1
|
van der Does de Willebois EML, Bellato V, Duijvestein M, van der Bilt JDW, van Dongen K, Spinelli A, D'Haens GR, Mundt MW, Furfaro F, Danese S, Vignali A, Bemelman WA, Buskens CJ. Effect of mesenteric sparing or extended resection in primary ileocolic resection for Crohn's disease on postoperative endoscopic recurrence (SPICY): an international, randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:793-801. [PMID: 39025100 DOI: 10.1016/s2468-1253(24)00097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Retrospective research suggests that excision of the affected mesentery can improve outcomes after an ileocoecal resection in Crohn's disease. However, prospective data from randomised controlled trials are scarce. We aimed to compare rates of postoperative recurrence in patients with Crohn's disease who underwent extended mesenteric resection. METHODS This international, randomised controlled trial was done in six hospitals and tertiary care centres in the Netherlands and Italy. Eligible patients were aged 16 years or older and had Crohn's disease that was previously confirmed by endoscopy in the terminal ileum or ileocolic region (L1 or L3 disease), with an imaging update in the past 3 months (ultrasound, MRI, or CT enterography). Eligible patients were scheduled to undergo primary ileocolic resection with ileocolic anastomosis. Enrolled patients were assigned by use of simple random allocation (1:1) to either extended mesenteric resection (intervention) or conventional mesenteric sparing resection (control). The primary endpoint was endoscopic recurrence 6 months after surgery. Analyses were done in all patients with primary endpoint data, excluding those who had no anastomosis, a postoperative diagnosis other than Crohn's disease, or withdrew consent. This trial was registered with ClinicalTrials.gov, NCT04538638. FINDINGS Between Feb 19, 2020, and April 24, 2023, we assessed 217 patients for eligibility. 78 patients were excluded due to failure to meet the inclusion criteria or refusal to participate. 139 patients were enrolled and randomly assigned to either extended mesenteric resection (n=71) or mesenteric sparing resection (n=68). All 139 patients underwent surgery. Six patients were excluded after random assignment due to withdrawal of consent (n=2), postoperative diagnosis other than Crohn's disease (n=2) and no anastomosis performed (in case of a stoma; n=2). Two patients were lost to follow-up, and two more patients deviated from the protocol by undergoing investigations other than endoscopy 6 months after. 133 patients were included in the baseline analysis (67 in the extended resection group and 66 in the sparing resection group) of whom 57 (43%) were male. Baseline characteristics were similar between the groups, and median patient age was 36 years (IQR 25-54). 131 patients were analysed for the primary outcome. There was no difference between groups in the rate of endoscopic recurrence at 6 months after surgery (28 [42%] of 66 patients in the extended mesenteric resection group vs 28 [43%] of 65 patients in the mesenteric sparing resection group, relative risk 0·985, 95% CI 0·663-1·464; p=1·0). Five (8%) of 66 patients in the extended mesenteric resection group had anastomotic leakage within the 30 days after surgery, as did one (2%) of 65 in the mesenteric sparing group. Postoperative complications of Clavien-Dindo grade IIIa or higher were reported in seven (11%) patients in the mesenteric resection group and five (8%) in the mesenteric sparing group. INTERPRETATION Extended mesenteric resection was not superior to conventional resection with regard to endoscopic Crohn's disease recurrence. These data support the guideline-recommended mesenteric sparing approach. FUNDING Topconsortia voor Kennis en Innovatie-Topsector Life Sciences & Health.
Collapse
Affiliation(s)
| | - Vittoria Bellato
- Minimally Invasive Surgery Unit, Tor Vergata University Hospital, Rome
| | - Marjolijn Duijvestein
- Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Koen van Dongen
- Department of Surgery, Pantein Hospital Boxmeer, Beugen, Netherlands
| | - Antonino Spinelli
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Marco W Mundt
- Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, Netherlands
| | - Federica Furfaro
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele, Milan, Italy
| | - Andrea Vignali
- Unit of Coloproctology and IBD Surgery, IRCCS San Raffaele, Milan, Italy
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Netherlands; Unit of Coloproctology and IBD Surgery, IRCCS San Raffaele, Milan, Italy
| | - Christianne J Buskens
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Netherlands.
| |
Collapse
|
2
|
Arkenbosch JHC, Becker MAJ, Buskens CJ, Witjes C, de Vries AC, van der Woude CJ, Fuhler G, Wildenberg ME, van Ruler O. Platelet-Rich stroma from Crohn's disease patients for treatment of perianal fistula shows a higher myeloid cell profile compared to non-IBD controls. Stem Cell Res 2023; 67:103039. [PMID: 36780756 DOI: 10.1016/j.scr.2023.103039] [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: 09/15/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND New cell-based therapies are under investigation to improve perianal fistulizing Crohn's disease (pCD) healing. Autologous stromal vascular fraction combined with platelet-rich plasma (referred to as platelet-rich stroma [PRS]) is a new adipose-derived stromal therapy. The effect of Crohn's disease (CD) on adipose tissue, and adipose-derived therapies, is largely unknown. We characterized the cellular composition of subcutaneous lipoaspirate and PRS of pCD patients and non-Inflammatory Bowel Disease (IBD) controls. METHODS Consecutive pCD patients (≥18 years) and non-IBD controls, who underwent liposuction for the purpose of autologous PRS therapy, were included (October 2020 and March 2021). Mechanically fractionated lipoaspirate and the combined PRS product were analyzed for cell surface marker expression using fluorescence-activated cell sorting analysis. RESULTS Twenty-three patients (37.8 [IQR 30.7-45.0] years; 9 [39.1 %] male; 11CD patients) were included. Similar total number of cells were found in CD and non-IBD lipoaspirate (CD 8.23 ± 1.62*105 cells/mL versus non-IBD 12.20 ± 3.39*105). Presence of stromal cells, endothelial like cells, immune cells, T-cells, myeloid cells and M2/M1 macrophage ratio were similar in CD and non-IBD lipoaspirate. In PRS samples, more cells/mL were seen in CD patients (P = 0.030). Myeloid cells were more abundant in CD PRS samples (P = 0.007), and appeared to have a higher regulatory M2/M1 ratio. Interdonor variation was observed between lipoaspirate and PRS samples. CONCLUSIONS The composition of CD and non-IBD lipoaspirate were found to be similar and interdonor variation was observed. However, PRS from CD patients showed more myeloid cells with a regulatory phenotype. Crohn's disease does not appear to alter the immunological composition of adipose-derived products.
Collapse
Affiliation(s)
- J H C Arkenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M A J Becker
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C Witjes
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - A C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - C J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - G Fuhler
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M E Wildenberg
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O van Ruler
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands.
| |
Collapse
|
3
|
Bouwman W, Verhaegh W, van de Stolpe A. Improved diagnosis of inflammatory bowel disease and prediction and monitoring of response to anti-TNF alpha treatment based on measurement of signal transduction pathway activity. Front Pharmacol 2022; 13:1008976. [PMID: 37090899 PMCID: PMC10115426 DOI: 10.3389/fphar.2022.1008976] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: Ulcerative colitis (UC) and Crohn’s disease (CD) are two subtypes of chronic inflammatory bowel disease (IBD). Differential diagnosis remains a challenge. Anti-TNFα treatment is an important treatment for IBD, yet resistance frequently occurs and cannot be predicted. Consequently, many patients receive ineffective therapy with potentially adverse effects. Novel assays are needed to improve diagnosis, and predict and monitor response to anti-TNF-α compounds.Design: Signal transduction pathway (STP) technology was used to quantify activity of STPs (androgen and estrogen receptor, PI3K, MAPK, TGFβ, Notch, Hedgehog, Wnt, NFκB, JAK-STAT1/2, and JAK-STAT3 pathways) in colon mucosa samples of CD and UC patients, based on transcriptome analysis. Previously described STP assay technology is based on computational inference of STP activity from mRNA levels of target genes of the STP transcription factor.Results: Results show that NFκB, JAK-STAT3, Wnt, MAPK, and androgen receptor pathways were abnormally active in CD and UC. Colon and ileum-localized CD differed with respect to STP activity, the JAK-STAT1/2 pathway being abnormally active in ileal CD. High activity of NFκB, JAK-STAT3, and TGFβ pathways was associated with resistance to anti-TNFα treatment in UC and colon-located CD, but not in ileal CD. Abnormal STP activity decreased with successful treatment.Conclusion: We believe that measuring mucosal STP activity provides clinically relevant information to improve differential diagnosis of IBD and prediction of resistance to anti-TNFα treatment in patients with colon-localized IBD, and provides new targets for treatment and overcoming anti-TNFα resistance.
Collapse
|
4
|
Pérez-Jeldres T, Pizarro B, Ascui G, Orellana M, Cerda-Villablanca M, Alvares D, de la Vega A, Cannistra M, Cornejo B, Baéz P, Silva V, Arriagada E, Rivera-Nieves J, Estela R, Hernández-Rocha C, Álvarez-Lobos M, Tobar F. Ethnicity influences phenotype and clinical outcomes: Comparing a South American with a North American inflammatory bowel disease cohort. Medicine (Baltimore) 2022; 101:e30216. [PMID: 36086782 PMCID: PMC10980497 DOI: 10.1097/md.0000000000030216] [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: 04/14/2022] [Accepted: 07/12/2022] [Indexed: 11/27/2022] Open
Abstract
Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn disease (CD), has emerged as a global disease with an increasing incidence in developing and newly industrialized regions such as South America. This global rise offers the opportunity to explore the differences and similarities in disease presentation and outcomes across different genetic backgrounds and geographic locations. Our study includes 265 IBD patients. We performed an exploratory analysis of the databases of Chilean and North American IBD patients to compare the clinical phenotypes between the cohorts. We employed an unsupervised machine-learning approach using principal component analysis, uniform manifold approximation, and projection, among others, for each disease. Finally, we predicted the cohort (North American vs Chilean) using a random forest. Several unsupervised machine learning methods have separated the 2 main groups, supporting the differences between North American and Chilean patients with each disease. The variables that explained the loadings of the clinical metadata on the principal components were related to the therapies and disease extension/location at diagnosis. Our random forest models were trained for cohort classification based on clinical characteristics, obtaining high accuracy (0.86 = UC; 0.79 = CD). Similarly, variables related to therapy and disease extension/location had a high Gini index. Similarly, univariate analysis showed a later CD age at diagnosis in Chilean IBD patients (37 vs 24; P = .005). Our study suggests a clinical difference between North American and Chilean IBD patients: later CD age at diagnosis with a predominantly less aggressive phenotype (39% vs 54% B1) and more limited disease, despite fewer biological therapies being used in Chile for both diseases.
Collapse
Affiliation(s)
- Tamara Pérez-Jeldres
- Department of Gastroenterology, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
- Instituto Chileno-Japonés, University of Chile, Santiago, Chile
| | - Benjamín Pizarro
- Radiology Department, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Gabriel Ascui
- La Jolla Institute for Allergy and Immunology, San Diego, CA
| | - Matías Orellana
- Department of Computer Science, Faculty of Physical Sciences and Mathematics of the University of Chile, Santiago, Chile
| | - Mauricio Cerda-Villablanca
- Integrative Biology Program, Institute of Biomedical Sciences, Center for Medical Informatics and Telemedicine, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Danilo Alvares
- Department of Statistics, Pontifical Catholic University of Chile, Santiago, Chile
| | | | - Macarena Cannistra
- Department of Gastroenterology, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Bárbara Cornejo
- Department of Gastroenterology, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Pablo Baéz
- Integrative Biology Program, Institute of Biomedical Sciences, Center for Medical Informatics and Telemedicine, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Verónica Silva
- Instituto Chileno-Japonés, University of Chile, Santiago, Chile
| | | | - Jesús Rivera-Nieves
- Inflammatory Bowel Disease Center, Division of Gastroenterology, University of California, San Diego, La Jolla, CA
| | - Ricardo Estela
- Instituto Chileno-Japonés, University of Chile, Santiago, Chile
| | - Cristián Hernández-Rocha
- Department of Gastroenterology, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Manuel Álvarez-Lobos
- Department of Gastroenterology, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Felipe Tobar
- Initiative for Data & Artificial Intelligence, University of Chile
- Center for Mathematical Modeling, University of Chile, Santiago, Chile
| |
Collapse
|
5
|
van der Does de Willebois EML. Mesenteric SParIng versus extensive mesentereCtomY in primary ileocolic resection for ileocaecal Crohn's disease (SPICY): study protocol for randomized controlled trial. BJS Open 2022; 6:6529311. [PMID: 35171266 PMCID: PMC8848735 DOI: 10.1093/bjsopen/zrab136] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/26/2021] [Indexed: 01/10/2023] Open
Abstract
Background There is emerging evidence to suggest that Crohn’s disease (CD) may be a disease of the mesentery, rather than of the bowel alone. A more extensive mesenteric resection, removing an increased volume of mesentery and lymph nodes to prevent recurrence of CD, may improve clinical outcomes. This study aims to analyse whether more extensive ‘oncological’ mesenteric resection reduces the recurrence rate of CD. Methods This is an international multicentre randomized controlled study, allocating patients to either group 1—mesenteric sparing ileocolic resection (ICR), the current standard procedure for CD, or group 2—extensive mesenteric ICR, up to the level of the ileocolic trunk. To detect a clinically relevant difference of 25 per cent in endoscopic recurrence at 6 months, a total of 138 patients is required (including 10 per cent dropout). Patients aged over 16 with CD undergoing primary ICR are eligible. Primary outcome is 6-month postoperative endoscopic recurrence rate (modified Rutgeerts score of greater than or equal to i2b). Secondary outcomes are postoperative morbidity, clinical recurrence, quality of life, and the need for (re)starting immunosuppressive medication. For long-term results, patients will be followed up for up to 5 years to determine the reoperation rate for recurrence of disease at the anastomotic site. Conclusion Analysing these two treatment strategies in a head-to-head comparison will allow an objective evaluation of the clinical relevance of extensive mesenteric resection in CD. If a clinical benefit can be demonstrated, this could result in changes to guidelines which currently recommend close bowel resection. Registration number NCT00287612 (http://www.clinicaltrials.gov)
Collapse
|
6
|
The Role of Inflammation in Crohn's Disease Recurrence after Surgical Treatment. J Immunol Res 2020; 2020:8846982. [PMID: 33426097 PMCID: PMC7781709 DOI: 10.1155/2020/8846982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Postoperative recurrence after surgery for Crohn's disease (CD) is virtually inevitable, and its mechanism is poorly known. Aim To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives. Methods A systematic literature search on CD POR, followed by a review of the main findings. Results The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation. Conclusions POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.
Collapse
|