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Meima - van Praag EM, Becker MA, van Rijn KL, Wasmann KA, Stoker J, D'Haens GR, Ponsioen CY, Gecse KB, Dijkgraaf MG, Spinelli A, Danese S, Bemelman WA, Buskens CJ. Short-term anti-TNF therapy with surgical closure versus anti-TNF therapy alone for Crohn's perianal fistulas (PISA-II): long-term outcomes of an international, multicentre patient preference, randomised controlled trial. EClinicalMedicine 2023; 61:102045. [PMID: 37457118 PMCID: PMC10344824 DOI: 10.1016/j.eclinm.2023.102045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Background The PISA-II trial showed that short-term anti-tumour necrosis factor (anti-TNF) therapy followed by surgical closure induces radiological healing of perianal fistulas in patients with Crohn's disease more frequently than anti-TNF therapy alone after 18 months. This study aimed to compare long-term outcomes of both treatment arms. Methods Follow-up data were collected from patients who participated in the PISA-II trial, an international patient preference randomised controlled trial. This multicentre trial was performed in nine hospitals in the Netherlands and one hospital in Italy. Patients with Crohn's disease above the age of 18 years with an active high perianal fistula and a single internal opening were asked to participate. Patients were allocated to anti-TNF therapy (intravenous infliximab, or subcutaneous adalimumab, at the discretion of the gastroenterologist) for one year, or surgical closure combined with 4-months anti-TNF therapy. Patients without a treatment preference were randomised (1:1) using random block randomisation (block sizes of six without stratification), and patients with a treatment preference were treated according to their preferred treatment arm. For the current follow-up study, data were collected until May 2022. Primary outcome was radiological healing on magnetic resonance imaging (MRI), including all participants with a MRI made less than 6 months ago at the time of data collection. Analysis was based on observed data. Findings Between September 14, 2013, and December 7, 2019, 94 patients were enrolled in the trial. Long-term follow-up data were available in 91 patients (36/38 (95%) anti-TNF + surgical closure, 55/56 (98%) anti-TNF). A total of 14/36 (39%) patients in the surgical closure arm were randomly assigned, which was not significantly different in the anti-TNF treatment arm (16/55 (29%) randomly assigned). Median follow-up was 5.7 years (interquartile range (IQR) 5-7). Radiological healing occurred significantly more often after anti-TNF + surgical closure (15/36 = 42% versus 10/55 = 18%; P = 0.014). Clinical closure was comparable (26/36 = 72% versus 34/55 = 62%; P = 0.18) in both groups. However, clinical closure in the surgical group was achieved with less re-interventions 4/26 (= 15%) versus 18/34 (= 53%), including (redo-)surgical closure procedures. Recurrences occurred in 0/25 (0%) patients with radiological healing versus 27/76 (36%) patients with clinical closure, sometime during follow-up. Anti-TNF trough levels were higher in patients with long-term clinical closure in both groups (P = 0.031 and P = 0.014). In 6/11 (55%) patients in the anti-TNF group with available trough levels, recurrences were diagnosed within three months of a drop under 3.5ug/ml. 36 patients stopped anti-TNF, after which 0/14 (0%) patients with radiological healing developed a recurrence and 9/22 (41%) with clinical closure. Self-rated (in)continence was comparable between groups, and 79% (60/76) of patients indicated comparable/improved continence after treatment. Decision-regret analysis showed that all (30/30) anti-TNF + surgical closure patients agreed or strongly agreed that surgery was the right decision versus 78% (36/46) in the anti-TNF arm. All surgical closure patients would go for the same treatment again, whereas this was 89% (41/46) in the anti-TNF arm. Interpretation This study confirmed that surgical closure should be considered in amenable patients with perianal fistulas and Crohn's disease as long-term outcomes were favourable, and that radiological healing should be the aim of treatment as recurrences only occurred in patients without radiological healing. In patients with complete MRI closure, anti-TNF could be safely stopped. Funding None.
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Affiliation(s)
- Elise M. Meima - van Praag
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marte A.J. Becker
- Tytgat Institute for Liver and Intestinal Research and Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kyra L. van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Karin A.T.G.M. Wasmann
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Geert R.A.M. D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Krisztina B. Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marcel G.W. Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Meibergdreef 9, Amsterdam, the Netherlands
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Willem A. Bemelman
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Christianne J. Buskens
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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Meima-van Praag EM, van Rijn KL, Wasmann KATGM, Snijder HJ, Stoker J, D'Haens GR, Gecse KB, Gerhards MF, Jansen JM, Dijkgraaf MGW, van der Bilt JDW, Mundt MW, Spinelli A, Danese S, Bemelman WA, Buskens CJ. Short-term anti-TNF therapy with surgical closure versus anti-TNF therapy in the treatment of perianal fistulas in Crohn's disease (PISA-II): a patient preference randomised trial. Lancet Gastroenterol Hepatol 2022; 7:617-626. [PMID: 35427495 DOI: 10.1016/s2468-1253(22)00088-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Guidelines on Crohn's perianal fistulas recommend anti-tumour necrosis factor (TNF) treatment and suggest considering surgical closure for patients with surgically amenable disease. However, long-term outcomes following these two strategies have not been directly compared. The aim of this study was to assess radiological healing in patients who received short-term anti-TNF treatment and surgical closure compared with those who received anti-TNF treatment alone. METHODS The PISA-II trial was a multicentre, patient preference study done in nine hospitals in the Netherlands and one hospital in Italy. Adult patients with Crohn's disease and an active high perianal fistula with a single internal opening were eligible for inclusion. After counselling, patients with no treatment preference were randomly assigned (1:1) using random block randomisation (block sizes of six without statification), to 4-month anti-TNF therapy and surgical closure or anti-TNF therapy for 1 year, after seton insertion. Patients with a treatment preference received their preferred therapy. The primary outcome was radiological healing assessed by MRI at 18 months, defined as a complete fibrotic tract or a MAGNIFI-CD (Magnetic Resonance Index for Fistula Imaging in Crohn's Disease) score of 0, assessed according to the intention-to-treat principle. Secondary outcomes included clinical closure, number of patients undergoing surgical reintervention and number of reinterventions, recurrences, and impact on quality of life measured by the Perianal Disease Activity Index (PDAI). Analyses were performed on an intention-to-treat basis and additionally an as-treated analysis for radiological healing and clinical closure. This study was registered at the Dutch Trial Registry, NL7625, and with EudraCT, 2018-002064-15, and is closed to accrual due to completion. FINDINGS Between Sept 14, 2013, and Dec 7, 2019, 94 patients were enrolled onto the trial, of whom 32 (34%) were randomly assigned and 62 (66%) chose a specific treatment. 38 (40%) patients were assigned to the surgical closure group and 56 (60%) patients to the anti-TNF group. At 18 months, radiological healing was significantly more common in the surgical closure group (12 [32%] patients) than in the anti-TNF group (five [9%] patients; p=0·005). By contrast, clinical closure was not significantly different between the two treatment groups (26 [68%] patients in the surgical closure group vs 29 [52%] patients in the anti-TNF group; p=0·076). Significantly fewer patients required a reintervention in the surgical closure group than in the anti-TNF therapy group (five [13%] patients in the surgical closure group, median one reintervention [IQR one to three] vs 24 [43%] patients in the anti-TNF group, median two reinterventions [one to two]; p=0·005). Among patients who reached clinical closure during follow-up, four (14%) of 29 in the surgical closure group and five (16%) of 31 in the anti-TNF therapy group had a recurrence, which occurred only in patients without radiological healing. PDAI was significantly lower in the surgical closure group than in the anti-TNF group after 18 months (p=0·031). Adverse events and serious adverse events were similar in both treatment groups and mostly entailed reinterventions. Ten (11%) patients had side-effects associated with anti-TNF treatment. Two serious adverse events unrelated to study treatment occurred (appendicitis and myocardial infarction). One patient died from a tongue base carcinoma, unrelated to study treatment. INTERPRETATION Short-term anti-TNF treatment combined with surgical closure induces long-term MRI healing more frequently than anti-TNF therapy in patients with Crohn's perianal fistulas. These data suggest that patients with Crohn's perianal fistula amenable for surgical closure should be counselled for this therapeutic approach. FUNDING Netherlands Organisation for Health Research and Development and Broad Medical Research Program.
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Affiliation(s)
- Elise M Meima-van Praag
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Kyra L van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Karin A T G M Wasmann
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Harmanna J Snijder
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Marco W Mundt
- Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, Netherlands
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Christianne J Buskens
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
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van Rijn KL, Stoker J, Menys A, de Jonge CS. Impact of bowel dilation on small bowel motility measurements with cine-MRI: assessment of two quantification techniques. BJR Open 2022; 4:20210049. [PMID: 36105419 PMCID: PMC9459865 DOI: 10.1259/bjro.20210049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/04/2022] [Accepted: 02/07/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives To evaluate the effect of bowel dilation on cine-MRI small bowel motility measurements, by comparing a conventional motility score (including bowel wall and lumen) with a bowel wall-specific motility score in healthy and diseased populations. Methods Four populations were included: 10 Crohn's patients with a stricture and prestricture dilation for segmental motility analysis, and 14 mannitol-prepared healthy subjects, 15 fasted healthy subjects and eight chronic intestinal pseudo-obstruction (CIPO) patients (characterized by dilated bowel loops) for global small bowel motility analysis. All subjects underwent a cine-MRI scan from which two motility scores were calculated: a conventional score (including bowel wall and lumen) and a bowel wall-specific score. The difference between the two scores was calculated per population and compared between groups with a one-way ANOVA and Tukey-Kramer analysis. Results In Crohn's patients, the median (IQR) change between the conventional and wall-specific motility score was 0% (-2 to +4%) within the stricture and 0% (-1 to +7%) in the prestricture dilation. For the global small bowel, this was -1% (-5 to 0%) in mannitol-prepared healthy subjects, -2% (-6 to +2%) in fasted healthy subjects and +14% (+6 to+20%) in CIPO patients. The difference between the two motility scores in CIPO patients differed significantly from the four other groups (p = 0.002 to p < 0.001). Conclusions The conventional small bowel motility score seems robust in Crohn's disease patients and healthy subjects. In patients with globally and grossly dilated bowel loops, a bowel-wall specific motility score may give a better representation of small bowel motility. Advances in knowledge These findings support researchers and clinicians with making informed choices for using cine-MRI motility analysis in different populations.
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Affiliation(s)
- Kyra L van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Catharina S de Jonge
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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van Rijn KL, Meima-van Praag EM, Bossuyt PM, D’Haens GR, Gecse KB, Horsthuis K, Snijder HJ, Tielbeek JAW, Buskens CJ, Stoker J. Fibrosis and MAGNIFI-CD Activity Index at Magnetic Resonance Imaging to Predict Treatment Outcome in Perianal Fistulizing Crohn's Disease Patients. J Crohns Colitis 2021; 16:708-716. [PMID: 34644395 PMCID: PMC9228904 DOI: 10.1093/ecco-jcc/jjab168] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Characteristic magnetic resonance imaging [MRI] features associated with long-term perianal fistula closure are still being discussed. This study evaluated the predictive value of degree of fibrosis and disease activity (MAGNIFI-CD index) at MRI for long-term clinical closure of Crohn's perianal fistulas. METHODS Crohn's disease [CD] patients treated with surgical closure following anti-tumour necrosis factor [anti-TNF] induction or anti-TNF alone for high perianal fistulas as part of a patient preference randomized controlled trial [PISA-II] between 2013 and 2020 with a post-treatment MRI and long-term clinical follow-up data were retrospectively included. Two radiologists scored the degree of fibrosis and MAGNIFI-CD index at pre- and post-treatment MRI. The accuracy of post-treatment MRI findings in predicting long-term clinical closure [12 months after the MRI] was evaluated using receiver operating characteristics [ROC] analysis. RESULTS Fifty patients were included: 31 female, median age 33 years (interquartile range [IQR] 26-45). Fourteen patients showed a 100% fibrotic fistula at post-treatment MRI, all of which had long-term clinical closure. Median MAGNIFI-CD index at post-treatment MRI was 0 [IQR 0-5] in 25 patients with long-term clinical closure and 16 [IQR 10-20] in 25 patients without. ROC analysis showed an area under the curve of 0.90 (95% confidence interval [CI] 0.82-0.99) for degree of fibrosis and 0.95 [95% CI 0.89-1.00] for the MAGNIFI-CD index, with a Youden cut-off point of 6 [91% specificity, 87% sensitivity]. CONCLUSIONS Degree of fibrosis and MAGNIFI-CD index at post-treatment MRI are accurate in predicting long-term clinical closure and seem valuable in follow-up of perianal CD. A completely fibrotic tract at MRI is a robust indicator for long-term fistula closure. EUDRACT 2013-002932-25 and 2018-002064-15.
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Affiliation(s)
- Kyra L van Rijn
- Corresponding author: Kyra L. van Rijn, MD, Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands. Tel: +31 (0) 20 7320783;
| | - Elise M Meima-van Praag
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Patrick M Bossuyt
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Geert R D’Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Karin Horsthuis
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Harmanna J Snijder
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen A W Tielbeek
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands,Department of Radiology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
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van Rijn KL, Bredenoord AJ, Smout AJPM, Bouma G, Tielbeek JAW, Horsthuis K, Stoker J, de Jonge CS. Fasted and fed small bowel motility patterns at cine-MRI in chronic intestinal pseudo-obstruction. Neurogastroenterol Motil 2021; 33:e14062. [PMID: 33369013 PMCID: PMC8244096 DOI: 10.1111/nmo.14062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/16/2020] [Accepted: 11/25/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) is a severe intestinal motility disorder of which the pathophysiology is largely unknown. This study aimed at gaining insight in fasted and fed small bowel motility in CIPO patients using cine-MRI with caloric stimulation. METHODS Eight adult patients with manometrically confirmed CIPO were prospectively included. Patients underwent a cine-MRI protocol after an overnight fast, comprising fasting-state scans and scans after ingestion of a meal (Nutridrink, 300 kcal). Small bowel motility was quantified resulting in a motility score in arbitrary units (AU) and visually assessed by three radiologists. Findings were compared with those in 16 healthy volunteers. KEY RESULTS Motility scores (median, IQR) in CIPO patients were 0.21 (0.15-0.30) in the fasting state and 0.23 (0.15-0.27) directly postprandially. In healthy volunteers, corresponding motility scores were 0.15 (0.13-0.18) and 0.22 (0.19-0.25), respectively. The postprandial change in motility score was +1% (-19 to +21%) in CIPO and +39% (+23 to +50%) in healthy volunteers (p = 0.001*). Visual analysis revealed increased small bowel contractility in four, normal in two, and decreased in two CIPO patients. CONCLUSIONS & INFERENCES Surprisingly, we found hyperactive small bowel motility in half of the CIPO patients, suggestive of uncoordinated motility. A wide variation in motility patterns was observed, both higher, lower, and comparable contractility compared with healthy subjects. No clear postprandial activation was seen in patients. Cine-MRI helps to gain insight in this complex disease and can potentially impact treatment decisions in the future.
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Affiliation(s)
- Kyra L. van Rijn
- Department of Radiology and Nuclear MedicineAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Albert J. Bredenoord
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - André J. P. M. Smout
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Jeroen A. W. Tielbeek
- Department of Radiology and Nuclear MedicineAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of RadiologySpaarne GasthuisHaarlemThe Netherlands
| | - Karin Horsthuis
- Department of Radiology and Nuclear MedicineAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear MedicineAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Catharina S. de Jonge
- Department of Radiology and Nuclear MedicineAmsterdam Gastroenterology, Endocrinology and MetabolismAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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de Jonge CS, Sprengers AMJ, van Rijn KL, Nederveen AJ, Stoker J. Assessment of fasted and fed gastrointestinal contraction frequencies in healthy subjects using continuously tagged MRI. Neurogastroenterol Motil 2020; 32:e13747. [PMID: 31828938 PMCID: PMC7027525 DOI: 10.1111/nmo.13747] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Continuously tagged MRI during free breathing can assess bowel motility at frequencies as low as the slow wave, motility pattern range. This study aimed to evaluate noninvasive gastrointestinal-tagged MRI for small bowel motility assessment and to observe the physiological response to a 300-kcal meal challenge in healthy, overnight-fasted volunteers. METHODS After overnight fasting, 16 healthy subjects (7 women, mean age 25.5, range 19-37 years) underwent a free breathing, tagged MRI scan to capture small bowel motility. Each subject underwent a (a) baseline motility scan, (b) food challenge, (c) postchallenge scan, and (d) second postchallenge scan (after 20 minutes). Motility was quantified using a frequency analysis technique for measuring the spectral power of the strain, referred to as motility score. Motility score was assessed in 20 frequency intervals between 1 and 20 contractions per minute (cpm), and the data were analyzed with linear mixed-effect models. KEY RESULT The stimulation protocol demonstrated an immediate, food-induced, motility response in the low-frequency range (2-10 cpm), which is consistent with the stomach and small bowel frequency range (3-12 cpm). CONCLUSIONS AND INFERENCES This study shows that this MRI tagging technique is able to quantify the fasted-to-fed response to a 300-kcal meal challenge within the specific small bowel motility frequency range in healthy subjects. The food provocation MRI protocol provides a tool to explore the gut's response to a stimulus in specific motility frequency ranges in patients with gastrointestinal dysmotility and functional disorders.
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Affiliation(s)
- Catharina S. de Jonge
- Department of Radiology and Nuclear MedicineAmsterdam UMCLocation Academic Medical CenterAmsterdam Gastroenterology & MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
| | - André M. J. Sprengers
- Department of Biomedical Engineering & PhysicsAmsterdam UMCLocation Academic Medical CenterAmsterdam Gastroenterology & MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kyra L. van Rijn
- Department of Radiology and Nuclear MedicineAmsterdam UMCLocation Academic Medical CenterAmsterdam Gastroenterology & MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
| | - Aart J. Nederveen
- Department of Radiology and Nuclear MedicineAmsterdam UMCLocation Academic Medical CenterAmsterdam Gastroenterology & MetabolismUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear MedicineAmsterdam UMCLocation Academic Medical CenterAmsterdam Gastroenterology & MetabolismCancer Center AmsterdamUniversity of AmsterdamAmsterdamThe Netherlands
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van Rijn KL, Lansdorp CA, Tielbeek JAW, Nio CY, Buskens CJ, D'Haens GRAM, Löwenberg M, Stoker J. Evaluation of the modified Van Assche index for assessing response to anti-TNF therapy with MRI in perianal fistulizing Crohn's disease. Clin Imaging 2019; 59:179-187. [PMID: 31821976 DOI: 10.1016/j.clinimag.2019.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/04/2019] [Accepted: 10/03/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Structured evaluation of magnetic resonance imaging (MRI) is important to guide clinical decisions of perianal fistulas in Crohn's disease (CD) patients. PURPOSE To evaluate the recently developed modified Van Assche index to assess clinical responses to anti-tumor necrosis factor (TNF) therapy in patients with perianal fistulizing CD. METHODS A search of medical records identified patients with fistulizing perianal CD who underwent baseline and follow-up MRI while receiving anti-TNF treatment. Patients were divided into clinical responders and non-responders based on physician's assessment. MRI-scans were scored using the original and modified Van Assche index and scores between baseline and follow-up were compared within clinical responders and non-responders. RESULTS Thirty cases were included (48% female, median age 27 years). Clinical responders (n = 16) had a median modified Van Assche score of 9.6 (IQR 5.8-12.7) at baseline and 5.8 (IQR 3.5-8.5) at follow-up (p = 0.008). In non-responders (n = 14), corresponding scores were 7.7 (IQR 5.8-13.5) and 8.2 (IQR 5.8-11.5) (p = 0.624). In clinical responders, 6/16 showed no drop in modified Van Assche score at follow-up. Scores obtained with the original Van Assche index dropped between baseline and follow-up in clinical responders (13.0 vs. 9.6, p = 0.011), whereas no decrease was observed in non-responders (11.5 vs. 11.5, p = 0.324). CONCLUSIONS While the modified Van Assche index overall decreases significantly in patients with perianal fistulas responding to anti-TNF treatment, one third of responders had unaltered scores at follow-up. Also, outcomes were comparable to the original Van Assche index. Further optimization of the modified Van Assche index is needed before application in larger studies.
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Affiliation(s)
- Kyra L van Rijn
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Corine A Lansdorp
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen A W Tielbeek
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
| | - C Yung Nio
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
| | - Christianne J Buskens
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Meibergdreef 9, the Netherlands
| | - Geert R A M D'Haens
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Mark Löwenberg
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap Stoker
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
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8
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de Jonge CS, Menys A, van Rijn KL, Bredenoord AJ, Nederveen AJ, Stoker J. Detecting the effects of a standardized meal challenge on small bowel motility with MRI in prepared and unprepared bowel. Neurogastroenterol Motil 2019; 31:e13506. [PMID: 30407694 PMCID: PMC7379305 DOI: 10.1111/nmo.13506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/03/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE MRI is increasingly used to evaluate small bowel contractility. The objective of this study was to validate a clinically practical stimulation test (300-kcal meal) for small bowel motility. METHODS Thirty-one healthy subjects underwent dynamic MRI to capture global small bowel motility after ±10h fasting, of which 15 underwent bowel preparation consisting of 1 L 2.5% mannitol solution and 16 did not. Each subject underwent (1) a baseline motility scan (2) a food challenge (3) a post-challenge scan, and (4) second post-challenge scan (after ±20 minutes). This protocol was repeated within 2 weeks. Motility was quantified using a validated motility assessment technique. KEY RESULTS Motility in prepared subjects at baseline was significantly higher than motility in unprepared subjects (0.36 AU vs 0.18 AU, P < 0.001). In the prepared group, the food challenge produced an 8% increase in motility (P = 0.33) while in the unprepared subjects a significant increase of 30% was observed (P < 0.001). Responses to food remained insignificant (P = 0.21) and significant (P = 0.003), for the prepared and unprepared subjects, respectively, ±20 minutes post food challenge. These results were confirmed in the repeated scan session. CONCLUSION & INFERENCES A significant response to a 300-kcal meal was measured within 10 minutes in unprepared bowel, supporting the clinical use of this challenge to provoke and assess motility changes. A caloric challenge did not produce an observable increase in motility in mannitol prepared subjects.
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Affiliation(s)
- Catharina S. de Jonge
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alex Menys
- Centre for Medical ImagingUniversity College London (UCL)LondonUK,Motilent, IDEALondonLondonUK
| | - Kyra L. van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Arjan J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Aart J. Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
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