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Bae HW, Lee YJ, Park MY, Yang SY, Han YD, Cho MS, Hur H, Lee KY, Cheon JH, Carmichael JC, Min BS. Clinical Significance of Prognostic Nutrition Index in Patients with Crohn's Disease after Primary Bowel Resection. Yonsei Med J 2024; 65:380-388. [PMID: 38910300 PMCID: PMC11199177 DOI: 10.3349/ymj.2023.0279] [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: 07/11/2023] [Revised: 01/08/2024] [Accepted: 01/23/2024] [Indexed: 06/25/2024] Open
Abstract
PURPOSE Although advancements in medical treatments have been made, approximately half of patients with intestinal Crohn's disease (CD) require intestinal resections during their lifetime. It is well-known that the nutritional status of CD patients can impact postoperative morbidity. The objective of this study was to evaluate the clinical significance of prognostic nutritional index (PNI) in patients with intestinal CD who underwent primary bowel resection. MATERIALS AND METHODS We retrospectively investigated patients who were diagnosed with CD and underwent intestinal surgery at Severance Hospital between January 2005 and October 2018. The patients were divided into two groups: PNI ≤40 (n=150) and PNI >40 (n=77). We assessed the clinical significance of PNI in terms of the incidence of postoperative infectious complications (PICs) and the postoperative recurrence of CD. RESULTS The low PNI group had significantly higher rates of infectious complications (32.0% vs. 10.4%, p=0.001) compared to the high PNI group. Multivariable analysis identified low PNI (≤40) and longer operation time (>180 min) as independent risk factors associated with PICs [odds ratio (OR)=2.754, 95% confidence interval (CI)=1.140-6.649, p=0.024; OR=2.986, 95% CI=1.451-6.143, p=0.003]. PICs were significantly associated with surgical recurrence (hazard ratio=2.217, 95% CI=1.064-4.617, p=0.034). CONCLUSION Preoperative PNI could serve as a predictive factor for PICs in CD patients who undergo intestinal resection. Additionally, PICs are significantly associated with a higher risk of surgical recurrence in CD.
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Affiliation(s)
- Hyeon Woo Bae
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Joon Lee
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Min Young Park
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yoon Yang
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Dae Han
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Division of Colon and Rectal Surgery, Department of Surgery, University of California School of Medicine, Irvine, CA, USA.
| | - Hyuk Hur
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Joseph C Carmichael
- Division of Colon and Rectal Surgery, Department of Surgery, University of California School of Medicine, Irvine, CA, USA
| | - Byung Soh Min
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Oh SY, Kim YI, Yoon YS, Cho MS, Park MY, Ryoo SB, Lee JL, Kim CW, Park IJ, Lim SB, Yu CS. Optimal surgical management of duodenal fistula in Crohn's disease: a Korean multicenter cohort study. Int J Colorectal Dis 2023; 38:106. [PMID: 37074597 DOI: 10.1007/s00384-023-04387-9] [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] [Accepted: 03/26/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE Duodenal fistula in Crohn's disease (CDF) is a rare condition with an unclear optimal surgical management approach. We reviewed a Korean multicenter cohort of CDF surgery cases and assessed their perioperative outcomes to evaluate the effectiveness of the surgical interventions. METHODS The medical records of patients who underwent CD surgery between January 2006 and December 2021 from three tertiary medical centers were retrospectively reviewed. Only CDF cases were included in this study. The demographic and preoperative characteristics, perioperative details, and postoperative outcomes were analyzed. RESULTS Among the initial population of 2149 patients who underwent surgery for CD, 23 cases (1.1%) had a CDF operation. Fourteen of these patients (60.9%) had a history of previous abdominal surgery, and 7 had duodenal fistula at the previous anastomosis site. All duodenal fistulas were excised and primarily repaired via a resection of the originating adjacent bowel. Additional procedures such as gastrojejunostomy, pyloric exclusion, or T-tube insertion were performed in 8 patients (34.8%). Eleven patients (47.8%) experienced postoperative complications including for anastomosis leakages. Fistula recurrence was noted in 3 patients (13%) of which one patient required a re-operation. Biologics administration was associated with fewer adverse events by multivariable analysis (P = 0.026, odds ratio = 0.081). CONCLUSION Optimal perioperative conditioning of patients receiving a primary repair of a fistula and resection of the original diseased bowel can successfully cure CDF. Along with primary repair of the duodenum, other complementary additional procedures should be considered for better postoperative outcomes.
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Affiliation(s)
- Soo Young Oh
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Min Soo Cho
- Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Young Park
- Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
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Increased Proportion of Colorectal Cancer in Patients with Ulcerative Colitis undergoing Surgery in the Netherlands. Am J Gastroenterol 2022; 118:848-854. [PMID: 36623170 PMCID: PMC10144357 DOI: 10.14309/ajg.0000000000002099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The aim of the current study was to assess if there is an indication shift for surgery in patients with UC from refractory disease to malignant degeneration over the last 3 decades. METHODS All patients with histologically confirmed UC who underwent a colorectal resection between 1991 and 2020 were extracted from the nationwide Dutch Pathology Registry (PALGA). The primary outcome was the proportion of CRC in the colon specimens. Outcomes were compared between 3 periods (P1: 1991-2000, P2: 2001-2010, P3: 2011-2020). RESULTS Overall, 6,094 UC patients were included of which 4,854 underwent a (procto)colectomy and 1,240 a segmental resection. In 1,031 (16.9%) patients, CRC was demonstrated in the pathological resection specimen after a median disease duration of 11 years [IQR 3.0-19.0]. The proportion of CRC increased from 11.3% in P1, to 16.1% in P2, and 22.8% in P3 (p<0.001). Median disease duration at the time of resection increased from 4 years in P1, to 10 years in P2, and 17 years in P3 (p<0.001). The proportion of patients diagnosed with advanced malignancy (pT3/T4) (P1: 61.2% vs. P2: 65.2% vs. P3: 62.4%, respectively, p=0.633) and lymph node metastasis (N+) (P1: 33.0% vs. P2: 41.9% vs. P3: 38.2%, respectively, p=0.113) did not change over time. DISCUSSION This nationwide pathology study demonstrated an increased proportion of surgery for CRC over the last 3 decades. We hypothesize that the expanding therapeutic armamentarium for UC leads to exhausting medical options and hence postponed colectomy. This however, might be at the expense of an increased risk of CRC in the long term.
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Kotze PG, Heuthorst L, Lightner AL, Damião AOMC, Bemelman WA. New insights on the surgical management of ulcerative colitis in the 21st century. Lancet Gastroenterol Hepatol 2022; 7:679-688. [DOI: 10.1016/s2468-1253(22)00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 10/18/2022]
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Jung S, Lee JL, Kim TW, Lee J, Yoon YS, Lee KY, Song KH, Yu CS, Cho YB. Molecular Characterization of Dysplasia-Initiated Colorectal Cancer With Assessing Matched Tumor and Dysplasia Samples. Ann Coloproctol 2021:ac.2021.00290.0041. [PMID: 34788527 PMCID: PMC8898627 DOI: 10.3393/ac.2021.00290.0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/20/2021] [Indexed: 10/26/2022] Open
Abstract
Purpose Ulcerative colitis (UC) is known to have an association with the increased risk of colorectal cancer (CRC), and UC-associated CRC does not follow the typical progress pattern of adenoma-carcinoma. The aim of this study is to investigate molecular characteristics of UC-associated CRC and further our understanding of the association between UC and CRC. Methods From 5 patients with UC-associated CRC, matched normal, dysplasia, and tumor specimens were obtained from formalin-fixed paraffin-embedded (FFPE) samples for analysis. Genomic DNA was extracted and whole exome sequencing was conducted to identify somatic variations in dysplasia and tumor samples. Statistical analysis was performed to identify somatic variations with significantly higher frequencies in dysplasia-initiated tumors, and their relevant functions were investigated. Results Total of 104 tumor mutation genes were identified with higher mutation frequencies in dysplasia-initiated tumors. Four of the 5 dysplasia-initiated tumors (80.0%) have TP53 mutations with frequent stop-gain mutations that were originated from matched dysplasia. APC and KRAS are known to be frequently mutated in general CRC, while none of the 5 patients have APC or KRAS mutation in their dysplasia and tumor samples. Glycoproteins including mucins were also frequently mutated in dysplasia-initiated tumors. Conclusion UC-associated CRC tumors have distinct mutational characteristics compared to typical adenoma-carcinoma tumors and may have different cancer-driving molecular mechanisms that are initiated from earlier dysplasia status.
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Affiliation(s)
- Sungwon Jung
- Department of Genome Medicine and Science, Gachon University College of Medicine, Incheon, Korea.,Gachon Institute of Genome Medicine and Science, Gachon University Gil Medical Center, Incheon, Korea
| | - Jong Lyul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Won Kim
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea
| | - Jongmin Lee
- Department of Genome Medicine and Science, Gachon University College of Medicine, Incheon, Korea
| | - Yong Sik Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kil Yeon Lee
- Department of Surgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ki-Hwan Song
- Department of Surgery, Koo Hospital, Daegu, Korea
| | - Chang Sik Yu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea.,Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Pak SJ, Kim YI, Yoon YS, Lee JL, Lee JB, Yu CS. Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn's disease: Propensity-score matching analysis. World J Gastroenterol 2021; 27:7159-7172. [PMID: 34887635 PMCID: PMC8613650 DOI: 10.3748/wjg.v27.i41.7159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/08/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic ileocolic resection (LICR) is the preferred surgical approach for primary ileocolic Crohn’s disease (CD) because it has greater recovery benefits than open ICR (OICR).
AIM To compare short- and long-term outcomes in patients who underwent LICR and OICR.
METHODS Patients who underwent ICR for primary CD from 2006 to 2017 at a single tertiary center specializing in CD were included. Patients who underwent LICR and OICR were subjected to propensity-score matching analysis. Patients were propensity-score matched 1:1 by factors potentially associated with 30-d perioperative morbidity. These included demographic characteristics and disease- and treatment-related variables. Factors were compared using univariate and multivariate analyses. Long-term surgical recurrence-free survival (SRFS) in the two groups was determined by the Kaplan-Meier method and compared by the log-rank test.
RESULTS During the study period, 348 patients underwent ICR, 211 by the open approach and 137 laparoscopically. Propensity-score matching yielded 102 pairs of patients. The rate of postoperative complication was significantly lower (14% versus 32%, P = 0.003), postoperative hospital stay significantly shorter (8 d versus 13 d, P = 0.003), and postoperative pain on day 7 significantly lower (1.4 versus 2.3, P < 0.001) in propensity-score matched patients who underwent LICR than in those who underwent OICR. Multivariate analysis showed that postoperative complications were significantly associated with preoperative treatment with biologics [odds ratio (OR): 3.14, P = 0.01] and an open approach to surgery (OR: 2.86, P = 0.005). The 5- and 10-year SRFS rates in the matched pairs were 92.9% and 83.3%, respectively, with SRFS rates not differing significantly between the OICR and LICR groups. The performance of additional procedures was an independent risk factor for surgical recurrence [hazard ratio (HR): 3.28, P = 0.02].
CONCLUSION LICR yielded better short-term outcomes and postoperative recovery than OICR, with no differences in long-term outcomes. LICR may provide greater benefits in selected patients with primary CD.
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Affiliation(s)
- Shin Jeong Pak
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Young Il Kim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Jong Lyul Lee
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
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Park J, Park S, Lee SA, Park SJ, Cheon JH. Improving the care of inflammatory bowel disease (IBD) patients: perspectives and strategies for IBD center management. Korean J Intern Med 2021; 36:1040-1048. [PMID: 34344146 PMCID: PMC8435511 DOI: 10.3904/kjim.2021.114] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/05/2021] [Indexed: 01/13/2023] Open
Abstract
The incidence and prevalence rates of inf lammatory bowel disease (IBD) have been increasing in East Asian countries over the past few decades. Accordingly, the general understanding and awareness of IBD among healthcare professionals has increased considerably in this region. This increase is ultimately associated with the evolving focus of IBD clinicians devoted to comprehensive patient care, especially in establishing IBD clinics/centers capable of providing multidisciplinary counseling. Comprehensive IBD care at IBD clinics/centers usually includes surgical and medication decision-making, transition from pediatric to adult clinics, care of extraintestinal manifestations, care of infectious diseases in patients undergoing immunomodulatory or biologic therapies, and nutritional, psychosocial, socioeconomic, and pharmacological care. Team members comprise specialists from various departments related to IBD and can be divided into core and ad hoc members. Usually, the scope of work in IBD clinics/centers involves patient care, patient outreach, and system management. Considering the environmental changes in IBD treatment, it is necessary to perform comprehensive IBD patient care in the form of a program based on competencies, rather than simply following the organization of previous IBD centers. The present review summarizes recent trends in IBD patient care and offers perspectives regarding IBD center management.
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Affiliation(s)
- Jihye Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Sinyoung Park
- Human Research Protection Center, Severance Hospital, Yonsei University Health System, Seoul,
Korea
| | - Shin Ae Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Soo Jung Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Jae Hee Cheon
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
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Park MY, Yoon YS, Kim HE, Lee JL, Park IJ, Lim SB, Yu CS, Kim JC. Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy. Asian J Surg 2021; 44:1383-1388. [PMID: 33966965 DOI: 10.1016/j.asjsur.2021.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/16/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE This study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy. METHODS Patients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared. RESULTS This study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques. CONCLUSION Surgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.
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Affiliation(s)
- Min Young Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Hyoung Eun Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Lyul Lee
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Abstract
PURPOSE The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions. METHODS A literature search of MEDLINE (PubMed) was conducted using the following search terms: 'Surgery' and 'Crohn'. Different current surgical treatment strategies are discussed based on disease location. RESULTS Several surgical options are possible in medically refractory or complex Crohn's disease as a last resort therapy. Recent evidence indicated that surgery could also be a good alternative in terms of effectiveness, quality of life and costs as first-line therapy if biologicals are considered, e.g. ileocolic resection for limited disease, or as part of combination therapy with biologicals, e.g. surgery aiming at closure of select perianal fistula in combination with biologicals. The role of the mesentery in ileocolic disease and Crohn's proctitis is an important surgical dilemma. In proctectomy, evidence is directing at removing the mesentery, and in ileocolic disease, it is still under investigation. Other surgical dilemmas are the role of the Kono-S anastomosis as a preventive measure for recurrent Crohn's disease and the importance of (non)conventional stricturoplasties. CONCLUSION Surgical management of Crohn's disease remains challenging and is dependent on disease location and severity. Indication and timing of surgery should always be discussed in a multidisciplinary team. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease rather than being a last resort therapy.
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Effect of Thiopurine on Potential Surgical Intervention in Crohn’s Disease in Korea: Results from the CONNECT Study. J Clin Med 2020; 10:jcm10010025. [PMID: 33374886 PMCID: PMC7796432 DOI: 10.3390/jcm10010025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Park SY. Surgical Treatment of Upper Gastrointestinal Tract Crohn Disease: A Long Way to Go to Identify the Optimal Method. Ann Coloproctol 2020; 36:207-208. [PMID: 32919433 PMCID: PMC7508480 DOI: 10.3393/ac.2020.07.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Choi YI, Kim YJ, Chung JW, Kim KO, Kim H, Park RW, Park DK. Effect of Age on the Initiation of Biologic Agent Therapy in Patients With Inflammatory Bowel Disease: Korean Common Data Model Cohort Study. JMIR Med Inform 2020; 8:e15124. [PMID: 32293578 PMCID: PMC7191339 DOI: 10.2196/15124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/23/2019] [Accepted: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The Observational Health Data Sciences and Informatics (OHDSI) network is an international collaboration established to apply open-source data analytics to a large network of health databases, including the Korean common data model (K-CDM) network. OBJECTIVE The aim of this study is to analyze the effect that age at diagnosis has on the prognosis of inflammatory bowel disease (IBD) in Korea using a CDM network database. METHODS We retrospectively analyzed the K-CDM network database from 2005 to 2015. We transformed the electronic medical record into the CDM version 5.0 used in OHDSI. A worsened IBD prognosis was defined as the initiation of therapy with biologic agents, including infliximab and adalimumab. To evaluate the effect that age at diagnosis had on the prognosis of IBD, we divided the patients into an early-onset (EO) IBD group (age at diagnosis <40 years) and a late-onset (LO) IBD group (age at diagnosis ≥40 years) with the cutoff value of age at diagnosis as 40 years, which was calculated using the Youden index method. We then used the logrank test and Cox proportional hazards model to analyze the effect that age at diagnosis (EO group vs LO group) had on the prognosis in patients with IBD. RESULTS A total of 3480 patients were enrolled. There was 2017 patients with ulcerative colitis (UC) and 1463 with Crohn's disease (CD). The median follow up period was 109.5 weeks. The EO UC group was statistically significant and showed less event-free survival (ie, experiences of biologic agents) than the LO UC group (P<.001). In CD, the EO CD group showed less event-free survival (ie, experiences of biologic agents) than the LO CD group. In the Cox proportional hazard analysis, the odds ratio (OR) of the EO UC group on experiences of biologic agents compared with the LO UC group was 2.3 (95% CI 1.3-3.8, P=.002). The OR of the EO CD group on experiences of biologic agents compared with the LO CD group was 5.4 (95% CI 1.9-14.9, P=.001). CONCLUSIONS The EO IBD group showed a worse prognosis than the LO IBD group in Korean patients with IBD. In addition, this study successfully verified the CDM model in gastrointestinal research.
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Affiliation(s)
- Youn I Choi
- Department of Gastroenterology, Gil Medical Center, Gachon University College of Internal Medicine, Incheon, Republic of Korea
| | - Yoon Jae Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University College of Internal Medicine, Incheon, Republic of Korea
| | - Jun-Won Chung
- Department of Gastroenterology, Gil Medical Center, Gachon University College of Internal Medicine, Incheon, Republic of Korea
| | - Kyoung Oh Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University College of Internal Medicine, Incheon, Republic of Korea
| | - Hakki Kim
- Health IT Research Center, Gil Medical Center, Gachon University, Incheon, Republic of Korea
| | | | - Dong Kyun Park
- Department of Gastroenterology, Gil Medical Center, Gachon University College of Internal Medicine, Incheon, Republic of Korea
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Moon JS, Lee JL, Yu CS, Lim SB, Park IJ, Yoon YS, Kim CW, Yang SK, Ye BD, Park SH, Alsaleem HA, Kim JC. Clinical Characteristics and Postoperative Outcomes of Patients Presenting With Upper Gastrointestinal Tract Crohn Disease. Ann Coloproctol 2020; 36:243-248. [PMID: 32178500 PMCID: PMC7508485 DOI: 10.3393/ac.2019.10.16.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Upper gastrointestinal (GI) tract involvement in Crohn disease (CD) is rare and effectiveness of surgical treatment is limited. The aim of this study was to evaluate characteristics and surgical outcomes of upper GI CD. METHODS Medical records of 811 patients who underwent intestinal surgery for CD between January 2006 and December 2015 at a single institution were reviewed. Upper GI CD was defined by involvement of the stomach to the fourth portion of duodenum, with or without concomitant small/large bowel CD involvement according to a modification of the Montreal classification. RESULTS We identified 24 patients (21 males, 3 females) who underwent surgery for upper GI CD. The mean age at diagnosis was 27 ± 12 years, the mean age at surgery was 33 ± 11 years, and the mean duration of CD was 73.6 ± 56.6 months. Fifteen patients (62.5%) had history of previous perianal surgery. Ten patients (41.7%) had duodenal or gastric stricture and 14 patients (58.3%) had penetrating fistula; patients with fistula were significantly more likely to develop complications (57.1% vs. 20.0%, P = 0.035). One patient with stricture had surgical recurrence. In seven patients with fistula, fistula was related to previous anastomosis. Patients with fistula had significantly longer hospital stays than those with stricture (16 days vs. 11 days, P = 0.01). CONCLUSION Upper GI CD is rare among CD types (2.96%). In patients with upper GI CD, penetrating fistula was associated with longer hospital stay and more complications.
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Affiliation(s)
- Joon Suk Moon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hassan Abdullah Alsaleem
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Jin Cheon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim CN. What Are the Major Changes in Korean Inflammatory Bowel Disease Surgery? Ann Coloproctol 2019; 34:277-279. [PMID: 30630300 PMCID: PMC6347337 DOI: 10.3393/ac.2018.11.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Chang-Nam Kim
- Department of Surgery, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
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