Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-α Antibody Use: 35 Years of Experience at a Single Institute in Korea

Effect of Thiopurine on Potential Surgical Intervention in Crohn’s Disease in Korea: Results from the CONNECT Study

Objectives: The incidence of Crohn's disease and the number of associated surgeries are increasing in Korea. This study investigated the effect of azathioprine/6-mercaptopurine (6-MP) and TNF-α antagonists on abdominal and perianal surgery in Korean patients with Crohn's disease. Design: A retrospective cohort study. Setting: Data from the Crohn's Disease Clinical Network and Cohort (CONNECT) were used. Patients with confirmed Crohn's disease between 1982 and 2008 from 32 hospitals in the Republic of Korea were enrolled. The effect of azathioprine/6-MP on abdominal and perianal surgery was analysed using logistic regression analysis adjusting for age and sex. Participants: In total, 1161 Crohn's disease patients were included in the Republic of Korea in the surgery (n = 462, male = 339, female = 123) and control groups (n = 699, male = 484, female = 215). Results: In total, 1161 patients were selected, with 462 patients who underwent abdominal (n = 245) or perianal surgery (n = 217). The preoperative usage rates of azathioprine/6-MP were 18.8% and 65.1% (p < 0.0001) in the surgery and control groups, respectively. The preoperative usage rates of TNF-α antagonists were 7.1% and 23.3% (p < 0.0001) in the surgery and control groups, respectively. A multivariate analysis revealed that the preoperative use of azathioprine/6-MP had an odds ratio of 0.094 for all surgeries (95% confidence interval [CI]: 0.070-0.127, p < 0.0001), 0.131 for abdominal surgery (95% CI: 397-1.599, p < 0.0001), and 0.059 for perianal surgery (95% CI: 0.038-0.091, p < 0.0001). The preoperative use of TNF-α antagonists had an odds ratio of 0.225 for all surgeries (95% CI: 0.151-0.335, p < 0.0001), 0.403 for abdominal surgery (95% CI: 0.261-0.623, p < 0.0001), and 0.064 for perianal surgery (95% CI: 0.026-0.160, p < 0.001). Strengths of this study: The study presents new evidence of the reduced risk of surgery following azathioprine use in Crohn's disease patients. Limitations of this study (1) This was not a controlled prospective study. (2) There was a selection bias specific to the CONNECT cohort. (3) The combination or sequential use of azathioprine/6-MP and TNF-α antagonists was not excluded. Conclusion: Azathioprine/6-MP is significantly associated with a reduced risk of abdominal and perianal surgery in Korean patients with Crohn's disease.

Inflammatory Bowel Disease Reoperation Rate Has Decreased Over Time If Corrected by Prevalence

Despite the recent emergence of expensive biologic therapies, hospitalization and surgery remain important contributors for the overall costs of inflammatory bowel disease (IBD). In this study, we aimed to describe the burden of reoperations in patients with IBD by evaluating reoperation rates, charges, and risk factors over 16 years.

Risk factors for postoperative surgical site infections in patients with Crohn's disease receiving definitive bowel resection

Surgical site infection presents as a significant problem that limits the potential benefits of surgical interventions. This study is to investigate risk factors for postoperative SSI in patients with Crohn’s disease receiving definitive bowel resection. A case-control study including 49 patients with SSI and 105 patients without SSI was performed. Demographics, clinical characteristics, laboratory information, medical and surgical data were compared between groups. Significant elements were subsequently brought into logistic regression analysis for further identification. Patients with SSI exhibited higher tobacco usage rate (p = 0.03), lower preoperative hemoglobin (p = 0.02) and pre-albumin level (p = 0.02). Bowel penetration instead of stricture was more frequent in patients with SSI (p = 0.04). Longer duration of operation (p = 0.03) and higher intraoperative lactate level (p = 0.02) were observed in patients with SSI. Logistic analysis identified that preoperative pre-albumin (95% CI: 0.2~0.7; OR = 0.5; p = 0.03), duration of operation (95% CI: 2.3~9.5; OR = 3.8; p = 0.03) and intraoperative lactate level (95% CI: 1.7~7.2; OR = 3.4; p = 0.04) were associated with postoperative surgical site outcome. Our data has identified that lower preoperative pre-albumin, longer duration of operation and higher intraoperative lactate level are risk factors for SSI in patients with Crohn’s disease receiving definitive bowel resection.

Effect of Tripterygium Wilfordii Polyglycoside on Experimental Prostatitis Caused by Ureaplasma Urealyticum in Rats

Background

Prostatitis is a common and refractory urological disease with complicated etiology. Ureaplasma urealyticum (UU) has a close relationship with human urinary tract infection that can induce nonbacterial prostatitis. Tripterygium wilfordii polyglycoside (TWP) is a non-steroidal immune inhibitor that causes significant immune suppression and anti-inflammatory effects. Its role in prostatitis caused by UU has not yet been established. The aim of this study was to investigate the effect of TWP on UU-infected prostatitis in a rat model.

Material/Methods

UU-infected prostatitis SD model rats were randomly divided into 2 groups: the prostatitis group (model group) and the TWP treatment group (treatment group). At 7 days after treatment, prostate weight, leucocyte count, lecithin corpuscles, UU infection rate, and UU microbe count were compared between the 2 groups. Serum inflammatory cytokines TNF-α was determined by ELISA, and ICAM-1 and NF-κB expression were detected.

Results

UU infection rate was 80% after modeling. The rat prostate weight and leucocyte count in the model group increased significantly, while lecithin corpuscles decreased. Compared with controls, inflammatory factor TNF-α, ICAM-1, and NF-κB expression were obviously higher (P<0.05). TWP markedly reduced prostate weight and leucocyte count, increased lecithin corpuscles, and decreased UU microbe count and TNF-α, ICAM-1, and NF-κB expression (P<0.05).

Conclusions

TWP can inhibit expression of inflammatory factors and may be useful in treating UU-infected prostatitis through reducing UU infection rate.

Advanced age impacts surgical characteristics and postoperative course in patients with Crohn's disease

PURPOSE

Due to a lack of data, the present study was designed to assess the impact of advanced age on surgical characteristics and short-term outcome of patients operated on for symptomatic Crohn's disease.

METHODS

We enrolled 454 consecutive Crohn's disease patients, who underwent intestinal resection at an academic tertiary referral center between 1997 and 2012. Patients were divided into 3 groups according to their age (group I: <30 years, group II: 30-50 years, group III: >50 years) and analyzed retrospectively.

RESULTS

Altogether, 152 (33.5%) patients were included in group I, 234 (51.5%) in group II and 68 (15.0%) in group III. Abscess formation and penetrating disease were significantly more common in younger patients (p = 0.0014 and p = 0.0182). The number of intestinal resections was higher in older patients (p < 0.0001), whereas the laparoscopic approach was more frequently observed in younger adults (p = 0.0006). Group II (n = 58 (24.8%)) and group III (n = 15 (22.1%)) showed significantly more complications compared to group I (n = 20 (13.2%)) (p = 0.0346). Notably, major complications and anastomotic leaks were significantly higher in older patients (p = 0.0004).

CONCLUSION

Crohn's disease patients of advanced age show different surgical characteristics compared to younger patients and are at an increased risk of developing postoperative complications.

Endoscopy-based management decreases the risk of postoperative recurrences in Crohn’s disease

AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.

METHODS: From the pathology department database, we retrospectively retrieved the data of all the patients operated on for Crohn’s disease (CD) in our center (1986-2015). Endoscopy-based management was defined as systematic postoperative colonoscopy (median time after surgery = 9.5 mo) in patients with no clinical postoperative recurrence at the time of endoscopy.

RESULTS: From 205 patients who underwent surgery, 161 patients (follow-up > 6 mo) were included. Endoscopic postoperative recurrence occurred in 67.6%, 79.7%, and 95.5% of the patients, respectively 5, 10 and 20 years after surgery. The rate of clinical postoperative recurrence was 61.4%, 75.9%, and 92.5% at 5, 10 and 20 years, respectively. The rate of surgical postoperative recurrence was 19.0%, 38.9% and 64.7%, respectively, 5, 10 and 20 years after surgery. In multivariate analysis, previous intestinal resection, prior exposure to anti-TNF therapy before surgery, and fistulizing phenotype (B3) were postoperative risk factors. Previous perianal abscess/fistula (other perianal lesions excluded), were predictive of only symptomatic recurrence. In multivariate analysis, an endoscopy-based management (n = 49/161) prevented clinical (HR = 0.4, 95%CI: 0.25-0.66, P < 0.001) and surgical postoperative recurrence (HR = 0.30, 95%CI: 0.13-0.70, P = 0.006).

CONCLUSION: Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.