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1
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Khan I, Holubar SD. Operative Management of Small and Large Bowel Crohn's Disease. Surg Clin North Am 2025; 105:247-276. [PMID: 40015815 DOI: 10.1016/j.suc.2024.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
The majority of patients with Crohn's disease, despite an ever-increasing number of advanced therapies, require abdominal surgery during their lifetime. In this review article, the authors provide a comprehensive overview of abdominal surgery for Crohn's disease, with an evidence-based focus on surgery for upper gastrointestinal Crohn's disease, bowel-preserving surgery with strictureplasties, selection of ileocolic anastomotic technique for terminal ileal Crohn's disease, extended resections and proctectomy for Crohn's proctocolitis, intentional ileoanal pouch for Crohn's disease, and several "hot topics" including early surgery for ileocolic Crohn's disease, and surgical approaches that target the mesentery including the Kono-S anastomosis and extended mesenteric excision.
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Affiliation(s)
- Imran Khan
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA.
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2
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Husnoo N, Morgan JL, Wyld L, Lobo AJ, Brown SR. The challenges of implementing earlier surgery for terminal ileal Crohn's disease-A qualitative study of the clinician's perspective. Colorectal Dis 2025; 27:e70027. [PMID: 39934956 DOI: 10.1111/codi.70027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 10/31/2024] [Accepted: 01/07/2025] [Indexed: 02/13/2025]
Abstract
AIM Evidence suggests that earlier bowel resection may offer more stable remission in localized luminal terminal ileal (TI) Crohn's disease compared with ongoing medical therapy. Surgery is still considered late in the treatment pathway. The aim of this study was to understand the clinician's perspective on 'early' surgery by qualitatively exploring how clinicians make treatment-related decisions. METHOD Semistructured interviews with clinicians across the UK with an interest in inflammatory bowel disease (IBD) were undertaken using videoconferencing (February-November 2022). Inductive thematic analysis of interview transcripts was performed; 10% of the data were double-coded. Data saturation was confirmed before stopping recruitment. RESULTS Participants included nine consultant surgeons, seven consultant gastroenterologists and seven specialist nurses (n = 23) from secondary care and tertiary referral centres. Five key themes were identified: timing of surgery in practice, barriers to timely surgery, factors influencing decision-making, offering choice and the patient's perspective. A practice of exhausting medical options before considering surgery was commonly described. A lack of IBD specialists (especially surgeons), inadequate opportunities for multidisciplinary teamwork and long waiting lists for surgical clinics and theatre were cited as barriers to timely surgery. According to interviewees, patients prefer medical therapy over surgery; the most dreaded risk is thought to be that of a stoma. CONCLUSION This study provides new insights into the barriers to earlier surgery for TI disease. Organizational barriers should be considered when designing local services. Collaborative multidisciplinary teamwork may allow clinicians to consider surgery sooner. A study investigating the patient perspective is warranted.
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Affiliation(s)
- Nilofer Husnoo
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Jenna L Morgan
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Doncaster and Bassetlaw Teaching Hospitals NHS Trust, Doncaster Royal Infirmary, Doncaster, UK
| | - Lynda Wyld
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Doncaster and Bassetlaw Teaching Hospitals NHS Trust, Doncaster Royal Infirmary, Doncaster, UK
| | - Alan J Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Steven R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
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3
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Madaffari I, Muttillo EM, Franca AL, Massimi F, Castagnola G, Coppola A, Furio S, Piccirillo M, Ferretti A, Mennini M, Parisi P, Cozzi DA, Ceccanti S, Felici E, Alessio PP, Lisi G, Illiceto MT, Sperduti I, Di Nardo G, Mercantini P. Early Surgical Resection in Pediatric Patients with Localized Ileo-Cecal Crohn's Disease: Results of a Retrospective Multicenter Study. J Clin Med 2025; 14:404. [PMID: 39860411 PMCID: PMC11766163 DOI: 10.3390/jcm14020404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2024] [Revised: 01/07/2025] [Accepted: 01/08/2025] [Indexed: 01/27/2025] Open
Abstract
Background: Crohn's disease (CD) is an inflammatory bowel disease (IBD) that also affects pediatric patients. It frequently presents as a localized disease, affecting the ileocecal area, ileum, or colon. It requires targeted therapy to achieve a good quality of life and long-term control of disease activity. Despite multiple medical therapies available, several patients benefit from surgical treatment. The aim of our study is to demonstrate how an early surgical approach can bring an improvement in disease activity, evaluating the Simple Endoscopic Score for Crohn's Disease (SES-CD) and the Pediatric Crohn's Disease Activity Index (PCDAI). Methods: A retrospective multicenter study was carried out from 2008 to 2023, including 29 patients, affected by localized CD. These data were analyzed: demographics, SES-CD, and PCDAI, before and after surgery. The differences between groups were analyzed using Student's t-test for continuous variables, and Pearson's Chi-squared test or Fisher's exact test for categorical variables. Results: The SES-CD significantly decreased from 12 (median, range 1-15) to 0 (median, range 0-6) (p < 0.0001) and the PCDAI decreased from 30 (median, range 10-50) to 0 (median, range 0-15) (p < 0.0001). The rate of patients receiving enteral nutrition decreased from 51.7% preoperatively to 0% postoperatively (p = 0.0001). The rate of antibiotic use decreased from 13.8% to 0% (p = 0.0001). The rate of patients receiving ≥2 drugs decreased from 10.3% to 0% (p = 0.0001). Conclusions: The early surgical approach can be considered an excellent therapeutic strategy in patients with localized CD. Both parameters examined, SES-CD and PCDAI, demonstrated a clear improvement in the endoscopic images and in disease activity.
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Affiliation(s)
- Isabella Madaffari
- Department of Medical Surgical Science and Translational Medicine, Sant’ Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.M.M.); (A.L.F.); (F.M.); (G.C.); (P.M.)
| | - Edoardo Maria Muttillo
- Department of Medical Surgical Science and Translational Medicine, Sant’ Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.M.M.); (A.L.F.); (F.M.); (G.C.); (P.M.)
| | - Alice La Franca
- Department of Medical Surgical Science and Translational Medicine, Sant’ Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.M.M.); (A.L.F.); (F.M.); (G.C.); (P.M.)
| | - Fanny Massimi
- Department of Medical Surgical Science and Translational Medicine, Sant’ Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.M.M.); (A.L.F.); (F.M.); (G.C.); (P.M.)
| | - Giorgio Castagnola
- Department of Medical Surgical Science and Translational Medicine, Sant’ Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.M.M.); (A.L.F.); (F.M.); (G.C.); (P.M.)
| | - Alessandro Coppola
- Department of General Surgery, Sapienza University of Rome, 00185 Roma, Italy;
| | - Silvia Furio
- NESMOS Department, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (S.F.); (M.P.); (A.F.); (M.M.); (P.P.); (G.D.N.)
| | - Marisa Piccirillo
- NESMOS Department, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (S.F.); (M.P.); (A.F.); (M.M.); (P.P.); (G.D.N.)
| | - Alessandro Ferretti
- NESMOS Department, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (S.F.); (M.P.); (A.F.); (M.M.); (P.P.); (G.D.N.)
| | - Maurizio Mennini
- NESMOS Department, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (S.F.); (M.P.); (A.F.); (M.M.); (P.P.); (G.D.N.)
| | - Pasquale Parisi
- NESMOS Department, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (S.F.); (M.P.); (A.F.); (M.M.); (P.P.); (G.D.N.)
| | - Denis A. Cozzi
- Pediatric Surgery Unit, Sapienza University of Rome, AOU Policlinico Umberto I, 00185 Roma, Italy; (D.A.C.); (S.C.)
| | - Silvia Ceccanti
- Pediatric Surgery Unit, Sapienza University of Rome, AOU Policlinico Umberto I, 00185 Roma, Italy; (D.A.C.); (S.C.)
| | - Enrico Felici
- Pediatric and Pediatric Emergency Unit, Children Hospital, AO SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
| | - Pini Prato Alessio
- Pediatric Surgery Unit, Children Hospital, AO SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
| | - Gabriele Lisi
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 2 Pediatric Surgery Unit, “Santo Spirito” Hospital of Pescara, 66100 Pescara, Italy;
| | - Maria Teresa Illiceto
- Pediatric Gastroenterology and Digestive Endoscopic Unit, Department of Pediatrics, “Santo Spirito” Hospital of Pescara, 65124 Pescara, Italy;
| | - Isabella Sperduti
- Biostatistical Unit, Clinical Trials Center, IRCSS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Giovanni Di Nardo
- NESMOS Department, Sant’Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (S.F.); (M.P.); (A.F.); (M.M.); (P.P.); (G.D.N.)
| | - Paolo Mercantini
- Department of Medical Surgical Science and Translational Medicine, Sant’ Andrea University Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.M.M.); (A.L.F.); (F.M.); (G.C.); (P.M.)
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Grellier N, Kirchgesner J, Uzzan M, Mclellan P, Stefanescu C, Lefèvre JH, Treton X, Panis Y, Sokol H, Beaugerie L, Seksik P. Early ileal resection in Crohn's disease is not associated with severe long-term outcomes: The ERIC study. Aliment Pharmacol Ther 2024; 60:1388-1397. [PMID: 39234950 DOI: 10.1111/apt.18247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/13/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Early complicated Crohn's disease (CD) may require ileal resection as first-line treatment. AIM To evaluate the long-term outcomes of patients who underwent early ileal resection. METHODS We conducted a retrospective study in two inflammatory bowel diseases (IBD) referral centres, including patients with ileocaecal resection and segmental ileal resection within 5 years of CD diagnosis. Early resection was defined as within 6 months of diagnosis, intermediate resection between 6 months and 2 years, and late resection between 2 and 5 years. The primary outcome was the cumulative risk of a second ileal surgery. Secondary outcomes included the use of postoperative treatments and morphological recurrence after initial surgery (Rutgeerts score ≥i2, or recurrence on imaging). RESULTS Among 393 patients who underwent ileal resection within 5 years of diagnosis, 130, 128 and 135, respectively, had early, intermediate and late resection. The cumulative risk of second surgery at 10 years was not significantly different in the early resection group (25.0% [95% CI 17.4-35.2]), than the intermediate (16.8% [95% CI 10.5-26.2]; p = 0.17) or late resection group (22.7% [95% CI 15.1-33.3]; p = 0.83). The early resection group required fewer postoperative treatments than the late resection group with median survivals without treatments of 3.7 and 0.9 years, respectively (p = 0.002). Patients who had early resection had significantly less morphological recurrence than the late resection group (p = 0.02). CONCLUSION Early ileal resection in CD is not associated with a higher risk of a second resection. It may be associated with reduced use of medical treatments and fewer morphological recurrences.
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Affiliation(s)
- Nathan Grellier
- Department of Gastroenterology, Poitiers University Hospital, Poitiers, France
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - Julien Kirchgesner
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - Mathieu Uzzan
- Department of Gastroenterology, Mondor Hospital, Paris, France
| | - Paul Mclellan
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - Carmen Stefanescu
- Department of Gastroenterology and Nutrition Beaujon Hospital, Clichy, France
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - Jérémie H Lefèvre
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
| | - Xavier Treton
- Department of Gastroenterology and Nutrition Beaujon Hospital, Clichy, France
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - Yves Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - Harry Sokol
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - Laurent Beaugerie
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - Philippe Seksik
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
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Zerbib P, Desreumaux P. Should first-line surgery for terminal ileum Crohn's disease be considered? J Visc Surg 2024; 161:291-292. [PMID: 38906787 DOI: 10.1016/j.jviscsurg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Affiliation(s)
- Philippe Zerbib
- Digestive Surgery and Transplantation Department, Hôpital Claude-Huriez, Lille université Nord de France, CHRU de Lille, 1, place de Verdun, 59000 Lille, France.
| | - Pierre Desreumaux
- Gastroenterology Department, Hôpital Claude-Huriez, Lille université Nord de France, CHRU de Lille, 1, place de Verdun, 59000 Lille, France
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6
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Park Y, Park SJ, Kim TI, Kim WH, Cheon JH. Primary surgery versus pharmacotherapy for newly diagnosed ileocecal Crohn's disease: a hospital-based cohort study. Korean J Intern Med 2024; 39:759-769. [PMID: 38910512 PMCID: PMC11384257 DOI: 10.3904/kjim.2023.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/28/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND/AIMS Limited knowledge exists regarding the optimal timing and relative advantages of primary surgery compared to medical treatment in ileocecal Crohn's disease (CD). This study aimed to compare long-term outcomes between medication-based treatment versus surgery in newly diagnosed ileocecal CD patients in an Asian population. METHODS Among the 885 patients diagnosed with CD and enrolled in the study site hospital cohort between 1980 and 2013, 93 (10.5%) had ileocecal CD. Patients were categorized into either the surgical or medical remission group based on their initial management strategy that led to remission. The rates of relapse, hospitalization, and surgery after achieving remission were compared using Kaplan-Meier curves. RESULTS The numbers of patients assigned to surgical and medical remission groups were 15 (17.0%) and 73 (83.0%), respectively. The surgical remission group exhibited a lower relapse rate and longer maintenance of remission (10.7 vs. 3.7 yr; p = 0.017) during a median follow-up of 6.6 years. Hospitalization after the first remission tended to be lower in the surgical remission group (p = 0.054). No cases required repeated intestinal resection after the initial surgical remission, whereas a 23% surgery rate was reported at 5 years after initial medical treatment (p = 0.037). In the multivariable analysis, the initial medication-based treatment was significantly associated with relapse (hazard ratio = 3.23, p = 0.039). CONCLUSION In selected cases of localized ileocecal CD, ileocolic resection might be a favorable alternative to medication- based treatment, as it demonstrates a lower relapse rate and longer maintenance of remission.
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Affiliation(s)
- Yehyun Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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7
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Gisbert JP, Chaparro M. Common Mistakes in Managing Patients with Inflammatory Bowel Disease. J Clin Med 2024; 13:4795. [PMID: 39200937 PMCID: PMC11355176 DOI: 10.3390/jcm13164795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.
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Affiliation(s)
- Javier P. Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28006 Madrid, Spain;
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Angriman I, Sampietro GM. Ileocaecal Crohn's disease. To resect or not to resect, is that the question? Dig Liver Dis 2024; 56:1298-1300. [PMID: 38734567 DOI: 10.1016/j.dld.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Imerio Angriman
- General Surgery Unit 3, Padua University Hospital, Padua, Italy
| | - Gianluca M Sampietro
- Division of General and HPB Surgery, Rho Memorial Hospital, ASST Rhodense, Rho Milano, Italy.
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Wu JF, Yen HH, Wang HY, Chang TA, Chang CH, Chang CW, Chao TH, Chou JW, Chou YH, Chuang CH, Hsu WH, Hsu TC, Huang TY, Hung TI, Le PH, Lin CC, Lin CC, Lin CP, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsai TJ, Wang CY, Weng MT, Wong JM, Wu DC, Wei SC. Management of Crohn's disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023. Intest Res 2024; 22:250-285. [PMID: 39099218 PMCID: PMC11309825 DOI: 10.5217/ir.2024.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 08/06/2024] Open
Abstract
Crohn's disease (CD) is a chronic, fluctuating inflammatory condition that primarily affects the gastrointestinal tract. Although the incidence of CD in Taiwan is lower than that in Western countries, the severity of CD presentation appears to be similar between Asia and the West. This observation indicates the urgency for devising revised guidelines tailored to the unique reimbursement system, and patient requirements in Taiwan. The core objectives of these updated guidelines include the updated treatment choices and the integration of the treat-to-target strategy into CD management, promoting the achievement of deep remission to mitigate complications and enhance the overall quality of life. Given the diversity in disease prevalence, severity, insurance policies, and access to medical treatments in Taiwan, a customized approach is imperative for formulating these guidelines. Such tailored strategies ensure that international standards are not only adapted but also optimized to local contexts. Since the inception of its initial guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease (TSIBD) has acknowledged the importance of continuous revisions for incorporating new therapeutic options and evolving disease management practices. The latest update leverages international standards and recent research findings focused on practical implementation within the Taiwanese healthcare system.
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Affiliation(s)
- Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Hsu-Heng Yen
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Post-Baccalaureate Medicine, National Chung Hsing University College of Medicine, Taichung, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital, Renai-Branch, Taipei, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colon and Rectal Surgery, Department of Surgery, Chiayi and Wangiao Branch, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-Wei Chou
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, MacKay Memorial Hospital, MacKay Medical College, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsung-I Hung
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chun-Che Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taipei, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Pin Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Children’s Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Forensic Medicine and Pathology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pathology, Good Liver Clinic, Taipei, Taiwan
| | - Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Gangshan Hospital, Kaohsiung, Taiwan
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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10
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Angriman I, Bordignon G, Kotsafti A, Mescoli C, Scarpa M, Ruffolo C, Fassan M, Dei Tos AP, D'Incà R, Savarino EV, Zingone F, Pucciarelli S, Bardini R, Castagliuolo I, Scarpa M. Innate Immunity Activation in Newly Diagnosed Ileocolonic Crohn's Disease: A Cohort Study. Dis Colon Rectum 2024; 67:681-692. [PMID: 38319717 DOI: 10.1097/dcr.0000000000003145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND Recent studies showed that early surgery for Crohn's disease leads to a lower recurrence rate. However, the underlying mechanism is unknown. OBJECTIVE The study aims to analyze the innate immunity microenvironment in ileal mucosa according to the duration of Crohn's disease. DESIGN A prospective cohort study. SETTINGS Tertiary referral center for IBD surgery. PATIENTS A total of 88 consecutive patients with Crohn's disease undergoing ileocolonic resection were prospectively enrolled. Mucosal samples were obtained from both healthy and inflamed ileum. Data from a public data set were analyzed as an external validation cohort. MAIN OUTCOME MEASURES Neutrophil infiltration was evaluated by histological asessment and macrophage subpopulation was assessed by immunohistochemistry. Expressions of TLR2 , TLR4 , TLR5 , DEFB1 , DEFB4A , DEFB103 , DEFA5 , and DEFA6 were quantified by real-time quantitative polymerase chain reaction. Concentrations of BDNF, CCL-11, ICAM-1, IL-1A, IL-1β, IL-1RN, IL-12p40, IL-12p70, IL-15, IL-17A, IL-23A, MMP-3, CCL-3, KITLG, and VEGFA were determined with an immunometric assay. RESULTS Neutrophil infiltration is inversely correlated with disease duration. DEFB4A mRNA expression tended to be higher in late-stage Crohn's disease ( p = 0.07). A higher number of macrophages expressed CD163 at low intensity in late-stage Crohn's disease ( p = 0.04). The concentration of IL-15 ( p = 0.02) and IL-23A ( p = 0.05) was higher in healthy ileal mucosa of early-stage patients. In the external cohort, expressions of DEFB1 ( p = 0.03), DEFB4A ( p = 0.01), IL-2 ( p = 0.04), and IL-3 ( p = 0.03) increased in patients with late-stage Crohn's disease. LIMITATIONS A relatively small number of patients, especially in the newly diagnosed group. CONCLUSIONS In newly diagnosed Crohn's disease, high levels of IL-15 and IL-23 in healthy mucosa suggest that innate immunity is the starter of acute inflammation. Moreover, M2 macrophages increase in the healthy mucosa of patients with late-stage Crohn's disease, suggesting that reparative and profibrotic processes are predominant in the long term, and in this phase, anti-inflammatory therapy may be less efficient. See Video Abstract . ACTIVACIN DE LA INMUNIDAD INNATA EN LA RECIENTEMENTE DIAGNOSTICADA ENFERMEDAD DE CROHN ILEOCLICA UN ESTUDIO DE COHORTE ANTECEDENTES:Estudios recientes demostraron que la cirugía temprana para la enfermedad de Crohn (EC) conduce a una menor tasa de recurrencia. Sin embargo, se desconoce el mecanismo subyacente.OBJETIVO:El estudio tiene como objetivo analizar el microambiente de la inmunidad innata en la mucosa ileal según la duración de la EC.DISEÑO:Un estudio de cohorte prospectivo.AJUSTES:Centro terciario de referencia para cirugía de EII.PACIENTES:Fueron registrados de manera prospectiva y consecutiva 88 pacientes con EC sometidos a resección ileocolónica. Se obtuvieron muestras de mucosa ileal, tanto del íleon sano como del íleon inflamado. Los datos se analizaron como una cohorte de validación externa.PRINCIPALES MEDIDAS DE RESULTADO:Fueron evaluados la infiltración de neutrófilos por histología y la subpoblación de macrófagos por inmunohistoquímica. La expresión de TLR2, TLR4, TLR5, DEFB1, DEFB4A, DEFB103, DEFA5 y DEFA6 fueron cuantificados mediante qPCR en tiempo real. Las concentraciones de BDNF, CCL-11, ICAM-1, IL-1A, IL-1B, IL-1RN, IL-12 p40, IL-12 p70, IL-15, IL-17A, IL-23A, MMP-3, CCL-3, KITLG, VEGFA se determinaron con ensayo inmunométrico.RESULTADOS:La infiltración de neutrófilos se correlaciona inversamente con la duración de la enfermedad. La expresión del ARNm de DEFB4A mostro una tendencia a ser mayor en la EC en etapa tardía ( p = 0,07). Un mayor número de macrófagos expresaron CD163 a baja intensidad en la etapa tardía ( p = 0,04). La concentración de IL15 ( p = 0,02) e IL23A ( p = 0,05) fue mayor en la mucosa ileal sana de pacientes en estadio temprano. En la cohorte externa, la expresión de DEFB1 ( p = 0,03) y DEFB4A ( p = 0,01), IL2 ( p = 0,04) e IL3 ( p = 0,03) aumentó en pacientes en etapa tardía.LIMITACIONES:Un número relativamente pequeño de pacientes, especialmente en el grupo recién diagnosticado.CONCLUSIONES:En la EC recién diagnosticada, los altos niveles de IL-15 e IL-23 en la mucosa sana sugieren que la inmunidad innata es el promotor de la inflamación aguda. Además, los macrófagos M2 aumentan en la mucosa sana de pacientes con EC en etapa tardía, lo que sugiere que los procesos reparadores y profibróticos son predominantes a largo plazo y en esta fase, la terapia antiinflamatoria puede ser menos eficiente. (Traducción-Dr. Osvaldo Gauto ).
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Affiliation(s)
- Imerio Angriman
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
| | | | - Andromachi Kotsafti
- Laboratory of Advanced Translational Research, Veneto Institute of Oncology IOV, IRCCS, Padua, Italy
| | - Claudia Mescoli
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Melania Scarpa
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Cesare Ruffolo
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
| | - Matteo Fassan
- Laboratory of Advanced Translational Research, Veneto Institute of Oncology IOV, IRCCS, Padua, Italy
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Angelo Paolo Dei Tos
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Renata D'Incà
- Gastroenterology Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | | | - Fabiana Zingone
- Gastroenterology Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | | | - Romeo Bardini
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
| | - Ignazio Castagliuolo
- Microbiology Unit, Department of Molecular Medicine (DMM), University of Padova, Padua, Italy
| | - Marco Scarpa
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
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11
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Avellaneda N, Maroli A, Tottrup A, Buskens C, Kotze PG, Pellino G, Dige A, Haase AM, Haanappel A, Giorgi L, Carvello M, Maruyama BY, Christensen P, Spinelli A. Short and long-term outcomes of surgery for inflammatory (uncomplicated) ileocecal Crohn's disease: Multicentric retrospective analysis of 211 patients. Dig Liver Dis 2024; 56:730-736. [PMID: 38044224 DOI: 10.1016/j.dld.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Surgical management for patients with inflammatory ileocecal Crohn's disease (CD) could be a reasonable alternative to second-line medical treatment. AIM To assess short and long-term outcomes of patients operated on for inflammatory, ileocecal Crohn's disease. METHODS A retrospective analysis of patients intervened at four referral hospitals during 2012-2021 was performed. RESULTS 211 patients were included. 43% of patients underwent surgery more than 5 years after diagnosis, and 49% had been exposed to at least one biologic agent preoperatively. 89% were operated by laparoscopy, with 1.6% conversion rate. The median length of the resected bowel was 25 cm (7-92) and three patients (1.43%) received a stoma. Median follow-up was 36 (17-70) months. The endoscopic recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 56%, 52%, 45%, 38%, and 33%, respectively. The clinical recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 83%, 79%, 76%, 74%, and 74%, respectively. In multivariate analysis, previous biological treatment (HR=2.01; p = 0.001) was associated with a higher risk of overall recurrence. CONCLUSION Surgery in patients with primary inflammatory ileocecal CD is associated with good postoperative outcomes, low postoperative morbidity with reasonable recurrence rates.
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Affiliation(s)
- Nicolas Avellaneda
- Department of Surgery, Aarhus University Hospital, Denmark; General Surgery Department, CEMIC, Buenos Aires, Argentina.
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
| | - Anders Tottrup
- Department of Surgery, Aarhus University Hospital, Denmark
| | - Christianne Buskens
- Colorectal Surgery Department, Amsterdam Medical Hospitals, Amsterdam, the Netherlands
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Brazil
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Anders Dige
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anouck Haanappel
- Colorectal Surgery Department, Amsterdam Medical Hospitals, Amsterdam, the Netherlands
| | - Lorenzo Giorgi
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy
| | - Michelle Carvello
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
| | | | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
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12
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Yamamoto-Furusho J, López-Gómez J, Bosques-Padilla F, Martínez-Vázquez M, De-León-Rendón J. Primer consenso mexicano de la enfermedad de Crohn. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2024; 89:280-311. [DOI: 10.1016/j.rgmx.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2024]
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13
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Yamamoto-Furusho JK, López-Gómez JG, Bosques-Padilla FJ, Martínez-Vázquez MA, De-León-Rendón JL. First Mexican Consensus on Crohn's disease. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:280-311. [PMID: 38762431 DOI: 10.1016/j.rgmxen.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown. OBJECTIVE The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico. MATERIAL AND METHODS Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement. RESULTS The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established. CONCLUSIONS Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - J G López-Gómez
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Centro Médico Nacional 20 de Noviembre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - F J Bosques-Padilla
- Departamento de Gastroenterología, Hospital Universitario de la Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - J L De-León-Rendón
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Coloproctología, Hospital General de México, Mexico City, Mexico
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14
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Bak MT, ten Bokkel Huinink S, Erler NS, Bodelier AG, Dijkstra G, Romberg-Camps M, de Boer NK, Hoentjen F, Stassen LP, van der Meulen–de Jong AE, West RL, van Ruler O, van der Woude CJ, de Vries AC. Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease. Am J Gastroenterol 2024; 119:306-312. [PMID: 37737675 PMCID: PMC10833187 DOI: 10.14309/ajg.0000000000002509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD. METHODS Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes. RESULTS Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence. DISCUSSION The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.
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Affiliation(s)
- Michiel T.J. Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastiaan ten Bokkel Huinink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicole S. Erler
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Heerlen-Sittard-Geleen, the Netherlands
| | - Nanne K.H. de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada;
| | - Laurents P.S. Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Rachel L. West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Ziekenhuis, Cappelle aan den IJssel, the Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annemarie C. de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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15
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Popivanov G, Kjossev K, Stoyanova D, Konaktchieva M, Mutafchiyski V. Early surgery for Crohn's disease - An appeal for a reassessment of biologics. Dig Liver Dis 2023; 55:1776. [PMID: 37722958 DOI: 10.1016/j.dld.2023.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/16/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023]
Affiliation(s)
- G Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria.
| | - K Kjossev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - D Stoyanova
- Department of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - M Konaktchieva
- Department of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - V Mutafchiyski
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
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16
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Park J, Kim HY, Lee YJ, Yoon H, Shin CM, Park YS, Kim N, Lee DH. Distribution of small bowel involvement and its association with clinical outcomes in patients with Crohn's disease. Medicine (Baltimore) 2023; 102:e35040. [PMID: 37800788 PMCID: PMC10553183 DOI: 10.1097/md.0000000000035040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/11/2023] [Indexed: 10/07/2023] Open
Abstract
We aimed to evaluate the distribution of small-bowel involvement in Crohn's disease (CD) and its association with clinical outcomes. This study included CD patients who underwent computed tomography (CT) at initial diagnosis from June 2006 to April 2021. Two abdominal radiologists reviewed the CT images, and independently rated the presence of "bowel wall thickening," "stricture," and "fistula or abscess" in the small bowel segments of jejunum, distal jejunum/proximal ileum, distal ileum, and terminal ileum, respectively. Based on findings of the image review, each patient's "disease-extent imaging score" and "behavior-weighted imaging score" (a higher score indicative of more structuring or penetrating disease) were calculated. Major clinical outcomes (emergency department [ED] visit, operation, and use of corticosteroids or biologics) were compared according to the 2 scores and L4 involvement by the Montreal classification. The proportions of involvement in the jejunum, distal jejunum/proximal ileum, distal ileum, and terminal ileum were 2.0%, 30.3%, 82.2%, and 71.7%, respectively, identifying 30.3% of patients as having L4 disease and 69.7% of patients as having involvement of multiple segments. Clinical outcomes were not significantly associated with the disease-extent imaging score or L4 involvement. However, significant differences were noted for the ED visits and the use of biologics, according to the behavior-weighted imaging score. Moreover, in multivariable analysis, disease behavior was the only factor associated with all clinical outcomes (ED visit, hazard ratio [HR] 2.127 [1.356-3.337], P = .001; operation, HR 8.216 [2.629-25.683], P < .001; use of corticosteroid, HR 1.816 [1.249-2.642], P = .002; and use of biologics, HR 2.352 [1.492-3.708], P < .001). Initial disease behavior seems to be a more critical factor for clinical outcomes of CD than the extent or distribution of small-bowel involvement on CT.
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Affiliation(s)
- Jin Park
- Department of Internal medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hae Young Kim
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyuk Yoon
- Department of Internal medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Cheol Min Shin
- Department of Internal medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Soo Park
- Department of Internal medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Nayoung Kim
- Department of Internal medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ho Lee
- Department of Internal medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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17
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Agrawal M, Ebert AC, Poulsen G, Ungaro RC, Faye AS, Jess T, Colombel JF, Allin KH. Early Ileocecal Resection for Crohn's Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study. Gastroenterology 2023; 165:976-985.e3. [PMID: 37321356 PMCID: PMC10527197 DOI: 10.1053/j.gastro.2023.05.051] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND & AIMS Early Crohn's disease (CD) treatment involves anti-tumor necrosis factor (TNF) agents, whereas ileocecal resection (ICR) is reserved for complicated CD or treatment failure. We compared long-term outcomes of primary ICR and anti-TNF therapy for ileocecal CD. METHODS Using cross-linked nationwide registers, we identified all individuals diagnosed with ileal or ileocecal CD between 2003 and 2018 and treated with ICR or anti-TNF agents within 1 year of diagnosis. The primary outcome was a composite of ≥1 of the following: CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD. We conducted adjusted Cox's proportional hazards regression analyses and determined the cumulative risk of different treatments after primary ICR or anti-TNF therapy. RESULTS Of 16,443 individuals diagnosed with CD, 1279 individuals fulfilled the inclusion criteria. Of these, 45.4% underwent ICR and 54.6% received anti-TNF. The composite outcome occurred in 273 individuals (incidence rate, 110/1000 person-years) in the ICR group and in 318 individuals (incidence rate, 202/1000 person-years) in the anti-TNF group. The risk of the composite outcome was 33% lower with ICR compared with anti-TNF (adjusted hazard ratio, 0.67; 95% confidence interval, 0.54-0.83). ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not other secondary outcomes. The proportion of individuals on immunomodulator, anti-TNF, who underwent subsequent resection, or were on no therapy 5 years post-ICR was 46.3%, 16.8%, 1.8%, and 49.7%, respectively. CONCLUSION These data suggest that ICR may have a role as first-line therapy in CD management and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Yet, given inherent biases associated with observational data, our findings should be interpreted and applied cautiously in clinical decision making.
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Affiliation(s)
- Manasi Agrawal
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Anthony C Ebert
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Gry Poulsen
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Ryan C Ungaro
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Adam S Faye
- Departments of Medicine & Population Health, New York University Grossman School of Medicine, New York, New York
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kristine H Allin
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Everhov ÅH, Söderling J, Befrits G, Khalili H, Bröms G, Neovius M, Askling J, Halfvarson J, Ludvigsson JF, Olén O. Increasing healthcare costs in inflammatory bowel disease 2007-2020 in Sweden. Aliment Pharmacol Ther 2023; 58:692-703. [PMID: 37594381 DOI: 10.1111/apt.17675] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/06/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Inflammatory bowel disease has been linked to increasing healthcare costs, but longitudinal data on other societal costs are scarce. AIM To assess costs, including productivity losses, in patients with prevalent Crohn's disease (CD) or ulcerative colitis (UC) in Sweden between 2007 and 2020. METHODS We linked data from national registers on all patients with CD or UC and a matched (sex, birthyear, healthcare region and education) reference population. We assessed mean costs/year in Euros, inflation-adjusted to 2020, for hospitalisations, out-patient visits, medications, sick leave and disability pension. We defined excess costs as the mean difference between patients and matched comparators. RESULTS Between 2007 and 2020, absolute mean annual societal costs in working-age (18-64 years) individuals decreased by 17% in CD (-24% in the comparators) and by 20% in UC (-27% in comparators), due to decreasing costs from sick leave and disability, a consequence of stricter sick leave regulations. Excess costs in 2007 were dominated by productivity losses. In 2020, excess costs were mostly healthcare costs. Absolute and excess costs increased in paediatric and elderly patients. Overall, costs for TNF inhibitors/targeted therapies increased by 274% in CD and 638% in UC, and the proportion treated increased from 5% to 26% in CD, and from 1% to 10% in UC. CONCLUSION Between 2007 and 2020, excess costs shifted from productivity losses to direct healthcare costs; that is, the patients' compensation for sickness absence decreased, while society increased its spending on medications. Medication costs were driven both by expanding use of TNF inhibitors and by high costs for newer targeted therapies.
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Affiliation(s)
- Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Hamed Khalili
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Gastroenterology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriella Bröms
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Gastroenterology Unit, Danderyd Hospital, Stockholm, Sweden
| | - Martin Neovius
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Gastroenterology and Nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden
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Spencer EA. Choosing the Right Therapy at the Right Time for Pediatric Inflammatory Bowel Disease: Does Sequence Matter. Gastroenterol Clin North Am 2023; 52:517-534. [PMID: 37543397 DOI: 10.1016/j.gtc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Despite the enlarging therapeutic armamentarium, IBD is still plagued by a therapeutic ceiling. Precision medicine, with the selection of the "rights," may present a solution, and this review will discuss the critical process of pairing the right patient with right therapy at the right time. Firstly, the review will discuss the shift to and evidence behind early effective therapy. Then, it delves into promising future strategies of patient profiling to identify a patients' biological pathway(s) and prognosis. Finally, the review lays out practical considerations that drive treatment selection, particularly the impact of the therapeutic sequence.
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Affiliation(s)
- Elizabeth A Spencer
- Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, Icahn School of Medicine, Mount Sinai, 17 East 102nd Street, 5th Floor, New York, NY 10029, USA.
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20
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Murthy SK, Weizman AV, Kuenzig ME, Windsor JW, Kaplan GG, Benchimol EI, Bernstein CN, Bitton A, Coward S, Jones JL, Lee K, Peña-Sánchez JN, Rohatinsky N, Ghandeharian S, Sabrie N, Gupta S, Brar G, Khan R, Im JHB, Davis T, Weinstein J, St-Pierre J, Chis R, Meka S, Cheah E, Goddard Q, Gorospe J, Kerr J, Beaudion KD, Patel A, Russo S, Blyth J, Blyth S, Charron-Bishop D, Targownik LE. The 2023 Impact of Inflammatory Bowel Disease in Canada: Treatment Landscape. J Can Assoc Gastroenterol 2023; 6:S97-S110. [PMID: 37674501 PMCID: PMC10478812 DOI: 10.1093/jcag/gwad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
The therapeutic landscape for inflammatory bowel disease (IBD) has changed considerably over the past two decades, owing to the development and widespread penetration of targeted therapies, including biologics and small molecules. While some conventional treatments continue to have an important role in the management of IBD, treatment of IBD is increasingly moving towards targeted therapies given their greater efficacy and safety in comparison to conventional agents. Early introduction of these therapies-particularly in persons with Crohn's disease-combining targeted therapies with traditional anti-metabolite immunomodulators and targeting objective markers of disease activity (in addition to symptoms), have been shown to improve health outcomes and will be increasingly adopted over time. The substantially increased costs associated with targeted therapies has led to a ballooning of healthcare expenditure to treat IBD over the past 15 years. The introduction of less expensive biosimilar anti-tumour necrosis factor therapies may bend this cost curve downwards, potentially allowing for more widespread access to these medications. Newer therapies targeting different inflammatory pathways and complementary and alternative therapies (including novel diets) will continue to shape the IBD treatment landscape. More precise use of a growing number of targeted therapies in the right individuals at the right time will help minimize the development of expensive and disabling complications, which has the potential to further reduce costs and improve outcomes.
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Affiliation(s)
- Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
| | - Adam V Weizman
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre IBD Centre, McGill University, Montréal, Quebec, Canada
| | - Stephanie Coward
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer L Jones
- Departments of Medicine, Clinical Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kate Lee
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Juan-Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Noelle Rohatinsky
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Nasruddin Sabrie
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarang Gupta
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gurmun Brar
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rabia Khan
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - James H B Im
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tal Davis
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jake Weinstein
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joëlle St-Pierre
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Roxana Chis
- Department of Gastroenterology and Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Saketh Meka
- Department of Neuroscience, McGill University, Montreal, Quebec, Canada
| | - Eric Cheah
- Department of Gastroenterology and Clinical Nutrition, The Royal Children’s Hospital Melbourne, Parkville, Australia
| | - Quinn Goddard
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julia Gorospe
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jack Kerr
- Department of Medicine, Memorial University of Newfoundland, St John’s Newfoundland, Canada
| | - Kayla D Beaudion
- Department of Interdisciplinary Science, McMaster University, Hamilton, Ontario, Canada
| | - Ashley Patel
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Sophia Russo
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Colombia, Canada
| | | | | | | | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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21
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Dignass A, Rath S, Kleindienst T, Stallmach A. Review article: Translating STRIDE-II into clinical reality - Opportunities and challenges. Aliment Pharmacol Ther 2023; 58:492-502. [PMID: 37382397 DOI: 10.1111/apt.17622] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/04/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND With the introduction of novel therapies for inflammatory bowel diseases (IBD), 'treat-to-target' strategies are increasingly discussed to improve short- and long-term outcomes in patients with IBD. AIM To discuss opportunities and challenges of a treat-to-target approach in light of the current 'Selecting Therapeutic Targets in Inflammatory Bowel Disease' (STRIDE-II) consensus METHODS: The 2021 update of STRIDE-II encompasses 13 evidence- and consensus-based recommendations for treat-to-target strategies in adults and children with IBD. We highlight the potential implications and limitations of these recommendations for clinical practice. RESULTS STRIDE-II provides valuable guidance for personalised IBD management. It reflects scientific progress as well as increased evidence of improved outcomes when more ambitious treatment goals such as mucosal healing are achieved. CONCLUSIONS Prospective studies, objective criteria for risk stratification, and better predictors of therapeutic response are needed to potentially render 'treating to target' more effective in the future.
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Affiliation(s)
- Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Frankfurt/Main, Germany
| | - Stefan Rath
- Department of Medical Immunology, AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
| | - Thomas Kleindienst
- Department of Medical Immunology, AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV, University Hospital Jena, Jena, Germany
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22
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Liu W, Zhou W. Minimally invasive surgery in Crohn's disease: state-of-the-art review. Front Surg 2023; 10:1216014. [PMID: 37529660 PMCID: PMC10388240 DOI: 10.3389/fsurg.2023.1216014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Surgery for Crohn's disease (CD) has undergone significant advancements over the last two decades, especially minimally invasive surgery. In addition to its feasibility and safety, minimally invasive surgery provides manifold advantages, including a decreased hospitalization duration, improved aesthetic results, and fewer occurrences of intra-abdominal adhesions. Due to the special intraoperative characteristics of CD, such as chronic inflammation, a thickened mesentery, fistulas, abscesses and large masses, a minimally invasive approach seems to be challenging. Complete implementation of this technique for complex disease has yet to be studied. In this review, we provide a review on the applicability of minimally invasive surgery in CD and future perspectives for the technical advances in the field.
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23
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Avellaneda N, Haug T, Worm Ørntoft MB, Harsløf S, Skovgaard Larsen LP, Tøttrup A. Short-Term Results of Operative Treatment of Primary Ileocecal Crohn's Disease: Retrospective, Comparative Analysis between Early (Luminal) and Complicated Disease. J Clin Med 2023; 12:2644. [PMID: 37048726 PMCID: PMC10095109 DOI: 10.3390/jcm12072644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Early surgical treatment for patients with ileocecal Crohn's disease (CD) could be an alternative to biological therapy. The aim of this study is to compare operative outcomes following ileocecal resection for patients with luminal and complicated CD. Patients operated for primary ileocecal CD during 8 years in one tertiary-referral hospital were allocated into 2 groups: those operated for early (luminal) disease (ECD), and for complications of CD (CCD). A retrospective comparative analysis was performed. A total of 273 patients were included in the analysis, 85 (31%) of which were in the ECD group. No difference was found regarding time from diagnosis to surgery. Surgical procedures were longer in the CCD group, with lower rates of laparoscopic approach (93 vs. 99%, p = 0.035) and higher conversion rates (20 vs. 2%, p < 0.001). ECD had non-significant differences in terms of major postoperative complications (9.4 vs. 14.9%, p = 0.215), shorter hospital stays, and lower rates of anastomotic leakage (3.5 vs. 6.8%, p = 0.285). Conversely, the CCD group had higher reoperation and re-hospitalization rates. Adequate timing for the indication of surgery in primary ileocecal CD, including an early discussion considering both medical and surgical treatment as options, could positively influence operative outcomes.
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Affiliation(s)
- Nicolas Avellaneda
- Inflammatory Bowel Disease Section, Surgery Department, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Tora Haug
- Department of Surgery, Gødstrup Hospital, 7400 Herning, Denmark
| | - Mai-Britt Worm Ørntoft
- Inflammatory Bowel Disease Section, Surgery Department, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Sanne Harsløf
- Inflammatory Bowel Disease Section, Surgery Department, Aarhus University Hospital, 8200 Aarhus, Denmark
| | | | - Anders Tøttrup
- Inflammatory Bowel Disease Section, Surgery Department, Aarhus University Hospital, 8200 Aarhus, Denmark
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24
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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Bashir NS, Hughes A, Ungar WJ. Infliximab Pricing in International Economic Evaluations in Inflammatory Bowel Disease to Inform Biologic and Biosimilar Access Policies: A Systematic Review. MDM Policy Pract 2023; 8:23814683231156433. [PMID: 36860664 PMCID: PMC9969457 DOI: 10.1177/23814683231156433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 01/17/2023] [Indexed: 03/03/2023] Open
Abstract
Background. Policies mandating the use of lower cost biosimilars in patients with inflammatory bowel disease (IBD) have created concerns for patients who prefer their original biologic. Purpose. To inform the cost-effectiveness of biosimilar infliximab treatment in IBD by systematically reviewing the effect of infliximab price variation on cost-effectiveness for jurisdictional decision making. Data Sources. MEDLINE, Embase, Healthstar, Allied and Complementary Medicine, Joanna Briggs Institute EBP Database, International Pharmaceutical Abstracts, Health and Psychosocial Instruments, Mental Measurements Yearbook citation databases, PEDE, CEA registry, HTA agencies. Study Selection. Economic evaluations of infliximab for adult or pediatric Crohn's disease and/or ulcerative colitis published from 1998 through 2019 in which drug price was varied in sensitivity analysis were included. Data Extraction. Study characteristics, main findings, and results of drug price sensitivity analyses were extracted. Studies were critically appraised. The cost-effective price of infliximab was determined based on the stated willingness-to-pay (WTP) thresholds for each jurisdiction. Data Synthesis. Infliximab price was examined in sensitivity analysis in 31 studies. Infliximab showed favorable cost-effectiveness at a price ranging from CAD $66 to $1,260 per vial, depending on jurisdiction. A total of 18 studies (58%) demonstrated cost-effectiveness ratios above the jurisdictional WTP threshold. Limitations. Drug prices were not always reported separately, WTP thresholds varied, and funding sources were not consistently reported. Conclusion. Despite the high cost of infliximab, few economic evaluations examined price variation, limiting the ability to infer the effects of biosimilar introduction. Alternative pricing strategies and access to treatment could be considered to enable IBD patients to maintain access to their current medications. Highlights In an effort to reduce public drug expenditures, Canadian and other jurisdictional drug plans have mandated the use of lower cost, but similarly effective, biosimilars in patients with newly diagnosed inflammatory bowel disease or require a nonmedical switch for established patients. This switch has created concerns for patients and clinicians who want to maintain the ability to make treatment decisions and remain with the original biologic.It is customary for economic evaluations to assess the robustness of results to variations in high-cost items such as medications. In the absence of economic evaluations of biosimilars, examining biologic drug price in sensitivity analysis provides insight into the cost-effectiveness of biosimilar alternatives. A total of 31 economic evaluations of infliximab for the treatment of inflammatory bowel disease varied the infliximab price in sensitivity analysis.The infliximab price deemed to be cost-effective within each study ranged from CAD $66 to CAD $1,260 per 100-mg vial. A total of 18 studies (58%) demonstrated an incremental cost-effectiveness ratio above the jurisdictional willingness-to-pay threshold. If policy decisions are based on price, then originator manufacturers could consider reducing the price or negotiating alternative pricing models to enable patients with inflammatory bowel disease to remain on their current medications.
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Affiliation(s)
- Naazish S. Bashir
- Program of Child Health Evaluative Sciences,
The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Avery Hughes
- Institute of Health Policy, Management and
Evaluation, the University of Toronto, Toronto, ON, Canada
| | - Wendy J. Ungar
- Wendy J. Ungar, Program of Child Health
Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for
Research and Learning, 686 Bay Street, 11th Floor, Toronto, ON M5G 0A4, USA;
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Pellino G, Sampietro GM. Defining the role of abdominal surgery and its impact on the disease course in patients with Crohn's disease: Unsolved issues and novel insights. Dig Liver Dis 2023; 55:587-588. [PMID: 36774220 DOI: 10.1016/j.dld.2023.01.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/13/2023]
Affiliation(s)
- Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Gianluca M Sampietro
- Division of General and HPB Surgery, ASST Rhodense, Rho Memorial Hospital, Milano, Italy.
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Le Berre C, Danese S, Peyrin-Biroulet L. Can we change the natural course of inflammatory bowel disease? Therap Adv Gastroenterol 2023; 16:17562848231163118. [PMID: 37153497 PMCID: PMC10159495 DOI: 10.1177/17562848231163118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/01/2023] [Indexed: 05/09/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are lifelong diseases characterized by chronic inflammation of the gastrointestinal tract leading to its progressive and irreversible destruction. Whether early initiation of IBD-specific therapy impacts the long-term course of the disease remains unclear and has to be further explored in prospective disease-modification trials. Historically, surgery and hospitalization rates have been the surrogate markers to measure disease progression in IBD, providing an overview of the effectiveness of medical therapies. However, neither surgery nor hospitalization necessarily reflects a fail in therapeutic medical management, and many confounding factors make them biased outcomes. The Selecting Endpoints for Disease-Modification Trials consensus has defined the disease-modification endpoints required for these trials, including the impact of the disease on patient's life (health-related quality of life, disability, and fecal incontinence), the mid-term disease complications (bowel damage in CD, IBD-related surgery and hospitalizations, disease extension in UC, extra-intestinal manifestations, permanent stoma, short bowel syndrome), and the development of dysplasia/cancer and mortality in the long term. Most available data in the literature regarding the impact of current therapies on disease progression focused on anti-tumor necrosis factor agents and are based on retrospective or post-hoc studies. Thus, prospective disease-modification trials are pressingly required to explore the effectiveness of early intensified treatment in patients with severe disease or at risk for disease progression.
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Affiliation(s)
| | - Silvio Danese
- Department of Gastroenterology and Digestive
Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele
University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE
U1256, University Hospital of Nancy, University of Lorraine,
Vandoeuvre-lès-Nancy, France
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Xia K, Gao RY, Wu XC, Yin L, Chen CQ. Timing of individualized surgical intervention in Crohn’s disease. World J Gastrointest Surg 2022; 14:1320-1328. [PMID: 36632120 PMCID: PMC9827570 DOI: 10.4240/wjgs.v14.i12.1320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/24/2022] [Accepted: 12/01/2022] [Indexed: 12/27/2022] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with an increasing incidence worldwide. Comprehensive therapy for CD focuses on symptom control and healing the intestinal mucosa to improve the quality of life and prevent complications. Surgical intervention plays a vital role in comprehensive therapy. However, deciding the optimal timing for surgical intervention has long been a focus of controversy. This review provides insights into the timing of surgery for CD and guides clinicians in daily treatment.
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Affiliation(s)
- Kai Xia
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Ren-Yuan Gao
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Xiao-Cai Wu
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Lu Yin
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Chun-Qiu Chen
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
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29
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Beelen EMJ, Nieboer D, Arkenbosch JHC, Regueiro MD, Satsangi J, Ardizzone S, López-Sanromán A, Savarino E, Armuzzi A, Janneke van der Woude C, de Vries AC. Risk Prediction and Comparative Efficacy of Anti-TNF vs Thiopurines, for Preventing Postoperative Recurrence in Crohn's Disease: A Pooled Analysis of 6 Trials. Clin Gastroenterol Hepatol 2022; 20:2741-2752.e6. [PMID: 34687970 DOI: 10.1016/j.cgh.2021.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The superiority of anti-TNF-α agents to thiopurines for the prevention of postoperative recurrence of Crohn's disease (CD) after ileocolonic resection remains controversial. In this meta-analysis of individual participant data (IPD), the effect of both strategies was compared and assessed after risk stratification. METHODS After a systematic literature search, IPD were requested from randomized controlled trials investigating thiopurines and/or anti-TNF-α agents after ileocolonic resection. Primary outcome was endoscopic recurrence (ER) (Rutgeerts score ≥i2) and secondary outcomes were clinical recurrence (Harvey-Bradshaw Index/Crohn's Disease Activity Index score) and severe ER (Rutgeerts score ≥i3). A fixed effect network meta-analysis was performed. Subgroup effects were assessed and a prediction model was established using Poisson regression models, including sex, smoking, Montreal classification, CD duration, history of prior resection and previous exposure to anti-TNF-α or thiopurines. RESULTS In the meta-analysis of IPD, 645 participants from 6 studies were included. In the total population, a superior effect was demonstrated for anti-TNF-α compared with thiopurine prophylaxis for ER (relative risk [RR], 0.52; 95% confidence interval [CI], 0.33-0.80), clinical recurrence (RR, 0.50; 95% CI, 0.26-0.96), and severe ER (RR, 0.41; 95% CI, 0.21-0.79). No differential subgroup effects were found for ER. In Poisson regression analysis, previous exposure to anti-TNF-α and penetrating disease behavior were associated with ER risk. The advantage of anti-TNF-α agents as compared with thiopurines was observed in low- and high-risk groups. CONCLUSIONS Anti-TNF-α is superior to thiopurine prophylaxis for the prevention of endoscopic and clinical postoperative CD recurrence after ileocolonic resection. The advantage of anti-TNF-α agents was confirmed in subgroup analysis and after risk stratification.
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Affiliation(s)
- Evelien M J Beelen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeanine H C Arkenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Miguel D Regueiro
- Digestive Disease and Surgery Institute, Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Nuffield Department of Medicine, Oxford, United Kingdom; Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, United Kingdom
| | - Sandro Ardizzone
- Gastroenterology Unit ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences L. Sacco, Università di Milano, Milan, Italy
| | - Antonio López-Sanromán
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, Madrid, Spain
| | - Edoardo Savarino
- Gastroenterology Section, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Alessandro Armuzzi
- Gastroenterology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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30
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Earlier surgery is associated to reduced postoperative morbidity in ileocaecal Crohn's disease: Results from SURGICROHN – LATAM study. Dig Liver Dis 2022; 55:589-594. [PMID: 37113020 DOI: 10.1016/j.dld.2022.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Early surgical resection is an emerging concept for patients with ileocaecal Crohn's disease (CD). The aim of this study was to compare postoperative outcomes after ileocaecal resections between patients with luminal and complicated CD. METHODS A retrospective analysis of patients operated for ileocaecal CD during an 8-year period in ten tertiary referral academic centres from Latin America was performed. Patients were allocated into 2 groups: those operated for early (luminal) disease (Early Crohn's Disease -ECD-) and for complications of CD (Complicated Crohn's disease -CCD-). A comparative analysis was performed regarding short-term outcomes of surgery, considering overall postoperative complications as main outcome. RESULTS 337 patients were included in the analysis, 60 (17.80%) in the ECD group. Smoking and exposure to perioperative biologic drugs were more prevalent in CCD group. CCD patients had increased requirement of urgent surgery (26.71 vs. 15%, p = 0.056), longer operative time (164.25 vs. 90.53 min, p< 0.01), lower rates of primary anastomosis (90.23 vs. 100%, p = 0.012), increased rate of overall postoperative complications (33.21 vs. 16.67%, p = 0.013), more reoperations (13.36 vs. 3.33%, p = 0.026), and higher rates of major anastomotic fistulas and hospital stay. On multivariable analysis, smoking (p = 0.001,95%CI: 2.59-32.11), operative time (p = 0.022,95%CI:1-1.02), associated procedures (p = 0.036,95%CI:1.09-15.72) and intraoperative complications (p = 0.021,95%CI:1.45-92.31) were independently related to presenting postoperative complications. CONCLUSION Early (luminal) ileocaecal resections were associated to lower rates of overall postoperative complications. Proper timing for surgery, avoiding delays in surgical indication can impact postoperative outcomes.
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31
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Noor NM, Sousa P, Paul S, Roblin X. Early Diagnosis, Early Stratification, and Early Intervention to Deliver Precision Medicine in IBD. Inflamm Bowel Dis 2022; 28:1254-1264. [PMID: 34480558 PMCID: PMC9340521 DOI: 10.1093/ibd/izab228] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Indexed: 12/15/2022]
Abstract
Despite huge advances in understanding the molecular basis of IBD, clinical management has continued to rely on a "trial and error" approach. In addition, a therapeutic ceiling has emerged whereby even the most effective interventions are only beneficial for approximately 30% of patients. Consequently, several tools have been developed to aid stratification and guide treatment-decisions. We review the potential application for many of these precision medicine approaches, which are now almost within reach. We highlight the importance of early action (and avoiding inaction) to ensure the best outcomes for patients and how combining early action with precision tools will likely ensure the right treatment is delivered at the right time and place for each individual person living with IBD. The lack of clinical impact to date from precision medicine, despite much hype and investment, should be tempered with the knowledge that clinical translation can take a long time, and many promising breakthroughs might be ready for clinical implementation in the near future. We discuss some of the remaining challenges and barriers to overcome for clinical adoption. We also highlight that early recognition, early diagnosis, early stratification, and early intervention go hand in hand with precision medicine tools. It is the combination of these approaches that offer the greatest opportunity to finally deliver on the promise of precision medicine in IBD.
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Affiliation(s)
- Nurulamin M Noor
- Department of Gastroenterology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Paula Sousa
- Department of Gastroenterology, Viseu Unit, Tondela-Viseu Hospital Centre, 3504–509 Viseu, Portugal
| | - Stéphane Paul
- Faculty of Medicine of Saint-Etienne, Immunology Unit University Hospital of Saint-Etienne, CIC INSERM 1408, Saint-Etienne, France
| | - Xavier Roblin
- Department of Gastroenterology, University Hospital of Sain- Etienne, Saint-Etienne, France
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32
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Bak MTJ, Ruiterkamp MFE, van Ruler O, Campmans-Kuijpers MJE, Bongers BC, van Meeteren NLU, van der Woude CJ, Stassen LPS, de Vries AC. Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review. World J Gastroenterol 2022; 28:2403-2416. [PMID: 35979261 PMCID: PMC9258284 DOI: 10.3748/wjg.v28.i22.2403] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/21/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.
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Affiliation(s)
- Michiel T J Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Marit F E Ruiterkamp
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel 2906 ZC, Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Marjo J E Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen 9713 GZ, Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht 6200 MD, Netherlands
- Department of Epidemiology, Care and Public Health Research Institute, Maastricht University, Maastricht 6200 MD, Netherlands
| | - Nico L U van Meeteren
- Department of Anaesthesiology, Erasmus MC University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht 6229 HX, Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
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Chandrasinghe P. Surgical Management of Small Bowel Crohn's Disease. Front Surg 2022; 9:759668. [PMID: 35495760 PMCID: PMC9051431 DOI: 10.3389/fsurg.2022.759668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.
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Le Berre C, Ricciuto A, Peyrin-Biroulet L, Turner D. Evolving Short- and Long-Term Goals of Management of Inflammatory Bowel Diseases: Getting It Right, Making It Last. Gastroenterology 2022; 162:1424-1438. [PMID: 34995529 DOI: 10.1053/j.gastro.2021.09.076] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/28/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022]
Abstract
Short- and long-term treatment targets in inflammatory bowel diseases (IBDs) evolved during the last decade, shifting from symptom control to endoscopic healing and patient-centered parameters. The STRIDE-II consensus placed these targets on a timeline from initiating treatment and introduced additional targets, normalization of serum and fecal biomarkers, restoration of quality of life, prevention of disability, and, in children, restoration of growth. Transmural healing in Crohn's disease and histologic healing in ulcerative colitis currently serve as adjunct measures to gauge remission depth. However, whether early treatment according to a treat-to-target paradigm affects the natural course of IBD remains unclear, leading to the need for prospective disease-modification trials. The SPIRIT consensus defined the targets for these trials to assess the long-term impact of early treatment on quality of life, disability, disease complications, risk of neoplastic lesions, and mortality. As further data emerge about the risk-benefit balance of aiming toward deeper healing, the targets in treating IBDs may continue to shift.
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Affiliation(s)
- Catherine Le Berre
- Department of Gastroenterology and Inserm TENS U1235, Institut des Maladies de l'Appareil Digestif, Nantes University Hospital, Nantes, France
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laurent Peyrin-Biroulet
- University of Lorraine, CHRU-Nancy, Department of Gastroenterology, F-54000 Nancy, France, and University of Lorraine, Inserm, NGERE, F-54000 Nancy, France
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Carvello M, Danese S, Spinelli A. Surgery versus Medical Therapy in Luminal Ileocecal Crohn's Disease. Clin Colon Rectal Surg 2022; 35:72-77. [PMID: 35069033 PMCID: PMC8763452 DOI: 10.1055/s-0041-1740031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The deeper understanding of the inflammatory process which gradually evolves into irreversible fibrosis and tissue damage has provided a precise picture of the disease course of luminal ileocecal Crohn's disease. According to the model of progressive structural damage, ideal time windows for medical and surgical treatment have been identified. While complicated disease clearly profits from surgical treatment, uncomplicated disease has become, in the last years, the most debatable setting in terms of different approaches including early surgery. On one hand, the rationale of traditional escalating medical therapy (step-up approach) has been undermined by the top-down medical approach. Indeed, the step-up approach has the possible drawback of delaying, up to a later disease stage, the use of more effective agents such as anti-tumor necrosis factors. Conversely, the top-down approach might expose patients to an overtreatment along with side effects including hypersensitivity to biologic agents. More recently, it has been shown how early surgery could be a valid option in this subset of patients being more cost-effective than medical therapy. Involving the surgeon at an early stage is considered now a good clinical practice and, in this scenario full of possibilities, the surgeon should be included into the decision-making process from the very beginning of patient management.
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Affiliation(s)
- Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy,Department of Gastroenterology, IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy,Address for correspondence Antonino Spinelli, MD, PhD Via Alessandro Manzoni, 56, Rozzano, 20089, MilanItaly
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Reynolds IS, Doogan KL, Ryan ÉJ, Hechtl D, Lecot FP, Arya S, Martin ST. Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection. Front Surg 2021; 8:804137. [PMID: 34977147 PMCID: PMC8718441 DOI: 10.3389/fsurg.2021.804137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ian S. Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
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37
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Łodyga M, Eder P, Gawron-Kiszka M, Dobrowolska A, Gonciarz M, Hartleb M, Kłopocka M, Małecka-Wojciesko E, Radwan P, Reguła J, Zagórowicz E, Rydzewska G. Guidelines for the management of patients with Crohn's disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology. PRZEGLAD GASTROENTEROLOGICZNY 2021; 16:257-296. [PMID: 34976235 PMCID: PMC8690943 DOI: 10.5114/pg.2021.110914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/25/2021] [Indexed: 12/13/2022]
Abstract
This paper is an update of the diagnostic and therapeutic recommendations of the National Consultant for Gastroenterology and the Polish Society of Gastroenterology from 2012. It contains 46 recommendations for the diagnosis and treatment, both pharmacological and surgical, of Crohn's disease in adults. The guidelines were developed by a group of experts appointed by the Polish Society of Gastroenterology and the National Consultant in the field of Gastroenterology. The methodology related to the GRADE methodology was used to assess the quality and strength of the available recommendations. The degree of expert support for the proposed statement, assessment of the quality of evidence and the strength of the recommendation was assessed on a 6-point Likert scale. Voting results, quality and strength ratings with comments are included with each statement.
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Affiliation(s)
- Michał Łodyga
- Department of Gastroenterology with the Inflammatory Bowel Disease Subdivision, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Heliodor Święcicki University Hospital, Poznan, Poland
| | - Magdalena Gawron-Kiszka
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Heliodor Święcicki University Hospital, Poznan, Poland
| | - Maciej Gonciarz
- Department of Gastroenterology and Internal Medicine, Military Institute of Medicine, Warsaw, Poland
| | - Marek Hartleb
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Maria Kłopocka
- Department of Gastroenterology and Nutritional Disorders, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | | | - Piotr Radwan
- Department of Gastroenterology, Medical University of Lublin, Lublin, Poland
| | - Jarosław Reguła
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Edyta Zagórowicz
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Grażyna Rydzewska
- Department of Gastroenterology with the Inflammatory Bowel Disease Subdivision, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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State-of-the-art surgery for Crohn's disease: Part I-small intestine/ileal disease. Langenbecks Arch Surg 2021; 407:885-895. [PMID: 34738167 DOI: 10.1007/s00423-021-02324-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/13/2022]
Abstract
The management of Crohn's disease has evolved significantly over the past 20 years. The arrival of biologic therapies has altered not only the management and outcomes but also rates for refractory disease requiring surgery. New surgical techniques have paralleled these medical advances, and this article will provide an overview of these new modalities as well as their outcomes. This is the first of a three-part series and will focus on terminal ileal and ileocolic disease.
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Siegel R. Langzeit-Nachbeobachtung der LIR!C-Studie bestätigt die Bedeutung der frühzeitigen laparoskopischen Ileozökalresektion bei Morbus Crohn. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The Revival of Surgery in Crohn's Disease-Early Intestinal Resection as a Reasonable Alternative in Localized Ileitis. Biomedicines 2021; 9:biomedicines9101317. [PMID: 34680434 PMCID: PMC8533348 DOI: 10.3390/biomedicines9101317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 12/20/2022] Open
Abstract
Crohn's disease (CD) represents a heterogeneous and complex disease with no curative therapeutic option available to date. Current therapy is mainly antibody-based focusing on the immune system while other treatment alternatives such as surgery are considered to be "last options". However, medical therapy for CD results in mild to severe side effects in a relevant amount of patients and some patients do not respond to the medication. Following that, quality of life is often significantly reduced in this patient cohort, thus, therapeutic alternatives are urgently needed. Updated evidence has revealed that surgery such as ileocecal resection (ICR) might be a potential therapeutic option in case of localized terminal ileitis since resection at early time points improves quality of life and significantly reduces the postoperative need for immunosuppressive medication with low rates of morbidity. In addition, new surgical approaches such as Kono-S anastomosis or inclusion of the mesentery result in significantly reduced rates of disease recurrence and reoperation. Based on the new evidence, the goal of this review is to provide an update on the role of surgery as a reasonable alternative to medical therapy in the interdisciplinary treatment of patients with CD.
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A Microsimulation Model to Determine the Cost-Effectiveness of Treat-to-Target Strategies for Crohn's Disease. Am J Gastroenterol 2021; 116:1709-1719. [PMID: 34587127 PMCID: PMC8481677 DOI: 10.14309/ajg.0000000000001263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cost-effectiveness of biomarker- vs endoscopy-based treat-to-target monitoring in Crohn's disease (CD) is unknown. METHODS A microsimulation model for CD was built to simulate biomarker (fecal calprotectin) vs endoscopy-based monitoring in a treat-to-target fashion. Published literature in combination with patient-level data from phase 3 clinical trials and population estimates for therapeutic drug monitoring were used to generate transition probabilities, costs, and utilities. Tracker variables were used to modify downstream probabilities and outcomes based on previous exposures, response patterns, and disease-related complications or surgery history. The primary outcome was cost-effectiveness over a 5-year horizon at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. Probabilistic sensitivity analyses in addition to multiple 1-, 2-, and 3-way microsimulation sensitivity analyses were performed. RESULTS In the base-case model, the endoscopy-based monitoring strategy dominated the biomarker-based monitoring strategy over a 5-year horizon. Over shorter periods of observation, the biomarker-based monitoring strategy became progressively more cost-effective, with cost-effectiveness achieved for this strategy over a 1-year horizon. Therapeutic drug monitoring did not influence short-term cost-effectiveness of biomarker-based monitoring. Once in endoscopic remission, continued biomarker-based vs endoscopy-based monitoring was more cost-effective. A hybrid biomarker-endoscopy-based monitoring strategy dominated the endoscopy-based monitoring strategy over a 5-year horizon. The strongest determinants for cost-effectiveness were cost of colonoscopy and diagnostic performance of fecal calprotectin. DISCUSSION The most cost-effective approach for treat-to-target monitoring in CD is up-front biomarker-based monitoring followed by endoscopy-based monitoring if not in endoscopic remission by 1 year and then returning to biomarker-based monitoring once in endoscopic remission.
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Agrawal M, Spencer EA, Colombel JF, Ungaro RC. Approach to the Management of Recently Diagnosed Inflammatory Bowel Disease Patients: A User's Guide for Adult and Pediatric Gastroenterologists. Gastroenterology 2021; 161:47-65. [PMID: 33940007 PMCID: PMC8640961 DOI: 10.1053/j.gastro.2021.04.063] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/29/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are chronic, progressive, immune-mediated diseases of adults and children that have no cure. IBD can cause significant morbidity and lead to complications such as strictures, fistulas, infections, and cancer. In children, IBD can also result in growth impairment and pubertal delays. IBD is highly heterogenous, with severity ranging from mild to severe and symptoms ranging from mild to debilitating. Delay in IBD diagnosis, especially in Crohn's disease, is common and associated with adverse outcomes. Early diagnosis and prompt institution of treatment are the cornerstones for improving outcomes and maximizing health. Early diagnosis requires a low threshold of suspicion and red flags to guide early specialist referral at the primary provider level. Although the armamentarium of IBD medications is growing, many patients will not respond to treatment, and the selection of first-line therapy is critical. Risk stratification of disease severity, based on clinical, demographic, and serologic markers, can help guide selection of first-line therapy. Clinical decision support tools, genomics, and other biomarkers of response to therapy and risk of adverse events are the future of personalized medicine. After starting appropriate therapy, it is important to confirm remission using objective end points (treat to target) with continued control of inflammation with adjustment of therapy using surrogate biomarkers (tight control). Lastly, IBD therapy extends far beyond medications, and other aspects of the overall health and wellbeing of the patient are critical. These include preventive health, nutrition, and psychobehavioral support addressing patients' concerns around complementary therapy and medication adherence, prevention of disability, and ensuring open communication.
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Affiliation(s)
- Manasi Agrawal
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Elizabeth A. Spencer
- The Division of Pediatric Gastroenterology and Nutrition, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryan C. Ungaro
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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Kuellmer A, Behn J, Beyna T, Schumacher B, Meining A, Messmann H, Neuhaus H, Albers D, Birk M, Probst A, Faehndrich M, Frieling T, Goetz M, Thimme R, Caca K, Schmidt A. Endoscopic full-thickness resection and its treatment alternatives in difficult-to-treat lesions of the lower gastrointestinal tract: a cost-effectiveness analysis. BMJ Open Gastroenterol 2021; 7:bmjgast-2020-000449. [PMID: 32816955 PMCID: PMC7437695 DOI: 10.1136/bmjgast-2020-000449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 11/05/2022] Open
Abstract
Objective Endoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives. Design Real data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer. Results The cost per case was €2852.20 for the EFTR group, €1712 for the standard endoscopic resection (SER) group, €8895 for the surgical resection group and €5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was €3708.98 for EFTR, €3115.10 for SER, €8924.05 for surgical treatment and €7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was €5196.47 for SER, €26 533.13 for surgical resection and €67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar. Conclusion EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juliane Behn
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Baden-Württemberg, Germany
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Nordrhein-Westfalen, Germany
| | - Alexander Meining
- Department of Medicine II, Interventional and Experimental Endoscopy (InExEn), University Hospital Wurzburg, Wurzburg, Bayern, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Horst Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Nordrhein-Westfalen, Germany
| | - Michael Birk
- Department of Gastroenterology, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Martin Faehndrich
- Department of Gastroenterology, Klinikum Dortmund, Dortmund, Nordrhein-Westfalen, Germany
| | - Thomas Frieling
- Department of Gastroenterology, HELIOS Klinikum Krefeld, Krefeld, Nordrhein-Westfalen, Germany
| | - Martin Goetz
- Department of Gastroenterology/Oncology, Klinikum Sindelfingen-Böblingen, Sindelfingen, Baden-Württemberg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Baden-Württemberg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Sninsky J, Barnes EL. Medical Management of Aggressive Inflammatory Bowel Disease: When Is the Time to Cut Your (and the Patient's) Losses? J Laparoendosc Adv Surg Tech A 2021; 31:905-910. [PMID: 34171979 DOI: 10.1089/lap.2021.0338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite a treatment armamentarium that continues to increase in terms of medical options for the therapy of Crohn's disease (CD) and ulcerative colitis (UC), a significant proportion of patients will require surgical intervention over their disease course. Surgery does not represent a failure of medical therapy in the treatment of patients with inflammatory bowel disease (IBD); rather, surgery represents an integral feature of the multidisciplinary approach to an individual patient. The timing, factors, and potential outcomes of each therapeutic decision in the pre-, peri- and postoperative periods must be weighed by each member of a multidisciplinary team with the goal of improving the quality of life for patients with IBD. In this article, we review the current evidence underlying approaches to the medical and surgical management of complications of CD and UC. We also outline opportunities for tailored decision-making and potentially earlier surgical intervention with the aim of improving long-term outcomes among patients with IBD.
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Affiliation(s)
- Jared Sninsky
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Post-surgical recurrence of Crohn's disease: Situational analysis and future prospects. J Visc Surg 2021; 158:401-410. [PMID: 33858790 DOI: 10.1016/j.jviscsurg.2021.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgery retains a major role in the treatment of Crohn's disease, and the prevention of post-operative recurrence is an essential issue. In fact, despite the increasing use of biotherapies, almost all of the patients who undergo surgery will present with a recurrence, initially endoscopic and then clinical, eventually leading to a second intervention in 15 to 20% of cases. Certain risk factors for recurrence such as smoking, repeated and/or extensive resections, anoperineal involvement, myenteric plexitis, epithelioid granulomas, penetrating disease behaviour and lack of post-operative prophylactic treatment have been well established. Currently, measures to prevent post-operative recurrence are based mainly on smoking cessation in all patients and the prescription of anti-TNFα medications for patients with a high risk of recurrence (at least two risk factors for recurrence). However, new surgical techniques have recently been described which could modify post-operative prevention strategies. Kono's lateral anti-mesenteric anastomosis could significantly reduce clinical and endoscopic recurrence compared to conventional anastomosis techniques. Long latero-lateral isoperistaltic stricturoplasties have been shown to be feasible and are associated with a low rate of long-term symptomatic recurrence requiring surgery. In a preliminary series, intestinal resections with extensive mesenteric resection reduced the rate of recurrence in comparison with patients operated on conventionally (3% vs. 40% at five years). If the results of these new surgical techniques are confirmed, the indications for post-operative immunomodulatory treatments could be downgraded in patients currently considered to be at high risk of recurrence.
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Singh H, Nguyen T, Pho C, Giles E. Early Infliximab in Crohn's is associated with decreased intestinal surgery and similar health care costs. Scand J Gastroenterol 2021; 56:397-402. [PMID: 33595389 DOI: 10.1080/00365521.2021.1880626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Using Infliximab early in Crohn's disease can provide a window of opportunity in children for restoration of growth and achievement of puberty. We aimed to compare clinical outcomes and costs of a retrospective pediatric Crohn's disease (pCD) cohort treated with early use Infliximab (EUI) within 12 months compared with later use Infliximab (LUI). METHODS Retrospective review of all children with pCD commenced on Infliximab was undertaken in a tertiary Australian pediatric center. RESULTS pCD progressing to Infliximab was identified in 70 children: 38 (54%) in the EUI cohort versus 32 (46%) in the LUI cohort. Intestinal surgery had a higher risk of occurring in EUI when compared with LUI (2 (5%) versus 9 (28%), HR 5.67 (95% CI 1.21-26.38); p = .027). No patients in EUI underwent intestinal surgery post Infliximab commencement compared with 3 (9%) in LUI (p = .09). Escalation of Infliximab in luminal Crohn's disease was not significantly different in EUI when compared with LUI (3 (10.3%) versus 9 (39.1%) (p = .1)). EUI was more frequently used than LUI in 2015-2018 (27 (71%) versus 14 (44%)) p = .029, with the inverse occurring in 2010-2014 (11 (29%) versus 18 (56%)). Hospital admissions per person per year in EUI and LUI were 43 (0.23 visits/person/year) versus 84 (0.67 visits/person/year); IRR 2.51 (95% CI 0.9-7.01); p = .078). Health costs were not significantly different between cohorts. CONCLUSION EUI in pCD is associated with an increased likelihood of being diagnosed in more recent years, less intestinal surgery and a trend toward decreased hospital admissions than LUI.
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Affiliation(s)
- H Singh
- Department of Paediatrics, Monash University, Melbourne, Australia.,Department of Gastroenterology, Monash Children's Hospital, Melbourne, Australia
| | - T Nguyen
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - C Pho
- Department of Pharmacy, Monash Children's Hospital, Melbourne, Australia
| | - E Giles
- Department of Paediatrics, Monash University, Melbourne, Australia.,Department of Gastroenterology, Monash Children's Hospital, Melbourne, Australia.,Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Melbourne, Australia
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Kelm M, Anger F, Eichlinger R, Brand M, Kim M, Reibetanz J, Krajinovic K, Germer CT, Schlegel N, Flemming S. Early Ileocecal Resection Is an Effective Therapy in Isolated Crohn's Disease. J Clin Med 2021; 10:731. [PMID: 33673222 PMCID: PMC7918661 DOI: 10.3390/jcm10040731] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 12/30/2022] Open
Abstract
Despite the increasing incidence and prevalence of Crohn's Disease (CD), no curative options exist and treatment remains complex. While therapy has mainly focused on medical approaches in the past, growing evidence reveals that in cases of limited inflammation, surgery can suffice as an alternative primary treatment. We retrospectively assessed the disease course and outcomes of 103 patients with terminal Ileitis who underwent primary surgery (n = 29) or received primary medical treatment followed by surgery (n = 74). Primary endpoint was the need for immunosuppressive medication after surgical treatment (ileocecal resection, ICR) during a two-years follow-up. Rates for laparoscopic ICR were enhanced in case of early surgery, but no differences were seen for postoperative complications. In case of immunosuppressive medication, patients with ICR at an early state of disease needed significantly less anti-inflammatory medication during the two-year postoperative follow-up compared to patients who were primarily treated medically. Furthermore, in a subgroup analysis for patients with localized ileocecal disease manifestation, early surgery consistently resulted in a decreased amount of medical therapy postoperatively. In conclusion primary ICR is safe and effective in patients with limited CD, and the need for immunosuppressive medication during the postoperative follow-up is low compared to patients receiving surgery at a later stage of disease.
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Affiliation(s)
- Matthias Kelm
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Robin Eichlinger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Markus Brand
- Department of Internal Medicine II, Section of Gastroenterology, Center of Internal Medicine (ZIM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany;
| | - Mia Kim
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Joachim Reibetanz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Katica Krajinovic
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
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Abstract
Despite the development and introduction of new pharmaceutical approaches for Crohn's disease, the treatment of these patients still remains a major clinical challenge due to the heterogeneity in the course, degree of inflammation and localization. Over the last decade surgery was mainly reserved for the treatment of complications during the long course of Crohn's disease; however, due to new evidence-based knowledge, primary surgical resection in patients suffering from isolated Crohn's disease of the terminal ileum represents an equally effective alternative to medicinal antibody-based treatment. Even if further randomized and controlled trials are necessary, the currently available follow-up studies show promising data regarding disease progression with a significant reduction in the need for immunosuppression, which is usually necessary in these patients primarily treated by medication. Therefore, in the interdisciplinary decision on treatment early/primary surgical treatment should be considered as an equally effective alternative for a suitable patient collective.
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Lange K, Stallmach A. [Drug treatment of chronic inflammatory bowel diseases-What must the surgeon know and perioperatively pay attention to?]. Chirurg 2021; 92:3-11. [PMID: 33125523 DOI: 10.1007/s00104-020-01305-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Mesalamine and topical or systemic corticosteroids form the basis of medicinal treatment of patients with chronic inflammatory bowel diseases (IBD), whereas immunosuppressants, biologicals and JAK inhibitors, so-called small molecules, are administered within so-called step-up treatment algorithms. Even though the frequency of operations has decreased during the last decades, surgical interventions still represent a relevant part of the overall concept in IBD treatment. Therefore, the effects of drug pretreatment on surgical approaches have to be put into specific perspectives and contexts. Treatment with corticosteroids unquestionably increases the rate of perioperative complications but there is no such correlation for the use of biologicals or immunosuppressants. Data from older studies pointed towards slightly increased rates of postoperative complications in patients treated with TNF-alpha antibodies; however, more recent studies have not confirmed this risk. The occurrence of postoperative complications is due to the multifactorial origin and is more dependent on the activity of the underlying disease, the comorbidities and the preoperative nutritional status. Preoperative use of the integrin inhibitor vedolizumab is comparable to TNF-alpha antibodies with respect to the postoperative complication rate. This also seems to apply to the interleukin 12/23 antagonist ustekinumab, although the data are still unreliable. The risks after treatment with the Janus kinase inhibitor tofacitinib cannot currently reliably be estimated. For the postoperative care an endoscopic follow-up should be performed within 6 months and prophylactic treatment with immunosuppressors or biologicals can be considered after taking the individual risk factors into account.
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Affiliation(s)
- Kathleen Lange
- Klinik für Innere Medizin IV, Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV, Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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50
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Abstract
PURPOSE The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions. METHODS A literature search of MEDLINE (PubMed) was conducted using the following search terms: 'Surgery' and 'Crohn'. Different current surgical treatment strategies are discussed based on disease location. RESULTS Several surgical options are possible in medically refractory or complex Crohn's disease as a last resort therapy. Recent evidence indicated that surgery could also be a good alternative in terms of effectiveness, quality of life and costs as first-line therapy if biologicals are considered, e.g. ileocolic resection for limited disease, or as part of combination therapy with biologicals, e.g. surgery aiming at closure of select perianal fistula in combination with biologicals. The role of the mesentery in ileocolic disease and Crohn's proctitis is an important surgical dilemma. In proctectomy, evidence is directing at removing the mesentery, and in ileocolic disease, it is still under investigation. Other surgical dilemmas are the role of the Kono-S anastomosis as a preventive measure for recurrent Crohn's disease and the importance of (non)conventional stricturoplasties. CONCLUSION Surgical management of Crohn's disease remains challenging and is dependent on disease location and severity. Indication and timing of surgery should always be discussed in a multidisciplinary team. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease rather than being a last resort therapy.
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