Predictors of recurrence of Crohn’s disease after ileocolectomy: A review

Anastomotic Configuration and Temporary Diverting Ileostomy Do Not Increase Risk of Anastomotic Stricture in Postoperative Crohn's Disease

INTRODUCTION

Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated.

METHODS

A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection.

RESULTS

A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection.

DISCUSSION

AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.

Mesenteric creeping fat index defined by CT enterography is associated with early postoperative recurrence in patients with Crohn's disease

OBJECTIVES

To investigate the value of mesenteric creeping fat index (MCFI) defined by computed-tomography enterography (CTE) in patients with Crohn's Disease (CD) for predicting early postoperative recurrence.

METHODS

A total of 110 patients with CD who underwent CTE and I-stage intestinal resection surgery from December 2013 to December 2018 were enrolled. Two radiologists independently assessed CTE parameters, including MCFI, with scores ranging from 1 to 8; bowel-wall thickening, with a scale of 1 to 3; mural hyperenhancement, mural stratification, submucosal fat deposition, mesenteric fibrofatty proliferation, mesenteric hypervascularity, mesenteric fat stranding, with a scale of 0 to 2; abscess/fistula, enlarged mesenteric lymph node, abdominal and pelvic effusion, with a scale of 0 to 1. Imaging findings associated with early recurrence were assessed using logistic regression analysis.

RESULTS

Within one year follow-up, early postoperative recurrence occurred in 56.4 % (62/110) patients with CD. In univariate analysis, MCFI, bowel-wall thickening, mesenteric hypervascularity, mesenteric fat stranding, abscess/fistula and mesenteric lymphadenopathy were associated with early postoperative recurrence. Among all variables, MCFI (score ≥ 4) contributes the optimal AUC (0.838 [0.758-0.919]), specificity (89.6 %), positive predictive value (90.7 %), accuracy (83.6 %), and risk ratio (OR = 32.42 [10.69-98.33], p < 0.001). In multivariate analysis, only MCFI was an independent predictor of early postoperative recurrence (OR = 25.71 [7.65-86.35], p < 0.001).

CONCLUSION

CTE features are useful in predicting early postoperative recurrence in patients with CD, MCFI may be a valuable tool for clinical monitoring and follow-up.

Stemming the tide with ileocecal Crohn's disease: when is pharmacotherapy enough?

INTRODUCTION

Crohn's disease (CD) mostly affects the terminal ileum and ileocecal region and up to 80% of patients end up requiring surgery. Previously reserved for complicated or refractory forms, surgery is now considered as an alternative to medical treatment in localized ileocecal disease.

AREAS COVERED

This review examines factors associated with response to medical treatment and those associated with the need for surgery in ileocecal CD to identify the patients' profile for whom pharmacotherapy might be enough. Factors associated with the recurrence and the postoperative complications are also reviewed to help the clinician identify patients for whom medical therapy might be preferred.

EXPERT’S OPINION

LIR!C study long-term follow-up data show that 38% of infliximab-treated patients were still treated with infliximab at the end of their follow-up, while 14% had switched to another biologic or had received immunomodulator or corticosteroid and 48% had CD-related surgery. Only the combination with an immunomodulator was associated with a greater likelihood of continuing infliximab. Patients with ileocecal CD for whom pharmacotherapy might be sufficient are probably those with no risk factors for CD-related surgery.In addition, patients with high risk of recurrence or of post-operative complications may benefit more from medical treatment than from surgery.

Constructing a prediction model of inflammatory bowel disease recurrence based on factors affecting the quality of life

Aim

This study aimed to determine the factors affecting the quality of life of patients with inflammatory bowel disease (IBD) and to construct a disease recurrence prediction model based on these influencing factors.

Methods

A prospective, single-center study in China was conducted between October 2020 and March 2021. The quality of life of patients was assessed using the Inflammatory Bowel Disease Questionnaire (IBDQ). Multiple stepwise regression analysis was used to analyze the factors influencing the quality of life of patients with IBD. The chi-square test and the point-biserial correlation analysis were performed to identify factors associated with clinical recurrence. A binary logistic regression model was constructed to predict the recurrence. The receiver operating characteristic curve was used to evaluate the prediction model. Patients with IBD from April 2021 to June 2021 were randomly included for model verification to evaluate the disease recurrence prediction model.

Results

The average IBDQ score of patients with IBD was 172.2 ± 35.0 (decreased by 23.2%). The scores of all dimensions of the IBDQ were decreased, especially emotional function and systemic symptoms. Disease activity, age, extraintestinal manifestations (EIMs), and annual household income were important factors influencing the IBDQ scores of patients with ulcerative colitis, and these accounted for ~57.0% of the factors affecting the quality of life. Disease activity, EIMs, and occupational stress were important factors influencing the IBDQ scores of patients with Crohn's disease, and they accounted for approximately 75.1% of the factors affecting the quality of life. Annual household income, occupational stress, and IBDQ scores were independent risk factors for recurrence. The area under the curve of the recurrence prediction model was 81.1%. The sensitivity and specificity were 81.7 and 71.7%, respectively. The Youden index of the model was 0.534. The established recurrence prediction model has good discriminant validity in the validation cohort.

Conclusion

The quality of life of patients with IBD was generally poor. The use of factors affecting the quality of life to predict disease recurrence has high predictive value and can support the management of IBD by selecting patients at a higher risk for relapse.

The impact of the COVID-19 pandemic on Clostridioides difficile infection and utilization of fecal microbiota transplantation

Previous research has demonstrated that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) gains cell entry through the angiotensin-converting enzyme 2 receptor, which is abundantly found throughout the gastrointestinal (GI) tract, resulting in a wide array of GI manifestations of coronavirus disease 2019 (COVID-19). By gaining entry into the intestinal epithelial and stromal cells, SARS-CoV-2 has been observed to cause intestinal inflammation and gut dysbiosis. Alterations in gut microbiota are known to be involved in the pathophysiology of Clostridioides difficile infection (CDI). During the initial stages of the COVID-19 pandemic, rates of CDI were similar to historical data despite the increased use of antibiotics. This may be due to increased emphasis on hygiene and protective equipment and reduced C. difficile testing as diarrhea was presumed to be COVID-19 related. Studies also demonstrated additional risk factors for CDI in COVID-19 patients, including length of hospitalization and new abdominal pain during admission. Although not associated with increased mortality, CDI was associated with increased length of hospital stay among patients admitted with COVID-19. Due to fecal viral shedding and concern of oral-fecal transmission of SARS-CoV-2, increased safety regulations were introduced to fecal microbiota transplantation (FMT) leading to reduced rates of this procedure during the COVID-19 pandemic. FMT for recurrent CDI during the COVID-19 pandemic remained highly effective without any reports of SARS-CoV-2 transmission. In addition, limited data show that FMT may be effective in treating COVID-19 and restoring healthy gut microbiota. The goal of this article is to review the impact that the COVID-19 pandemic has had on hospital-acquired CDI and the utilization of FMT.

Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

Role of Intestinal Ultrasound in the Evaluation of Postsurgical Recurrence in Crohn’s Disease: Correlation with Endoscopic Findings

<b><i>Introduction:</i></b> Endoscopy remains the exam of choice in the evaluation of activity in Crohn’s disease (CD) after surgery (ACD-AS). However, intestinal ultrasound (IUS) may represent a noninvasive alternative. The objective of this study is to determine the diagnostic accuracy of this modality compared to endoscopy. <b><i>Material and Methods:</i></b> This is a cross-sectional study, comprising a period of 14 months, carried out in patients with established CD and ileocecal resection due to the disease. IUS (HI-VISION Avius®, Tokyo, Japan) was performed with linear probe B-mode/Doppler prior to ileocolonoscopy. IUS and ileocolonoscopy were performed on the same day by 2 specialists in Gastroenterology dedicated to ultrasound and inflammatory bowel disease, in a double-blind mode. Collected demographic and clinical data (Harvey-Bradshaw Index [HBI]; remission ≤4), serological/fecal inflammatory parameters (leukocytes [4–10 × 10⁹ cells/L], C-reactive protein [≤0.5 mg/dL], and fecal calprotectin [&#x3c;50 mg/kg]), endoscopy (Rutgeerts score: remission &#x3c;i2), and ultrasound (intestinal wall thickening [≤3 mm] and digestive wall vascularization using the semiquantitative score of Limberg [absent = 0, sparse = 1, moderate = 2, and marked = 3]). <b><i>Results:</i></b> Thirty-nine patients (female: 64.1%, mean age: 43.5 ± 15.3 years) were included. The median post-surgery follow-up was 9 years (IQR 3–12). The Montreal classification was as follows: L1, 61.5% (<i>n</i> = 24); L3, 38.5% (<i>n</i> = 15); B1 and B2, 28.2% (<i>n</i> = 11); and B3, 43.6% (<i>n</i> = 17). Most patients were in clinical remission (87.2%; <i>n</i> = 34), with a mean HBI of 2.1 ± 2.2. Twenty-two patients (56.4%) had normal inflammatory markers. IUS (intestinal wall thickening &#x3e;3 mm and/or Limberg score &#x3e;1) was abnormal in 61.5% (<i>n</i> = 24) of the cases. Endoscopic remission (Rutgeerts score &#x3c;i2) in 53.8% (<i>n</i> = 21) of the cases. Compared to endoscopy, IUS (area under the receiver operating characteristic curve [AUROC] = 0.75, <i>p</i> = 0.007) showed a diagnostic accuracy superior to that of inflammatory parameters (AUROC = 0.66, <i>p</i> = 0.083) and clinical parameters (AUROC = 0.64, <i>p</i> = 0.139). IUS showed a moderate concordance with endoscopy (κ = 0.5, <i>p</i> = 0.001), which was higher than that with inflammatory parameters (ĸ = 0.33, <i>p</i> = 0.041) or clinical parameters (ĸ = 0.29, <i>p</i> = 0.01). <b><i>Conclusions:</i></b> Ultrasound evaluation of the digestive wall is a noninvasive technique that shows a good diagnostic accuracy and a moderate concordance with endoscopy, being superior to clinical and serological/fecal inflammatory parameters.

Clinical and Genetic Factors Impact Time to Surgical Recurrence After Ileocolectomy for Crohn's Disease

OBJECTIVE

The aim of this study was to evaluate factors associated with time to surgical recurrence after Crohn's ileocolectomy.

SUMMARY BACKGROUND DATA

The most common surgery performed for Crohn's disease is ileocolectomy. Identifying patients at high risk for surgical recurrence may assist with medical and surgical decision-making.

METHODS

Data were obtained from 409 patients with Crohn's disease (CD) who had undergone ≥1 ileocolectomies at Penn State Hershey Medical Center. Six single-nucleotide polymorphisms (SNPs) associated with CD were evaluated in these patients: rs2076756, rs2066844, and rs2066845 in NOD2, rs4958847 and rs13361189 in IRGM, and rs2241880 in ATG16L1. Genotype and clinical factors were analyzed to determine associations with time to recurrent ileocolectomy. A subgroup analysis was performed on 241 patients naïve to biologics before initial ileocolectomy to assess the effect of biologic therapy on time to recurrent surgery.

RESULTS

There were 286 patients who underwent a single ileocolectomy, whereas 123 required multiple ileocolectomies. Ileocolonic involvement [hazard ratio (HR) 1.90, 95% confidence interval (CI) 1.21-3.00, P = 0.006] and rs2066844 in NOD2 (HR 1.8, 95% CI 1.17-2.77, P = 0.007) were associated with decreased time to surgical recurrence by multivariate analysis. In patients naïve to preoperative biologics, the initiation of postoperative biologics was associated with a 40% decreased incidence of surgical recurrence (HR 0.60, CI 0.39-0.93, P = 0.02) over time.

CONCLUSIONS

Ileocolonic distribution of disease and the rs2066844 SNP in NOD2 are associated with shorter time to recurrent ileocolectomy. The initiation of postoperative biologics in naïve patients was associated with a reduced incidence of recurrence over time.

Wireless Capsule Endoscopy for Diagnosis and Management of Post-Operative Recurrence of Crohn's Disease

Despite aggressive medical therapy, many patients with Crohn's disease require surgical intervention over time. After surgical resection, disease recurrence is common. Ileo-colonoscopy and the Rutgeerts score are commonly used for diagnosis and monitoring of post-operative endoscopic recurrence. The latter is the precursor of clinical recurrence and therefore it impacts prognosis and patient management. However, due to the limited length of bowel assessed by ileo-colonoscopy, this procedure can miss out-of-reach, more proximal lesions in the small bowel. This limitation introduces an important uncertainty when evaluating post-operative relapse by ileo-colonoscopy. In addition, the Rutgeerts score 'per se' bears a number of ambiguities. Here we will discuss the pros and cons of ileo-colonoscopy and other imaging studies including wireless capsule endoscopy to diagnose and manage post-operative recurrence of Crohn's disease. A number of studies provide evidence that wireless capsule endoscopy is a potentially more accurate as well as less invasive and less costly alternative to conventional techniques including ileo-colonoscopy.

MR Enterography of Complicated Crohn Disease: Stricturing and Penetrating Disease

ABSTRACT

Stricturing and penetrating disease are complications of Crohn disease (CD) that significantly affect patient outcomes. Careful evaluation for such complications is critical to the interpretation of magnetic resonance enterography. This manuscript outlines the key findings related to stricturing and penetrating CD and discusses current understanding of the pathophysiology and prognosis of complicated CD based on the literature.

Prophylaxis of Crohn's disease recurrence: A surgeon's perspective

Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.

Faecal calprotectin in inflammatory bowel diseases: a review focused on meta-analyses and routine usage limitations

A growing body of evidence has been published about the usefulness of measuring calprotectin in faecal samples (FCAL) in inflammatory bowel disease (IBD) assessment, including diagnosis, monitoring of disease activity and relapse prediction. Several systematic reviews with meta-analyses compiling studies for each particular clinical setting have been carried out in recent years. Most of these were focused on the use of FCAL in IBD diagnosis and showed a relevant role for this marker in selecting patients with gastrointestinal symptoms who would not need a further examination by endoscopy. Although a lesser number of meta-analyses have been performed on the use of FCAL as a surrogate marker of disease activity, a close correlation between FCAL and endoscopic activity of IBD has been shown. With respect to the predictive capacity of FCAL for IBD relapse, a single meta-analysis published indicates that this role is more limited. Furthermore, FCAL thresholds vary considerably depending on the clinical setting and, what is more concerning, among different commercially available assays due to a lack of FCAL concentration interchangeability. Here, we summarise recent publications about the role and limitations of FCAL in IBD, with a special focus on meta-analyses, and give an overview of alternative faecal biomarkers.

Dietary Patterns Associated to Clinical Aspects in Crohn's Disease Patients

Diet is an important factor in both the pathogenesis and in the clinical course of Crohn's disease (CD). However, data on dietary patterns of CD patients are rather limited in the literature. This cross-sectional study included 60 patients with CD, aged 18-60 years. Dietary intake was assessed using a validated food frequency questionnaire to measure food consumption patterns by principal component analysis (PCA). Multiple regression analysis was performed to investigate the association between dietary patterns and clinical and demographic variables. Three dietary patterns were identified: "Traditional + FODMAP" was associated with symptoms, gender, previous surgeries, and duration of the disease. "Fitness style" was positively associated with physical activity and negatively associated with body mass index and smoking. "Snacks and processed foods" was positively associated with duration of the disease and negatively associated with age. According to the weekly food consumption analysis, patients with active disease consumed less coffee and tea. We found significant associations between the three dietary patterns and the variables, but not with the stage of the disease. Prospective studies are necessary to determine the effects of food consumption patterns on the clinical course of CD.

Chronic diarrhoea due to bile salt malabsorption: nurse-led assessment, medical treatment and dietary management

Bile salt malabsorption (BSM) occurs when bile salts, which are secreted in the small bowel to aid digestion of fats and vitamins, are not sufficiently re-absorbed in the terminal ileum. Consequently, an excess of bile salts enters the colon, causing chronic explosive diarrhoea, associated with abdominal cramps, flatulence and urgent, frequent and unpredictable bowel habits. BSM affects around 1% of the population, often occuring in ileal Crohn's disease or after ileal resection. Diagnosis begins with a nurse-led assessment, including blood and stool tests, to exclude other potential organic causes of chronic diarrhoea. BSM can then be confirmed and classified with a75Se-homocholic acid taurine (SeHCAT) scan. BSM can be treated medically with bile salt sequestrants, including colestyramine sachets, which are approved but have an unpleasant taste, and colesevelam tablets, which are more tolerable but more expensive and not yet approved. However, long-term sequestrant use can impact absorption of vitamins and other medications. BSM can also be managed with a low-fat diet, which is cost-effective and can reduce the amount of bile secreted. Nurses should provide patient education to ensure adherence and safe use.

Isolated ileal blind loop inflammation after intestinal resection with ileocolonic anastomosis in Crohn's disease: an often neglected endoscopic finding with an unfavorable outcome

OBJECTIVE

Postoperative endoscopic recurrence in patients with Crohn's disease (CD) is commonly classified using the Rutgeerts score. Ulcerations in the ileal blind loop are not taken into account in the Rutgeerts score, and the clinical relevance of these lesions is unknown. This study aimed to assess the outcome of isolated ileal blind loop inflammation (IBLI) in postoperative CD patients.

METHODS

Adult CD patients who underwent intestinal surgery with ileocolonic anastomosis between 1997 and 2017 were included and postoperative endoscopy reports were retrospectively reviewed. IBLI was defined as isolated inflammation of the ileal blind loop with or without ulcera confined to the anastomosis. Outcome was assessed using endoscopic recurrence (Rutgeerts >i2) and surgical recurrence (re-resection).

RESULTS

A total of 341 CD patients were included. In 125 out of 341 (37%) patients, the ileal blind loop was described in the endoscopy reports. IBLI was reported in 43 of 341 (13%) patients. Start or step-up drug therapy was initiated in 10 of 32 (31%) IBLI patients with abdominal symptoms within a median of 0.9 months [interquartile range (IQR) 0.7-1.4] after ileocolonoscopy. Endoscopic recurrence occurred in 4 out of 38 (11%) IBLI patients without re-resection, within a median of 12.4 months (IQR 6.8-13.3). Intestinal re-resection was performed in 5 out of 43 (16%) IBLI patients within a median of 3.7 months (IQR 3.5-10.8).

CONCLUSION

IBLI is associated with symptoms and an unfavorable outcome, with a high risk of endoscopic recurrence in the neoterminal ileum and intestinal re-resection during short-term follow-up. Therefore, the blind ileal loop needs to be assessed during endoscopy in postoperative CD patients.

Early Initiation of Tumor Necrosis Factor Antagonist-Based Therapy for Patients With Crohn's Disease Reduces Costs Compared With Late Initiation

BACKGROUND & AIMS

Antagonists of tumor necrosis factor (TNF) are effective for induction and maintenance of remission of Crohn's disease (CD) and are generally prescribed when patients do not respond to conventional, less-costly medical therapies. Early initiation of anti-TNF therapy reduced rates of surgery and dose escalation due to loss of response. However, these drugs are expensive, so studies are needed on the cost effectiveness of early initiation. We aimed to determine the cost effectiveness of initiating treatment early in the disease course (within 2 years of CD diagnosis) vs later in the disease course (more than 2 years after diagnosis).

METHODS

We constructed a Markov model of a hypothetical cohort of patients with CD in Canada to simulate disease progression after initiation of infliximab or adalimumab therapy. We used published loss-of-response rates to compare the lifetime cost effectiveness of early vs late initiation of anti-TNF therapies. Transition probabilities and utilities were obtained through a literature search, and costs were obtained from the Alberta Ministry of Health. Sensitivity analysis was used to characterize uncertainty.

RESULTS

Early initiation of infliximab yielded an additional 0.72 quality-adjusted life-years (QALYs) and saved $50,418 compared with late initiation. Early initiation of adalimumab yielded an additional 0.54 QALYs and saved $43,969. At a willingness-to-pay threshold of $50,000, early initiations of infliximab or adalimumab therapy had a 74% chance of being cost effective compared with late initiation.

CONCLUSIONS

In a Markov model analysis, we found initiation of either infliximab or adalimumab within 2 years of CD diagnosis to provide significant cost savings and QALYs compared with later initiation (more than 2 years after diagnosis).

Fecal calprotectin is not superior to serum C-reactive protein or the Harvey-Bradshaw index in predicting postoperative endoscopic recurrence in Crohn's disease

BACKGROUND

Fecal calprotectin (FC) is a widely used noninvasive marker of gut inflammation that is associated with endoscopic severity in Crohn's disease (CD). However, FC has been inconsistent in predicting postoperative recurrence of CD, and its utility in the postoperative setting remains unclear.

MATERIALS AND METHODS

Blood and fecal samples were collected in consecutively recruited patients with CD who had undergone ileocolonic resection and required a colonoscopy to assess postoperative recurrence, as defined by the Rutgeerts score (RS).

RESULTS

A total of 86 patients were prospectively recruited at five centers. Overall, 49 (57%) had CD recurrence (RS≥i2). FC concentrations trended to increase with RS severity; FC median (interquartile range) was significantly higher in patients with endoscopic recurrence than those in endoscopic remission [172.5 (75-375) vs. 75 (36.5-180.5) μg/g, respectively]. The same occurred for C-reactive protein (CRP) [0.5 (0.1-0.95) vs. 0.1 (0.02-0.27)] mg/dl and the Harvey-Bradshaw index (HBI) [4 (2-7) vs. 1 (0-3.5)]. The three variables significantly correlated. The area under the curve to discriminate between patients in endoscopic remission and recurrence was 0.698 for FC, with 62 μg/g being the optimal cut-off point. This indicated FC would have 85.7% sensitivity and 45.9% specificity in detecting any recurrence, having positive predictive value and negative predictive value of 67.7 and 70.8%, respectively. Area under the curve for CRP and HBI were both 0.710. The combination of CRP and HBI provided a positive predictive value 95.7 and a diagnostic odds ratio of 30.8.

CONCLUSION

FC is not better than CRP combined with HBI to predict endoscopic postoperative recurrence of CD.

Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence

BACKGROUND AND AIMS

Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease.

METHODS

Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells.

RESULTS

Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes.

CONCLUSIONS

Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

A comparison of the risk of postoperative recurrence between African-American and Caucasian patients with Crohn's disease

BACKGROUND

Many patients with Crohn's disease will develop complications that require surgery. Recurrence after surgery is common.

AIM

To assess racial differences in postoperative recurrence between African-Americans and Caucasians.

METHODS

Medical records of Crohn's disease patients who underwent surgery (ileal, colonic, or ileocolonic resection) between June 2014 and June 2016 were reviewed. The primary endpoints were clinical and endoscopic remission at 6-12 months after a Crohn's disease surgery. Secondary outcomes included biological and histologic remission. Risks of recurrence were assessed by univariate, multivariate, and propensity score-matched analysis.

RESULTS

Thirty-six African-American and 167 Caucasian patients with Crohn's disease were included for analysis. There was no difference in disease location, disease behaviour, type of surgery performed, and pre- or postoperative medication use between the two groups. The rate of endoscopic remission did not differ between African-American and Caucasian patients (50% vs 42%, P = 0.76), and race did not influence the risk of endoscopic recurrence on univariate, multivariate, or propensity score-matched analysis. The rate of clinical remission was significantly lower in African-American patients compared to Caucasian patients (36% vs. 63%, P = 0.008). African-American race was significantly associated with clinical recurrence on univariate (odds ratio (OR) 6.76, 95% CI 1.50-30.40; P = 0.01), multivariate (OR 5.02, 95% CI 1.60-15.80; P = 0.006), and propensity-matched analysis (68% vs. 32% in Caucasians, P = 0.005). Rates of biologic and histologic remission were similar between the two groups on all analyses.

CONCLUSIONS

We found that African-American patients with Crohn's disease have a similar degree of objective measures of mucosal inflammation after surgery including endoscopic recurrence as compared to Caucasian patients. However, African-American race was significantly associated with clinical recurrence, suggesting the presence of ethnic variation in postoperative presentation in Crohn's disease.

Vedolizumab as a rescue therapy for patients with medically refractory Crohn's disease

AIM

Vedolizumab, a monoclonal antibody resulting in gut-selective anti-inflammatory activity, was approved by the US Food and Drug Administration in 2014 for use in patients with Crohn's disease (CD). The aim of this study was to investigate the efficacy of vedolizumab as a rescue therapy when other medical therapies have failed.

METHOD

A retrospective review was performed on consecutive patients with CD receiving vedolizumab at the Penn State Hershey IBD Center between May 2014 and March 2016. These patients were unresponsive or intolerant to tumour necrosis factor (TNF) antagonist therapy, and previously would have been candidates for surgery. Outcomes included surgical intervention, clinical response and endoscopic improvement.

RESULTS

A total of 48 patients with medically refractory CD receiving vedolizumab were included. The median length of follow-up was 69 weeks (range 15-113 weeks). A majority (81%) of patients previously failed at least two TNF antagonists, and 77% had prior surgery for CD. Surgical intervention was required in 21 (44%) patients and 13 (27%) patients required intra-abdominal operations. At the conclusion of the study, 23 (48%) patients reported continued improvement of symptoms, and 22 of 37 (59%) patients undergoing endoscopy showed improvement. Patients with the inflammatory CD phenotype were more likely to improve clinically and avoid surgery.

CONCLUSION

Vedolizumab alone or in combination with immunomodulators or steroids may be used as a rescue therapy in patients with medically refractory CD and may decrease the rate of surgical intervention. Patients with the inflammatory CD phenotype had the best clinical response and decreased need for surgery, suggesting that vedolizumab is most effective in the inflammatory phenotype.

Predictive value of myenteric and submucosal plexitis for postoperative Crohn's disease recurrence

Objectives: To assess the predictive values of myenteric and submucosal plexitis for postoperative endoscopic recurrence of Crohn's disease (CD). Methods: A retrospective study of CD patients who underwent intestinal resection between 1995 and 2013 in the Department of Surgery 2, Tokyo Women's Medical University was performed. Proximal resection margins were analyzed and plexitis was evaluated by counting the number of inflammatory cells in myenteric and submucosal plexuses. The sizes of the most severely inflamed ganglion (MIG) were measured. Multiple regression analysis was used to identify independent risk factors for postoperative endoscopic recurrence. Results: Of the 51 included patients, 40 patients underwent colonoscopy after surgery. Endoscopic recurrence was observed in 21 patients (52.5%). Mean duration (±standard deviation) from surgery to recurrence was 49.7±34.7 months. Endoscopic recurrence rates at 1, 3, and 5 years were 5.0%, 24.1%, and 45.1%, respectively. Submucosal plexitis and myenteric plexitis were observed in 36 (90.0%) and 37 patients (92.5%), respectively. On multivariate analysis, initial intestinal resection, rate of plexitis <50%, size of the MIG in the myenteric plexus ≥867 μm², and total number of inflammatory cells in the submucosal plexus ≥8 were independent risk factors for postoperative endoscopic recurrence. Conclusions: Pathological findings of proximal resection margins, especially submucosal plexitis and large sizes of myenteric plexus, are predictive of postoperative endoscopic recurrence in CD.

Risk factors for postoperative recurrence after primary bowel resection in patients with Crohn’s disease

AIM

To evaluate the risk factors for postoperative recurrence after primary bowel resection in a cohort of Korean Crohn’s disease (CD) patients.

METHODS

This study included 260 patients with no history of previous bowel surgery who underwent primary surgery for CD between January 2000 and December 2010 at Asan Medical Center (Seoul, South Korea). The median follow-up period was 101 mo.

RESULTS

During the follow-up period, 66 patients (25.4%) underwent a second operation for disease recurrence. At 1, 5 and 10 years after the first operation, the cumulative rate of surgical recurrence was 1.1%, 8.3% and 35.9% and clinical recurrence occurred in 1.2%, 23.6% and 68.1%, respectively. In multivariate analysis, undergoing an emergency operation was a significant risk factor for surgical recurrence-free survival (SRFS) [HR = 2.431, 95%CI: 1.394-4.240, P = 0.002], as were the presence of perianal disease after the first operation (HR = 1.715, 95%CI: 1.005-2.926, P = 0.048) and history of smoking (HR = 1.798, 95%CI: 1.088-2.969, P = 0.022). The postoperative use of anti-tumor necrosis factor (TNF) agents reduced SRFS risk (HR = 0.521, 95%CI: 0.300-0.904, P = 0.02).

CONCLUSION

History of smoking, postoperative perianal disease and undergoing an emergency operation were independent risk factors for surgical recurrence. Using anti-TNF agents may reduce surgical recurrence.

Impact of NOD2/CARD15 polymorphisms on response to monoclonal antibody therapy in Crohn's disease: a systematic review and meta-analysis

OBJECTIVE

Crohn's disease (CD) is frequently treated with anti-tumor necrosis factor (TNF)α monoclonal antibodies, and NOD2/CARD15 polymorphisms have been reported to predict treatment response. The purpose of this study was to perform a meta-analysis to determine the effect of NOD2/CARD15 polymorphisms on treatment response in patients with CD.

METHODS

Medline, Cochrane, EMBASE, and Google Scholar databases were searched until 19 December 2015 using the keywords: NOD2, CARD15, polymorphism, Crohn's disease. Randomized controlled trials, prospective, retrospective, and cohort studies of patients with CD who received NOD2/CARD15 genetic analysis and were treated with monoclonal antibodies were included. The primary outcome was treatment response.

RESULTS

Of 104 records identified, only four studies were relevant and included in the analysis. The four studies included 355 patients with CD, patient age ranged from 35 to 41 years, and the proportion of males ranged from 33% to 38%; however, only two studies reported age and sex data. Patients were treated with adalimumab and/or infliximab. Analysis revealed that NOD2/CARD15 mutations were not significantly associated with response to adalimumab or infliximab treatment (pooled odds ratio [OR] = 1.35, 95% confidence interval [CI]: 0.78 to 2.32, p = .278).

CONCLUSIONS

NOD2/CARD15 polymorphisms do not predict response to adalimumab and infliximab in patients with CD. However, the number of included studies was small and treatment protocols varied. Further studies are necessary to determine the role of NOD2/CARD15 polymorphisms in patients with CD.

The utility of faecal calprotectin to predict post-operative recurrence in Crohńs disease

OBJECTIVE

Endoscopic recurrence in Crohńs disease occurs in up to 80% of patients during the first year after surgery. Due to this, these patients need close monitoring. Faecal calprotectin has been proposed to be used as a non-invasive marker to monitor inflammatory activity. Up to now the use of faecal markers in endoscopic recurrence has been scarcely studied and with contradictory results.

MATERIAL AND METHODS

This was a cross-sectional observational study of diagnostic validity. It included all patients with Crohńs disease (CD) and ileocolic resection retrospectively who had had an ileocolonoscopy and a determination of faecal calprotectin before this colonoscopy, from 2007 to 2015.

RESULTS

Ninety-seven patients were included. We observed that the mean value of faecal calprotectin increased as the Rutgeerts score increased. The variable of that most statistical significance obtained in bivariate analysis was faecal calprotectin (p < 0.0001). Area under curve (AUC) of faecal calprotectin in endoscopic recurrence was 0.74 (95% CI: 0.644-0.842), and an optimal cut-off of 60 mcrgr/gr, obtained a score of 0.45 using Youden test. This indicated that calprotectin would have 88% Sensitivity and 58% Specificity in detecting any recurrence, the NPV was approximately 83,9%. None of the other variables studied had a significant correlation.

CONCLUSION

Faecal calprotectin predicts endoscopic recurrence in CD patients who have gone through surgery, however the cut-off point is still a problem so we cannot recommend calprotectin as a substitute of colonoscopy for CD monitoring and treatment adjustment.

European Crohn's and Colitis Organisation Topical Review on Prediction, Diagnosis and Management of Fibrostenosing Crohn's Disease

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focused on prediction, diagnosis, and management of fibrostenosing Crohn's disease [CD]. The objective was to achieve evidence-supported, expert consensus that provides guidance for clinical practice.

Stereomicroscopic 3D-pattern profiling of murine and human intestinal inflammation reveals unique structural phenotypes

Histology is fundamental to assess two-dimensional intestinal inflammation; however, inflammatory bowel diseases (IBDs) are often indistinguishable microscopically on the basis of mucosal biopsies. Here, we use stereomicroscopy (SM) to rapidly profile the entire intestinal topography and assess inflammation. We examine the mucosal surface of >700 mice (encompassing >16 strains and various IBD-models), create a profiling catalogue of 3D-stereomicroscopic abnormalities and demonstrate that mice with comparable histological scores display unique sub-clusters of 3D-structure-patterns of IBD pathology, which we call 3D-stereoenterotypes, and which are otherwise indiscernible histologically. We show that two ileal IBD-stereoenterotypes ('cobblestones' versus 'villous mini-aggregation') cluster separately within two distinct mouse lines of spontaneous ileitis, suggesting that host genetics drive unique and divergent inflammatory 3D-structural patterns in the gut. In humans, stereomicroscopy reveals 'liquefaction' lesions and hierarchical fistulous complexes, enriched with clostridia/segmented filamentous bacteria, running under healthy mucosa in Crohn's disease. We suggest that stereomicroscopic (3D-SMAPgut) profiling can be easily implemented and enable the comprehensive study of inflammatory 3D structures, genetics and flora in IBD.