yao
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Emma P Halmos
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia.
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14
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Meade S, Patel KV, Luber RP, O'Hanlon D, Caracostea A, Pavlidis P, Honap S, Anandarajah C, Griffin N, Zeki S, Ray S, Mawdsley J, Samaan MA, Anderson SH, Darakhshan A, Adams K, Williams A, Sanderson JD, Lomer M, Irving PM. A retrospective cohort study: pre-operative oral enteral nutritional optimisation for Crohn's disease in a UK tertiary IBD centre. Aliment Pharmacol Ther 2022; 56:646-663. [PMID: 35723622 PMCID: PMC9544188 DOI: 10.1111/apt.17055] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/04/2022] [Accepted: 05/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low-quality evidence suggests that pre-operative exclusive enteral nutrition (E/EN) can improve postoperative outcomes in patients with Crohn's disease (CD). It is not standard practice in most centres. AIMS To test the hypothesis that pre-operative EN in patients undergoing ileal/ileocolonic surgery for CD is associated with improved postoperative outcome. METHODS We performed a single centre retrospective observational study comparing surgical outcomes in patients receiving pre-operative EN (≥600 kcal/day for ≥2 weeks) with those who received no nutritional optimisation. Consecutive adult patients undergoing ileal/ileocolonic resection from 2008 to 2020 were included. The primary outcome was postoperative complications <30 days. Secondary outcomes included EN tolerance, specific surgical complications, unplanned stoma formation, length of stay, length of bowel resected, readmission and biochemical/anthropometric changes. RESULTS 300 surgeries were included comprising 96 without nutritional optimisation and 204 optimised cases: oral EN n = 173, additional PN n = 31 (4 of whom had received nasogastric/nasojejunal EN). 142/204 (69.6%) tolerated EN. 125/204 (61.3%) initiated EN in clinic. Patients in the optimised cohort were younger at operation and diagnosis, with an increased frequency of penetrating disease and exposure to antibiotics or biologics, and were more likely to undergo laparoscopic surgery. The optimised cohort had favourable outcomes on multivariate analysis: all complications [OR 0.29; 0.15-0.57, p < 0.001], surgical complications [OR 0.41; 95% CI 0.20-0.87, p = 0.02], non-surgical complications [OR 0.24 95% CI 0.11-0.52, p < 0.001], infective complications [OR 0.32; 95% CI 0.16-0.66, p = 0.001]. CONCLUSIONS Oral EN was reasonably well tolerated and associated with a reduction in 30-day postoperative complications. Randomised controlled trials are required to confirm these findings.
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Affiliation(s)
- Susanna Meade
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Kamal V. Patel
- Department of GastroenterologySt George's HospitalLondonUK
| | | | | | | | | | - Sailish Honap
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Sebastian Zeki
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Shuvra Ray
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Joel Mawdsley
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Mark A. Samaan
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Katie Adams
- Department of Colorectal SurgerySt Thomas' HospitalLondonUK
| | | | | | | | - Peter M. Irving
- IBD CentreGuy's and St Thomas' NHS Foundation TrustLondonUK,School of Immunology and Microbial SciencesKing's College LondonUK
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15
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Gold SL, Raman M. Editorial: a formula shake each day keeps the complications away - the tolerability and effect of orally-delivered enteral nutrition in improving post-operative outcomes in patients with Crohn's disease. Aliment Pharmacol Ther 2022; 56:739-740. [PMID: 35879892 DOI: 10.1111/apt.17087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Stephanie L Gold
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maitreyi Raman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
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16
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Bak MTJ, Ruiterkamp MFE, van Ruler O, Campmans-Kuijpers MJE, Bongers BC, van Meeteren NLU, van der Woude CJ, Stassen LPS, de Vries AC. Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review. World J Gastroenterol 2022; 28:2403-2416. [PMID: 35979261 PMCID: PMC9258284 DOI: 10.3748/wjg.v28.i22.2403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/21/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.
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Affiliation(s)
- Michiel T J Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Marit F E Ruiterkamp
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel 2906 ZC, Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Marjo J E Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen 9713 GZ, Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht 6200 MD, Netherlands
- Department of Epidemiology, Care and Public Health Research Institute, Maastricht University, Maastricht 6200 MD, Netherlands
| | - Nico L U van Meeteren
- Department of Anaesthesiology, Erasmus MC University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht 6229 HX, Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
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17
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Myrelid P, Soop M, George BD. Surgical Planning in Penetrating Abdominal Crohn's Disease. Front Surg 2022; 9:867830. [PMID: 35592128 PMCID: PMC9110798 DOI: 10.3389/fsurg.2022.867830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mattias Soop
- Department of Surgery, Ersta Hospital, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Bruce D. George
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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18
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Shariff S, Moran G, Grimes C, Cooney RM. Current Use of EEN in Pre-Operative Optimisation in Crohn's Disease. Nutrients 2021; 13:4389. [PMID: 34959941 PMCID: PMC8709272 DOI: 10.3390/nu13124389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022] Open
Abstract
Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.
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Affiliation(s)
- Sharafaath Shariff
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham B15 2GW, UK; (S.S.); (R.M.C.)
| | - Gordon Moran
- Room D1406 West Block: Queen’s Medical Centre, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Caris Grimes
- Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK;
| | - Rachel Margaret Cooney
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham B15 2GW, UK; (S.S.); (R.M.C.)
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19
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Mitrev N, Huang H, Hannah B, Kariyawasam VC. Review of exclusive enteral therapy in adult Crohn's disease. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000745. [PMID: 34580154 PMCID: PMC8477235 DOI: 10.1136/bmjgast-2021-000745] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background Exclusive enteral nutrition (EEN) is a potentially effective but underused therapy for Crohn’s disease (CD) in adults. It is first-line induction treatment for paediatric patients but remains a second-line or third-line therapy in adults. Objective To analyse the evidence for EEN in adult patients with CD, and summarise this in a narrative review. Methods In April/May 2020 and July 2021, a literature search was performed using the Medical Subject Headings (MeSH) terms: ‘Crohn’s disease’, ‘CD’, ‘inflammatory bowel disease’, ‘IBD’, ‘exclusive enteral nutrition’, ‘enteral nutrition’, ‘EEN’, in PubMed, Scopus, Cochrane. Additional studies were obtained from references of search result articles as well as general reading. Studies with adult patients with CD treated with EEN were selected. 79 articles of relevance were found. Where data in adults were lacking, data from paediatric studies as extrapolated with care. Results EEN in adult patients been shown to improve clinical, biomarker, endoscopic and radiologic measures of disease activity. EEN avoids the potential adverse effects of recurrent corticosteroids for induction such as metabolic derangements and opportunistic infections. EEN has also demonstrated benefits among adult patients with fistulising and stricturing CD. It may avoid surgery in such patients. Preoperative EEN has also been shown to reduce postoperative complications and recurrence. There appears to be benefits in combing EEN with antitumour necrosis factor agents, however, benefits of combination therapy with other biologics are less clear. A major drawback of EEN therapy in adults has been poor compliance. More palatable polymeric formulations improved patient education and dietitian support may overcome this. Evidence in adults is limited to small studies, often with suboptimal control arms and lack of blinding. Larger scale studies with improved study design are needed to confirm these beneficial effects. Conclusion Despite limitations in evidence EEN should be considered in treating adults with CD.
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Affiliation(s)
- Nikola Mitrev
- Department of Gastroenterology, Blacktown Hospital, Blacktown, New South Wales, Australia.,Western Sydney University Blacktown Mount Druitt Medical School, Blacktown, New South Wales, Australia
| | - Hin Huang
- Western Sydney University Blacktown Mount Druitt Medical School, Blacktown, New South Wales, Australia
| | - Barbara Hannah
- Department of Gastroenterology, Blacktown Hospital, Blacktown, New South Wales, Australia
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20
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Di Chio T, Sokollik C, Peroni DG, Hart L, Simonetti G, Righini-Grunder F, Borrelli O. Nutritional Aspects of Pediatric Gastrointestinal Diseases. Nutrients 2021; 13:nu13062109. [PMID: 34205445 PMCID: PMC8235230 DOI: 10.3390/nu13062109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/16/2022] Open
Abstract
In the last decade, the role of nutritional management in pediatric gastrointestinal diseases has gained increasing popularity. Disease-specific diets have been introduced as conventional treatments by international guidelines. Patients tend to more willingly accept food-based therapies than drugs because of their relatively “harmless” nature. Apart from a diet’s therapeutic role, nutritional support is crucial in maintaining growth and improving clinical outcomes in pediatric patients. Despite the absence of classical “side effects”, however, it should be emphasized that any dietary modification might have negative consequences on children’s growth and development. Hence, expert supervision is always advised, in order to support adequate nutritional requirements. Unfortunately, the media provide an inaccurate perception of the role of diet for gastrointestinal diseases, leading to misconceptions by patients or their caregivers that tends to overestimate the beneficial role of diets and underestimate the potential adverse effects. Moreover, not only patients, but also healthcare professionals, have a number of misconceptions about the nutritional benefits of diet modification on gastrointestinal diseases. The aim of this review is to highlight the role of diet in pediatric gastrointestinal diseases, to detect misconceptions and to give a practical guide for physicians on the basis of current scientific evidence.
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Affiliation(s)
- Teresa Di Chio
- Pediatric Institute of Southern Switzerland, Ospedale Regionale di Bellinzona e Valli, Via Ospedale 12, 6500 Bellinzona, Switzerland;
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
| | - Christiane Sokollik
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital, Inselspital, University of Bern, 3010 Bern, Switzerland
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
| | - Diego G. Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, 56126 Pisa, Italy;
| | - Lara Hart
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, McMaster University, Hamilton, ON L8N 3Z5, Canada;
| | - Giacomo Simonetti
- Pediatric Institute of Southern Switzerland, Ospedale Regionale di Bellinzona e Valli, Via Ospedale 12, 6500 Bellinzona, Switzerland;
- Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Franziska Righini-Grunder
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucerne Children’s Hospital, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, University College London (UCL) Institute of Child Health and Great Ormond Street, London WC1N 3JH, UK
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
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21
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Scarallo L, Lionetti P. Dietary Management in Pediatric Patients with Crohn's Disease. Nutrients 2021; 13:1611. [PMID: 34064976 PMCID: PMC8150738 DOI: 10.3390/nu13051611] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022] Open
Abstract
It has been widely endorsed that a multifactorial etiology, including interaction between genetic and environmental factors, can contribute to Crohn's Disease (CD) pathogenesis. More specifically, diet has proven to be able to shape gut microbiota composition and thus is suspected to play a significant role in inflammatory bowel disease (IBD) pathogenesis. Moreover, poor nutritional status and growth retardation, arising from several factors such as reduced dietary intake or nutrient leakage from the gastrointestinal tract, represent the hallmarks of pediatric CD. For these reasons, multiple research lines have recently focused on the utilization of dietary therapies for the management of CD, aiming to target concurrently mucosal inflammation, intestinal dysbiosis and optimization of nutritional status. The forerunner of such interventions is represented by exclusive enteral nutrition (EEN), a robustly supported nutritional therapy; however, it is burdened by monotony and low tolerance in the long term. Novel dietary interventions, such as Crohn's Disease Exclusion Diet or Crohn's Disease treatment with eating, have shown their efficacy in the induction of remission in pediatric patients with CD. The aim of the present narrative review is to provide a synopsis of the available nutritional strategies in the management of pediatric CD and to discuss their application in the dietary management of these patients.
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Affiliation(s)
- Luca Scarallo
- Gastroenterology and Nutrition Unit, Meyer Children’s Hospital, 50139 Florence, Italy;
| | - Paolo Lionetti
- Gastroenterology and Nutrition Unit, Meyer Children’s Hospital, 50139 Florence, Italy;
- Department NEUROFARBA, University of Florence, 50139 Florence, Italy
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22
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Bertani L, Ribaldone DG, Bellini M, Mumolo MG, Costa F. Inflammatory Bowel Diseases: Is There a Role for Nutritional Suggestions? Nutrients 2021; 13:nu13041387. [PMID: 33924119 PMCID: PMC8074318 DOI: 10.3390/nu13041387] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/17/2021] [Accepted: 04/18/2021] [Indexed: 02/07/2023] Open
Abstract
Nutrition has an important impact on inflammatory bowel diseases (IBD). In particular, several studies have addressed its role in their pathogenesis, showing how the incidence of IBD significantly increased in recent years. Meanwhile, nutrition should be considered a component of the treatment of the disease, both as a therapy itself, and especially in the perspective of correcting the various nutritional deficiencies shown by these patients. In this perspective, nutritional suggestions are very important even in the most severe forms of IBD, requiring hospitalization or surgical treatment. Although current knowledge about nutrition in IBD is increasing over time, nutritional suggestions are often underestimated by clinicians. This narrative review is an update summary of current knowledge on nutritional suggestions in IBD, in order to address the impact of nutrition on pathogenesis, micro- and macro-nutrients deficiencies (especially in the case of sarcopenia and obesity), as well as in hospitalized patients.
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Affiliation(s)
- Lorenzo Bertani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy; (L.B.); (M.B.)
| | | | - Massimo Bellini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56100 Pisa, Italy; (L.B.); (M.B.)
| | - Maria Gloria Mumolo
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, 56124 Pisa, Italy;
| | - Francesco Costa
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, 56124 Pisa, Italy;
- Correspondence: ; Tel.: +39-050-997-392
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Abstract
The purpose of this article is to provide an updated review of the definition, prevalence, causes, and clinical management of malnutrition in inflammatory bowel disease (IBD). Prevalence of malnutrition in IBD is estimated to be between 6.1% and 69.7% depending on the definition used, the type of IBD, the clinical setting, and whether the IBD is active or in remission. Whereas older definitions of malnutrition have been found to be correlated with mortality and length of hospital stay, the more recent European Society for Clinical Nutrition and Metabolism (ESPEN) 2015 and the Global Leadership Initiative on Malnutrition (GLIM) definitions provide significantly different prevalence estimates of malnutrition when applied to the same patient population, and further work is needed to validate these two definitions against clinical outcomes. In patients with IBD with identified malnutrition, oral nutrition supplementation, enteral nutrition, or parenteral nutrition should be started. In malnourished patients with Crohn's disease undergoing surgery, preoperative enteral nutrition has been demonstrated to reduce the rate of postoperative complications. Overall, patients with IBD are at significant risk for malnutrition and should be screened for malnutrition by using a validated screening tool. The management of malnutrition in IBD is complex, and studies are often limited in their size or their ability to demonstrate an improvement in clinical outcomes based on specific nutrition-related interventions. Future studies particularly regarding the validation of new screening tools and perioperative management of malnutrition may provide insight into the standardization of diagnosis and management of malnutrition in IBD.
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Affiliation(s)
- Austin Lin
- Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois, USA
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Sakurai Kimura CM, Scanavini Neto A, Queiroz NSF, Horvat N, Camargo MGM, Borba MR, Sobrado CW, Cecconello I, Nahas SC. Abdominal Surgery in Crohn's Disease: Risk Factors for Complications. Inflamm Intest Dis 2020; 6:18-24. [PMID: 33850835 DOI: 10.1159/000510999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/17/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD. Methods A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018. Results Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively). Conclusion Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.
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Affiliation(s)
- Cintia Mayumi Sakurai Kimura
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Arceu Scanavini Neto
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Natally Horvat
- Department of Radiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Marcelo Rodrigues Borba
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Yamamoto T, Lightner AL, Spinelli A, Kotze PG. Perioperative management of ileocecal Crohn's disease in the current era. Expert Rev Gastroenterol Hepatol 2020; 14:843-855. [PMID: 32729736 DOI: 10.1080/17474124.2020.1802245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The ileocecal region is most commonly involved in patients with Crohn's disease (CD). AREAS COVERED In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention. EXPERT OPINION Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center & Department of Surgery, Yokkaichi Hazu Medical Center , Yokkaichi, Japan
| | - Amy Lee Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS , Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University , Rozzano, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR) , Curitiba, Brazil
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Yang SB, Du SW, Wang JH. Correlation between age of onset and gastrointestinal stenosis in hospitalized patients with Crohn's disease. World J Clin Cases 2020; 8:2769-2777. [PMID: 32742987 PMCID: PMC7360709 DOI: 10.12998/wjcc.v8.i13.2769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/26/2020] [Accepted: 06/13/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients affected by Crohn's disease (CD) are more likely to develop gastrointestinal stenosis and often undergo surgery during the duration of disease.
AIM To identify the risk factors for gastrointestinal stenosis in hospitalized CD patients in China.
METHODS The clinical data of CD patients hospitalized at the Seventh Medical Center, Chinese People's Liberation Army General Hospital from January 2010 to December 2018 were included. Patients with gastrointestinal stenosis were compared to those without gastrointestinal stenosis for clinical variables. The risk factors for gastrointestinal stenosis were identified using univariate and multivariable logistic regression analyses. The treatments for patients with gastrointestinal stenosis were analyzed, and the characteristics of different treatment methods were discussed.
RESULTS The incidence of gastrointestinal stenosis was 59.02% in the 122 hospitalized CD patients. Age of onset of more than 40 years (odds ratio [OR] = 3.072, 95% confidence interval [CI]: 1.298-7.272, P = 0.009) and duration of disease of more than 5 years (OR = 2.101, 95%CI: 1.002-4.406, P = 0.048) were associated with the occurrence of gastrointestinal stenosis. Fifteen (20.83%) patients did not undergo surgery and received internal medicine and nutrition treatment. Surgical treatments were performed in 72.22% (52) of cases. The rate of postoperative complications was 15.38% (8 cases), and during a median follow-up period of 46 mo, 11.54% (6 cases) underwent reoperation. A total of 29.17% (21 cases) were treated with endoscopic therapy, and during a median follow-up period of 32 mo, 76.19% (16 cases) had no surgical event, 23.81% (5 cases) failed to avoid surgical treatments, and no serious postoperative complications occurred after endoscopic therapy.
CONCLUSION Age of onset of more than 40 years and duration of disease of more than 5 years may be strongly correlated with a higher risk of gastrointestinal stenosis in hospitalized CD patients. Endoscopic therapy for gastrointestinal stenosis is relatively safe and effective, and may help to prevent or delay surgery.
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Affiliation(s)
- Shan-Bing Yang
- Department of Gastroenterology, the Seventh Medical Center, Chinese People’s Liberation Army General Hospital, Beijing 100700, China
| | - Shu-Wen Du
- Department of Gastroenterology, the Seventh Medical Center, Chinese People’s Liberation Army General Hospital, Beijing 100700, China
| | - Ji-Heng Wang
- Department of Gastroenterology, the Seventh Medical Center, Chinese People’s Liberation Army General Hospital, Beijing 100700, China
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Di Candido F, Moggia E, Spinelli A. Pre-operative optimisation in Crohn's Disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sharma S, Gupta A, Kedia S, Agarwal S, Singh N, Goyal S, Jain S, Gupta V, Sahu P, Vuyyuru SK, Kante B, Sharma R, Panwar R, Sahni P, Makharia G, Ahuja V. Efficacy and tolerability of exclusive enteral nutrition in adult patients with complicated Crohn's disease. Intest Res 2020; 19:291-300. [PMID: 32447877 PMCID: PMC8322023 DOI: 10.5217/ir.2019.09172] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Exclusive enteral nutrition (EEN), an established modality for pediatric Crohn's disease (CD) is seldomly utilized in adults. The present study reports the outcome of EEN in adult CD patients at a tertiary care hospital in India. METHODS This was a retrospective analysis of CD patients who received EEN as a sole modality/adjunct to other treatment. The primary and secondary outcomes changed in Crohn's Disease Activity Index (CDAI), and clinical response (decline in CDAI > 70), respectively, at 4 and 8 weeks. Subgroup analysis evaluated response across different phenotypes, EEN formulations and prior treatment. Linear mixed effect model was created to assess the predictors of EEN response. RESULTS Thirty-one CD patients received EEN over median duration of 4 weeks (range, 2-6 weeks). CDAI showed a significant improvement post EEN at 4 (baseline 290 [260-320] vs. 240 [180-280], P= 0.001) and 8 weeks (baseline 290 [260-320] vs. 186 [160-240], P= 0.001), respectively. The cumulative clinical response rates at 4 and 8 weeks were 37.3% and 80.4% respectively. The clinical response rates at 8 weeks across B1 (n = 4), B2 (n = 18) and B3 (n = 9) phenotypes were 50%, 78.8% and 100% respectively (log-rank test, P= 0.093). The response rates at 8 weeks with polymeric (n = 8) and semi-elemental diet (n = 23) were 75% and 82.6%% respectively (log-rank test, P= 0.49). Baseline CDAI (odds ratio, 1.008; 95% confidence interval, 1.002-1.017; P= 0.046) predicted response to EEN. CONCLUSIONS EEN was effective in inducing clinical response across different phenotypes of CD. Baseline disease activity remained the most important predictor of clinical response to EEN.
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Affiliation(s)
- Sanchit Sharma
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Arti Gupta
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Goyal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saransh Jain
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vipin Gupta
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Pabitra Sahu
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer Kumar Vuyyuru
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Kante
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Panwar
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Adamina M, Gerasimidis K, Sigall-Boneh R, Zmora O, de Buck van Overstraeten A, Campmans-Kuijpers M, Ellul P, Katsanos K, Kotze PG, Noor N, Schäfli-Thurnherr J, Vavricka S, Wall C, Wierdsma N, Yassin N, Lomer M. Perioperative Dietary Therapy in Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:431-444. [PMID: 31550347 DOI: 10.1093/ecco-jcc/jjz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The incidence of inflammatory bowel disease [IBD] is rising worldwide and no cure is available. Many patients require surgery and they often present with nutritional deficiencies. Although randomised controlled trials of dietary therapy are lacking, expert IBD centres have long-established interdisciplinary care, including tailored nutritional therapy, to optimise clinical outcomes and resource utilisation. This topical review aims to share expertise and offers current practice recommendations to optimise outcomes of IBD patients who undergo surgery. METHODS A consensus expert panel consisting of dietitians, surgeons, and gastroenterologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. Nutritional evaluation and dietary needs, perioperative optimis ation, surgical complications, long-term needs, and special situations were critically appraised. Statements were developed using a Delphi methodology incorporating three successive rounds. Current practice positions were set when ≥80% of participants agreed on a recommendation. RESULTS A total of 26 current practice positions were formulated which address the needs of IBD patients perioperatively and in the long term following surgery. Routine screening, perioperative optimisation by oral, enteral, or parenteral nutrition, dietary fibre, and supplements were reviewed. IBD-specific situations, including management of patients with a restorative proctocolectomy, an ostomy, strictures, or short-bowel syndrome, were addressed. CONCLUSIONS Perioperative dietary therapy improves the outcomes of IBD patients who undergo a surgical procedure. This topical review shares interdisciplinary expertise and provides guidance to optimise the outcomes of patients with Crohn's disease and ulcerative colitis. taking advantage of contemporary nutrition science.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, Glasgow Royal Infirmary, Glasgow, UK
| | - Rotem Sigall-Boneh
- PIBD Research Center, Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Zmora
- Department of Surgery, Assaf Harofeh Medical Center, Tel Aviv, Israel
| | | | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | | | - Stephan Vavricka
- Department of Surgery, Kantonsspital Winterthur, Winerthur, Switzerland
| | - Catherine Wall
- Department of Nutritional Sciences, King's College London, London, UK
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Nuha Yassin
- Department of Colorectal Surgery, Wolverhampton Hospital, Wolverhampton, UK
| | - Miranda Lomer
- Department of Nutritional Sciences, King's College London, London, UK.,Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Yamamoto T, Nakahigashi M, Shimoyama T, Umegae S. Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study. Colorectal Dis 2020; 22:554-561. [PMID: 31782874 DOI: 10.1111/codi.14922] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
AIM Currently, the notion that preoperative optimization with enteral nutrition (EN) reduces the incidence of complication after surgery in Crohn's disease (CD) patients is being debated. This case-matched study was to evaluate the impact of preoperative EN on surgical outcomes in patients with CD. METHOD Twenty-four patients received EN therapy with an elemental diet (1800-2400 kcal/day) for at least 2 weeks before the planned surgery (EN group). A further 24 patients who underwent surgery without receiving preoperative EN or parenteral nutrition formed a control group based on four matched criteria: age (≤/>40 years), the use of preoperative medications (corticosteroids/azathioprine/biologics), disease behaviour (inflammatory/stricturing/penetrating) and main surgical procedure (ileal resection/ileocolonic resection/colectomy). The incidence of complications observed within 30 days after surgery was compared between the two groups. Septic complications were defined as anastomotic leak, intra-abdominal abscess, entero-cutaneous fistula or wound infection. RESULTS In the EN group, the median serum albumin level significantly increased, while C-reactive protein (CRP) significantly decreased during the preoperative EN (albumin, from 3.0 mg/dl to 3.1 mg/dl, P = 0.04; CRP, from 3.05 mg/dl to 2.52 mg/dl, P = 0.02). The incidence of postoperative septic complications was significantly lower in the EN group compared with the control group (4% vs 25%, P = 0.04). The occurrence rate of overall complications was lower in the EN group (21% vs 29%, P = 0.51), but not statistically significant. CONCLUSION In patients with CD, preoperative optimization with EN reduced the overall rate of postoperative complications and significantly decreased postoperative septic complications.
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Affiliation(s)
- T Yamamoto
- Department of Surgery and Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - M Nakahigashi
- Faculty of Health Sciences, Suzuka University of Medical Science, Suzuka, Japan
| | - T Shimoyama
- Department of Surgery and Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - S Umegae
- Department of Surgery and Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
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Prehabilitation: The Impact of Preoperative Exclusive Enteral Nutrition on Paediatric Patients With Crohn Disease. J Pediatr Gastroenterol Nutr 2020; 70:503-507. [PMID: 31880668 DOI: 10.1097/mpg.0000000000002595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Exclusive enteral nutrition (EEN) is effective in inducing remission in paediatric Crohn Disease (CD) and has been shown to reduce inflammation and improve outcomes in adult CD patients when used before resectional surgery. This retrospective study demonstrates that preoperative EEN is achievable in paediatric CD patients undergoing right hemicolectomy and is associated with positive peri-operative outcomes. Seventeen patients (8 who received preoperative EEN and 9 who did not) were included in the study. Six of 8 (75.0%) managed EEN orally; 1 via nasogastric tube and another via a previously sited gastrostomy. Use of preoperative EEN was associated with a decreased rate of moderate/severe disease on resection pathology (5/8 [62.5%] vs 9/9 [100%]; P = 0.04). Larger studies are required to determine the wider potential benefits of preoperative EEN on postoperative outcomes within paediatric practice.
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Soop M, Khan H, Nixon E, Teubner A, Abraham A, Carlson G, Lal S. Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre. J Crohns Colitis 2020; 14:1558-1564. [PMID: 32215559 PMCID: PMC7648168 DOI: 10.1093/ecco-jcc/jjaa060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported. METHODS Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records. RESULTS A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2. CONCLUSIONS IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.
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Affiliation(s)
- Mattias Soop
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK,Corresponding author: Mattias Soop, MD PhD, Department of Surgery, Ersta Hospital, Box 4619, SE 116 91 Stockholm, Sweden. Tel.: +4867146100;
| | - Haroon Khan
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Emma Nixon
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Antje Teubner
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Arun Abraham
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Gordon Carlson
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Simon Lal
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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Erős A, Soós A, Hegyi P, Szakács Z, Benke M, Szűcs Á, Hartmann P, Erőss B, Sarlós P. Sarcopenia as an independent predictor of the surgical outcomes of patients with inflammatory bowel disease: a meta-analysis. Surg Today 2019; 50:1138-1150. [PMID: 31617016 PMCID: PMC7501129 DOI: 10.1007/s00595-019-01893-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/08/2019] [Indexed: 12/11/2022]
Abstract
Patients with inflammatory bowel disease (IBD) are at risk of sarcopenia, which is associated with poor clinical outcomes. We conducted this study to assess whether sarcopenia predicts the need for surgery and postoperative complications in patients with IBD. We performed a systematic search of four electronic databases, last updated in March, 2019. Data from studies comparing rates of surgery and postoperative complications in sarcopenic IBD patients versus non-sarcopenic IBD patients were pooled with the random-effects models. We calculated the odds ratios (OR) with a 95% confidence interval (CI). Ten studies with a collective total of 885 IBD patients were included in our meta-analysis. Although the analysis of raw data did not reveal significant differences between the two groups with respect to the rate of surgery and postoperative complications (OR = 1.826; 95% CI 0.913–3.654; p = 0.089 and OR = 3.265; 95% CI 0.575–18.557; p = 0.182, respectively), the analysis of adjusted data identified sarcopenia as an independent predictor for both of the undesirable outcomes (OR = 2.655; 95% CI 1.121–6.336; p = 0.027 and OR = 6.097; 95% CI 1.756–21.175; p = 0.004, respectively). Thus, early detection of sarcopenia in patients with IBD is important to prevent undesirable outcomes.
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Affiliation(s)
- Adrienn Erős
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, 7624, Hungary.,Szentágothai Research Centre, University of Pécs, 20 Ifjúság Street, Pécs, 7624, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, 7624, Hungary.,Clinical Medicine Doctoral School, University of Szeged, 6 Korányi fasor, Szeged, 6720, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, 7624, Hungary.,Clinical Medicine Doctoral School, University of Szeged, 6 Korányi fasor, Szeged, 6720, Hungary.,Hungarian Academy of Sciences, University of Szeged Momentum Gastroenterology Multidisciplinary Research Group, 8-10 Korányi fasor, Szeged, 6720, Hungary.,First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság Street, Pécs, 7624, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, 7624, Hungary.,Szentágothai Research Centre, University of Pécs, 20 Ifjúság Street, Pécs, 7624, Hungary
| | - Márton Benke
- First Department of Surgery, Semmelweis University, 78 Üllői Street, Budapest, 1082, Hungary
| | - Ákos Szűcs
- First Department of Surgery, Semmelweis University, 78 Üllői Street, Budapest, 1082, Hungary
| | - Petra Hartmann
- Institute of Surgical Research, University of Szeged, 1 Pulz Street, Szeged, 6724, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, 7624, Hungary.,Szentágothai Research Centre, University of Pécs, 20 Ifjúság Street, Pécs, 7624, Hungary
| | - Patricia Sarlós
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, 7624, Hungary. .,Szentágothai Research Centre, University of Pécs, 20 Ifjúság Street, Pécs, 7624, Hungary. .,First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság Street, Pécs, 7624, Hungary.
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Di Caro S, Fragkos KC, Keetarut K, Koo HF, Sebepos-Rogers G, Saravanapavan H, Barragry J, Rogers J, Mehta SJ, Rahman F. Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift. Nutrients 2019; 11:E2222. [PMID: 31540038 PMCID: PMC6770416 DOI: 10.3390/nu11092222] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.
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Affiliation(s)
- Simona Di Caro
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Konstantinos C Fragkos
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Katie Keetarut
- Department of Dietetics, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hui Fen Koo
- UCL Medical School, 74 Huntley Street, Bloomsbury, London WC1E 6DE, UK.
| | - Gregory Sebepos-Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hajeena Saravanapavan
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - John Barragry
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Jennifer Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Shameer J Mehta
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Farooq Rahman
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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McKenna NP, Habermann EB, Zielinski MD, Lightner AL, Mathis KL. Body mass index: Implications on disease severity and postoperative complications in patients with Crohn's disease undergoing abdominal surgery. Surgery 2019; 166:703-708. [PMID: 31262567 DOI: 10.1016/j.surg.2019.04.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/27/2019] [Accepted: 04/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity is increasing in prevalence among patients with Crohn's disease, but how body mass index affects disease severity and postoperative outcomes remains unknown. METHODS A retrospective review of ileocolic resections for Crohn's disease performed at a single institution between January 2007 and December 2017 was conducted. On the day of surgery, patients were grouped by body mass index into underweight, normal weight, overweight, and obese categories. Intergroup comparisons and trend tests were performed on disease characteristics and postoperative outcomes. A multivariable model for superficial surgical site infection was constructed. RESULTS A total of 758 patients were identified; 80 (11%) patients were underweight, 372 (49%) were normal weight, 178 (23%) were overweight, and 128 (17%) were obese. Both fistulizing Crohn's phenotype and preoperative immunosuppression occurred less frequently in obese patients compared with other body mass index groups (both P < 0.01). Conversion to open surgery and superficial surgical site infection were increased in obese patients, and obesity was an independent risk factor for superficial surgical site infection on multivariable analysis (odds ratio 3.0, 95% confidence interval: 1.6-5.6). CONCLUSION Although obese patients had less severe Crohn's disease at the time of surgery, they experienced increased postoperative infectious complications. Preoperative weight loss and consideration of alternative wound closure methods may reduce these complications.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Martin D Zielinski
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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Liu RQ, Qiao SH, Wang KH, Guo Z, Li Y, Cao L, Gong JF, Wang ZM, Zhu WM. Prospective evaluation of intestinal decompression in treatment of acute bowel obstruction from Crohn's disease. Gastroenterol Rep (Oxf) 2019; 7:263-271. [PMID: 31413833 PMCID: PMC6688739 DOI: 10.1093/gastro/goz002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/27/2018] [Accepted: 09/16/2018] [Indexed: 02/03/2023] Open
Abstract
Background Conservative therapy for Crohn’s disease (CD)-related acute bowel obstruction is essential to avoid emergent surgery. The present study aimed to evaluate the efficacy of using a long intestinal decompression tube (LT) in treatment of CD with acute intestinal obstruction. Methods This is a prospective observational study. Comparative analysis was performed in CD patients treated with LT (the LT group) and nasogastric tube (the GT group). The primary outcome was the avoidance of emergent surgery. Additionally, predictive factors for failure of decompression and subsequent surgery were investigated. Results There were 27 and 42 CD patients treated with LT and GT, respectively, in emergent situations. Twelve (44.4%) patients using LT were managed conservatively without laparotomy, while only nine (21.4%) patients in the GT group were spared from emergent surgery (P < 0.05). Both in surgery-free and in surgery patients, the time to alleviation of symptoms was significantly shorter in the LT groups than in the GT groups (both P < 0.01). C-reactive protein decrease after intubation and 48-hour drainage volume >500 mL were predictors of unavoidable surgery (both P < 0.05). The rate of temporary stoma and incidence of incision infection in the LT surgery group were significantly lower than those in the GT group (both P < 0.05). No significant differences were observed in the frequency of medical and surgical recurrences between the LT and GT groups (all P > 0.05). Conclusions Endoscopic placement of LT could improve the emergent status in CD patients with acute bowel obstruction. The drainage output and changes in C-reactive protein after intubation could serve as practical predictive indices for subsequent surgery. Compared to traditional GT decompression, LT decompression was associated with fewer short-term complications and did not appear to affect long-term recurrence.
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Affiliation(s)
- Rui-Qing Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shuai-Hua Qiao
- Department of Cardiology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ke-Hao Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Jian-Feng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Zhi-Ming Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Wei-Ming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Rocha A, Bessa I, Lago P, Santos MD, Leite J, Castro-Poças F. Preoperative Enteral Nutrition and Surgical Outcomes in Adults with Crohn's Disease: A Systematic Review. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 26:184-195. [PMID: 31192287 DOI: 10.1159/000494674] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 10/16/2018] [Indexed: 12/14/2022]
Abstract
Background and Aim Enteral nutrition (EN) is applicable to adult Crohn's disease (CD) in treating malnutrition and in inducing remission - here as a less effective alternative than corticosteroids. The purpose of this review is to determine whether preoperative EN impacts postoperative complications of adult CD, either by means of nutritional or therapeutic effects. Summary A systematic review of English written full-text research articles published between January 1990 and November 2017, including adult patients undergoing abdominal surgery for complicated CD after EN, was performed. Four studies out of 22 were selected, all of which institutional, retrospective, case-control cohorts, one classified as "good quality" and three as "poor quality," as rated by the Newcastle-Ottawa Scale. The application of inclusion and exclusion criteria resulted in a non-intentional absence of studies referring to supplemental EN among those reviewed. The reduced number of heterogeneous eligible studies impeded meta-analysis. In all studies, exclusive EN (EEN) was used and well tolerated, allowing to defer or even avoid surgery altogether, improving patients' global state. The two studies with the greatest number of patients found preoperative EEN to be an independent factor against infectious and non-infectious complications in 219 patients and against anastomotic leaks or abscesses in 38 patients. Also, in univariate analysis, EEN was found to increase preop-erative immunosuppressant-free intervals and to protect against anastomotic dehiscences, intra-abdominal abscesses, surgical wound infections, ileus, stomas, and reoperations in the largest study; in another study it was related to fewer intra-abdominal septic complications. Key Messages All reviewed studies are retrospective and, consequently, of limited relevance. Nonetheless, all of them call the attention of the scientific community to the potential benefits of preoperative EEN on postoperative outcomes in adult CD, calling for prospective multi-institutional studies and randomized controlled trials.
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Affiliation(s)
- Anabela Rocha
- General Surgery Service - Digestive Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Inês Bessa
- General Surgery Service - Colorectal Unit, Hospital de São Sebastião, Centro Hospitalar de Entre-o-Douro-e-Vouga, Santa Maria da Feira, Portugal
| | - Paula Lago
- Gastroenterology Service, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Marisa D Santos
- General Surgery Service - Digestive Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Júlio Leite
- Surgery Service, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Fernando Castro-Poças
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal.,Gastroenterology Service, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
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Stoner PL, Kamel A, Ayoub F, Tan S, Iqbal A, Glover SC, Zimmermann EM. Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support. Gastroenterol Res Pract 2018; 2018:7890161. [PMID: 30344603 PMCID: PMC6174741 DOI: 10.1155/2018/7890161] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/28/2018] [Indexed: 12/16/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.
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Affiliation(s)
- Patrick L. Stoner
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Amir Kamel
- Department of Pharmacotherapy, College of Pharmacy, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Fares Ayoub
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sanda Tan
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Atif Iqbal
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sarah C. Glover
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Ellen M. Zimmermann
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
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Levine A, Sigall Boneh R, Wine E. Evolving role of diet in the pathogenesis and treatment of inflammatory bowel diseases. Gut 2018; 67:1726-1738. [PMID: 29777041 DOI: 10.1136/gutjnl-2017-315866] [Citation(s) in RCA: 219] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/12/2022]
Abstract
Recent advances in basic and clinical science over the last 3 years have dramatically altered our appreciation of the role of diet in inflammatory bowel diseases (IBD). The marked increase in incidence of these diseases along with the important role of non-genetic susceptibility among patients with IBD has highlighted that these diseases have a strong environmental component. Progress in the field of microbiome and IBD has demonstrated that microbiome appears to play an important role in pathogenesis, and that diet may in turn impact the composition and functionality of the microbiome. Uncontrolled clinical studies have demonstrated that various dietary therapies such as exclusive enteral nutrition and newly developed exclusion diets might be potent tools for induction of remission at disease onset, for patients failing biologic therapy, as a treatment for disease complications and in reducing the need for surgery. We review these advances from bench to bedside, along with the need for better clinical trials to support these interventions.
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Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Eytan Wine
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Readmission After Abdominal Surgery for Crohn's Disease: Identification of High-Risk Patients. J Gastrointest Surg 2018; 22:1585-1592. [PMID: 29770917 DOI: 10.1007/s11605-018-3805-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/02/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although many predictive factors for postoperative morbidity are known, few data are available about readmission after abdominal surgery for Crohn's disease (CD). The objective of this study is to identify predictive factors and high-risk patients for readmission after abdominal CD surgery. METHODS All patients who underwent abdominal surgery for CD in one tertiary referral center between January 2004 and December 2016 were included. Patients who required readmission and those without were compared. Perineal procedures, elective readmissions, and abdominal procedures for non-Crohn's indications were not included. RESULTS Nine hundred eight abdominal procedures were performed in 712 patients. Readmission rates were 8, 8.5, 8.6, 8.8, and 8.9% at 30, 60, and 90 days and 12 and 60 months, respectively. The main reasons were wound infection (14%), deep abscess (13%), small-bowel obstruction (13%), and dehydration (11%). Eight (11%) patients required percutaneous drainage and 19 (27%) underwent an unplanned surgery. After multivariate analysis, three independent predictive factors for readmission were identified: older age (OR 1.02, 95%CI 1.005-1.04; p < 0.006), a history of previous proctectomy (OR 3, 95%CI 1.2-9, p < 0.02), and higher blood loss volume during surgery (OR 1.0001, 95%CI 1-1.002, p < 0.05). CONCLUSION Readmission occurred in 8-9% of abdominal procedures for CD within 1-3 months after surgery and it required unplanned reoperation in a quarter of them. Identification of high-risk groups and knowledge of the more common postoperative complications requiring readmission help in increasing postoperative vigilance to select patients who may benefit from early interventions.
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Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:997-1002. [PMID: 29738326 DOI: 10.1097/meg.0000000000001162] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Crohn's disease (CD) patients frequently develop complications that require surgery for management. The high prevalence of malnutrition in CD patients presents a challenge because poor preoperative nutritional status has been shown to increase postoperative complications. In this study, we assessed whether preoperative enteral nutrition (EN) or total parenteral nutrition (TPN) decreases postoperative complications in CD patients. MATERIALS AND METHODS A three-point systematic and comprehensive literature search was carried out on multiple databases followed by a meta-analysis with results presented as odds ratio (OR) using two models, the Mantel-Haenszel model and the DerSimonian and Laird model. The I measure of inconsistency was utilized to assess heterogeneity. If statistically significant heterogeneity was identified, the results underwent a separate sensitivity analysis. RESULTS Five studies met inclusion criteria totaling 1111 CD patients. The rate of postoperative complications in the group receiving preoperative nutrition (EN or TPN) support was 20.0% compared with 61.3% in the group who had standard care without nutrition support [OR=0.26, 95% confidence interval (CI): 0.07-0.99, P<0.001]. Postoperative complications occurred in 15.0% of patients in the group who received preoperative TPN compared with 24.4% in the group who did not (OR=0.65, 95% CI: 0.23-1.88, P=0.43). Postoperative complications occurred in 21.9% in the group who received preoperative EN compared with 73.2% in the group that did not received preoperative EN (OR=0.09, 95% CI: 0.06-0.13, P<0.001). CONCLUSION Preoperative nutrition supplementation reduces postoperative complications in CD patients. In particular, EN in CD patients before undergoing surgery is superior to standard of care without nutrition support with a number needed to treat of 2. There is a trend toward TPN being superior to standard of care without nutrition support, but this trend did not reach statistical significance. Further studies are necessary to evaluate specific components in EN or TPN that may be most beneficial for CD patients requiring surgical intervention.
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Zangenberg MS, Horesh N, Kopylov U, El-Hussuna A. Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review. Int J Colorectal Dis 2017; 32:1663-1676. [PMID: 29051981 DOI: 10.1007/s00384-017-2915-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical management of inflammatory bowel disease (IBD) is a challenging task. The aim of preoperative optimization (PO) is to decrease the risk of complications and reduce the length of postoperative stay. The aim of this study was to review and grade the available evidence, attain clear recommendations, and point out potential future research. METHODS Studies were identified from electronic databases (PubMed, Embase, and Cochrane Library) and scanning reference lists in relevant papers. English-written studies examining PO in adult patients with IBD were included. Eight PO factors were investigated. RESULTS Management of IBD is a multidisciplinary task. Steroid withdrawal is recommended while steroid stress dose is not recommended. Thiopurines appear to be safe, but it may be prudent to plan the procedure remotely from the last dose of an anti-TNF agent. Nutritional risk screening is recommended to unveil and correct any malnutrition. Thrombosis prophylaxis prior to surgery is well supported by evidence while extended 4-week prophylaxis needs further research. Percutaneous ultrasound or CT-guided drainage for intra-abdominal abscesses is recommended, but it is unclear for how long supplementary antibiotics (ABs) should be used. Oral AB 24 h prior to open surgery might improve outcome if given as complementary to IV perioperative AB. Mechanical bowel preparation is not supported by evidence. Comorbidities must be treated accordingly prior to surgical intervention. Smoking cessation can be beneficial for wound healing. CONCLUSION Multimodel PO intervention in IBD patients is recommended.
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Affiliation(s)
| | - Nir Horesh
- Department of Surgery, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.
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Assa A, Shamir R. Exclusive enteral nutrition for inducing remission in inflammatory bowel disease in paediatric patients. Curr Opin Clin Nutr Metab Care 2017; 20:384-389. [PMID: 28768295 DOI: 10.1097/mco.0000000000000402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Enteral nutrition as a treatment for inflammatory bowel diseases is an ongoing area of interest. Even in the era of biologic agents, exclusive enteral nutrition (EEN) offers a unique, drug-free measure for induction of remission in luminal Crohn's disease. The purpose of this review is to discuss the role of EEN in the evolving therapeutic scheme for Crohn's disease, to report on new evidence for short and long-term efficacy and highlight findings on the mechanisms of the anti-inflammatory effects of EEN in light of current understanding of disease pathogenesis. RECENT FINDINGS Recent clinical studies have suggested that EEN has an established advantage over corticosteroids for inducing remission in children with luminal Crohn's disease with comparable clinical efficacy but superior mucosal healing effect as well as better safety profile. Preoperative EEN therapy can also improve postoperative outcome of intestinal resection. Basic research has demonstrated that EEN has direct anti-inflammatory properties, can correct localization of tight junction proteins, alter micro RNAs expression, and profoundly affect the intestinal microbiota. SUMMARY EEN is an effective treatment for induction of remission in pediatric luminal Crohn's disease and should be offered as a first-line treatment. Accumulating evidence suggest that EEN has direct anti-inflammatory properties with an effect on the intestinal microbiota. However, the relationships between these effects and the specific triggers for these changes have yet to be elucidated.
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Affiliation(s)
- Amit Assa
- aInstitute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petach TikvabSackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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46
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Preoperative Nutritional Conditioning of Crohn’s Patients—Systematic Review of Current Evidence and Practice. Nutrients 2017. [DOI: 10.3390/nu9060661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Grass F, Pache B, Martin D, Hahnloser D, Demartines N, Hübner M. Preoperative Nutritional Conditioning of Crohn's Patients-Systematic Review of Current Evidence and Practice. Nutrients 2017; 9:nu9060562. [PMID: 28587182 PMCID: PMC5490541 DOI: 10.3390/nu9060562] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022] Open
Abstract
Crohn’s disease is an incurable and frequently progressive entity with major impact on affected patients. Up to half of patients require surgery in the first 10 years after diagnosis and over 75% of operated patients require at least one further surgery within lifetime. In order to minimize surgical risk, modifiable risk factors such as nutritional status need to be optimized. This systematic review on preoperative nutritional support in adult Crohn’s patients between 1997 and 2017 aimed to provide an overview on target populations, screening modalities, routes of administration, and expected benefits. Pertinent study characteristics (prospective vs. retrospective, sample size, control group, limitations) were defined a priori. Twenty-nine studies were retained, of which 14 original studies (9 retrospective, 4 prospective, and 1 randomized controlled trial) and 15 reviews. Study heterogeneity was high regarding nutritional regimens and outcome, and meta-analysis could not be performed. Most studies were conducted without matched control group and thus provide modest level of evidence. Consistently, malnutrition was found to be a major risk factor for postoperative complications, and both enteral and parenteral routes were efficient in decreasing postoperative morbidity. Current guidelines for nutrition in general surgery apply also to Crohn’s patients. The route of administration should be chosen according to disease presentation and patients’ condition. Further studies are needed to strengthen the evidence.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - David Martin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
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Risk factors of surgical site infections in patients with Crohn's disease complicated with gastrointestinal fistula. Int J Colorectal Dis 2017; 32:635-643. [PMID: 28091846 DOI: 10.1007/s00384-017-2751-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn's disease (CD) complicated with gastrointestinal fistula. METHODS This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI. RESULTS A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m2. The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273-26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131-10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086-43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073-0.920). CONCLUSION Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.
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Heerasing N, Thompson B, Hendy P, Heap GA, Walker G, Bethune R, Mansfield S, Calvert C, Kennedy NA, Ahmad T, Goodhand JR. Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease. Aliment Pharmacol Ther 2017; 45:660-669. [PMID: 28105752 DOI: 10.1111/apt.13934] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/20/2016] [Accepted: 12/18/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have reported the systematic use of exclusive enteral nutrition in the perioperative setting. AIM To test the hypothesis that exclusive enteral nutrition provides a safe and effective bridge to surgery and reduces post-operative complications, in adult patients with Crohn's disease requiring urgent surgery for stricturing or penetrating complications. METHODS Patients treated with exclusive enteral nutrition prior to surgery were each matched with two control patients for disease behaviour, type of surgery, age at diagnosis and disease duration. Data on disease phenotype, nutritional status, operative course and post-operative complications were obtained. RESULTS Twenty-five per cent [13/51] patients treated with exclusive enteral nutrition avoided surgery. Exclusive enteral nutrition had no effect on pre-operative weight, but it significantly reduced serum CRP [median at baseline 36 (interquartile range, IQR: 13-91] vs. pre-operation 8 (4-31) mg/L, P = 0.02]. The median (IQR) length of surgery was shorter in patients pre-optimised with exclusive enteral nutrition than controls [3.0 (2.5-3.5) vs. 3.5 (3.0-4.0) hours respectively, P < 0.001]. Multivariable logistic regression analysis confirmed that going straight-to-surgery compared exclusive enteral nutrition pre-optimisation was associated with a ninefold increase in the incidence of post-operative abscess and/or anastomotic leak [OR 9.1; 95% CI (1.2-71.2), P = 0.04]. CONCLUSIONS Exclusive enteral nutrition frequently down-stages the need for surgery in patients presenting with stricturing or penetrating complications of Crohn's disease; it is associated with a reduction in systemic inflammation, operative times and the incidence of post-operative abscess or anastomotic leak. Further trials are needed to elucidate how exclusive enteral nutrition may improve operative outcomes.
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Affiliation(s)
- N Heerasing
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - B Thompson
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - P Hendy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G A Heap
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G Walker
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - R Bethune
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - S Mansfield
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - C Calvert
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - N A Kennedy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - T Ahmad
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J R Goodhand
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Zheng XB, Peng X, Xie XY, Lian L, Wu XR, Hu JC, He XW, Ke J, Chen YF, Zhi M, Wu XJ, He XS, Lan P. Enteral nutrition is associated with a decreased risk of surgical intervention in Crohns disease patients with spontaneous intra-abdominal abscess. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:834-842. [DOI: 10.17235/reed.2017.5116/2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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