Safety and Efficacy of Inpatient Infliximab Rescue Therapy for Acute Crohn's Disease Flares

PURPOSE

Describe the safety, complications, and need for urgent surgery in patients requiring inpatient rescue infliximab for acute Crohn's disease (CD) flare.

BACKGROUND

Infliximab is increasingly used for patients hospitalized with acute severe ulcerative colitis as rescue therapy; however, optimal management for patients hospitalized for CD flares remains unclear.

METHODS

A single-institution retrospective study of patients aged 18+ admitted from 2008 to 2020 with acute Crohn's flare requiring induction of rescue infliximab therapy. Outcomes included postoperative and medication-related complications and need for urgent surgery.

RESULTS

52 patients were included in analysis; 8% required surgery on index admission, and 19% required surgery within 90 days of infliximab. Postoperative complications included 1 anastomotic leak, 3 superficial wound infections, 3 prolonged ileus, and 1 urinary infection. There were no adverse reactions to infliximab infusion, and medical complication rates were low. Patients with penetrating disease were more likely to undergo surgery within 90 days of infliximab (43% vs 8%; P = .01). Mean LOS was longer for patients undergoing surgery within 90 days of therapy compared to those who did not (13.4 vs 8.3 days, P = .04).

CONCLUSION

Inpatient rescue infliximab is safe for treating acute Crohn's disease flare in addition to standard steroid therapy. The majority of patients hospitalized with Crohn's flare requiring rescue infliximab avoided surgery with low postoperative and medication-related complications. More research is needed to clarify the optimal rescue infliximab therapy dosage.

Mental health disorders as a risk factor in young patients with rectal prolapse

BACKGROUND

Rectal prolapse (RP) typically presents in the elderly, though it can present in younger patients lacking traditional risk factors. The current study compares medical and mental health history, presentation, and outcomes for young and older patients with RP.

METHODS

This is a single-center retrospective review of patients who underwent abdominal repair of RP between 2005 and 2019. Individuals were dichotomized into two groups based on age greater or less than 40 years.

RESULTS

Of 156 patients, 25 were < 40. Younger patients had higher rates of diagnosed mental health disorders (80% vs 41%, p < 0.001), more likely to take SSRIs (p = .02), SNRIs (p = .021), anxiolytics (p = 0.033), and antipsychotics (p < 0.001). Younger patients had lower preoperative incontinence but higher constipation. Both groups had low rates of recurrence (9.1% vs 11.6%, p = 0.73).

CONCLUSIONS

Young patients with RP present with higher concomitant mental health diagnoses and represent unique risk factors characterized by chronic straining compared to pelvic floor laxity.

Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction

PURPOSE

Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy.

RESULTS

Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05).

CONCLUSION

Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.

Early C-reactive protein after colorectal surgery is not predictive of anastomotic leak: a retrospective cohort study

PURPOSE

Prior studies suggest postoperative C-reactive protein (CRP) trends are sensitive for predicting anastomotic leak (AL) after elective colorectal surgery. However, in the setting of enhanced recovery pathways, multi-day CRP trends may not be feasible. This study aimed to assess the realistic and clinical utility of CRP in prediction of AL.

METHODS

A retrospective review of patients who underwent elective colectomy or proctectomy from January 2019 to October 2020 at a single institution was performed. Comorbidities, operative characteristics, and perioperative outcomes were recorded. CRP was checked routinely on POD1 and on a clinical basis subsequently. The association between 10-point change in CRP-POD1 and AL was evaluated using multivariable logistic regression. The relationships between CRP-POD3, CRP-POD1, and AL were assessed using exploratory analyses.

RESULTS

Among 332 patients, 23 (6.9%) developed AL, of which 9 cases (39%) were diagnosed upon readmission. AL was not associated with mortality. Median length of stay was 3 days (IQR 2-5). Median days to AL diagnosis was 7 (IQR 4-15). Adjusting for diverting stoma, steroid use, diagnosis, and open surgery, each 10-point increase in CRP was associated with increased odds of AL (OR 1.12, 95% CI 1.03-1.21, p=0.008). CRP-POD1 had poor discriminant utility for detecting AL (AUC 0.62, 95% CI = 0.494-0.746; p=0.061).

CONCLUSION

CRP on POD1 is not a reliable method to predict a leak, and trending CRP may not be practical with decreasing lengths of stay in colorectal surgery.

Perioperative use of NSAIDs and the risk of short-term endoscopic recurrence in Crohn's disease patients: A retrospective cohort study

BACKGROUND

More evidence is needed on the use of NSAID based postoperative pain regimens for Crohn's disease (CD) and its association with recurrence. Our goal is to assess the impact of perioperative use of NSAIDs on endoscopic disease recurrence in patients with CD.

METHODS

A retrospective cohort study was conducted. The primary outcome measured was endoscopic disease recurrence within 24 months of surgery, defined as a Rutgeerts score ≥ i2.

RESULTS

We identified 107 patients with CD that underwent index ileocolectomy with primary anastomosis between January 2009 and July 2019. Endoscopic disease recurrence was identified in 28 (26.2%) and clinical recurrence in 18 (16.8%) patients. Exposure to NSAIDs did not increase 24-month endoscopic recurrence risk (22.2% vs. 38.5% patients, p = 0.12).

CONCLUSION

In patients with CD undergoing elective ileocolic resection and primary ileocolic anastomosis, NSAID use in the perioperative period did not impact endoscopic or clinical disease recurrence rate.

Alcohol Acutely Antagonizes Refeeding-Induced Alterations in the Rag GTPase-Ragulator Complex in Skeletal Muscle

The Ragulator protein complex is critical for directing the Rag GTPase proteins and mTORC1 to the lysosome membrane mediating amino acid-stimulated protein synthesis. As there is a lack of evidence on alcohol's effect on the Rag-Ragulator complex as a possible mechanism for the development of alcoholic skeletal muscle wasting, the aim of our study was to examine alterations in various protein-protein complexes in the Rag-Ragulator pathway produced acutely by feeding and how these are altered by alcohol under in vivo conditions. Mice (C57Bl/6; adult males) were fasted, and then provided rodent chow for 30 min ("refed") or remained food-deprived ("fasted"). Mice subsequently received ethanol (3 g/kg ethanol) or saline intraperitoneally, and hindlimb muscles were collected 1 h thereafter for analysis. Refeeding-induced increases in myofibrillar and sarcoplasmic protein synthesis, and mTOR and S6K1 phosphorylation, were prevented by alcohol. This inhibition was not associated with a differential rise in the intracellular leucine concentration or plasma leucine or insulin levels. Alcohol increased the amount of the Sestrin1•GATOR2 complex in the fasted state and prevented the refeeding-induced decrease in Sestrin1•GATOR2 seen in control mice. Alcohol antagonized the increase in the RagA/C•Raptor complex formation seen in the refed state. Alcohol antagonized the increase in Raptor with immunoprecipitated LAMPTOR1 (part of the Ragulator complex) after refeeding and decreased the association of RagC with LAMPTOR1. Finally, alcohol increased the association of the V1 domain of v-ATPase with LAMPTOR1 and prevented the refeeding-induced decrease in v-ATPase V1 with LAMPTOR1. Overall, these data demonstrate that acute alcohol intake disrupts multiple protein-protein complexes within the Rag-Ragulator complex, which are associated with and consistent with the concomitant decline in nutrient-stimulated muscle protein synthesis under in vivo conditions.

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.

Marginal dietary zinc deprivation augments sepsis-induced alterations in skeletal muscle TNF-α but not protein synthesis

Severe zinc deficiency is associated with an increased systemic inflammatory response and mortality after sepsis. However, the impact of mild zinc deficiency, which is more common in populations with chronic illnesses and sepsis, is unknown. In this study, we hypothesized that marginal dietary Zn deprivation (ZM) would amplify tissue inflammation and exacerbate the sepsis-induced decrease in muscle protein synthesis. Adult male C57BL/6 mice were fed a zinc-adequate (ZA) or ZM diet (30 or 10 mg Zn/kg, respectively) over 4 weeks, peritonitis was induced by cecal ligation and puncture (CLP), and mice were examined at either 24 h (acute) or 5 days (chronic) post-CLP Acute sepsis decreased the in vivo rate of skeletal muscle protein synthesis and the phosphorylation of the mTOR substrate 4E-BP1. Acutely, sepsis increased TNF-α and IL-6 mRNA in muscle, and the increase in TNF-α was significantly greater in ZM mice. However, muscle protein synthesis and 4E-BP1 phosphorylation returned to baseline 5 days post-CLP in both ZA and ZM mice. Protein degradation via markers of the ubiquitin proteasome pathway was increased in acute sepsis, yet only MuRF1 mRNA was increased in chronic sepsis and ZM amplified this elevation. Our data suggest that mild zinc deficiency increases TNF-α in muscle acutely after sepsis but does not significantly modulate the rate of muscle protein synthesis.

Force Comparison of Commercially Available Transfascial Suture Passers

BACKGROUND

Transfascial suture passers (TSPs) are a commonly used surgical tool available in a wide array of tip configurations. We assessed the insertion force of various TSPs in an ex vivo porcine model.

METHODS

Uniform sections of porcine abdominal wall were secured to a 3D-printed platform. Nine TSPs were passed through the abdominal wall both without and with prolene suture under the following scenarios: abdominal wall only and abdominal wall plus underlay ePTFE or composite ePTFE/polypropylene mesh. Insertion forces were recorded in Newton (N).

RESULTS

When passed without suture through the abdominal wall, smaller diameter TSPs required less insertional force (1.50 ± 0.17 N vs 9.68 ± 1.50 N [ P = 0.00072]). Through composite mesh, the solid tipped TSPs required less force than hollow tipped ones (3.87 ± 0.25 N vs 7.88 ± 0.20 N [ P = 0.00026]). Overall, smaller diameter TSPs required less force than the larger TSPs when passed through ePTFE empty (Gore 2.95 ± 0.83 N vs Carter-Thomason 16.07 ± 2.10 N [ P = .0005]) or with suture (Gore 8.37 ± 2.59 N vs Carter-Thomason 19.12 ± 1.10 N [ P = .003]).

CONCLUSIONS

Diameter plays the greatest role in the force required for TSP penetration. However, when passed through underlay mesh or while holding suture, distal tip shape, the mechanism of suture holding, and shaft diameter all contribute to the forces necessary for penetration. These factors should be considered when choosing a TSP for intraoperative use.

Inability to replete white adipose tissue during recovery phase of sepsis is associated with increased autophagy, apoptosis, and proteasome activity

Adipose tissue is an important energy depot and endocrine organ, and the degree of adiposity impacts the host response to infection. However, little is known regarding the mechanisms by which white adipose tissue (WAT) is lost acutely and then restored after the resolution of sepsis. Therefore, the signaling pathways governing protein synthesis, autophagy, apoptosis, and the ubiquitin-proteasome were investigated to identify potential mechanisms mediating the acute (24 h) loss of WAT after cecal ligation and puncture as well as the failure to replenish WAT during recovery (day 10). While whole body fat mass was decreased equally in pair-fed control and septic mice at 5 days after cecal ligation and puncture, fat mass remained 35% lower in septic mice at day 10 During sepsis-recovery, protein synthesis in epididymal WAT was increased compared with control values, and this increase was associated with an elevation in eukaryotic translation initiation factor (eIF)2Bε but no change in mammalian target of rapamycin complex 1 activity (eIF4E-binding protein-1 or S6 kinase 1 phosphorylation). Protein breakdown was increased during sepsis-recovery, as evidenced by the elevation in ubiquitin-proteasome activity. Moreover, indexes of autophagy (light chain 3B-II, autophagy-related protein 5/12, and beclin) were increased during sepsis-recovery and associated with increased AMP-activated kinase-dependent Ser⁵⁵⁵-phosphorylated Unc-51-like autophagy activating kinase-1. Apoptosis was increased, as suggested by the increased cleavage of caspase-3 and poly(ADP-ribose) polymerase. These changes were associated with increased inflammasome activity (increased NLR family, pyrin domain containing 3; TMS1; and caspase-1 cleavage) and the endoplasmic reticulum stress response (increased eIF2α and activating transcription factor-4) and browning (uncoupling protein-1) in epididymal WAT. Our data suggest that WAT stores remain depleted during recovery from sepsis due to sustained inflammation and elevations in protein and cellular degradation, despite the increase in protein synthesis.

Immune and metabolic responses in early and late sepsis during mild dietary zinc restriction

BACKGROUND

Mild dietary zinc (Zn) deficiency is widespread in human populations, but its influence on recovery after acute illness is poorly understood. In a mouse model of abdominal sepsis (cecal ligation puncture), systemic immune responses and liver metabolism were monitored in early (24 h) and late (5 d) phases, under control conditions and during mild dietary Zn restriction.

METHODS

Mice were fed diets adequate or marginally deficient (ZM) in Zn (30 versus 10 mg zinc/kg diet) for 4 wk, before undergoing laparotomy alone (nonseptic control) or cecal ligation puncture (septic).

RESULTS

Among nonseptic mice, the ZM state was not associated with differences in inflammation or metabolic responses. Among septic mice, mortality did not differ between the zinc adequate and ZM groups. In the early phase, the ZM state amplified increases in plasma interleukin (IL) 6, tumor necrosis factor alpha, and IL-10, while dampening the interferon gamma response. In the late phase, subtle but significant ZM-associated increases were observed in plasma IL-5 and interferon gamma levels and hepatic protein synthesis, the latter of which appeared to be mammalian target of rapamycin independent and was associated with increased hepatic tumor necrosis factor alpha messenger RNA content.

CONCLUSIONS

Without increasing mortality, the ZM state is associated with a more disordered acute systemic inflammatory response and persistence or enhancement of acute phase responses within the liver parenchyma.

Decreased Whole-Body Fat Mass Produced by Chronic Alcohol Consumption is Associated with Activation of S6K1-Mediated Protein Synthesis and Increased Autophagy in Epididymal White Adipose Tissue

BACKGROUND

Chronic alcohol consumption leads to a loss of white adipose tissue (WAT) but the underlying mechanisms for this lipodystrophy are not fully elucidated. This study tested the hypothesis that the reduction in WAT mass in chronic alcohol-fed mice is associated with a decreased protein synthesis specifically related to impaired function of mammalian target of rapamycin (mTOR).

METHODS

Adult male mice were provided an alcohol-containing liquid diet for 24 weeks or an isonitrogenous isocaloric control diet. In vivo protein synthesis was determined at this time and thereafter epididymal WAT (eWAT) was excised for analysis of signal transduction pathways central to controling protein synthesis and degradation.

RESULTS

While chronic alcohol feeding decreased whole-body and eWAT mass, this was associated with a discordant increase in protein synthesis in eWAT. This increase was not associated with a change in mTOR, 4E-BP1, Akt, or PRAS40 phosphorylation. Instead, a selective increase in phosphorylation of S6K1 and its downstream substrates, S6 and eIF4B was detected in alcohol-fed mice. Alcohol also increased eEF2K phosphorylation and decreased eEF2 phosphorylation consistent with increased translation elongation. Alcohol increased Atg12-5, LC3B-I and -II, and ULK1 S555 phosphorylation, suggesting increased autophagy, while markers of apoptosis (cleaved caspase-3 and -9, and PARP) were unchanged. Lipolytic enzymes (ATGL and HSL phosphorylation) were increased and lipogenic regulators (PPARγ and C/EBPα) were decreased in eWAT by alcohol. Although alcohol increased TNF-α, IL-6, and IL-1β mRNA, no change in key components of the NLRP3 inflammasome (NLRP3, ACS, and cleaved caspase-1) was detected suggesting alcohol did not increase pyroptosis. Plasma insulin did not differ between groups.

CONCLUSIONS

These results demonstrate that the alcohol-induced decrease in whole-body fat mass resulted in part from activation of autophagy in eWAT as protein synthesis was increased and mediated by the specific increase in the activity of S6K1.

Disruption of REDD1 gene ameliorates sepsis-induced decrease in mTORC1 signaling but has divergent effects on proteolytic signaling in skeletal muscle

Sepsis-induced skeletal muscle atrophy and weakness are due in part to decreased mTORC1-mediated protein synthesis and increased proteolysis via the autophagy-lysosomal system and ubiquitin-proteasome pathway. The REDD1 (regulated in development and DNA damage-1) protein is increased in sepsis and can negatively regulate mTORC1 activity. However, the contribution of REDD1 to the sepsis-induced change in muscle protein synthesis and degradation has not been determined. Sepsis was produced by cecal ligation and puncture in female REDD1(-/-) or wild-type (WT) mice, and end points were assessed 24 h later in gastrocnemius; time-matched, pair-fed controls of each genotype were included. Sepsis increased REDD1 protein 300% in WT mice, whereas REDD1 was absent in REDD1(-/-) muscle. Sepsis decreased protein synthesis and phosphorylation of downstream targets of mTORC1 (S6K1 Thr(389), rpS6 Ser(240/244), 4E-BP1 Ser(65)) in WT but not REDD1(-/-) mice. However, Akt and PRAS40 phosphorylation was suppressed in both sham and septic muscle from REDD1(-/-) mice despite unaltered PDK1, PP2A, or TSC2 expression. Sepsis increased autophagy as indicated by decreased ULK1 Ser(757) phosphorylation and p62 abundance and increased LC3B-II/I in WT mice, whereas these changes were absent in septic REDD1(-/-) mice. Conversely, REDD1 deletion did not prevent the sepsis-induced decrease in IGF-I mRNA or the concomitant increase in IL-6, TNFα, MuRF1, and atrogin1 mRNA expression. Lastly, 5-day survival in a separate set of septic mice did not differ between WT and REDD1(-/-) mice. These data highlight the central role of REDD1 in regulating both protein synthesis and autophagy in skeletal muscle during sepsis.

Risk factors and implications of anastomotic complications after surgery for Crohn’s disease

Anastomotic complications occur more frequently in patients with Crohn’s disease leading to postoperative intra-abdominal septic complications (IASC). Patients with IASC often require re-operation or drainage to control the sepsis and have an increased frequency of disease recurrence. The aim of this article was to examine the factors affecting postoperative IASC in Crohn’s disease after anastomoses, since some risk factors remain controversial. Studies investigating IASC in Crohn’s operations were included, and all risk factors associated with IASC were evaluated: nutritional status, presence of abdominal sepsis, medication use, Crohn’s disease type, duration of disease, prior operations for Crohn’s, anastomotic technique, extent of resection, operative timing, operative length, and perioperative bleeding. In this review, the factors associated with an increased risk of IASC are preoperative weight loss, abdominal abscess present at time of surgery, prior operation, and steroid use. To prevent IASC in Crohn’s patients, preoperative optimization with nutritional supplementation or drainage of abscess should be performed, or a diverting stoma should be considered for patients with multiple risk factors.

Impact of Alcohol on Glycemic Control and Insulin Action

Alcohol has profound effects on tissue and whole-body fuel metabolism which contribute to the increased morbidity and mortality in individuals with alcohol use disorder. This review focuses on the glucose metabolic effects of alcohol, primarily in the muscle, liver and adipose tissue, under basal postabsorptive conditions and in response to insulin stimulation. While there is a relatively extensive literature in this area, results are often discordant and extrapolating between models and tissues is fraught with uncertainty. Comparisons between data generated in experimental cell and animals systems will be contrasted with that obtained from human subjects as often times results differ. Further, the nutritional status is also an important component of the sometimes divergent findings pertaining to the effects of alcohol on the regulation of insulin and glucose metabolism. This work is relevant as the contribution of alcohol intake to the development or exacerbation of type 2 diabetes remains ill-defined and a multi-systems approach is likely needed as both alcohol and diabetes affect multiple targets within the body.

Surveillance of pancreatic cancer patients after surgical resection

BACKGROUND

There are no clear recommendations to guide posttreatment surveillance in patients with pancreatic cancer. Our goal was to describe the posttreatment surveillance patterns in patients undergoing curative-intent resection for pancreatic cancer.

METHODS

We used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2005) to identify CT scans and physician visits in patients with pancreatic cancer who underwent curative resection (n = 2393). Surveillance began 90 days after surgery, and patients were followed for 2 years at 6-month intervals. Patients were censored if they died, experienced recurrence of disease, or entered hospice.

RESULTS

A total of 2045 patients survived uncensored to the beginning of the surveillance period. CT scan use decreased from 20.9% of patients in month 4 to 6.4% in month 27. There was no temporal pattern in CT use to suggest regular surveillance. Twenty-three percent of patients did not receive a CT scan in the year after surgery, increasing to 42% the second year. Patients who underwent adjuvant therapy and patients diagnosed in later years had higher CT scan use over the surveillance periods. Most patients visited both a primary care physician and a cancer specialist in each 6-month surveillance period. Patients who visited cancer specialists were more likely to have any CT scan and to be scanned more frequently.

CONCLUSIONS

Current surveillance patterns after resection for pancreatic cancer reflect the lack of established guidelines, implying a need for evaluation and standardization of surveillance protocols. The lack of a temporal pattern in CT testing suggests that most were obtained to evaluate symptoms rather than for routine surveillance.