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Vuyyuru SK, Ma C, Sharma T, Nguyen TM, Bessissow T, Narula N, Singh S, Rieder F, Jairath V. Characteristics of Interventional Trials for Patients Living With Intestinal Stoma Registered in ClinicalTrials.gov With a Focus on Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad293. [PMID: 38135729 DOI: 10.1093/ibd/izad293] [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: 04/28/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND This systematic review was performed to characterize the landscape of research conducted in patients with intestinal stoma (IS) and highlight unmet needs for clinical research in Crohn's disease (CD) and IS. METHODS We searched ClinicalTrials.gov from inception to May 25, 2022, to identify clinical trials assessing interventions in patients with an IS, as well as those with an IS and CD. Studies were grouped according to type of intervention. We excluded observational studies with no treatment arm. RESULTS A total of 253 studies were included in the final analysis. Most studies investigated devices (n = 122 [48.2%]), or surgical procedures (n = 63 [24.9%]), followed by behavioral interventions (n = 30 [11.8%]), drugs (n = 20 [7.9%]), dietary interventions (n = 2 [0.8%]), skin care products (n = 2 0.8%]), and others (n = 14 [5.5%]). A total of 50.9% (n = 129) of studies had completed recruitment, enrolling 11 116 participants. Only 6 studies (surgery: n = 3; physiological studies: n = 2; drugs: n = 1) exclusively included patients with inflammatory bowel disease (IBD), and 16 studies commented that patients with IBD were excluded in their eligibility criteria. No study assessed efficacy of drugs in patients with CD and IS. Approximately one-quarter of studies (n = 65 of 253) included quality of life as an outcome measure. CONCLUSION There is a paucity of research in IBD patients with IS, with the majority focusing on devices and surgical procedures. There have been no drug trials evaluating efficacy in patients with CD and IS. There is an urgent need to identify barriers to enrollment and develop eligibility and outcome measures that enable the inclusion of patients with CD with stoma into clinical trials.
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Affiliation(s)
- Sudheer K Vuyyuru
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University, London, ON, Canada
| | - Christopher Ma
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tanmay Sharma
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University, London, ON, Canada
| | - Tran M Nguyen
- Lawson Health Research Institute, Western University, London, ON, Canada
| | - Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University, London, ON, Canada
- Lawson Health Research Institute, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Vuyyuru SK, Rieder F, Solitano V, Nguyen TM, Crowley E, Narula N, Singh S, Ma C, Jairath V. Patients With Crohn's Disease and Permanent Ileostomy Are Universally Excluded From Clinical Trials: A Systematic Review. Am J Gastroenterol 2023; 118:1285-1288. [PMID: 36757156 PMCID: PMC10958372 DOI: 10.14309/ajg.0000000000002215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/31/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION We performed a systematic review to investigate whether patients with Crohn's disease (CD) and permanent ileostomy (PI) have been included in clinical trials evaluating biologics and small molecules. METHODS MEDLINE, Embase and Cochrane library (CENTRAL) data bases were searched from inception to May 16, 2022 for placebo controlled induction and/or maintenance randomized controlled trials assessing biologics and oral small molecules in adult patients with active CD. RESULTS Of the 81 induction and maintenance trials assessing biologics and oral small molecules in CD, none permitted the enrollment of patients with PI. Patients with CD and PI have been universally excluded from pharmaceutical trials of biologics and small molecules to date. DISCUSSION There is an urgent need to identify barriers to enrollment and develop eligibility and outcome measures enabling the inclusion of patients with CD and PI into clinical trials.
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Affiliation(s)
- Sudheer K. Vuyyuru
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Virginia Solitano
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Tran M. Nguyen
- Lawson Health Research Institute, Western University, London, Ontario, Canada
| | - Eileen Crowley
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children’s Hospital Western Ontario, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Neeraj Narula
- Department of Medicine, Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Christopher Ma
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
- Lawson Health Research Institute, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Gleason L, Gunnells D. Ileocolic Anastomoses. Clin Colon Rectal Surg 2022; 36:5-10. [PMID: 36619280 PMCID: PMC9815909 DOI: 10.1055/s-0042-1757786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ileocolic anastomoses are commonly performed by surgeons in both open and minimally invasive settings and can be created by using many different techniques and configurations. Here the authors review both current literature and the author's preference for creation of ileocolic anastomoses in the setting of malignancy, inflammatory bowel disease, and colonic inertia. The authors also review evidence surrounding adjuncts to creation of anastomoses such as use of indocyanine green and closing mesenteric defects. While many techniques of anastomotic creation have adapted with new evidence and technologies, several key principles still provide the foundation for current practice.
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Affiliation(s)
- Lauren Gleason
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama Medical Center, Birmingham, Alabama
| | - Drew Gunnells
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama Medical Center, Birmingham, Alabama,Address for correspondence Drew Gunnells, MD Division of Gastrointestinal Surgery, University of Alabama at Birmingham1808 7th Ave South, BDB 557 35294, Birmingham, AL 35223
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Lee KE, Cantrell S, Shen B, Faye AS. Post-operative prevention and monitoring of Crohn's disease recurrence. Gastroenterol Rep (Oxf) 2022; 10:goac070. [PMID: 36405006 PMCID: PMC9667961 DOI: 10.1093/gastro/goac070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 10/22/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are relapsing and remitting chronic inflammatory diseases of the gastrointestinal tract. Although surgery for UC can provide a cure, surgery for CD is rarely curative. In the past few decades, research has identified risk factors for postsurgical CD recurrence, enabling patient risk stratification to guide monitoring and prophylactic treatment to prevent CD recurrence. A MEDLINE literature review identified articles regarding post-operative monitoring of CD recurrence after resection surgery. In this review, we discuss the evidence on risk factors for post-operative CD recurrence as well as suggestions on post-operative management.
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Affiliation(s)
- Kate E Lee
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Adam S Faye
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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Abstract
PURPOSE OF REVIEW Nearly one-third of patients with inflammatory bowel disease (IBD) do not achieve remission despite our best therapies. When this happens, it is critical to understand the reason for treatment failure. Once nonresponse is confirmed, these patients should be referred to an IBD centre for multidisciplinary care. This review will discuss the remaining treatment options, including escalation of biologics to unlicensed doses, combination biologics, nonvalidated therapies and surgical options. It will additionally provide updates in the management of acute severe ulcerative colitis (ASUC). RECENT FINDINGS There is an increasing interest in combination biologics to treat refractory IBD, although data supporting its safety and effectiveness are limited. The use of hyperbaric oxygen, mesenchymal stem cell therapy and dietary interventions also show early promise in this area. Studies have additionally focused on personalized therapy to identify aggressive phenotypes and predict treatment response in these challenging patients. In ASUC, infliximab and cyclosporine remain mainstays of treatment, and tofacitinib shows promise as a salvage therapy. SUMMARY Refractory IBD is common, yet large knowledge gaps remain. Recent and ongoing studies have focused on medical, surgical and dietary approaches with mixed success. Larger prospective studies are desperately needed to address this complex issue.
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Hollis RH, Smith N, Sapci I, Click B, Regueiro M, Hull TL, Lightner AL. Small Bowel Crohn's Disease Recurrence is Common After Total Proctocolectomy for Crohn's Colitis. Dis Colon Rectum 2022; 65:390-398. [PMID: 34759246 DOI: 10.1097/dcr.0000000000002328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical intervention for Crohn's disease involving the colon is often a total proctocolectomy with end ileostomy. There are limited data regarding postoperative small bowel recurrence rates in the recent era. OBJECTIVE The purpose of this study was to determine the rate of small bowel Crohn's disease recurrence following total proctocolectomy and secondarily define risk factors for disease recurrence. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at four hospitals within a single healthcare system. PATIENTS Patients were those with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2009-2019. MAIN OUTCOME MEASURES Main outcome measures were clinical, endoscopic, radiographic, and/or surgical Crohn's disease recurrence. RESULTS In total, 193 patients were included with a median follow-up of 1.8 years (IQR 0.4-4.6). Overall, 74.6% (n = 144) of patients had been previously exposed to biologic therapy, and 51.3% (n = 99) had a history of small bowel Crohn's disease. Postoperatively, 14.5% (n = 28) of patients received biologic therapy. Crohn's disease recurrence occurred in 23.3% (n = 45) of patients with an estimated median 5-year recurrence rate of 40.8% (95% CI' 30.2-51.4). Surgical recurrence occurred in 8.8% (n = 17) of patients with an estimated median 5-year recurrence rate of 16.9% (95% CI' 8.5-25.3). On multivariable analysis, prior small bowel surgery for Crohn's disease (HR 2.61; 95% CI' 1.42-4.81) and Crohn's diagnosis at age <18 years (HR 2.56; 95% CI' 1.40-4.71) were associated with Crohn's recurrence. In patients without prior small bowel Crohn's disease, 14.9% (n = 14) had Crohn's recurrence with an estimated 5-year overall recurrence rate of 31.1% (95% CI' 13.3-45.3) and 5-year surgical recurrence rate of 5.7% (95% CI' 0.0-12.0). LIMITATIONS The study was limited by its retrospective design and lack of consistent follow-up on all patients. CONCLUSIONS Greater than one third of patients who underwent total proctocolectomy for Crohn's disease were estimated to have small bowel Crohn's recurrence at 5 years after surgery. Patients with a history of small bowel surgery for Crohn's and diagnosis at any early age may benefit from more intensive postoperative surveillance and consideration for early medical prophylaxis. See Video Abstract at http://links.lww.com/DCR/B762. RECURRENCIA FRECUENTE DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUS DE LA PROCTOCOLECTOMA TOTAL POR COLITIS DE CROHN ANTECEDENTES:La cirugia para la enfermedad de Crohn que involucra el colon es a menudo una proctocolectomía total con ileostomía terminal. Hay datos limitados con respecto a las tasas de recurrencia posoperatoria de la enfermedad de Crohn del intestino delgado en la actualidad.OBJETIVO:Buscamos determinar la tasa de recurrencia de la enfermedad de Crohn del intestino delgado después de la proctocolectomía total y, en segundo lugar, definir los factores de riesgo de recurrencia de la enfermedad.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Cuatro hospitales de un mismo sistema sanitario.PACIENTES:Pacientes con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2009-2019.PRINCIPALES MEDIDAS DE VALORACIÓN:Recurrencia clínica, endoscópica, radiográfica y / o quirúrgica de la enfermedad de Crohn.RESULTADOS:Se incluyeron 193 pacientes con un seguimiento promedio de 1,8 años (IQR 0,4-4,6). El 74,6% (n = 144) de los pacientes habían recibido previamente terapia biológica y el 51,3% (n = 99) tenían antecedentes de enfermedad de Crohn del intestino delgado. Después de la operación, el 14,5% (n = 28) de los pacientes recibieron terapia biológica. La recurrencia de la enfermedad de Crohn ocurrió en el 23,3% (n = 45) de los pacientes con una tasa de recurrencia media estimada a los 5 años del 40,8% (IC del 95%: 30,2-51,4). La recidiva quirúrgica se produjo en el 8,8% (n = 17) de los pacientes con una tasa de recidiva media estimada a los 5 años del 16,9% (IC del 95%: 8,5-25,3). En el análisis multivariable, la cirugía previa del intestino delgado para la enfermedad de Crohn (HR 2,61, IC del 95%: 1,42-4,81) y el diagnóstico de Crohn a la edad <18 (HR 2,56, IC del 95%: 1,40-4,71) se asociaron con la recurrencia de Crohn. En pacientes sin enfermedad previa de Crohn del intestino delgado, el 14,9% (n = 14) tuvo recurrencia de Crohn con una tasa de recurrencia general estimada a 5 años del 31,1% (IC del 95%: 13,3-45,3) y una tasa de recurrencia quirúrgica a 5 años del 5,7% (IC del 95%: 0,0-12,0).LIMITACIONES:Diseño retrospectivo, falta de seguimiento constante de todos los pacientes.CONCLUSIONES:Se estimó que más de un tercio de los pacientes que se sometieron a proctocolectomía total tenían recurrencia de Crohn del intestino delgado a los 5 años después de la cirugía. Los pacientes con antecedentes de cirugía por enfermedad de Crohn del intestino delgado y diagnóstico a una edad temprana pueden beneficiarse de una vigilancia posoperatoria más intensiva y la consideración de una profilaxis médica temprana. Consulte Video Resumen en http://links.lww.com/DCR/B762. (Traducción- Dr. Ingrid Melo).
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Affiliation(s)
- Robert H Hollis
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas Smith
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin Click
- Department of Gastroenterology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tracy L Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
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Lightner AL, Regueiro M. Anorectal Strictures in Complex Perianal CD: How to Approach? Clin Colon Rectal Surg 2022; 35:44-50. [PMID: 35069029 PMCID: PMC8763464 DOI: 10.1055/s-0041-1740037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anorectal strictures are a notoriously difficult to treat phenotype of perianal Crohn's disease. Quality of life is diminished due to ongoing pain, incontinence, difficulty with stool evacuation, and recurrent medical and surgical treatments. Medical therapy is aimed at treating luminal disease and mucosal ulceration to prevent worsening of fibrosis. Clinical examination and endoscopic intervention can be used for serial dilations of strictures. Unfortunately, despite optimal medical therapy and endoscopic intervention with serial anal dilations, surgery with intestinal diversion or proctocolectomy may be required as part of the treatment algorithm in a significant proportion of patients.
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Affiliation(s)
- Amy L. Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio,Address for correspondence Amy L. Lightner, MD Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic9500 Euclid Ave, Cleveland, OH 44195
| | - Miguel Regueiro
- Department of Gastroenterology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
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Vedamurthy A, Gangasani N, Ananthakrishnan AN. Vedolizumab or Tumor Necrosis Factor Antagonist Use and Risk of New or Recurrent Cancer in Patients With Inflammatory Bowel Disease With Prior Malignancy: A Retrospective Cohort Study. Clin Gastroenterol Hepatol 2022; 20:88-95. [PMID: 33065312 DOI: 10.1016/j.cgh.2020.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Treatment of patients with inflammatory bowel diseases (IBD; Crohn's disease (CD), ulcerative colitis (UC) who have a prior history of cancer pose a unique challenge. The impact of Vedolizumab (VDZ) on the risk of new or recurrent cancers in patients with a previous malignancy is unknown. METHODS This was a retrospective study of patients with IBD with a history of current or prior cancer who were subsequently initiated on VDZ, tumor necrosis factor α antagonists (anti-TNF), or had no immunosuppressive therapy after the index cancer diagnosis. The occurrence of a new primary cancer or recurrent cancer was ascertained on follow-up. Multivariable Cox-proportional hazard models were used to determine the independent effect of post-cancer treatment on new/recurrent cancer. RESULTS The study included 96 patients exposed to VDZ after a prior diagnosis of cancer who were compared to 184 and 183 patients exposed to anti-TNF or no immunosuppressive therapy, respectively. The most common primary cancer were solid tumors (50%). Over a median of 6.2 person-years of follow-up, 18 patients on VDZ developed new (7) or recurrent (11) cancer corresponding to a rate of 22 per 1000 person-years after cancer diagnosis. In a multivariable Cox-model, after adjusting for confounders, there was no increase in the risk of new or recurrent cancer with VDZ (HR 1.38 95% CI 0.38 - 1.36) or anti-TNF therapy (HR 1.03, 95% CI 0.65 - 1.64), when compared to no IS. CONCLUSIONS Neither Vedolizumab nor TNF-antagonists were associated with increased risk of new or recurrent cancers in patients with prior malignancy.
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Affiliation(s)
- Amar Vedamurthy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nikitha Gangasani
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Ashwin N Ananthakrishnan
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Abstract
BACKGROUND Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. OBJECTIVE To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. DATA SOURCES An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. STUDY SELECTION Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. INTERVENTION(S) Medical and surgical management. MAIN OUTCOME MEASURES Symptomatic relief, need for proctocolectomy. RESULTS Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. LIMITATIONS Limited literature published, all retrospective in nature. CONCLUSIONS Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.
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Vespa E, Furfaro F, Allocca M, Fiorino G, Correale C, Gilardi D, Argollo M, Zilli A, Zacharopoulou E, Loy L, Danese S. Endoscopy after surgery in inflammatory bowel disease: Crohn's disease recurrence and pouch surveillance. Expert Rev Gastroenterol Hepatol 2020; 14:829-841. [PMID: 32758015 DOI: 10.1080/17474124.2020.1807325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Crohn's disease (CD) and ulcerative colitis (UC) are immune-mediated disorders characterized by a chronic inflammation, with intermittent exacerbations of symptoms and inflammation. In both diseases, medical treatment has made revolutionary steps forward. Nevertheless, surgery is still required in many cases due to inefficacy of multiple medical therapies. It is not clear whether surgery rates in inflammatory bowel diseases (IBD) are currently decreasing despite all improvements. AREAS COVERED Multidisciplinary management is critical in surgical patients to improve long-term outcomes. Endoscopy plays a crucial role, both before and after surgery, in planning therapeutic strategies and stratifying risk of recurrence. Aim of this review is to provide a deeper insight into the central role of endoscopy in the postoperative management of IBD patients, focusing on recent research advances, future challenges and unresolved questions. EXPERT OPINION Both UC and CD surgical patients need endoscopy to define the correct therapeutic choice, predict subsequent disease course and adopt the correct surveillance strategy. In the next future, newer endoscopic techniques could be systematically applied in IBD patients after surgery, to assess early postoperative inflammation, response to treatment, or, regarding UC, to provide enhanced pouch surveillance, allowing for early detection of inflammation and dysplasia.
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Affiliation(s)
- Edoardo Vespa
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Mariangela Allocca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Gionata Fiorino
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Carmen Correale
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Marjorie Argollo
- IBD Unit, Department of Gastroenterology, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Alessandra Zilli
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Eirini Zacharopoulou
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Laura Loy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
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Mark-Christensen A, Erichsen R, Veres K, Laurberg S, Sørensen HT. Extracolonic Cancer Risk After Total Colectomy for Inflammatory Bowel Disease: A Population-based Cohort Study. J Crohns Colitis 2020; 14:630-635. [PMID: 31811282 DOI: 10.1093/ecco-jcc/jjz199] [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: 12/26/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease are at increased risk of extracolonic cancers. Little is known regarding this risk following total colectomy [TC]. METHODS Patients who underwent TC for inflammatory bowel disease in Denmark during 1977-2013 were identified from the Danish National Patient Registry. Incidence rates of extracolonic cancers were determined through record linkage to the Danish Cancer Registry and compared with expected incidence rates in the general population. Standardized incidence ratios [SIRs] were calculated as the observed vs expected cancer incidence. RESULTS In total, 4430 patients (3441 with ulcerative colitis [UC]; 989 with Crohn's disease [CD]) were followed for 54,183 person-years after TC. Following their surgery, 372 patients were diagnosed with extracolonic cancer compared to 331 expected [SIR = 1.1 (95% confidence interval {CI}: 1.0-1.2)]. The risk of extracolonic cancer overall was increased among patients with CD and TC (SIR = 1.5 [95% CI: 1.2-1.8]), but not among patients with UC and TC (SIR = 1.0 [95% CI: 0.9-1.2]). Patients with UC and TC had a higher risk of intestinal extracolonic cancer (SIR = 2.0 [95% CI: 1.4-2.7]). Patients with CD and TC had a higher risk of smoking-related cancers (SIR = 1.9 [95% CI: 1.2-2.9]), intestinal extracolonic cancer (SIR = 3.1 [95% CI: 1.6-5.5]) and immune-mediated cancers (SIR = 1.5 [95% CI: 1.0-2.1]). CONCLUSION Patients with CD and TC had a higher risk of extracolonic cancer overall compared to the general population, while patients with UC and TC did not. Site-specific cancer risk varied according to inflammatory bowel disease type.
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Affiliation(s)
- Anders Mark-Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus N, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Katalin Veres
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Søren Laurberg
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus N, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
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Abstract
Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.
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Affiliation(s)
- John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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13
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Kim D, Taleban S. A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population. Drugs Aging 2019; 36:607-624. [PMID: 31055789 DOI: 10.1007/s40266-019-00672-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.
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Affiliation(s)
- David Kim
- Division of Gastroenterology and Hepatology, Banner University Medical Center, Tucson, AZ, USA.,Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tucson, AZ, USA
| | - Sasha Taleban
- Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tucson, AZ, USA. .,Arizona Center on Aging, University of Arizona, Tucson, AZ, USA.
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14
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Wang X, Shen B. Management of Crohn's Disease and Complications in Patients With Ostomies. Inflamm Bowel Dis 2018; 24:1167-1184. [PMID: 29722891 DOI: 10.1093/ibd/izy025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Indexed: 12/13/2022]
Abstract
Fecal diversion with ostomy construction can be a temporary or definitive surgical measure for the treatment of refractory inflammatory bowel disease (IBD). However, the fecal diversion surgery is associated with various stoma, peristomal complications, and recurrence or occurrence of de novo small bowel Crohn's disease (CD). Stoma complications often need enterostomal therapy or surgical revision. Peristomal cutaneous lesions, such as pyoderma gangrenosum, usually require immunomodulator or biological therapy. Routine monitoring for occurrence or recurrence of CD with endoscopy or imaging should be performed, and prophylaxis with mesalamines, antibiotics, immunomodulators, or anti-TNFα or anti-integrin agents is needed for patients at risk. Those agents, along with corticosteroids, may also be used for the treatment of CD of the neo-small intestine, particularly inflammatory and fistulizing phenotypes. Endoscopic balloon dilation or endoscopic stricturotomy via stoma is safe and feasible to treat short (<4-5 cm), straight strictures in the neo-small intestine. Medically or endoscopically refractory fibrostenotic disease usually requires surgical intervention, with bowel-sparing stricturoplasty being the surgical treatment of choice.
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Affiliation(s)
- Xinying Wang
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
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Lightner AL. Segmental Resection versus Total Proctocolectomy for Crohn's Colitis: What is the Best Operation in the Setting of Medically Refractory Disease or Dysplasia? Inflamm Bowel Dis 2018; 24:532-538. [PMID: 29462390 DOI: 10.1093/ibd/izx064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Indexed: 12/16/2022]
Abstract
Crohn's disease (CD) may affect any part of the gastrointestinal tract. When isolated to the colon, and patients become medically refractory, there are several surgical options - segmental resection, subtotal colectomy with ileorectal anastomosis, or a total proctocolectomy and end ileostomy. Unfortunately, surgery does not cure CD, and, regardless of the extent of bowel removed, recurrence may be seen in the small bowel. This may lead to need for further immunosuppression or surgery. Therefore, when appropriate, a segmental colectomy or subtotal colectomy may prevent a permanent ostomy required with a total proctocolectomy. In the setting of dysplasia identified on colonoscopy, low quality evidence guides our treatment paradigms. Even though identification of dysplasia has greatly improved with chromoendoscopy, rates of synchronous or metachronous neoplasm remain high. Thus, a total proctocolectomy and end ileostomy, whereas a larger operation, may be best for the patient to remove all at risk tissue. Further research with prospective or randomized control trials is needed to improve our practice guidelines of both scenarios.
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Affiliation(s)
- Amy L Lightner
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester MN
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Lightner AL, Shen B. Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era". Gastroenterol Rep (Oxf) 2017; 5:165-177. [PMID: 28852521 PMCID: PMC5554387 DOI: 10.1093/gastro/gow046] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, MN, USA
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, OH, USA
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Fumery M, Dulai PS, Meirick P, Farrell AM, Ramamoorthy S, Sandborn WJ, Singh S. Systematic review with meta-analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy. Aliment Pharmacol Ther 2017; 45:381-390. [PMID: 27928830 PMCID: PMC5253136 DOI: 10.1111/apt.13886] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 07/31/2016] [Accepted: 11/13/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC-PI) may be a treatment option for medically refractory colonic Crohn's disease (CD). AIM To perform a systematic review and meta-analysis to evaluate the rate, risk factors and outcomes of CD recurrence after TC-PI. METHODS In a systematic review ending 31 March 2016, we identified 18 cohort studies (1438 adults) who underwent TC-PI for colonic CD (median follow-up, 7.4 years; interquartile range, 5.3-9.0). We estimated pooled rates [with 95% confidence interval (CI)] of clinical and surgical recurrence, and risk factors for disease recurrence. RESULTS On meta-analysis, the risk of clinical recurrence after TC-PI was 28.0% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients), with a 5 and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60) respectively. The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients), with a 5 and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34) respectively. The risk of clinical and surgical recurrence in patients without ileal disease at baseline was 11.5% (95% CI, 7.7-16.8) and 10.4% (95% CI, 4.5-22.5) respectively. History of ileal disease was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6). Other inconsistent risk factors for disease recurrence were penetrating disease and young age at disease onset. CONCLUSIONS Small bowel clinical recurrence occurs in about 28% of patients after total colectomy with permanent ileostomy for colonic Crohn's disease. Disease recurrence risk is 3.2 times higher in patients with history of ileal disease, and continued medical therapy may be advisable in this population. In patients without ileal inflammation at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy.
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Affiliation(s)
- Mathurin Fumery
- Division of Gastroenterology, University of California San Diego, La Jolla, California
- Gastroenterology Unit, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Paul Meirick
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Ann M. Farrell
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
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Annede P, Seisen T, Klotz C, Mazeron R, Maroun P, Petit C, Deutsch E, Bossi A, Haie-Meder C, Chargari C, Blanchard P. Inflammatory bowel diseases activity in patients undergoing pelvic radiation therapy. J Gastrointest Oncol 2017; 8:173-179. [PMID: 28280621 DOI: 10.21037/jgo.2017.01.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Few studies with contradictory results have been published on the safety of pelvic radiation therapy (RT) in patients with inflammatory bowel disease (IBD). METHODS From 1989 to 2015, a single center retrospective analysis was performed including all IBD patients who received pelvic external beam radiation therapy (EBRT) or brachytherapy (BT) for a pelvic malignancy. Treatment characteristics, IBD activity and gastrointestinal (GI) toxicity were examined. RESULTS Overall, 28 patients with Crohn's disease (CD) (n=13) or ulcerative colitis (n=15) were included in the present study. Median follow-up time after irradiation was 5.9 years. Regarding IBD activity, only one and two patients experienced a severe episode within and after 6 months of follow-up, respectively. Grade 3/4 acute GI toxicity occurred in 3 (11%) patients, whereas one (3.6%) patient experienced late grade 3/4 GI toxicity. Only patients with rectal IBD location (P=0.016) or low body mass index (BMI) (P=0.012) experienced more severe IBD activity within or after 6 months following RT, respectively. CONCLUSIONS We report an acceptable tolerance of RT in IBD patients with pelvic malignancies. Specifically, a low risk of uncontrolled flare-up was observed.
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Affiliation(s)
- Pierre Annede
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Thomas Seisen
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Caroline Klotz
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
| | - Pierre Maroun
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
| | - Claire Petit
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Eric Deutsch
- Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France;; Department of Molecular Radiotherapy, University Paris-Sud, SIRIC SOCRATES, Faculté de Médecine, Le Kremlin-Bicetre, France
| | - Alberto Bossi
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Christine Haie-Meder
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France;; NRBC Department, Institut de Recherche Biomédicale des Armées, Bretigny-sur-Orge, France
| | - Pierre Blanchard
- Brachytherapy Unit, Gustave Roussy, Villejuif, France;; Department of Radiotherapy Department, Gustave Roussy, Villejuif, France;; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France
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Fortinsky KJ, Kevans D, Qiang J, Xu W, Bellolio F, Steinhart H, Milgrom R, Greenberg G, Cohen Z, Macrae H, Stempak J, McLeod R, Silverberg MS. Rates and Predictors of Endoscopic and Clinical Recurrence After Primary Ileocolic Resection for Crohn's Disease. Dig Dis Sci 2017; 62:188-196. [PMID: 27778204 DOI: 10.1007/s10620-016-4351-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 10/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS The utility of postoperative medical prophylaxis (POMP) and the treatment of mild endoscopic recurrence remain controversial. METHODS This study is a retrospective review of patients undergoing a primary ileocolic resection for CD at a single academic center. Endoscopic recurrence (ER) was defined using the Rutgeerts score (RS), and clinical recurrence (CR) was defined as symptoms of CD with endoscopic or radiologic evidence of neo-terminal ileal disease. RESULTS There were 171 patients who met inclusion criteria. The cumulative probability of ER (RS ≥ i-1) at 1, 2, and 5 years was 29, 51, and 77 %, respectively. The only independent predictors of ER were the absence of POMP (HR 1.50; P = 0.03) and penetrating disease behavior (HR 1.50; P = 0.05). The cumulative probability of CR at 1, 2, and 5 years was 8, 13, and 27 %, respectively. There was a higher rate of clinical recurrence in patients with RS-2 compared to RS-1 on the initial postoperative endoscopy (HR 2.50; P = 0.02). In 11 patients not exposed to POMP with i-1 on initial endoscopy, only 2 patients (18 %) progressed endoscopically during the study period while 5 patients (45 %) regressed to i-0 on subsequent endoscopy without treatment. CONCLUSIONS Postoperative medical prophylaxis decreased the likelihood of ER while certain phenotypes of CD appear to increase the risk of developing ER and CR. There may be a role for watchful waiting in patients with mild endoscopic recurrence on the initial postoperative endoscopy.
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Affiliation(s)
| | | | | | - Wei Xu
- University of Toronto, Toronto, Canada
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Chongthammakun V, Fialho A, Fialho A, Lopez R, Shen B. Correlation of the Rutgeerts score and recurrence of Crohn's disease in patients with end ileostomy. Gastroenterol Rep (Oxf) 2016; 5:271-276. [PMID: 28039168 PMCID: PMC5691374 DOI: 10.1093/gastro/gow043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/16/2016] [Indexed: 01/25/2023] Open
Abstract
Background Recurrence of Crohn’s disease (CD) can occur after surgery, including end ileostomy (EI). The Rutgeerts score (RS) was developed to predict postsurgical CD recurrence via ileocolonoscopy in patients having ileocolonic resection. The role of ileoscopic evaluation via stoma for assessing recurrence of CD has not been investigated. The aim of this study was to evaluate the role of ileoscopy for predicting disease recurrence in CD patients after EI with the use of RS. Methods A total of 73 eligible CD patients with at least two ileoscopies in our institution following EI were included. Mucosal inflammation of the neo-terminal ileum was graded based on the RS. The primary outcomes were the need for endoscopic stricture dilation and subsequent surgery due to recurrence of disease. The secondary outcomes were CD-related hospitalization and the need to escalate CD-associated medications. Results The median duration of CD until EI was 9 years (interquartile range: 4-13 years), and the median duration from EI to the first ileoscopy was 28 months (interquartile range: 11-93 months). The RSs in the neo-terminal ileum close to EI were calculated, and subjects were divided into two groups: the normal RS group with the score being zero (n = 25) and the abnormal RS group with the RS score being ≥1 (n = 48). Patients in the abnormal RS group were more likely to have recurrence of CD (92% vs 27%) and need endoscopic dilation of stricture (40% vs 10%), subsequent bowel surgery (68% vs 15%), disease-related hospitalizations (80% vs 23%) and escalation of CD medications (64% vs 25%) than those in the normal RS group. Time-to-event analysis showed that patients in the abnormal RS group were at a higher risk of endoscopic dilation (odds ratio (OR) = 1.5; 95% CI: 1.09–1.9), need of second bowel surgery (OR = 1.5; 95%CI: 1.2–1.8) and disease-related hospitalizations (OR = 1.3; 95%CI: 1.1–1.6) after adjusting for factors such as duration from surgery to sensor, duration of disease and the patient’s sex (all P < 0.001). Further multivariable analysis showed that patients in the abnormal RS group were more likely to need escalation of CD-related medications after adjusting for duration from surgery and age (OR = 5.3; 95% CI: 1.7–16.5; P = 0.004). Conclusion RS can be used to predict the recurrence of CD in patients with EI. A high RS score based on ileoscopy appeared to be associated with poor outcomes. This may be considered a useful decision-making tool for monitoring disease after ileostomy surgery.
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Affiliation(s)
| | - Andre Fialho
- Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Andrea Fialho
- Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- The Center for Inflammatory Bowel Diseases, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Abstract
BACKGROUND Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease. OBJECTIVE The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. DESIGN Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. SETTINGS The study was conducted at a tertiary care research center. PATIENTS Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. MAIN OUTCOME MEASURES Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy. RESULTS Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis. LIMITATIONS The study was limited by its retrospective nature and small sample size. CONCLUSIONS Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.
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Nguyen V, Kanth R, Gazo J, Sorrentino D. Management of post-operative Crohn's disease in 2017: where do we go from here? Expert Rev Gastroenterol Hepatol 2016; 10:1257-1269. [PMID: 27678049 DOI: 10.1080/17474124.2016.1241708] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Postoperative recurrence (POR) of Crohn's disease is common after surgical resection. How to best manage POR remains uncertain. Areas covered: In this review, we will first describe the natural course and the best modalities to diagnose this surgical sequela. We will then focus on the potential risk factors for relapse and highlight the main shortcomings in the current study designs and endoscopic and clinical scoring systems, which may partly explain the unexpected outcomes of recent clinical trials. Finally, we will propose a strategy to address the management of POR. Expert commentary: Anti-tumor necrosis factor (Anti-TNF) agents are the most effective therapy to prevent POR in Crohn's disease. Patient risk stratification and active monitoring with scheduled ileocolonoscopy are cornerstones of optimal POR management. Further studies are needed to address areas of uncertainty including timing and duration of therapy and the role of therapeutic drug monitoring in this setting.
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Affiliation(s)
- Vu Nguyen
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States
| | - Rajan Kanth
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States
| | - Joshua Gazo
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States
| | - Dario Sorrentino
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States.,b Clinical and Experimental Medical Sciences , University of Udine Medical School , Udine , Italy
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Abstract
BACKGROUND The potential need for an ostomy is a main concern for patients with inflammatory bowel disease. We performed this study to evaluate the impact of a long-term ostomy (≥6 mo duration) on the functional status and specific patient-reported outcomes in a population of patients with Crohn's disease (CD). METHODS We performed a cross-sectional analysis within the Crohn's and Colitis Foundation of America Partners cohort. Bivariate analyses and logistic regression models were used to investigate associations between ostomy and various demographic, disease factors, and patient-reported outcomes for health-related quality of life. RESULTS A total of 402 CD patients with ostomy for a minimum duration of 6 months were compared with 4331 CD patients with no ostomy. Patients with ostomy were more likely to be in clinical remission compared with those without ostomy, 48.5% versus 31.3%, respectively. Having an ostomy did not impact the overall health-related quality of life and was not associated with anxiety, depression, sleep disturbances, or reduced sexual interest and satisfaction. However, the presence of ostomy was associated with reduced social role satisfaction in both patients with controlled and active disease. Additionally, in the subset of patients who did not achieve clinical remission, those with ostomy experienced greater pain interference (odds ratio, 1.63; 95% confidence interval, 1.12-2.35) and fatigue (odds ratio, 1.66; 95% confidence interval, 1.15-2.39). CONCLUSIONS Ostomy is well tolerated in CD patients, particularly when clinical remission is achieved.
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Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
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25
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Han YM, Kim JW, Koh SJ, Kim BG, Lee KL, Im JP, Kim JS, Jung HC. Patients with perianal Crohn's disease have poor disease outcomes after primary bowel resection. J Gastroenterol Hepatol 2016; 31:1436-42. [PMID: 26850090 DOI: 10.1111/jgh.13310] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The presence of perianal disease in Crohn's disease patients is one of the factors of postoperative recurrence. The aim of this study is to evaluate long-term prognosis of perianal Crohn's disease patients in Asian. METHODS Patients with Crohn's disease who had undergone surgical bowel resection were divided into two groups according to the presence of perianal lesion. We monitored the occurrences of abdominal and/or perianal reoperation and readmission due to disease flare-up. RESULTS The 132 patients included in the study were divided into 2 groups, those with perianal disease (45 patients, 34.1%) and those without perianal disease (87 patients, 65.9%). Patients with perianal disease was younger in age (33.8 years versus 39.8 years, p = 0.015) and had been diagnosed as CD at a younger age (21.9 years versus 28.6 years, p = 0.005) than patients without perianal disease. Patients with perianal disease showed more extra-intestinal manifestation than patients without perianal disease (8 versus 3, p = 0.008). Reoperation was required in 46 (44.8%) patients during the follow-up period. The presence of perianal disease independently increased the risk of reoperation [hazard ratio (HR), 3.112; confidence interval (CI), 1.707-5.675]. Furthermore, patients with perianal disease had increasing risks of abdominal reoperation (HR 1.978; 95% CI, 1.034-3.784). CONCLUSIONS Patients with Crohn's disease and perianal lesions had a higher risk of reoperation. Considering these findings, physicians should consider aggressive and early top down therapy for patients with perianal Crohn's disease.
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Affiliation(s)
- Yoo Min Han
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Won Kim
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Gwan Kim
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kook Lae Lee
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Singh S, Ding NS, Mathis KL, Dulai PS, Farrell AM, Pemberton JH, Hart AL, Sandborn WJ, Loftus EV. Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease. Aliment Pharmacol Ther 2015; 42:783-92. [PMID: 26264359 PMCID: PMC6698449 DOI: 10.1111/apt.13356] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/14/2015] [Accepted: 07/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success. AIMS To perform a systematic review with meta-analysis to evaluate the effectiveness, long-term outcomes and factors associated with success of temporary faecal diversion for perianal CD. METHODS Through a systematic literature review through 15 July 2015, we identified 16 cohort studies (556 patients) reporting outcomes after temporary faecal diversion. We estimated pooled rates [with 95% confidence interval (CI)] of early clinical response, attempted and successful restoration of bowel continuity after temporary faecal diversion (without symptomatic relapse), and rates of re-diversion (in patients with attempted restoration) and proctectomy (with or without colectomy and end-ileostomy). We identified factors associated with successful restoration of bowel continuity. RESULTS On meta-analysis, 63.8% (95% CI: 54.1-72.5) of patients had early clinical response after faecal diversion for refractory perianal CD. Restoration of bowel continuity was attempted in 34.5% (95% CI: 27.0-42.8) of patients, and was successful in only 16.6% (95% CI: 11.8-22.9). Of those in whom restoration was attempted, 26.5% (95% CI: 14.1-44.2) required re-diversion because of severe relapse. Overall, 41.6% (95% CI: 32.6-51.2) of patients required proctectomy after failure of temporary faecal diversion. There was no difference in the successful restoration of bowel continuity after temporary faecal diversion in the pre-biological or biological era (13.7% vs. 17.6%, P = 0.60), in part due to selection bias. Absence of rectal involvement was the most consistent factor associated with restoration of bowel continuity. CONCLUSIONS Temporary faecal diversion may improve symptoms in approximately two-thirds of patients with refractory perianal Crohn's disease, but bowel restoration is successful in only 17% of patients.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.,Division of Gastroenterology, University of California San Diego, La Jolla, California, U.S.A
| | - Nik S. Ding
- Department of Gastroenterology, St. Mark’s Hospital, North West London Hospitals NHS Trust, Harrow, United Kingdom
| | - Kellie L. Mathis
- Division of Colorectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California, U.S.A
| | - Ann M. Farrell
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - John H. Pemberton
- Division of Colorectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Ailsa L. Hart
- Department of Gastroenterology, St. Mark’s Hospital, North West London Hospitals NHS Trust, Harrow, United Kingdom
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, U.S.A
| | - Edward V. Loftus
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Patterns and Predictors of Long-term Nonuse of Medical Therapy Among Persons with Inflammatory Bowel Disease. Inflamm Bowel Dis 2015; 21:1615-22. [PMID: 25970546 DOI: 10.1097/mib.0000000000000418] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND To evaluate patterns and predictors of long-term nonuse of inflammatory bowel disease (IBD)-specific medications among patients with IBD. METHODS All incident cases of IBD diagnosed between 1987 and 2012 were identified from the population-based University of Manitoba IBD Epidemiology Database. Point prevalence of long-term medication nonuse (defined as no receipt of IBD-specific medications for a year or longer) was determined over calendar time and the course of disease. Cox proportional hazard regression analysis was performed to identify factors associated with delayed initiation and with becoming a long-term nonuser. RESULTS Among 6451 persons with IBD followed since 1987 (46.8% male, 47.8% with Crohn's disease), 11.7% were not dispensed an IBD-specific medication within the first year and 6.2% within 5 years after diagnosis. Factors associated with delayed initiation included having Crohn's disease (hazard ratio [HR] = 0.78, 95% confidence interval [CI], 0.73-0.83), lower socioeconomic status (HR = 0.91, 95% CI, 0.84-0.98), age more than 65 years (HR = 0.76, 95% CI, 0.67-0.86), and having any medical comorbidity. The prevalence of long-term nonuse consistently remained between 40% and 50% of persons with IBD across the study years. Patients with Crohn's disease (HR = 1.14, 95% CI, 1.04-1.25), lower socioeconomic status (HR = 1.14, 95% CI, 1.02-1.27), patients with IBD-associated surgery (HR = 1.72, 95% CI, 1.51-1.96), or delayed initiation of first IBD medication were more likely to become long-term nonusers after initiation. CONCLUSIONS At any given time, roughly half of all patients with IBD have not used IBD-specific medications in the previous year. Further work is required to evaluate the clinical implications of long-term medication nonuse in IBD.
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