Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease

Impact of preoperative enteral nutritional support on postoperative outcome in patients with Crohn's disease complicated by malnutrition: Results of a subgroup analysis of the nationwide cohort registry from the GETAID Chirurgie group

AIM

Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort.

METHOD

Malnutrition was defined as body mass index <18 kg/m² and/or albuminaemia <30 g/L and/or weight loss >10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma.

RESULTS

Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016).

CONCLUSION

Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.

Nutritional Treatment in Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) which can affect any part of the whole gastrointestinal tract (from mouth to anus). Malnutrition affects 65-75% of CD patients, and it is now well acknowledged that diet is of paramount importance in the management of the disease. In this review, we would like to highlight the most recent findings in the field of nutrition for the treatment of CD. Our analysis will cover a wide range of topics, from the well-established diets to the new nutritional theories, along with the recent progress in emerging research fields, such as nutrigenomics.

Dietary Management in Pediatric Patients with Crohn's Disease

It has been widely endorsed that a multifactorial etiology, including interaction between genetic and environmental factors, can contribute to Crohn's Disease (CD) pathogenesis. More specifically, diet has proven to be able to shape gut microbiota composition and thus is suspected to play a significant role in inflammatory bowel disease (IBD) pathogenesis. Moreover, poor nutritional status and growth retardation, arising from several factors such as reduced dietary intake or nutrient leakage from the gastrointestinal tract, represent the hallmarks of pediatric CD. For these reasons, multiple research lines have recently focused on the utilization of dietary therapies for the management of CD, aiming to target concurrently mucosal inflammation, intestinal dysbiosis and optimization of nutritional status. The forerunner of such interventions is represented by exclusive enteral nutrition (EEN), a robustly supported nutritional therapy; however, it is burdened by monotony and low tolerance in the long term. Novel dietary interventions, such as Crohn's Disease Exclusion Diet or Crohn's Disease treatment with eating, have shown their efficacy in the induction of remission in pediatric patients with CD. The aim of the present narrative review is to provide a synopsis of the available nutritional strategies in the management of pediatric CD and to discuss their application in the dietary management of these patients.

Inflammatory Bowel Diseases: Is There a Role for Nutritional Suggestions?

Nutrition has an important impact on inflammatory bowel diseases (IBD). In particular, several studies have addressed its role in their pathogenesis, showing how the incidence of IBD significantly increased in recent years. Meanwhile, nutrition should be considered a component of the treatment of the disease, both as a therapy itself, and especially in the perspective of correcting the various nutritional deficiencies shown by these patients. In this perspective, nutritional suggestions are very important even in the most severe forms of IBD, requiring hospitalization or surgical treatment. Although current knowledge about nutrition in IBD is increasing over time, nutritional suggestions are often underestimated by clinicians. This narrative review is an update summary of current knowledge on nutritional suggestions in IBD, in order to address the impact of nutrition on pathogenesis, micro- and macro-nutrients deficiencies (especially in the case of sarcopenia and obesity), as well as in hospitalized patients.

Nutrition Considerations in Inflammatory Bowel Disease

The purpose of this article is to provide an updated review of the definition, prevalence, causes, and clinical management of malnutrition in inflammatory bowel disease (IBD). Prevalence of malnutrition in IBD is estimated to be between 6.1% and 69.7% depending on the definition used, the type of IBD, the clinical setting, and whether the IBD is active or in remission. Whereas older definitions of malnutrition have been found to be correlated with mortality and length of hospital stay, the more recent European Society for Clinical Nutrition and Metabolism (ESPEN) 2015 and the Global Leadership Initiative on Malnutrition (GLIM) definitions provide significantly different prevalence estimates of malnutrition when applied to the same patient population, and further work is needed to validate these two definitions against clinical outcomes. In patients with IBD with identified malnutrition, oral nutrition supplementation, enteral nutrition, or parenteral nutrition should be started. In malnourished patients with Crohn's disease undergoing surgery, preoperative enteral nutrition has been demonstrated to reduce the rate of postoperative complications. Overall, patients with IBD are at significant risk for malnutrition and should be screened for malnutrition by using a validated screening tool. The management of malnutrition in IBD is complex, and studies are often limited in their size or their ability to demonstrate an improvement in clinical outcomes based on specific nutrition-related interventions. Future studies particularly regarding the validation of new screening tools and perioperative management of malnutrition may provide insight into the standardization of diagnosis and management of malnutrition in IBD.

Comparison of primary anastomosis and staged surgery in emergency treatment of complicated Crohn's disease

OBJECTIVES

Staged surgery (SS) and primary anastomosis (PA) are alternatives to emergency surgery in Crohn's disease (CD). This study aimed to compare postoperative patient outcomes and medical cost of SS and PA for CD emergencies.

METHODS

Consecutive patients with CD undergoing emergency surgery between December 1997 and January 2017 in three centers were included. The PA and SS groups were compared regarding patient outcomes including postoperative complications and surgical recurrence, as well as hospitalization costs.

RESULTS

Altogether 96 (39.5%) patients underwent an emergency PA, and 147 (60.5%) underwent an emergency SS. The incidence of intra-abdominal septic complications (IASC) in the PA group was 15.6% compared with 7.5% in the SS group (P = 0.04). The length of hospitalization was longer (32.36 ± 1.76 d vs 19.33 ± 2.36 d, P <0.01) and the hospitalization cost was higher in the SS group (USD 15 811.1 ± 1697.1 vs USD 8345.3 ± 919.5, P <0.01) than the PA group. SS correlated with a lower surgical recurrence rate than PA (log-rank test, P = 0.04). Presence of diffuse peritonitis, perforating or colonic disease, decision of operation choice made by a senior consultant and more than two concurrent surgical indications were related to the need for SS in emergencies. Localized peritonitis, body mass index (>18.5 kg/m2 ) and iatrogenic perforation were significantly associated with a low risk of IASC in the PA group.

CONCLUSION

SS can be performed with limited IASC and low surgical recurrence rates for surgical emergencies in CD, although it increases hospitalization costs and delays discharge.

Management of Pregnant Inflammatory Bowel Disease Patients During the COVID-19 Pandemic

The rapid emergence of the novel coronavirus [SARS-CoV2] and the coronavirus disease 2019 [COVID-19] has caused significant global morbidity and mortality. This is particularly concerning for vulnerable groups such as pregnant women with inflammatory bowel disease [IBD]. Care for pregnant IBD patients in itself is a complex issue because of the delicate balance between controlling maternal IBD as well as promoting the health of the unborn child. This often requires continued immunosuppressive maintenance medication or the introduction of new IBD medication during pregnancy. The current global COVID-19 pandemic creates an additional challenge in the management of pregnant IBD patients. In this paper we aimed to answer relevant questions that can be encountered in daily clinical practice when caring for pregnant women with IBD during the current COVID-19 pandemic.

PODCAST

This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

Perioperative management of ileocecal Crohn's disease in the current era

INTRODUCTION

The ileocecal region is most commonly involved in patients with Crohn's disease (CD).

AREAS COVERED

In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention.

EXPERT OPINION

Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.

Elemental Diet Enriched with Amino Acids Alleviates Mucosal Inflammatory Response and Prevents Colonic Epithelial Barrier Dysfunction in Mice with DSS-Induced Chronic Colitis

BACKGROUND

Clinical data suggest that enteral nutrition (EN) effectively decreases disease activity and maintains remission in patients with inflammatory bowel disease (IBD). However, the modulatory effects of EN on the intestinal mucosal immune system remain unclear.

AIMS

This study first aimed at comparing the therapeutic effects of three EN formulas on ameliorating dextran sulfate sodium- (DSS-) induced chronic colitis; with the most effective formula, we then examined its influence on the mucosal inflammatory response and epithelial barrier function.

METHODS

The effect of EN formulas on colitis in mice was assessed by body weight, disease activity index scores, colon length, and H&E staining for pathological examination. Colonic and circulating cytokine expression levels and the frequencies of immune cells were also analyzed. Intestinal epithelial barrier function was evaluated by detecting tight junction proteins.

RESULTS

We found that among the three EN formulas, an elemental diet (ED) containing enriched amino acids restored the colitis-related reduction in body weight better than the other two EN formulas. ED amino acids suppressed the release of colonic proinflammatory mediators and maintained the expression of tight junction proteins in these mice. ED amino acid treatment mitigated the colitis-induced increase in CD103+CD11b+ dendritic cells and CD4+ and CD8+ T cells and inhibited the predominant Th1/Th17 responses particularly in the colonic mucosal lamina propria of mice with colitis.

CONCLUSIONS

We showed that ED amino acids can be an effective immunomodulatory agent to reduce colitis-related inflammation by inhibiting proinflammatory mediators and Th1/Th17 cell responses and by repairing the disrupted epithelial barrier.

Diet Recommendations for Hospitalized Patients With Inflammatory Bowel Disease: Better Options Than Nil Per Os

Hospitalizations are a time when providers often have uncertainty about what to feed patients with inflammatory bowel disease (IBD). While there are many trials evaluating the role of diet in the management of IBD, the role of diet for the hospitalized patient is less clear. The hospitalization may serve as an opportunity to educate patients about the role of diet, try different diets, and develop dietary recommendations for after discharge. Here, we review the literature for dietary considerations during hospitalizations and acute settings, as well as upon discharge. Patients with IBD benefit from screening and nutritional support for malnutrition and nutritional deficiencies. Enteral nutrition and exclusion diets are promising as induction and maintenance therapies, but no specific recommendations during hospitalization for adult patients are available currently. There are very few reasons to enforce bowel rest or clear liquids other than bowel obstruction, uncontrolled sepsis, or need for urgent or emergent surgery; most patients - including many with penetrating or stricturing disease - benefit from feeding in whichever capacity is tolerated, with enteral and parenteral nutrition used as needed to reach nutritional goals. Future studies are needed to define how the use of different diets can influence the outcomes of patients hospitalized for IBD.

Correlation between age of onset and gastrointestinal stenosis in hospitalized patients with Crohn's disease

BACKGROUND

Patients affected by Crohn's disease (CD) are more likely to develop gastrointestinal stenosis and often undergo surgery during the duration of disease.

AIM

To identify the risk factors for gastrointestinal stenosis in hospitalized CD patients in China.

METHODS

The clinical data of CD patients hospitalized at the Seventh Medical Center, Chinese People's Liberation Army General Hospital from January 2010 to December 2018 were included. Patients with gastrointestinal stenosis were compared to those without gastrointestinal stenosis for clinical variables. The risk factors for gastrointestinal stenosis were identified using univariate and multivariable logistic regression analyses. The treatments for patients with gastrointestinal stenosis were analyzed, and the characteristics of different treatment methods were discussed.

RESULTS

The incidence of gastrointestinal stenosis was 59.02% in the 122 hospitalized CD patients. Age of onset of more than 40 years (odds ratio [OR] = 3.072, 95% confidence interval [CI]: 1.298-7.272, P = 0.009) and duration of disease of more than 5 years (OR = 2.101, 95%CI: 1.002-4.406, P = 0.048) were associated with the occurrence of gastrointestinal stenosis. Fifteen (20.83%) patients did not undergo surgery and received internal medicine and nutrition treatment. Surgical treatments were performed in 72.22% (52) of cases. The rate of postoperative complications was 15.38% (8 cases), and during a median follow-up period of 46 mo, 11.54% (6 cases) underwent reoperation. A total of 29.17% (21 cases) were treated with endoscopic therapy, and during a median follow-up period of 32 mo, 76.19% (16 cases) had no surgical event, 23.81% (5 cases) failed to avoid surgical treatments, and no serious postoperative complications occurred after endoscopic therapy.

CONCLUSION

Age of onset of more than 40 years and duration of disease of more than 5 years may be strongly correlated with a higher risk of gastrointestinal stenosis in hospitalized CD patients. Endoscopic therapy for gastrointestinal stenosis is relatively safe and effective, and may help to prevent or delay surgery.

Preoperative enteral nutrition in adults with complicated Crohn's disease: Effect on disease outcomes and gut microbiota

OBJECTIVES

The use of exclusive enteral nutrition (EEN) in patients with Crohn's disease (CD) before surgical resection can reduce disease activity and improve nutritional status. The mechanism of EEN action is unclear, but it might involve modulation of the intestinal microbiota. The aim of this study was to evaluate the effects (namely changes in gut microbiota) of preoperative EEN in adults with complicated CD referred to surgery.

METHODS

This was a prospective study of adult patients with CD referred to surgery. Patients with body mass index <18.5 kg/m², weight loss >10 %, serum albumin <3 g/dL, or a combination of some or all three, received EEN for ≥2 wk. The effects of EEN on clinical (Harvey-Bradshaw Index [HBI]) and laboratory markers (C-reactive protein [CRP], serum albumin, and fecal calprotectin) and fecal microbiota were analyzed after EEN (before surgery) and 6 mo later. We used 16 S rRNA gene sequencing to determine changes in the fecal microbiota.

RESULTS

Fifteen patients were included, of whom 60% were men with a mean age of 45.4 ± 19.1 y. Of those, 10 received EEN. The median duration of preoperative EEN was 41.5 d (15-70 d). During EEN, there was a significant reduction in mean HBI (8.7 ± 1.9 versus 4.1 ± 2.4; P = 0.001) and CRP (11.7 ± 10.3 versus 0.8 ± 0.8 mg/dL; P = 0.008) and an increase in serum albumin (3.1 ± 0.6 versus 4 ± 0.6 g/dL; P = 0.022). Two patients did not require surgery after EEN. The overall microbial composition changed after EEN (Permutational analysis of variance test, P = 0.046) and there was a significant reduction in α diversity (8 ± 2.3 versus 5.2 ± 1.5; P = 0.023). EEN significantly changed the relative abundance of 11 taxonomic operational units (OTUs). At the family level, we found this was mainly due to the decrease in the Enterobacteriaceae family (7 OTUs). Six months after surgery, α diversity was not different from that before or after EEN; at this time point 6 OTUs were significantly different, mainly due to the decrease of Clostridiales order (3 OTUs). The incidence of postoperative complications and hospital length of stay were similar in EEN and immediate surgery groups, as well as clinical and endoscopic recurrence rates 6 mo after surgery.

CONCLUSIONS

Preoperative EEN improved disease activity and nutritional status in patients with CD referred to surgery. Despite being malnourished, patients given EEN did not have increased postoperative complications compared with well-nourished patients. During EEN, overall microbiota composition changed and α diversity decreased. EEN did not influence postoperative recurrence and gut microbiota 6 mo after surgery.

Preoperative hypoalbuminemia is an independent risk factor for postoperative complications in Crohn's disease patients with normal BMI: A cohort study

BACKGROUND

Malnutrition is universal in Crohn's disease (CD). The body mass index (BMI) is used to assess nutritional status to predict postoperative complications in CD patients. However, some CD patients have a normal BMI. The aim of this study was to evaluate risk factors for postoperative complications in CD patients with normal preoperative BMI values.

METHODS

This retrospective observational study included 315 CD patients who underwent surgical treatment between December 2012 and January 2020. Patient data were collected from a prospectively maintained database. The risk factors for postoperative complications in CD patients with normal BMI values were identified by univariate and multivariate analyses.

RESULTS

In total, 315 eligible patients were included. The incidence of postoperative complications was 30.8%, consisting of 22.5% mild complications and 18.4% major complications. The albumin level, the C-reactive protein level, laparoscopic surgery, and operative time were significantly associated with postoperative outcomes. Multivariate analysis showed that a low preoperative albumin level (P = 0.013, OR = 2.991, 95% CI: 1.255-7.131) was an independent risk factor for postoperative complications in CD patients with normal BMI values.

CONCLUSIONS

A low preoperative albumin level was a risk factor for postoperative complications in CD patients with normal BMI values. Although some patients have a normal BMI, clinicians should still consider the preoperative albumin level in CD patients to evaluate their nutritional status and provide timely intervention to reduce the risk of postoperative complications.

British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic

The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government's advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.

Perioperative Dietary Therapy in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease [IBD] is rising worldwide and no cure is available. Many patients require surgery and they often present with nutritional deficiencies. Although randomised controlled trials of dietary therapy are lacking, expert IBD centres have long-established interdisciplinary care, including tailored nutritional therapy, to optimise clinical outcomes and resource utilisation. This topical review aims to share expertise and offers current practice recommendations to optimise outcomes of IBD patients who undergo surgery.

METHODS

A consensus expert panel consisting of dietitians, surgeons, and gastroenterologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. Nutritional evaluation and dietary needs, perioperative optimis ation, surgical complications, long-term needs, and special situations were critically appraised. Statements were developed using a Delphi methodology incorporating three successive rounds. Current practice positions were set when ≥80% of participants agreed on a recommendation.

RESULTS

A total of 26 current practice positions were formulated which address the needs of IBD patients perioperatively and in the long term following surgery. Routine screening, perioperative optimisation by oral, enteral, or parenteral nutrition, dietary fibre, and supplements were reviewed. IBD-specific situations, including management of patients with a restorative proctocolectomy, an ostomy, strictures, or short-bowel syndrome, were addressed.

CONCLUSIONS

Perioperative dietary therapy improves the outcomes of IBD patients who undergo a surgical procedure. This topical review shares interdisciplinary expertise and provides guidance to optimise the outcomes of patients with Crohn's disease and ulcerative colitis. taking advantage of contemporary nutrition science.

Inflammatory Bowel Diseases: Host-Microbial-Environmental Interactions in Dysbiosis

Crohn's Disease (CD) and Ulcerative Colitis (UC) are world-wide health problems in which intestinal dysbiosis or adverse functional changes in the microbiome are causative or exacerbating factors. The reduced abundance and diversity of the microbiome may be a result of a lack of exposure to vital commensal microbes or overexposure to competitive pathobionts during early life. Alternatively, many commensal bacteria may not find a suitable intestinal niche or fail to proliferate or function in a protective/competitive manner if they do colonize. Bacteria express a range of factors, such as fimbriae, flagella, and secretory compounds that enable them to attach to the gut, modulate metabolism, and outcompete other species. However, the host also releases factors, such as secretory IgA, antimicrobial factors, hormones, and mucins, which can prevent or regulate bacterial interactions with the gut or disable the bacterium. The delicate balance between these competing host and bacteria factors dictates whether a bacterium can colonize, proliferate or function in the intestine. Impaired functioning of NOD2 in Paneth cells and disrupted colonic mucus production are exacerbating features of CD and UC, respectively, that contribute to dysbiosis. This review evaluates the roles of these and other the host, bacterial and environmental factors in inflammatory bowel diseases.

Inpatient Management of Inflammatory Bowel Disease-Related Complications

Despite advances in therapeutic options, a sizeable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. While current treatment guidelines for the management of ulcerative colitis and Crohn's disease cover the spectrum of disease severity and behavior, management of acute complications of inflammatory bowel disease can present unique challenges that are not always addressed in these guidelines. In this review, the authors provide a comprehensive summary of the existing literature focused on management of patients hospitalized with complications of inflammatory bowel disease. Proposed management algorithms are provided to guide clinicians through common scenarios to determine the most appropriate interventions - escalation of medical therapies, non-surgical therapeutic interventions (drainage of intra-abdominal abscess or endoscopic balloon dilation) or surgery. Prevention of complications is proposed through a multi-disciplinary approach that involves surgeons, dieticians, radiologists, pathologists and infectious disease consultants.

Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study

AIM

Currently, the notion that preoperative optimization with enteral nutrition (EN) reduces the incidence of complication after surgery in Crohn's disease (CD) patients is being debated. This case-matched study was to evaluate the impact of preoperative EN on surgical outcomes in patients with CD.

METHOD

Twenty-four patients received EN therapy with an elemental diet (1800-2400 kcal/day) for at least 2 weeks before the planned surgery (EN group). A further 24 patients who underwent surgery without receiving preoperative EN or parenteral nutrition formed a control group based on four matched criteria: age (≤/>40 years), the use of preoperative medications (corticosteroids/azathioprine/biologics), disease behaviour (inflammatory/stricturing/penetrating) and main surgical procedure (ileal resection/ileocolonic resection/colectomy). The incidence of complications observed within 30 days after surgery was compared between the two groups. Septic complications were defined as anastomotic leak, intra-abdominal abscess, entero-cutaneous fistula or wound infection.

RESULTS

In the EN group, the median serum albumin level significantly increased, while C-reactive protein (CRP) significantly decreased during the preoperative EN (albumin, from 3.0 mg/dl to 3.1 mg/dl, P = 0.04; CRP, from 3.05 mg/dl to 2.52 mg/dl, P = 0.02). The incidence of postoperative septic complications was significantly lower in the EN group compared with the control group (4% vs 25%, P = 0.04). The occurrence rate of overall complications was lower in the EN group (21% vs 29%, P = 0.51), but not statistically significant.

CONCLUSION

In patients with CD, preoperative optimization with EN reduced the overall rate of postoperative complications and significantly decreased postoperative septic complications.

Nomogram to Predict Postoperative Intra-abdominal Septic Complications After Bowel Resection and Primary Anastomosis for Crohn's Disease

BACKGROUND

Postoperative intra-abdominal septic complications of Crohn's disease substantially increase the healthcare expenditure and prolong hospitalization.

OBJECTIVE

We aimed to develop and validate a prediction model for intra-abdominal septic complications after bowel resection and primary anastomosis for Crohn's disease.

DESIGN

This was a retrospective cohort study.

SETTINGS

This study was conducted in a tertiary center.

PATIENTS

Data of 949 Crohn's disease-related primary bowel resections and anastomosis from January 2011 to December 2017 were collected.

MAIN OUTCOME MEASURES

Primary outcomes were prevalence of intra-abdominal septic complications.

RESULTS

Overall prevalence of intra-abdominal septic complications after Crohn's disease surgery was 11.6%. Predictors included preoperative C-reactive protein level ≥40 mg/L (OR = 3.545), preoperative glucocorticoids (OR = 1.829) and infliximab use (OR = 3.365), upper GI involvement (OR = 2.072), and hypoalbuminemia (albumin level <30 g/L, OR = 2.406). Preoperative exclusive enteral nutrition was a protector for postoperative septic complications (OR = 0.192) compared with partial enteral nutrition/parenteral nutrition/straight to surgery. A nomogram was computed to facilitate risk calculation; this had a predictive discrimination, measured as area under the receiver operating characteristic curve, of 0.823.

LIMITATIONS

This model is generated from retrospective data. A major limitation of this model is the lack of external validation.

CONCLUSIONS

A new model to predict postoperative intra-abdominal septic complications was developed, which may guide preoperative optimization and candidate selection for primary anastomosis after bowel resection for Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B178. NOMOGRAMA PARA PREDECIR COMPLICACIONES SéPTICAS INTRAABDOMINALES POSTOPERATORIAS DESPUéS DE RESECCIóN INTESTINAL Y ANASTOMOSIS PRIMARIA EN ENFERMEDAD DE CROHN: Las complicaciones sépticas intraabdominales postoperatorias en la enfermedad de Crohn aumentan sustancialmente los costos de atención médica y prolongan la hospitalización.Nuestro objetivo fue desarrollar y validar un modelo de predicción para las complicaciones sépticas intraabdominales después de resección intestinal y anastomosis primaria en enfermedad de Crohn.Este fue un estudio de cohorte retrospectivo.Este estudio se realizó en un centro de tercer nivel.Se recopilaron datos de 949 resecciones intestinales primarias con anastomosis por enfermedad de Crohn de enero de 2011 a diciembre de 2017.El resultado primario fue la prevalencia de complicaciones sépticas intraabdominales.La prevalencia general de complicaciones sépticas intraabdominales después de cirugía por enfermedad de Crohn fue 11.6%. Los predictores incluyeron un nivel preoperatorio de proteína C reactiva ≥ 40 mg / L (odds ratio = 3.545), glucocorticoides preoperatorios (odds ratio = 1.829) y uso de infliximab (odds ratio = 3.365), compromiso gastrointestinal superior (odds ratio = 2.072) e hipoalbuminemia (albúmina <30g / L, odds ratio = 2.406). La nutrición enteral exclusiva preoperatoria fue un protector para las complicaciones sépticas postoperatorias (odds ratio = 0.192, en comparación con la nutrición enteral parcial / nutrición parenteral / envío directo a cirugía. Se calculó un nomograma para facilitar el cálculo del riesgo; esto tuvo una discriminación predictiva, medida como área bajo la curva de la característica de operación del receptor, de 0.823.Este modelo se generó a partir de datos retrospectivos. Una limitación importante de este modelo es la falta de validación externa.Se desarrolló un nuevo modelo para predecir complicaciones sépticas intraabdominales postoperatorias, que puede guiar la optimización preoperatoria y la selección de candidatos para anastomosis primaria después de resección intestinal en enfermedad de Crohn. Consulte Video Resumen en http://links.lww.com/DCR/B178. (Traducción-Dr. Jorge Silva Velazco).

British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic

The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government’s advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.

Prehabilitation: The Impact of Preoperative Exclusive Enteral Nutrition on Paediatric Patients With Crohn Disease

Exclusive enteral nutrition (EEN) is effective in inducing remission in paediatric Crohn Disease (CD) and has been shown to reduce inflammation and improve outcomes in adult CD patients when used before resectional surgery. This retrospective study demonstrates that preoperative EEN is achievable in paediatric CD patients undergoing right hemicolectomy and is associated with positive peri-operative outcomes. Seventeen patients (8 who received preoperative EEN and 9 who did not) were included in the study. Six of 8 (75.0%) managed EEN orally; 1 via nasogastric tube and another via a previously sited gastrostomy. Use of preoperative EEN was associated with a decreased rate of moderate/severe disease on resection pathology (5/8 [62.5%] vs 9/9 [100%]; P = 0.04). Larger studies are required to determine the wider potential benefits of preoperative EEN on postoperative outcomes within paediatric practice.

Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease

BACKGROUND AND AIM

Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research.

METHODS

A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified.

RESULTS

An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed.

CONCLUSION

EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.

Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre

BACKGROUND AND AIMS

Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported.

METHODS

Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records.

RESULTS

A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2.

CONCLUSIONS

IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.

Reducing Perioperative Risks of Surgery in Crohn's Disease

BACKGROUND

Approximately one-third of all patients suffering from Crohn's disease (CD) undergo surgery within the first 10 years after diagnosis and another 20% will have a second operation in the 10 years after their first operation. Surgery will remain an essential part of managing CD and therefore it is crucial to prevent perioperative complications by optimizing perioperative management.

METHODS

We reviewed the current literature on managing immunomodulating therapy, nutritional support, and thromboembolic prophylaxis in the perioperative situation.

RESULTS

CD patients with serious nutritional deficits (weight loss >10% in the last 3-6 months, body mass index <18.5 kg/m2, or albumin levels <30 g/L) benefit from intensive enteral or parenteral nutritional support, thereby reducing the risk of surgical-site infections and post-operative septic complications. Immunosuppressive therapy with prednisolone doses >20 mg should be avoided. The risk of therapy with anti-TNFα agents, vedolizumab, and ustekinumab for surgical complications has not been fully established. Analysis of currently available data suggests that an interval of 4-8 weeks is prudent to avoid complications and reduce risk by performing protective ostomy in the emergency setting. Finally, due to the high risk of venous thromboembolism, prophylactic therapy with heparin is recommended.

CONCLUSION

As most cases of CD-related surgery are performed in a non-emergency setting, careful planning and risk management can reduce the rate of surgical complications, increase quality of life, and also reduce costs.

Nutritional approach as therapeutic manipulation in inflammatory bowel disease

Malnutrition is observed more frequently in patients with inflammatory bowel disease (IBD) than in the general population and associated with adverse clinical outcomes. This study aimed to review the current knowledge regarding the efficacy of dietary and nutritional intervention in IBD patients. Exclusive enteral nutrition might be inferior to corticosteroid treatment in adults with active Crohn’s disease (CD) but might even be superior considering the adverse effects of corticosteroid treatment in children. Total parenteral nutrition has no advantage over enteral nutrition, which is considered a more physiologic modality in organ function. Current guidelines do not yet recommend ω3-polyunsaturated fatty acid supplementation for the prevention and maintenance of remission in IBD patients. Dietary fiber supplementation could be effective in the relief of symptoms and maintenance of remission in ulcerative colitis (UC). Although vitamin D may be favorable to clinical course of IBD and bone density. Probiotic supplementation has proven to be effective in preventing and treating pouchitis for UC but is less effective in treating CD. Nutritional interventions not only correct nutritional deficiencies but also improve symptoms and clinical courses of the disease. Hence, nutritional approaches need to be developed to significantly evaluate the effectiveness of dietary interventions used to treat IBD.

Benefits of Exclusive Enteral Nutrition in Adults With Complex Active Crohn’s Disease: A Case Series of 13 Consecutive Patients

Background and Aims

Immunosuppressive therapy is routine for adults with complex active Crohn’s disease (CD), however carries risks, particularly in the setting of sepsis. Exclusive enteral nutrition (EEN) is widely used in paediatric CD, yet efficacy data in adults are sparse. This study evaluated outcomes of EEN in adults with complex active CD.

Methods

Between December 2016 and June 2018, 13 patients with complex active CD (range 20–74 years) managed at a single hospital received 2 or more weeks of EEN. Patients were offered EEN based on either malnutrition, contraindication to immunosuppression, or CD refractory to multiple therapies. Subjective and objective outcomes were recorded at 2 and 6 weeks and compared with baseline data.

Results

Nine of 13 patients experienced subjective improvement in wellbeing. Objective improvements included nine CRP decrements (median = 87.7 mg/L, IQR = 70.6 mg/L), nine serum albumin increments (median = 7 g/L, IQR = 4 g/L), and six gained weight (median = 3.6 kg, IQR = 3.0 kg). All five patients with complex abscess resolved without surgery. One ileocolic fistula and one enterocutaneous fistula achieved resolution without surgery. One of two perianal fistulae cases resolved without surgery. Seven of 10 patients initially thought to need surgery avoided it due to disease resolution. Only one of the three patients who proceeded to surgery sustained a post-operative complication. There were no EEN-associated complications.

Conclusions

In complex active CD, our real-world data show that EEN improves wellbeing, decreases inflammatory markers, leads to healthy weight gain, reduces need for surgical intervention, and reduces postoperative complications.

Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift

Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.

Synergistic effect of enteral nutrition on remission induction in a patient with penetrating Crohn disease: A case report

RATIONALE

Crohn disease includes 3 phenotypes, inflammatory, stricturing, and penetrating. In cases where corticosteroids and immunosuppressive agents are not suitable treatment options, enteral nutrition (EN) can be used to reduce disease severity and enhance barrier defense with fewer potential adverse effects.

PATIENT CONCERNS

A 23-year-old man with abdominal pain and diarrhea presented at our hospital in 2014. The frequency of defecation was 3 or 4 times a day without mucus or blood in the stool. His body mass index was 15.8, and in laboratory tests the erythrocyte sedimentation rate was 42.4 mm/h, serum C reactive protein was 65.2 mg/L, the leukocyte count was 11.64 × 109/L, and hemoglobin was 111 g/L.

DIAGNOSIS

In computed tomography (CT) enterography the ascending colon was thickened, and there was effusion and enlarged lymph nodes around the colon. Colonoscopy revealed ulcer, polypoid proliferation, and bowel stenosis in many segments. Chronic inflammation was evident in multiple biopsies. Crohn disease was diagnosed based on the above observations.

INTERVENTIONS

Mesalazine was administered at a dose of 4 g daily for 2 years. The patient was hospitalized again due to severe abdominal pain and ongoing fever. Intestinal perforation was detected via CT. Percutaneous drainage was performed followed by administration of intravenous metronidazole (0.5 g) and ciprofloxacin (0.2 g) twice a day. Peptison liquid was used as exclusive EN. After 2 weeks the antibiotics regimen was changed to metronidazole 0.4 g twice a day and ciprofloxacin 0.25 g 3 times a day, both administered orally.

OUTCOMES

CT revealed that the infection was eliminated and the fistula was healed after 10 weeks, at which point antibiotics and exclusive EN was discontinued. Azathioprine was prescribed at a dose of 2 mg/kg daily to maintain clinical remission. The patient did not report any pain or diarrhea at a 1-year follow-up visit.

LESSONS

The present case suggests that exclusive EN combined with antibiotics is useful in inducing remission in Crohn disease patients with active disease and penetrating complications.

Diet as Adjunctive Treatment for Inflammatory Bowel Disease: Review and Update of the Latest Literature

PURPOSE OF REVIEW

Diet plays an integral role in development of inflammatory bowel disease (IBD) and continues to act as a mediator of intestinal inflammation once disease sets in. Most clinicians provide little dietary guidance to IBD patients, in part due to lack of knowledge in nutrition and lack of available nutritional resources. The purpose of this review is to provide clinicians with a brief summary of the latest evidence behind diets popular among IBD patients, to highlight diets with known efficacy, and to provide guidance that may help busy practitioners.

RECENT FINDINGS

The latest studies show that exclusive enteral nutrition (EEN) remains the most effective diet for induction of remission in Crohn's disease (CD), either in the form of elemental, semi-elemental, or polymeric formulas. Recent studies also show that EEN can be useful in complicated CD including in enterocutaneous fistulas closure and to optimize nutrition in the pre-operative setting. Although new studies suggest that partial enteral nutrition supplemented with elimination diets may be beneficial in ulcerative colitis (UC) and CD, larger controlled studies are needed to support their use. The autoimmune diet also shows promise but lacks larger studies. Recent uncontrolled clinical studies evaluating the specific carbohydrate diet (SCD) suggest that this diet may improve biochemical markers of inflammation and induce mucosal healing, although larger studies are needed to support its use, especially because the SCD is very restrictive. Short-term use of the low FODMAP diet is appropriate when in the setting of an acute flare up and/or in stricturing disease, but long-term restriction of FODMAPs is not recommended given long-term changes observed in the microbiome. Recent studies suggest that avoidance of processed foods, packaged with preservatives and emulsifiers, may be important in decreasing intestinal inflammation; many of the recent popular diets share a common concept, avoidance of processed foods. In this review of the latest literature, we highlight that dietary studies are still in a rudimentary stage. Large prospective randomized control studies are underway evaluating head to head comparisons on the efficacy of some of these diets. We offer general guiding principles that may help gastroenterologists in the meantime.

Diet and inflammatory bowel disease: The Asian Working Group guidelines

INTRODUCTION

These Asian Working Group guidelines on diet in inflammatory bowel disease (IBD) present a multidisciplinary focus on clinical nutrition in IBD in Asian countries.

METHODOLOGY

The guidelines are based on evidence from existing published literature; however, if objective data were lacking or inconclusive, expert opinion was considered. The conclusions and 38 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

Diet has an important role in IBD pathogenesis, and an increase in the incidence of IBD in Asian countries has paralleled changes in the dietary patterns. The present consensus endeavors to address the following topics in relation to IBD: (i) role of diet in the pathogenesis; (ii) diet as a therapy; (iii) malnutrition and nutritional assessment of the patients; (iv) dietary recommendations; (v) nutritional rehabilitation; and (vi) nutrition in special situations like surgery, pregnancy, and lactation.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 38 recommendations.

An overview of the role of exclusive enteral nutrition for complicated Crohn's disease

The role and efficacy of exclusive enteral nutrition (EEN) in the treatment of luminal Crohn's disease (CD) has been well established over the last 2 decades. Consequently, in many centers nutritional therapy is now considered first line therapy in the induction of remission of active CD. However, the use of nutritional therapy in complicated CD has yet to be fully determined. This article aimed to review case reports and clinical trials published in the last decade that have considered and evaluated nutritional therapy in the setting of complicated CD in children and adults. Published literature focusing upon the use of nutritional therapy as part of medical therapy in the management of complicated CD were identified and reviewed. Although there continue to be various interventions utilized for complicated CD, the currently available literature demonstrates that nutritional therapies, especially EEN, have important roles in the management of these complex scenarios. Further assessments, involving large numbers of patients managed with consistent approaches, are required to further substantiate these roles.

The role of exclusive enteral nutrition in the preoperative optimization of laparoscopic surgery for patients with Crohn's disease: A cohort study

BACKGROUND

Growing evidence has shown that there are significant advantages associated with the use of laparoscopic surgery for Crohn's disease (CD). However, the impact of preoperative exclusive enteral nutrition (EEN) on postoperative complications and CD recurrence following laparoscopic surgery have not been investigated.

METHODS

A total of 120 CD patients undergoing bowel resection with laparoscopic surgery were eligible for this study. Patient data were collected from a prospectively maintained database. Before laparoscopic surgery, 45 CD patients received EEN for at least 4 weeks, and 75 CD patients had no EEN. Postoperative complications, and endoscopic and clinical recurrence were subsequently measured and compared after laparoscopic surgery and during follow-up assessments.

RESULTS

Patients who received EEN had significant improvements in their nutritional (albumin, prognostic nutritional index (PNI), and hemoglobin) and inflammatory (C-reactive protein) status after the EEN treatment prior to surgery (P < 0.05). Patients who received EEN also experienced fewer postoperative complications, decreased surgical site infections, and a lower comprehensive complication index (P < 0.05). The endoscopic recurrence rates 6 months after surgery were also decreased significantly in patients who received EEN (P < 0.05). However, the incidence of clinical recurrence was similar in the 2 groups at 1-year follow-up. Endoscopic recurrence was correlated with ileocolonic disease, EEN before surgery, and PNI (P < 0.05). PNI remained independently associated with endoscopic recurrence after surgery.

CONCLUSIONS

Preoperative EEN for at least 4 weeks improved CD patients' nutritional and inflammatory status, which in turn reduced postoperative complications following laparoscopic surgery and endoscopic recurrence on follow-up.

Preoperative Enteral Nutrition and Surgical Outcomes in Adults with Crohn's Disease: A Systematic Review

Background and Aim

Enteral nutrition (EN) is applicable to adult Crohn's disease (CD) in treating malnutrition and in inducing remission - here as a less effective alternative than corticosteroids. The purpose of this review is to determine whether preoperative EN impacts postoperative complications of adult CD, either by means of nutritional or therapeutic effects.

Summary

A systematic review of English written full-text research articles published between January 1990 and November 2017, including adult patients undergoing abdominal surgery for complicated CD after EN, was performed. Four studies out of 22 were selected, all of which institutional, retrospective, case-control cohorts, one classified as "good quality" and three as "poor quality," as rated by the Newcastle-Ottawa Scale. The application of inclusion and exclusion criteria resulted in a non-intentional absence of studies referring to supplemental EN among those reviewed. The reduced number of heterogeneous eligible studies impeded meta-analysis. In all studies, exclusive EN (EEN) was used and well tolerated, allowing to defer or even avoid surgery altogether, improving patients' global state. The two studies with the greatest number of patients found preoperative EEN to be an independent factor against infectious and non-infectious complications in 219 patients and against anastomotic leaks or abscesses in 38 patients. Also, in univariate analysis, EEN was found to increase preop-erative immunosuppressant-free intervals and to protect against anastomotic dehiscences, intra-abdominal abscesses, surgical wound infections, ileus, stomas, and reoperations in the largest study; in another study it was related to fewer intra-abdominal septic complications.

Key Messages

All reviewed studies are retrospective and, consequently, of limited relevance. Nonetheless, all of them call the attention of the scientific community to the potential benefits of preoperative EEN on postoperative outcomes in adult CD, calling for prospective multi-institutional studies and randomized controlled trials.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Long-Term Outcome of Endoscopic Balloon Dilatation for Strictures in Patients with Crohn's Disease

BACKGROUND/AIMS

Endoscopic balloon dilatation (EBD) is an alternative to surgery for strictures in patients with Crohn's disease (CD). The aim of the present study was to clarify the efficacy and safety of EBD for strictures in patients with CD.

METHODS

Twenty-six patients with CD who underwent EBD for strictures from August 2008 to November 2015 were followed up after dilatation. Short-term success was defined as the disappearance of obstructive symptoms after technically adequate dilatation was achieved. The short-term success rate of EBD, safety profile of EBD, and cumulative surgery-free and redilatation-free rates were analyzed.

RESULTS

Sixty-five EBDs were performed for CD patients in the follow-up period. The short-term success rate was 100% (26/26), and no complications were encountered during this study. Two (7.7%) patients underwent surgery during the observation period. The cumulative surgery-free rate after the initial EBD was 90.3% at both 2 and 3 years. The cumulative redilatation-free rate after the initial EBD was 52.1% at 2 years and 39.1% at 3 years.

CONCLUSION

EBD for strictures secondary to CD provides not only short-term success but also long-term efficacy. Although a high redilatation rate is one of the clinical problems of this procedure, EBD is an effective therapy for avoiding intestinal recession in CD -stricture.

Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support

Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.

Evolving role of diet in the pathogenesis and treatment of inflammatory bowel diseases

Recent advances in basic and clinical science over the last 3 years have dramatically altered our appreciation of the role of diet in inflammatory bowel diseases (IBD). The marked increase in incidence of these diseases along with the important role of non-genetic susceptibility among patients with IBD has highlighted that these diseases have a strong environmental component. Progress in the field of microbiome and IBD has demonstrated that microbiome appears to play an important role in pathogenesis, and that diet may in turn impact the composition and functionality of the microbiome. Uncontrolled clinical studies have demonstrated that various dietary therapies such as exclusive enteral nutrition and newly developed exclusion diets might be potent tools for induction of remission at disease onset, for patients failing biologic therapy, as a treatment for disease complications and in reducing the need for surgery. We review these advances from bench to bedside, along with the need for better clinical trials to support these interventions.

Glasgow prognostic score is a practical predictive index for postoperative intra-abdominal septic complications after bowel resection in Crohn's disease patients

PURPOSE

Postoperative intra-abdominal septic complications (IASCs) are not uncommon in patients with Crohn's disease (CD). The appropriate index to predict postoperative IASCs in these individuals remains unknown. This study investigates whether the inflammation-based Glasgow prognostic score (GPS) is predictive in the setting of postoperative IASC CD patients who underwent elective bowel resection.

METHODS

A consecutive cohort of 163 CD patients who underwent elective intestinal resection from July 2012 to March 2016 was retrospectively analyzed. Patients were divided into two GPS groups, one lower and one higher. The GPS was defined by serum levels of C-reactive protein and albumin. Univariate and multivariate analyses were conducted to identify risk factors for postoperative IASCs.

RESULTS

Postoperative IASCs occurred in 25 (15.3%) patients. Compared with patients in the lower GPS group, patients with a higher GPS had a higher incidence of postoperative IASCs (9.85 vs. 38.71%, P < 0.001) and experienced longer postoperative hospital stay (10.53 ± 7.00 vs. 15.71 ± 9.17, P = 0.001). Univariate and multivariate analyses revealed preoperative GPS [odds ratio (OR) 5.016, 95% confidence interval (CI) 1.134-22.193, P = 0.034] and penetrating behavior (OR 4.495, 95% CI 1.377-14.670, P = 0.013) to be independent risk factors for postoperative IASCs.

CONCLUSIONS

A preoperative GPS can serve as a useful index for predicting manifestation of postoperative IASCs after bowel resection in patients with CD. Perioperative optimization is required to improve postoperative outcomes for patients with higher GPS.

Enteral Nutrition in the Management of Pediatric and Adult Crohn's Disease

Genetic and environmental factors are thought to profoundly influence the pathophysiology of Crohn’s disease (CD). Changes in dietary and hygiene patterns affect the interactions between the immune system and environment. The gut microbiome is responsible for mediating host immune response with significant dysbiosis observed in individuals with CD. Diet therapy using exclusive enteral nutrition (EEN) has been studied as primary therapy for the management of CD. EEN may cultivate the presence of beneficial microbiota, improve bile acid metabolism, and decrease the number of dietary microparticles possibly influencing disease and immune activity. In this review, we will address the current evidence on EEN in the management of adult and pediatric CD. In adults, EEN appears to be moderately beneficial for the induction of remission of CD; however, its use is understudied and underutilized. Stronger evidence is in place to support the use of EEN in pediatric CD with the added benefit of nutrition support and steroid-sparing therapy during the growth phase. Overall, EEN is an established therapy in inducing CD remission in the pediatric population while its role as primary therapy of adult Crohn’s disease remains to be defined.

Semi-automated ultrasound guidance applied to nasogastrojejunal tube replacement for enteral nutrition in critically ill adults

BACKGROUND AND OBJECTIVE

At present, the enteral nutrition approaches via nose and duodenum (or nose and jejunum) are the preferred method of nutritional support in the medical engineering field, given the superiority of in line with physiological processes and no serious complication. In this study, the authors adopted saline as the acoustic window, and gave enteral nutrition support to critically ill patients, via the nasogastrojejunal approach guided by semi-automated ultrasound. These above patients benefited a lot from this kind of nutrition support treatment, and we aimed to report the detailed information.

METHODS

Critically ill patients (n = 41) who had been treated with hospitalized intestine nutrition were identified. The Apogee 1200 ultrasonic diagnostic apparatus, and nasogastrojejunal tubes were adopted to carry out intestine nutrition treatment guided by semi-automated ultrasound. In order to confirm the specific positions of cardia, gastric body, antrum of stomach, and pylorus, the semi-automated ultrasound was utilized to probe the stomach cavity. And then, the ultrasonic probe was placed in the cardia location, and the nasogastrojejunal tube was slowly inserted through the metal thread. After operation, the nursing service satisfaction of patients and mean operation time were calculated, respectively.

RESULTS

All the patients were treated with enteral nutrition via nasogastrojejunal tube, and the whole procedure was under the guidance of semi-automated ultrasonography. The end of the feeding tube is attached to the surface of the stomach with a greater curvature, which can be bent on account of a no gastric peristalsis squeeze function, and thereby were prevented from entering into the antrum and pylorus locations. After this procedure, the mental thread was taken out, and the tube was pushed forward by a "drift" approach in order to allow it to enter into the intestine. The total nursing service satisfaction of patients was 90.24%, and the total incidence of adverse reactions was 17.07%.

CONCLUSIONS

In summary, the application of saline can be taken as sound window, and the metal wire as the tracking target, the bedside nasogastrojejunal tube guided by semi-automated ultrasound is an effective feeding tube placement method, with relatively good clinical application value in medical engineering.

Medical management of pediatric inflammatory bowel disease

Inflammatory bowel diseases (IBD) are chronic autoimmune conditions of the gut affecting both pediatric and adult patients. Medical therapy is often successful at inducing and maintaining remission and preventing disease complications. The mainstays of treatment are medications and other therapies that reduce inflammation and suppress the overactive immune system. Here we review current medical therapies for pediatric IBD, discuss future therapeutics, and present current treatment goals and approaches.

The Adjunctive Role of Nutritional Therapy in the Management of Phlegmon in Two Children with Crohn's Disease

Crohn's disease may be complicated by the development of penetrating (fistulizing) or structuring complications. The presentation of an intra-abdominal phlegmon or abscess with or without an associated fistula has traditionally required surgical intervention. This series of two cases illustrates a beneficial role of non-surgical management, with parenteral and then enteral nutrition playing central roles. This report further elaborates the potential adjunctive role of enteral nutrition in the management of this complication of CD.

Safety and Efficacy of Exclusive Enteral Nutrition for Percutaneously Undrainable Abdominal Abscesses in Crohn's Disease

Background

The percutaneously undrainable abdominal abscesses in Crohn's disease (CD) are not uncommon. The treatment protocol is still under debate. This study was conducted to assess the safety and efficacy of exclusive enteral nutrition (EEN) for percutaneously undrainable abscesses in CD.

Methods

A consecutive cohort of 83 CD patients with percutaneously undrainable abdominal abscesses between January 2011 and June 2015 was retrospectively analyzed. They were divided into the EEN group and the non-EEN group.

Results

The cumulative surgical rate was significantly lower in the EEN group than in the non-EEN group (P = 0.001). Fifteen percent patients treated with EEN avoided surgery. EEN (P = 0.002) was associated with a decreased need for surgery. Previous abdominal surgery (P = 0.009) and abscess diameter > 3 cm (P = 0.022) were associated with an increased need for operation. EEN increased the albumin level, while decreased ESR and CRP significantly for patients requiring surgery. The risk of postoperative intra-abdominal septic complications (P = 0.036) was significantly lower in the EEN group compared with the non-EEN group.

Conclusions

EEN is feasible in CD patients presenting with percutaneously undrainable abdominal abscesses. It is associated with a reduction in surgical rate, optimized preoperative condition, and improved postoperative outcomes in these specific groups of patients.