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Hammoudi N, Sachar D, D'Haens G, Reinisch W, Kotze PG, Vermeire S, Schölmerich J, Kamm MA, Griffiths A, Panes J, Ghosh S, Siegel CA, Bemelman W, O'Morain C, Steinwurz F, Fleshner P, Mantzaris GJ, Sands B, Abreu MT, Dotan I, Turner D, Dignass A, Allez M. Outcomes and Endpoints of Postoperative Recurrence in Crohn's Disease: Systematic Review and Consensus Conference. J Crohns Colitis 2024; 18:943-957. [PMID: 38112601 DOI: 10.1093/ecco-jcc/jjad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/24/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Outcomes after ileocolonic resection in Crohn's disease [CD] are heterogeneous, and a clear definition of postoperative recurrence remains to be determined. Our Endpoints Working Group of the International Organization for the study of Inflammatory Bowel Disease [IOIBD] aimed to standardise postoperative outcomes, to discuss which endpoints should be used for postoperative clinical trials, and to define those which could be used in trials or registries. METHODS Based on a systematic review of the literature, recommendations and statements were drafted and sent to all IOIBD members for a first round of voting. Recommendations and statements were revised based on the voters' comments during a consensus hybrid conference open to all IOIBD members. If no agreement was reached after two rounds of voting, the statement was excluded. RESULTS In the systematic review, 3071 manuscripts were screened of which 434 were included. Sixteen recommendations were identified, of which 11 were endorsed. Recommendations and statements include that endoscopy remains the gold standard and should be used as a short-term primary endpoint in both observational cohorts and randomised controlled trials. Clinical symptoms classically used in clinical trials for luminal CD are not reliable in this specific situation. For that reason, longer-term endpoints should be based on the evidence of macroscopic inflammation assessed by imaging techniques, endoscopy, or as reflected by the presence of complications. CONCLUSIONS Agencies recommend the use of clinical evaluations, as in the case of luminal CD, and do not recognise primary endpoints based solely on endoscopy. This consensus has led to agreement on the need to define postoperative endoscopy-based and/or imaging-based endpoints.
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Affiliation(s)
- Nassim Hammoudi
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - David Sachar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Geert D'Haens
- Department of Gastroenterology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Walter Reinisch
- Department Internal Medicine III, Division Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Severine Vermeire
- Department of Gastroenterology & Hepatology, University Hospital Leuven, Leuven, Belgium
| | | | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anne Griffiths
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Julian Panes
- Formerly Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Corey A Siegel
- IBD Center, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, USA
| | - Willem Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Colm O'Morain
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Flavio Steinwurz
- Department of Gastroenterology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Bruce Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria T Abreu
- Department of Medicine, Division of Gastroenterology, Crohn's and Colitis Center, Leonard M. Miller School of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medica Center, Petah-Tikva, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt Am Main, Germany
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
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van der Does de Willebois EML, Bellato V, Duijvestein M, van Dieren S, Danese S, Sileri P, Buskens CJ, Vignali A, Bemelman WA. How Reliable Is Endoscopic Scoring of Postoperative Recurrence in Crohn Disease?: A Systematic Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2024; 5:e397. [PMID: 38883962 PMCID: PMC11175939 DOI: 10.1097/as9.0000000000000397] [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: 09/05/2023] [Accepted: 02/12/2024] [Indexed: 06/18/2024] Open
Abstract
Objective Guidelines advise to perform endoscopic surveillance following ileocolic resection (ICR) in Crohn disease (CD) for timely diagnosis of recurrence. This study aims to assess the variation in endoscopic recurrence (ER) rates in patients after ICR for CD using the most commonly used classification systems, the Rutgeerts score (RS) and modified Rutgeerts score (mRS) classifications. Methods A systematic literature search using MEDLINE, Embase, and the Cochrane Library was performed. Randomized controlled trials and cohort studies describing ER < 12 months after an ICR for CD were included. Animal studies, reviews, case reports (<30 included patients), pediatric studies, and letters were excluded. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration's tool were used to assess risk of bias. Main outcome was the range of ER rates within 12 months postoperatively, defined as RS ≥ i2 and/or mRS ≥ i2b. A proportional meta-analysis was performed. The final search was performed on January 4, 2022. The study was registered at PROSPERO, CRD42022363208. Results Seventy-six studies comprising 7751 patients were included. The weighted mean of ER rates in all included studies was 44.0% (95% confidence interval, 43.56-44.43). The overall range was 5.0% to 93.0% [interquartile range (IQR), 29.2-59.0]. The weighted means for RS and mRS were 44.0% and 41.1%, respectively. The variation in ER rates for RS and mRS were 5.0% to 93.0% (IQR, 29.0-59.5) and 19.8% to 62.9% (IQR, 37.3-46.5), respectively. Within studies reporting both RS and mRS, the weighted means for ER were 61.3% and 40.6%, respectively. Conclusions This study demonstrates a major variation in ER rates after ICR for CD, suggesting a high likelihood of inadequate diagnosis of disease recurrence, with potentially impact on quality of life and health care consumption. Therefore, there is an important need to improve endoscopic scoring of recurrent disease.
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Affiliation(s)
| | - Vittoria Bellato
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | | | - Susan van Dieren
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Silvio Danese
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | - Pierpaolo Sileri
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | - Christianne J Buskens
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Andrea Vignali
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | - Willem A Bemelman
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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3
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Hamilton AL, De Cruz P, Wright EK, Dervieux T, Jain A, Kamm MA. Non-invasive Serological Monitoring for Crohn's Disease Postoperative Recurrence. J Crohns Colitis 2022; 16:1797-1807. [PMID: 35689453 PMCID: PMC9721459 DOI: 10.1093/ecco-jcc/jjac076] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Crohn's disease recurs after intestinal resection. This study evaluated accuracy of a new blood test, the Endoscopic Healing Index [EHI], in monitoring for disease recurrence. METHODS Patients enrolled in the prospective POCER study [NCT00989560] underwent a postoperative colonoscopic assessment at 6 [2/3 of patients] and 18 months [all patients] following bowel resection, using the Rutgeerts score [recurrence ≥i2]. Serum was assessed at multiple time points for markers of endoscopic healing using the EHI, and paired with the Rutgeerts endoscopic score as the reference standard. RESULTS A total of 131 patients provided 437 serum samples, which were paired with endoscopic assessments available in 94 patients [30 with recurrence] at 6 months and 107 patients [44 with recurrence] at 18 months. The median EHI at 6 months was significantly lower in patients in remission [Rutgeerts <i2] than those with recurrence; p = 0.033. The area under the receiver operating curve [AUROC] for EHI to detect recurrence at 6 months was comparable to that of faecal calprotectin [0.712 vs 0.779, p = 0.414]. EHI of <20 at 6 months had a negative predictive value of 75.7% (95% confidence interval [CI] 58.8-88.2), and sensitivity of 70% [95% CI 50.6-85.3] for detecting recurrence. Combining all time points, an EHI <20 had a negative predictive value of 70.3%. Changes in EHI significantly associated with changes in Rutgeerts scores over the 18 months. CONCLUSIONS The non-invasive multi-marker EHI has sufficient accuracy to be used to monitor for postoperative Crohn's disease recurrence. A monitoring strategy that combines EHI with ileocolonoscopy, with or without faecal calprotectin, should now be prospectively tested.
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Affiliation(s)
- Amy L Hamilton
- Department of Gastroenterology, St Vincent’s Hospital and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Peter De Cruz
- Department of Gastroenterology, St Vincent’s Hospital, Department of Gastroenterology, Austin Health and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent’s Hospital and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | | | | | - Michael A Kamm
- Corresponding author: Professor Michael Kamm, St Vincent’s Hospital, Victoria Parade, Fitzroy 3065, Melbourne, VIC, Australia. Tel.:+61 3 9417 5064; Fax: +61 3 9416 2485;
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Ble A, Renzulli C, Cenci F, Grimaldi M, Barone M, Sedano R, Chang J, Nguyen TM, Hogan M, Zou G, MacDonald JK, Ma C, Sandborn WJ, Feagan BG, Merlo Pich E, Jairath V. The Relationship Between Endoscopic and Clinical Recurrence in Postoperative Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2021; 16:490-499. [PMID: 34508572 PMCID: PMC8919832 DOI: 10.1093/ecco-jcc/jjab163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND AIMS We aimed to quantify the magnitude of the association between endoscopic recurrence and clinical recurrence [symptom relapse] in patients with postoperative Crohn's disease. METHODS Databases were searched to October 2, 2020, for randomised controlled trials [RCTs] and cohort studies of adult patients with Crohn's disease with ileocolonic resection and anastomosis. Summary effect estimates for the association between clinical recurrence and endoscopic recurrence were quantified by risk ratios [RR] and 95% confidence intervals [95% CI]. Mixed-effects meta-regression evaluated the role of confounders. Spearman correlation coefficients were calculated to assess the relationship between these outcomes as endpoints in RCTs. An exploratory mixed-effects meta-regression model with the logit of the rate of clinical recurrence as the outcome and the rate of endoscopic recurrence as a predictor was also evaluated. RESULTS In all, 37 studies [N = 4053] were included. For eight RCTs with available data, the RR for clinical recurrence for patients who experienced endoscopic recurrence was 10.77 [95% CI 4.08 to 28.40; GRADE moderate certainty evidence]; the corresponding estimate from 11 cohort studies was 21.33 [95% CI 9.55 to 47.66; GRADE low certainty evidence]. A single cohort study showed a linear relationship between Rutgeerts score and clinical recurrence risk. There was a strong correlation between endoscopic recurrence and clinical recurrence treatment effect estimates as trial outcomes [weighted Spearman correlation coefficient 0.51]. CONCLUSIONS The associations between endoscopic recurrence and subsequent clinical recurrence lend support to the choice of endoscopic recurrence to monitor postoperative disease activity and as a primary endpoint in clinical trials of postoperative Crohn's disease.
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Affiliation(s)
| | | | - Fabio Cenci
- Corporate R&D, Alfasigma S.p.A., Bologna, Italy
| | | | | | - Rocio Sedano
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - Joshua Chang
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Tran M Nguyen
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Malcolm Hogan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Guangyong Zou
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John K MacDonald
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - William J Sandborn
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G Feagan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Vipul Jairath
- Corresponding author: Vipul Jairath, MB, ChB, DPhil, Department of Medicine, Western University, 399 Windermere Road, London, ON, Canada N6A 5A5. Tel.: 519-685-8500, ext. 33655;
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5
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Arbogast JP, Urbanik S, Schmidt R, Mennigen R, Pascher A, Rijcken E. Impact of the Crohn's disease digestive damage score (Lémann Index) on the perioperative course in patients with Crohn's disease and ileocolic anastomosis. Scand J Gastroenterol 2021; 56:239-246. [PMID: 33410352 DOI: 10.1080/00365521.2020.1868565] [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: 02/04/2023]
Abstract
BACKGROUND Risk factors influencing the high postoperative morbidity in Crohn`s disease are controversially discussed but the role of cumulative structural bowel damage, as assessed by the Crohn's disease digestive damage score (Lémann Index), has been neglected so far. Our aim was evaluating the influence of the Lémann Index on postoperative complications and investigating its suitability for surgical decision making. METHODS A single-center, retrospective cohort study was conducted including Crohn`s disease patients who underwent ileocolic anastomosis. Lémann Indices were calculated and, additionally, categorized into three groups [0-3; 3-10; >10] due to the strong influence of previous bowel resections on high indices. A multivariate regression model was used to analyze the index`s influence on postoperative complications. RESULTS Patients with higher Lémann Index were more likely to need open surgery (p < .001) or stoma creation (p = .03). Overall, of the 103 patients enrolled, 18 (17.5%) showed postoperative complications Clavien-Dindo > 2. The Lémann Index was higher in patients with complications compared to those without (median 6.15 [IQR 4.16-11.98] vs. 3.88 [1.63-12.63]), but not linearly associated with postoperative complications. After categorization, patients with Lémann Index 3-10 had an 8.42 (95% CI 1.8-54.55) times higher chance to develop a complication compared to patients with Lémann Index 0-3 (p = .01). CONCLUSIONS The Lémann Index might affect surgical decision making but is not linearly associated with postoperative morbidity. However, medium indices (3-10) - mainly accounted for by high amounts of intraabdominal active Crohn`s lesions - showed significantly higher rates of complications, potentially defining a group at risk.
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Affiliation(s)
- Jan P Arbogast
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
| | - Sarah Urbanik
- Faculty of Statistics, TU Dortmund University, Dortmund, Germany
| | - Rebecca Schmidt
- Institute for Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Rudolf Mennigen
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
| | - Emile Rijcken
- Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
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Abstract
Despite the development and introduction of new pharmaceutical approaches for Crohn's disease, the treatment of these patients still remains a major clinical challenge due to the heterogeneity in the course, degree of inflammation and localization. Over the last decade surgery was mainly reserved for the treatment of complications during the long course of Crohn's disease; however, due to new evidence-based knowledge, primary surgical resection in patients suffering from isolated Crohn's disease of the terminal ileum represents an equally effective alternative to medicinal antibody-based treatment. Even if further randomized and controlled trials are necessary, the currently available follow-up studies show promising data regarding disease progression with a significant reduction in the need for immunosuppression, which is usually necessary in these patients primarily treated by medication. Therefore, in the interdisciplinary decision on treatment early/primary surgical treatment should be considered as an equally effective alternative for a suitable patient collective.
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Lange K, Stallmach A. [Drug treatment of chronic inflammatory bowel diseases-What must the surgeon know and perioperatively pay attention to?]. Chirurg 2021; 92:3-11. [PMID: 33125523 DOI: 10.1007/s00104-020-01305-5] [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: 02/07/2023]
Abstract
Mesalamine and topical or systemic corticosteroids form the basis of medicinal treatment of patients with chronic inflammatory bowel diseases (IBD), whereas immunosuppressants, biologicals and JAK inhibitors, so-called small molecules, are administered within so-called step-up treatment algorithms. Even though the frequency of operations has decreased during the last decades, surgical interventions still represent a relevant part of the overall concept in IBD treatment. Therefore, the effects of drug pretreatment on surgical approaches have to be put into specific perspectives and contexts. Treatment with corticosteroids unquestionably increases the rate of perioperative complications but there is no such correlation for the use of biologicals or immunosuppressants. Data from older studies pointed towards slightly increased rates of postoperative complications in patients treated with TNF-alpha antibodies; however, more recent studies have not confirmed this risk. The occurrence of postoperative complications is due to the multifactorial origin and is more dependent on the activity of the underlying disease, the comorbidities and the preoperative nutritional status. Preoperative use of the integrin inhibitor vedolizumab is comparable to TNF-alpha antibodies with respect to the postoperative complication rate. This also seems to apply to the interleukin 12/23 antagonist ustekinumab, although the data are still unreliable. The risks after treatment with the Janus kinase inhibitor tofacitinib cannot currently reliably be estimated. For the postoperative care an endoscopic follow-up should be performed within 6 months and prophylactic treatment with immunosuppressors or biologicals can be considered after taking the individual risk factors into account.
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Affiliation(s)
- Kathleen Lange
- Klinik für Innere Medizin IV, Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV, Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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8
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Vavricka SR, Greuter T, Brüngger B, Blozik E, Celeiro J, Schoepfer AM, Bähler C. Follow-Up Ileocolonoscopy Is Underused in Crohn's Disease Patients after Ileocecal Resection despite Higher Total and Inpatient Health-Care Costs Compared to Controls. Inflamm Intest Dis 2020; 5:100-108. [PMID: 32999882 DOI: 10.1159/000507115] [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: 10/12/2019] [Accepted: 03/11/2020] [Indexed: 11/19/2022] Open
Abstract
Background Postoperative recurrence is frequently observed after ileocecal resection in Crohn's disease (CD) patients. Since 2010, endoscopy within 1 year is considered the gold standard for its diagnosis. However, if and how frequent such endoscopies are performed in clinical practice remains unknown. Methods We analyzed 1-year follow-up data on CD patients who underwent ileocecal resection between 2012 and 2014 and compared them with hospitalized, non-resected CD controls. Data were extracted from the Helsana database. Helsana is one of the largest Swiss health insurance companies providing coverage for 1.2 million individuals. Results A total of 645 CD patients were identified with ≥1 hospitalization between 2012 and 2014 and a follow-up of 1 year. Of these, 79 (12.2%) underwent ileocecal resection. Although endoscopy rates increased over time and were higher in patients with resection versus controls (p = 0.029), in only 54.4% a 1-year follow-up ileocolonoscopy was performed. Postoperative prophylaxis with anti-tumor necrosis factor or azathioprine was prescribed in 63.3%. Female sex and age >60 years were independent predictors for not receiving prophylaxis (odds ratio [OR] 0.36, p = 0.048, and OR 0.2, p = 0.022). Patients with resection had significantly lower numbers of rehospitalizations (1.2 vs. 1.8, p = 0.021), with resection being an independent negative predictor for number of rehospitalizations in a Poisson regression model (incident risk ratio 0.64, p = 0.029). However, disease-related surgery was more often the cause for rehospitalization after resection versus controls (47.6 vs. 22.1%, p = 0.015). Total and inpatient health-care costs were higher in these patients. Conclusion Endoscopies are underused after ileocecal resection. This contrasts current guidelines. Physicians should be aware of this underuse and perform follow-up examinations more often.
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Affiliation(s)
- Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Zentrum für Gastroenterologie und Hepatologie, Zurich, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,GZO - Zurich Regional Health Center, Wetzikon, Switzerland
| | - Beat Brüngger
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | | | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, CHUV - University Hospital Lausanne, Lausanne, Switzerland
| | - Caroline Bähler
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
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9
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Argollo M, Kotze PG, Lamonaca L, Gilardi D, Furfaro F, Yamamoto T, Danese S. Prevention of Postoperative Recurrence in CD: Tailoring Treatment to Patient Profile. Curr Drug Targets 2020; 20:1327-1338. [PMID: 30894106 DOI: 10.2174/1389450120666190320110809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is an immune-mediated condition characterized by the transmural inflammation of the gut tissue, associated with progressive bowel damage often leading to surgical intervention. As operative resection of the damaged segment is not curative, a majority of patients undergoing intestinal resections for complicated CD present disease recurrence within 3 years after the intervention. Postoperative recurrence can be defined as endoscopic, clinical, radiological or surgical. Endoscopic recurrence rates within 1 year exceed 60% and the severity, according to the Rutgeerts' score, is associated with worse prognosis and can predict clinical recurrence (in up to 1/3 of the patients). Most importantly, about 50% of patients will undergo a reoperation after 10 years of their first intestinal resection. Therefore, the prevention of postoperative recurrence in CD remains a challenge in clinical practice and should be properly managed. We aim to summarize the most recent data on the definition, risk factors, assessment and treatment of postoperative CD recurrence.
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Affiliation(s)
- Marjorie Argollo
- Department of Gastroenterology, Universidade Federal de São Paulo, São Paulo, Brazil.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Paulo Gustavo Kotze
- IBD outpatient clinics, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Laura Lamonaca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Takayuki Yamamoto
- Department of Surgery and IBD Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Luglio G, Rispo A, Imperatore N, Giglio MC, Amendola A, Tropeano FP, Peltrini R, Castiglione F, De Palma GD, Bucci L. Surgical Prevention of Anastomotic Recurrence by Excluding Mesentery in Crohn's Disease: The SuPREMe-CD Study - A Randomized Clinical Trial. Ann Surg 2020; 272:210-217. [PMID: 32675483 DOI: 10.1097/sla.0000000000003821] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This trial aimed to provide randomized controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis. BACKGROUND Recently, a new antimesenteric, functional, end-to-end, hand-sewn ileocolic anastomosis (Kono-S) has shown a significant reduction in endoscopic recurrence score and surgical recurrence rate in Crohn disease (CD). METHODS Randomized controlled trial (RCT) at a tertiary referral institution. Primary endpoint: endoscopic recurrence (ER) (Rutgeerts score ≥i2) after 6 months. Secondary endpoints: clinical recurrence (CR) after 12 and 24 months, ER after 18 months, and surgical recurrence (SR) after 24 months. RESULTS In all, 79 ileocolic CD patients were randomized in Kono group (36) and Conventional group (43). After 6 months, 22.2% in the Kono group and 62.8% in the Conventional group presented an ER [P < 0.001, odds ratio (OR) 5.91]. A severe postoperative ER (Rutgeerts score ≥i3) was found in 13.8% of Kono versus 34.8% of Conventional group patients (P = 0.03, OR 3.32). CR rate was 8% in the Kono group versus 18% in the Conventional group after 12 months (P = 0.2), and 18% versus 30.2% after 24 months (P = 0.04, OR 3.47). SR rate after 24 months was 0% in the Kono group versus 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis presented a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes. CONCLUSIONS This is the first RCT comparing Kono-S anastomosis and standard anastomosis in CD. The results demonstrate a significant reduction in postoperative endoscopic and clinical recurrence rate for patients who underwent Kono-S anastomosis, and no safety issues.ClinicalTrials.gov ID NCT02631967.
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Affiliation(s)
- Gaetano Luglio
- Surgery, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Antonio Rispo
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Mariano Cesare Giglio
- Surgery, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Alfonso Amendola
- Surgery, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Francesca Paola Tropeano
- Surgery, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Roberto Peltrini
- Surgery, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Fabiana Castiglione
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Giovanni Domenico De Palma
- Surgical Endoscopy, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
| | - Luigi Bucci
- Surgery, Department of Clinical Medicine and Surgery, School of Medicine Federico II of Naples, Naples, Italy
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11
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Hammoudi N, Auzolle C, Tran Minh ML, Boschetti G, Bezault M, Buisson A, Pariente B, Treton X, Seksik P, Fumery M, Le Bourhis L, Nancey S, Allez M. Postoperative Endoscopic Recurrence on the Neoterminal Ileum But Not on the Anastomosis Is Mainly Driving Long-Term Outcomes in Crohn's Disease. Am J Gastroenterol 2020; 115:1084-1093. [PMID: 32618659 DOI: 10.14309/ajg.0000000000000638] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Early ileocolonoscopy within the first year after surgery is the gold standard to evaluate recurrence after ileocolonic resection for Crohn's disease (CD). The aim of the study was to evaluate the association between the presence and severity of anastomotic and ileal lesions at early postoperative ileocolonoscopy and long-term outcomes. METHODS The REMIND group conducted a prospective multicenter study. Patients operated for ileal or ileocolonic CD were included. An ileocolonoscopy was performed 6 months after surgery. An endoscopic score describing separately the anastomotic and ileal lesions was built. Clinical relapse was defined by the CD-related symptoms, confirmed by imaging, endoscopy or therapeutic intensification; CD-related complications; or subsequent surgery. RESULTS Among 225 included patients, long-term follow-up was available in 193 (median follow-up: 3.82 years [interquartile range: 2.56-5.41]). Median clinical recurrence-free survival was 47.6 months. Clinical recurrence-free survival was significantly shorter in patients with ileal lesions at early postoperative endoscopy whatever their severity was (I(1) or I(2,3,4)) as compared to patients without ileal lesions (I(0)) (I(0) vs I(2,3,4): P = 0.0003; I(0) vs I(1): P = 0.0008 and I(1) vs I(2,3,4): P = 0.43). Patients with exclusively ileal lesions (A(0)I(1,2,3,4)) had poorer clinical long-term outcomes than patients with exclusively anastomotic lesions (A(1,2,3)I(0)) (P = 0.009). DISCUSSION A score describing separately the anastomotic and ileal lesions might be more appropriate to define postoperative endoscopic recurrence. Our data suggest that patients with ileal lesions, including mild ones (I(1)), could beneficiate from treatment step-up to improve long-term outcomes.
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Affiliation(s)
- Nassim Hammoudi
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Claire Auzolle
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - My-Linh Tran Minh
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Gilles Boschetti
- Gastroenterology Department, Hospices Civils de Lyon, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Madeleine Bezault
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Anthony Buisson
- Université Clermont Auvergne, Inserm U1071, M2iSH, 3iHP, CHU Clermont-Ferrand, Service de Médecine de l'Appareil Digestif, Clermont-Ferrand, France
| | - Benjamin Pariente
- Gastroenterology Department, Hôpital Claude Huriez, University of Lille 2, Lille, France
| | - Xavier Treton
- Hôpital Beaujon, Service de Gastroentérologie, MICI et Assistance Nutritive, Clichy, France
| | - Philippe Seksik
- Sorbonne Universités, Department of Gastroenterology, Saint Antoine Hospital, AP-HP, Ecole normale supérieure, PSL Research University, CNRS, INSERM, Laboratoire des Biomolécules (LBM), Paris, France
| | - Mathurin Fumery
- Gastroenterology Department, Amiens University Hospital, and Peritox, UMR-I 01, Université de Picardie Jules Verne, Amiens, France
| | - Lionel Le Bourhis
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Stéphane Nancey
- Gastroenterology Department, Hospices Civils de Lyon, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Matthieu Allez
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
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12
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Strömbeck A, Lasson A, Strid H, Sundin J, Stotzer PO, Simrén M, Magnusson MK, Öhman L. Fecal microbiota composition is linked to the postoperative disease course in patients with Crohn's disease. BMC Gastroenterol 2020; 20:130. [PMID: 32366222 PMCID: PMC7197162 DOI: 10.1186/s12876-020-01281-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/22/2020] [Indexed: 12/17/2022] Open
Abstract
Background The role of the fecal microbiota composition for the postoperative disease course of patients with Crohn’s disease (CD) who have undergone ileocecal resection remains to be established. In this study, we investigated if the fecal microbiota composition, determined by a high throughput test quantifying a pre-selected set of bacteria, is associated with the postoperative disease course of CD patients. Methods Fecal samples were obtained from healthy subjects as well as from CD patients, 3–10 weeks and 1 year after ileocaecal resection. The fecal microbial composition was analyzed by Genetic Analysis GA-map Dysbiosis test, targeting ≥300 bacteria on different taxonomic levels. Postoperative disease status was assessed endoscopically according to Rutgeerts scoring system 1 year after surgery. Differences in fecal microbiota composition between groups were analyzed by multivariate factor analyses and cluster analysis. Microbial stability over time was determined using Bray-Curtis dissimilarity. Results One year after surgery, the fecal microbiota composition differed between CD patients (n = 21) and healthy subjects (n = 7). At this time point, the microbiota composition of CD patients was associated with disease course, clearly separating patients with disease relapse (n = 8) and patients in remission (n = 13). Further, the microbial within-patient stability was high during the first year after surgery, irrespective of disease course. Conclusion The fecal microbiota composition of CD patients, analyzed by GA-map Dysbiosis test, is subject to little variation over time, and may potentially be used as a non-invasive diagnostic tool for the postoperative disease course.
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Affiliation(s)
- Anna Strömbeck
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Box 435, 405 30, Gothenburg, Sweden.
| | - Anders Lasson
- Department of Internal Medicine, Södra Älvsborg Hospital, Borås, Sweden
| | - Hans Strid
- Department of Internal Medicine, Södra Älvsborg Hospital, Borås, Sweden
| | - Johanna Sundin
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Box 435, 405 30, Gothenburg, Sweden
| | - Per-Ove Stotzer
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria K Magnusson
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Box 435, 405 30, Gothenburg, Sweden
| | - Lena Öhman
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Box 435, 405 30, Gothenburg, Sweden
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13
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Iborra M, Juliá B, Martín Arranz MD, Barreiro-de Acosta M, Gutiérrez A, García-Sánchez V, Taxonera C, Gisbert JP, Cea-Calvo L, Domènech E. Management and outcomes of patients with Crohn's disease with first vs multiple surgeries: results from the PRACTICROHN study. Gastroenterol Rep (Oxf) 2020; 7:411-418. [PMID: 32211194 PMCID: PMC7081962 DOI: 10.1093/gastro/goz029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/29/2019] [Accepted: 03/01/2019] [Indexed: 01/14/2023] Open
Abstract
Background Surgery in Crohn's disease (CD) may be associated with poor prognosis and clinical and surgical recurrence. The aim of this study was to describe and compare the post-operative management and outcomes of patients with CD who underwent first vs recurrent surgeries. Methods Observational study that included adult CD patients from 26 Spanish hospitals who underwent ileocolonic resection with ileocolonic anastomosis between January 2007 and December 2010. Data were retrospectively collected from the medical records. Results Data from 314 patients were analysed, of whom 262 (83%) underwent first surgery and 52 (17%) referred to previous CD surgeries. Baseline characteristics were similar between the two groups except for a higher rate of stricturing behavior at diagnosis among re-operated patients (P = 0.03). After surgery, a higher proportion of re-operated patients received prophylactic treatment with immunomodulators compared with patients with first surgery (P = 0.04). In re-operated patients, time to clinical recurrence was not associated with the fact of receiving or not prophylaxis, whereas, in patients with first surgery, recurrence-free survival was greater when prophylaxis was received (P = 0.03). Conclusions After surgery, a higher proportion of patients with previous surgeries received prophylactic treatment with immunomodulators compared with patients with first surgery. Although prophylactic treatment was beneficial for preventing clinical recurrence in patients operated on for the first time, it did not significantly reduce the risk of further recurrence in patients with previous surgeries. This suggests that effective prophylactic therapies are still needed in this subset of patients.
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Affiliation(s)
- Marisa Iborra
- Gastroenterology Department, Hospital La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Berta Juliá
- Medical Department, Merk Sharp and Dohme (MSD), Madrid, Spain
| | | | - Manuel Barreiro-de Acosta
- Gastroenterology Unit, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Digestive Medicine Department, Hospital General de Alicante, Alicante, Spain
| | - Valle García-Sánchez
- Unit of Clinical Management of Gastrointestinal Tract, Hospital Universitario Reina Sofia, Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Cordoba University, Cordoba, Spain
| | - Carlos Taxonera
- Gastroenterology Department, Hospital Clínico San Carlos, Madrid, Spain.,Instituto de Investigación del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Luis Cea-Calvo
- Medical Department, Merk Sharp and Dohme (MSD), Madrid, Spain
| | - Eugeni Domènech
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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14
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Yerushalmy-Feler A, Assa A. Pharmacological Prevention and Management of Postoperative Relapse in Pediatric Crohn's Disease. Paediatr Drugs 2019; 21:451-460. [PMID: 31628665 DOI: 10.1007/s40272-019-00361-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pediatric Crohn's disease (CD) is characterized by an aggressive course that commonly requires more intensive pharmacological and surgical treatments. In spite of the therapeutic advances in monitoring and management, including the widespread use of biologic therapy, the cumulative incidence of surgery in children with CD is still high. However, surgery is usually not curative and disease recurrence after small bowel resection is common. Gastrointestinal endoscopy is currently the gold standard to evaluate disease progression after surgery, but other non-invasive methods have been suggested. Although the efficacy of several drugs as medical prophylaxis to reduce the rate of disease recurrence following intestinal resection has been evaluated, selecting the most appropriate preventive therapeutic intervention remains a challenge. The current recommendations, mostly based on adult studies due to limited pediatric data, state that treatment should be guided by risk for recurrence. Low-risk patients may be given no prophylaxis or only 5-ASA. Maintenance enteral nutrition may also be considered. Thiopurines may be used in moderate risk of CD recurrence. In high risk patients for postoperative recurrence (extensive disease, short disease duration from diagnosis to surgery, recurrent surgery, long resected segment, surgery for fistulizing disease, disease complications, perianal disease, smoking), prophylactic treatment with anti-TNFα is recommended. subsequently, therapy should be guided by repeated measurement of objective measures including endoscopic re-evaluation at 6-12 months following surgery.
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Affiliation(s)
- Anat Yerushalmy-Feler
- Pediatric Gastroenterology Unit, 'Dana-Dwek' Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach-Tikva, Israel. .,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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15
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Cañete F, Mañosa M, Casanova MJ, González-Sueyro RC, Barrio J, Bermejo F, Nos P, Iglesias-Flores E, García-Planella E, Pérez-Calle JL, Vicente R, Vera M, Ramos L, Rivero M, De Francisco R, Montserrat A, Benítez O, Navarro P, Taxonera C, Hinojosa E, Márquez-Mosquera L, Navarro-Llavat M, Ramírez-de la Piscina P, Gomollón F, Rodríguez-Alonso L, Núñez-Alonso A, Fernández-Salazar L, Almela P, Ríos León R, De Castro L, Gisbert JP, Ricart E, Cabré E, Domènech E. Adalimumab or Infliximab for the Prevention of Early Postoperative Recurrence of Crohn Disease: Results From the ENEIDA Registry. Inflamm Bowel Dis 2019; 25:1862-1870. [PMID: 31006801 DOI: 10.1093/ibd/izz084] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor agents (anti-TNFs) are efficacious at preventing the postoperative recurrence (POR) of Crohn disease, as demonstrated in 2 randomized controlled trials. However, real-life data for infliximab or adalimumab in this setting are scarce. Our aim was to assess both the efficiency of anti-TNFs at preventing early POR of Crohn disease in clinical practice and the associated risk factors for POR. METHODS Patients in whom anti-TNFs were prescribed for the prevention of POR within 3 months after ileocolonic resection and who had an endoscopic assessment within 18 months were identified from the ENEIDA registry. Clinical and endoscopic features were collected within 18 months after surgery. RESULTS In total, 152 patients were included (55 treated with infliximab, 97 with adalimumab, and 39% with concomitant immunosuppressants). Anti-TNF treatment was started after a median time of 29 days (IQR 13-44) after surgery. Eighty-two percent of patients had at least one risk factor for POR, and 82% had been exposed to anti-TNFs before the index surgery. Overall, 34% had endoscopic POR (as defined using a Rutgeerts endoscopic score > i1); 14% had advanced endoscopic POR (>i2); and 20% had clinical POR, with no differences between infliximab and adalimumab. In the multivariate analysis, only perianal disease (odds ratio 2.73, 95% confidence interval [CI] 1.26-5.91) and rectal involvement (odds ratio 2.79, 95% CI 1.09-7.14) were independent predictors of endoscopic POR. CONCLUSIONS In clinical practice, anti-TNFs for the prevention of POR of Crohn disease are frequently used in patients experienced with anti-TNFs and with concomitant immunosuppressants. The efficacy of infliximab and adalimumab for POR prevention is similar and in accordance with the results obtained in randomized controlled trials.
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Affiliation(s)
- Fiorella Cañete
- Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Universitat Autònoma de Barcelona, Spain
| | - Míriam Mañosa
- Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - María José Casanova
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Hospital de La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autònoma de Madrid, Madrid, Spain
| | | | - Jesús Barrio
- Hospital Universitario Río Hortega, Valladolid, Spain
| | - Fernando Bermejo
- Hospital Universitario de Fuenlabrada, and Instituto de Investigación Sanitaria IdiPaz, Madrid, Spain
| | - Pilar Nos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | - Maribel Vera
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Laura Ramos
- Hospital Universitario de Canarias, Tenerife, Spain
| | - Montserrat Rivero
- Hospital Universitario Marqués de Valdecilla and IDIVAL, Santander, Spain
| | | | | | - Olga Benítez
- Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Pablo Navarro
- Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | | | | | | | | | - Fernando Gomollón
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | | | - Pedro Almela
- Hospital General Universitario de Castellón, Castellón, Spain
| | | | | | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Hospital de La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autònoma de Madrid, Madrid, Spain
| | - Elena Ricart
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Hospital Clinic and IDIBAPS, Barcelona, Spain
| | - Eduard Cabré
- Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Eugeni Domènech
- Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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16
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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17
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Burr NE, Lord R, Hull MA, Subramanian V. Decreasing Risk of First and Subsequent Surgeries in Patients With Crohn's Disease in England From 1994 through 2013. Clin Gastroenterol Hepatol 2019; 17:2042-2049.e4. [PMID: 30583051 DOI: 10.1016/j.cgh.2018.12.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/31/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastrointestinal (GI) surgery is an important part of the treatment algorithm for patients with Crohn's disease (CD) that is complicated or does not respond to medical therapy. Cohort studies from Denmark and Canada have shown that the risk of primary surgery is decreasing but there is a lack of contemporary data on subsequent resections. We examined trends in first and second GI resections in patients with CD. METHODS We performed a retrospective cohort study using the United Kingdom primary care database ResearchOne, collecting data from patients with Crohn's disease from 1994 through 2013. We compared rates of first and second GI resections with etiological factors. RESULTS Among 3059 incident cases of CD, 13%, 21%, and 26% of the patients underwent surgical resections after 1, 5, and 10 years, respectively. Of patients with an initial resection, 20% required an additional operation when followed for 10 years after the initial resection. We found a significant reduction in first surgery, from 44% to 21% after 10 years of disease, from 1994 to 2003 (χ2 for trend, P < .05). There was a significant reduction in second resections, in a 10-year follow-up period, from 40% in 1994 to 17% in 2003 (χ2 for trend, P < .05). Duration of disease, younger age at diagnosis, smoking, and immunomodulator use were positively associated with first surgeries. Duration of disease was significantly associated with the risk of undergoing a second resection. CONCLUSION In a retrospective analysis of a United Kingdom primary care database, we observed a significant reduction in first and subsequent GI surgeries among patients with CD over the past 20 years in England.
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Affiliation(s)
- Nicholas E Burr
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, United Kingdom; Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard Lord
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, United Kingdom; Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Mark A Hull
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, United Kingdom; Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Venkataraman Subramanian
- Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, United Kingdom; Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
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18
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Barreiro-De Acosta M, Domènech E, Martín Arranz MD, García Sánchez V, Gutiérrez Casbas A, Chaparro M, Alcain G, Iborra M, Taxonera C, Rodriguez-Lago I, Menchén L, Khorrami S, Romero C, Cea-Calvo L, Juliá B. Endoscopic follow-up and therapeutic attitude after ileocolonic resection in a nationwide Spanish cohort of Crohn's disease patients: the Practicrohn study. Expert Rev Gastroenterol Hepatol 2019; 13:807-813. [PMID: 31203691 DOI: 10.1080/17474124.2019.1626717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: In patients with Crohn's disease (CD), endoscopic recurrence precedes clinical recurrence after ileocolonic resection. Guidelines recommend ileocolonoscopy within the first year after surgery. The study examined endoscopic monitoring and treatment decisions in CD patients in a real-world setting. Methods: The Practicrohn study involved adult patients from 26 Spanish hospitals who underwent ileocolonic resection with anastomosis from 2007 to 2010. Medical records data were collected retrospectively from diagnosis to index surgery and up to 5 years after surgery. Results: Of 314 analyzed patients, 262 (83%) underwent endoscopic evaluation, but only 30% (n = 95) had planned endoscopy as part of follow-up within the first year after surgery. An upward trend was observed in the proportion of endoscopies performed or planned within the first year after surgery across the selection period. More patients with than without endoscopic recurrence in the first year after surgery had a medication change, mainly for endoscopic activity in the absence of clinical symptoms (54 vs 13%; p = 0.02). Conclusions: Between 2007 and 2010, endoscopic monitoring of patients within the first year after CD-related surgery was less than adequate based on current standards, but showed improvement. Medication changes were in general agreement with current guideline recommendations. This work was presented as a poster (number P686) by M. Barreiro-de Acosta et al. at ECCO (European Crohn's and Colitis Organisation) '18 in Vienna, Austria, 14-17 February 2018.
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Affiliation(s)
- Manuel Barreiro-De Acosta
- a Gastroenterology Unit, Complejo Hospitalario Universitario de Santiago , Santiago de Compostela , Spain
| | - Eugeni Domènech
- b Gastroenterology Unit, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain
| | | | | | - Ana Gutiérrez Casbas
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,f Digestive Medicine Department, Hospital General de Alicante , Spain
| | - María Chaparro
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,g Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Guillermo Alcain
- h Gastroenterology Unit, Hospital Virgen de la Victoria , Málaga , Spain
| | - Marisa Iborra
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,i Gastroenterology Unit, Hospital La Fe , Valencia , Spain
| | - Carlos Taxonera
- j Gastroenterology Unit, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos (IdISSC) , Madrid , Spain
| | - Iago Rodriguez-Lago
- k Hospital de Galdakao, Galdakao Biocruces Bizkaia Health Research Institute , Barakaldo , Spain
| | - Luis Menchén
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,l Gastroenterology Unit, Hospital General Universitario Gregorio Marañón , Madrid , Spain.,m Medicine Department, Universidad Complutense de Madrid , Spain
| | - Sam Khorrami
- n Gastroenterology Unit, Hospital Son Espases , Palma de Mallorca , Spain
| | - Cristina Romero
- o Medical Department, Merck Sharp & Dohme of Spain , Madrid , Spain
| | - Luis Cea-Calvo
- o Medical Department, Merck Sharp & Dohme of Spain , Madrid , Spain
| | - Berta Juliá
- o Medical Department, Merck Sharp & Dohme of Spain , Madrid , Spain
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19
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Gutiérrez A, Rivero M, Martín-Arranz MD, García Sánchez V, Castro M, Barrio J, de Francisco R, Barreiro-de Acosta M, Juliá B, Cea-Calvo L, Romero C, Borruel Sainz N, Domènech E. Perioperative management and early complications after intestinal resection with ileocolonic anastomosis in Crohn's disease: analysis from the PRACTICROHN study. Gastroenterol Rep (Oxf) 2019; 7:168-175. [PMID: 31217980 PMCID: PMC6573802 DOI: 10.1093/gastro/goz010] [Citation(s) in RCA: 10] [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] [Received: 08/06/2018] [Revised: 11/07/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This study is aimed at describing the prevalence of and risk factors associated with early post-operative complications after Crohn's disease-related intestinal resection. METHODS This was a retrospective analysis of data from the PRACTICROHN cohort. Adult Crohn's disease patients who underwent ileocolonic resection with ileocolonic anastomosis between January 2007 and December 2010 were included. The complications evaluated included death, ileus, anastomotic leak, abscess, wound infection, catheter-related infection, digestive bleeding and other extra-abdominal infections that occurred in the 30 days after surgery. RESULTS A total of 364 patients (median age at surgery 38 years and 50% men) were included. Indication for surgery was: stricturing disease (46.4%), penetrating disease (31.3%), penetrating and stricturing disease (14.0%) or resistance to medical treatment (5.8%). Early complications were recorded in 100 (27.5%) patients, with wound infection, intra-abdominal abscess and anastomotic leakage being the most frequent complications. Median hospitalization duration was 16 days for patients with complications vs. 9 days without complications (P < 0.001). Complications were more common among patients with penetrating disease (36/114, 31.6%) and those refractory to treatment (9/21, 42.9%) compared with stricturing disease (45/169, 26.6%) or stricturing + penetrating disease (6/51, 11.8%) (P = 0.040). The rate of complications was higher among patients with diagnosis made at the time of surgery (15/31, 48.4%) compared with the rest (85/331, 25.7%) (P = 0.013). Medication received at the time of surgery did not affect the rate of complications. CONCLUSIONS Almost a quarter of patients developed early complications after intestinal resection. Penetrating disease and urgent surgery were associated with an increased risk of complications.
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Affiliation(s)
- Ana Gutiérrez
- Gastroenterology Department, General University Hospital of Alicante and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III Health Institute, Madrid, Spain
| | - Montserrat Rivero
- Gastroenterology Department, Marques de Valdecilla General University Hospital, Santander, Spain
| | - Maria Dolores Martín-Arranz
- Gastroenterology Department, La Paz General University Hospital, Instituto de Investigación Biomédica La Paz (IdiPaz), Madrid, Spain
| | - Valle García Sánchez
- Clinical Management of Gastrointestinal Tract Diseases Unit, Reina Sofia University Hospital, Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Cordoba University, Cordoba, Spain
| | - Manuel Castro
- Gastroenterology Department, Valme University Hospital, Sevilla, Spain
| | - Jesús Barrio
- Gastroenterology Department, University Hospital, Río Hortega, Valladolid, Spain
| | - Ruth de Francisco
- Gastroenterology Department, University Hospital Central de Asturias, Oviedo, Spain
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Inflammatory Bowel Disease Unit, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Berta Juliá
- Medical Department, Merck Sharp and Dohme, Madrid, Spain
| | - Luis Cea-Calvo
- Medical Department, Merck Sharp and Dohme, Madrid, Spain
| | | | - Natalia Borruel Sainz
- Crohn-Colitis Care Unit (UACC), Digestive Tract Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Germans Trias i Pujol University Hospital and CIBERehd, Badalona, Spain
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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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Mañosa M, Calafat M, de Francisco R, García C, Casanova MJ, Huelín P, Calvo M, Tosca J, Fernández-Salazar L, Arajol C, Zabana Y, Bastida G, Hinojosa J, Márquez L, Barreiro-de-Acosta M, Calvet X, Monfort D, Gómez-Garcia MR, Rodríguez E, Huguet JM, Rojas-Feria M, Hervias D, Atienza R, Busquets D, Zapata E, Dueñas C, Charro M, Martínez-Cerezo FJ, Plaza R, Vázquez JM, Gisbert JP, Cañete F, Cabré E, Domènech E. Phenotype and natural history of elderly onset inflammatory bowel disease: a multicentre, case-control study. Aliment Pharmacol Ther 2018; 47:605-614. [PMID: 29369387 DOI: 10.1111/apt.14494] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/14/2017] [Accepted: 12/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Onset during old age has been reported in upto 10% of total cases of inflammatory bowel disease (IBD). AIM To evaluate phenotypic characteristics and the use of therapeutic resources in patients with elderly onset IBD. METHODS Case-control study including all those patients diagnosed with IBD over the age of 60 years since 2000 who were followed-up for >12 months, identified from the IBD databases. Elderly onset cases were compared with IBD patients aged 18 to 40 years at diagnosis, matched by year of diagnosis, gender and type of IBD (adult-onset). RESULTS One thousand three hundred and seventy-four elderly onset and 1374 adult-onset cases were included (62% ulcerative colitis (UC), 38% Crohn's disease (CD)). Among UC patients, elderly onset cases had a lower proportion of extensive disease (33% vs 39%; P < 0.0001). In CD, elderly onset cases showed an increased rate of stenosing pattern (24% vs 13%; P < 0.0001) and exclusive colonic location (28% vs 16%; P < 0.0001), whereas penetrating pattern (12% vs 19%; P < 0.0001) was significantly less frequent. Regarding the use of therapeutic resources, there was a significantly lower use of corticosteroids (P < 0.0001), immunosuppressants (P < 0.0001) and anti-TNFs agents (P < 0.0001) in elderly onset cases. Regarding surgery, we found a significantly higher surgery rate among elderly onset UC cases (8.3% vs 5.1%; P < 0.009). Finally, elderly onset cases were characterised by a higher rate of hospitalisations (66% vs 49%; P < 0.0001) and neoplasms (14% vs 0.5%; P < 0.0001). CONCLUSIONS Elderly onset IBD shows specific characteristics and they are managed differently, with a lower use of immunosuppressants and a higher rate of surgery in UC.
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Nguyen VQ, Mays JL, Lang M, Wu Y, Dassopoulos T, Regueiro M, Moss A, Proctor DD, Sorrentino D. Knowledge Gaps in the Management of Postoperative Crohn's Disease: A US National Survey. Dig Dis Sci 2018; 63:53-60. [PMID: 29147878 DOI: 10.1007/s10620-017-4844-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/07/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Postoperative recurrence (POR) of Crohn's disease (CD) is common. Guidelines on POR management have recently been issued, but clinical practice may vary. AIMS To examine the current clinical practice of POR management in the USA METHODS: A web-based survey was sent to all members of the American Gastroenterological Association and the American College of Gastroenterology. The survey consisted of multiple-choice questions with clinical scenarios to assess how participants manage POR. RESULTS A total of 189 responses were received from practices in 34 states. 44% of participants were from academic settings. The median number of CD patients seen each month was 20-30 patients per participant. The majority of participants considered smoking, prior intestinal surgery, penetrating disease, perianal fistula, early disease onset, and long extent of disease as high-risk factors for POR. To diagnose and grade endoscopic recurrence, 57% of participants used an endoscopic scoring system; 86% defined clinical recurrence using a combination of symptoms and endoscopic findings; and 79% of participants routinely performed colonoscopy after surgery. In high-risk patients, 65% offered medical prophylaxis-most often biologics and/or immunomodulators-immediately after surgery, while 34% offered medical prophylaxis regardless of the patient's risk of POR. 64% of participants never stopped medical prophylaxis once initiated. CONCLUSIONS Most gastroenterologists routinely perform colonoscopy to guide POR management. The majority of these providers continue medical prophylaxis indefinitely regardless of subsequent endoscopic findings. Further research is needed to determine the risks and benefits of continuing versus deescalating therapy in patients with potentially surgically induced remission.
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Affiliation(s)
- Vu Q Nguyen
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, 3rd Floor Gastroenterology, Roanoke, VA, 24016, USA
| | - Jessica L Mays
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, 3rd Floor Gastroenterology, Roanoke, VA, 24016, USA
| | - Marissa Lang
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, 3rd Floor Gastroenterology, Roanoke, VA, 24016, USA
| | - Yingxing Wu
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, 3rd Floor Gastroenterology, Roanoke, VA, 24016, USA
| | | | - Miguel Regueiro
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alan Moss
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Deborah D Proctor
- Division of Gastroenterology, Yale University School of Medicine, New Haven, CT, USA
| | - Dario Sorrentino
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, 3rd Floor Gastroenterology, Roanoke, VA, 24016, USA.
- Department of Clinical and Experimental Medical Sciences, University of Udine School of Medicine, Udine, Italy.
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