Risk factors associated with postoperative recurrence and repeat surgery in Japanese patients with Crohn's disease

A retrospective, observational study to examine the effect of early tumor necrosis factor inhibitor use on rates of surgery for Crohn's disease in Japan

BACKGROUND

Crohn's disease (CD) is an incurable inflammatory condition that often requires multiple surgeries, negatively impacting quality of life. As such, treatment strategies that aim to prevent damage to the bowel and reduce the burden of surgeries for patients with CD are important. This retrospective, long-term, observational study investigated whether tumor necrosis factor inhibitor (TNFi) treatment was associated with decreased rates of abdominal surgery in Japanese patients with CD.

METHODS

Patients were divided into two groups based on prior TNFi therapy (TNFi-treated and TNFi-untreated). Outcomes assessed included surgery rate, cumulative surgery-free survival rate, and time to surgery. For surgery rate, treatment groups were compared through estimation of an odds ratio (OR) with 95% confidence intervals (CIs). Cumulative surgery-free survival rate and time to surgery was calculated using Kaplan-Meier methodology and compared using log-rank tests. The primary analysis compared outcomes between the TNFi-treated and TNFi-untreated groups. Subgroup analyses compared outcomes between two subgroups of the TNFi-treated group (infliximab-treated vs. adalimumab-treated) and the TNFi-untreated group.

RESULTS

Overall, 124 patients with CD were included in the analysis (TNFi-treated: N = 86; TNFi-untreated: N = 38). Of those patients who received TNFi treatment, 62 received infliximab and 24 received adalimumab. The median (range) observation period in the TNFi-treated and TNFi-untreated groups was 4.62 (0.41-13.75) years and 8.13 (0.08-30.25) years, respectively. Median time to surgery was 3 years in the TNFi-untreated group and 6.58 years in the TNFi-treated group. A significantly lower proportion of patients in the TNFi-treated group required surgery (3/86) compared with those in the TNFi-untreated group (17/38; OR [CI]: 0.0446 [0.0120-0.1667]; P < 0.0001). Cumulative surgery-free survival rates were significantly higher in the TNFi-treated group versus the TNFi-untreated group (P < 0.0001). Compared with the TNFi-untreated group, the proportion of patients who required surgery was significantly lower with both infliximab (1/62; OR [CI]: 0.0203 [0.0025-0.1616]; P = 0.0002) and adalimumab (2/24; OR [CI]: 0.1123 [0.0231-0.5466]; P = 0.0068). Cumulative surgery-free survival rates were significantly higher in the infliximab-treated group versus the TNFi-untreated group (P < 0.0001).

CONCLUSIONS

Introduction of TNFis for the treatment of CD may lead to a reduction in surgery rates and prolong time to surgery.

Risk Factors for Recurrence of Crohn's Disease After Ileocecal Resection and Management Strategies

INTRODUCTION

Pediatric patients with ileocecal Crohn's Disease (CD) refractory to medical management frequently require ileocecectomy. However, risk factors for post-operative ileocecal recurrence and appropriate management strategies are poorly defined in the pediatric literature in the biologic era.

METHODS

We queried our institutional database from 1/1/2012-12/31/2022 for patients aged 1-21 who underwent primary ileocecectomy for CD. We analyzed baseline characteristics, operative details, medical management, recurrence patterns, and management patterns.

RESULTS

We identified 208 patients who underwent primary ileocecal resection, of which 66 (23%) demonstrated endoscopic recurrence at 2.1 ± 0.5 years and 28 (13%) developed clinical recurrence at 2.5 ± 0.8 years. Recurrence was at the surgical anastomosis in 43 (21%). Before surgery, 138 (66%) were treated with a biologic, of which 25 (18%) were transitioned to a second line biologic pre-operatively. Requiring a separate intervention for perianal or intestinal disease increased the odds of recurrence on multivariable analysis, as did requiring a second line biologic. Of those with endoscopic recurrence, most [62/66 (94%)] were successfully managed with medical optimization alone. Only four (6.7%) required procedural intervention with two being managed with endoscopic balloon dilation and two requiring repeat resection and re-anastomosis. Median follow up was 2.6 years [IQR 1.2-4.5].

CONCLUSION

Requiring separate interventions for perianal or intestinal disease and demonstrating disease difficult to medically control may increase the risk of recurrent post-operative ileocecal CD. Such patients should be closely surveilled for endoscopic recurrence and may warrant more aggressive medical regimens. Recurrence can typically be managed medically with few patients requiring procedural intervention.

LEVEL OF EVIDENCE

III.

Perianal fistulizing lesions of Crohn's disease are associated with long-term behavior and its transition: a Chinese cohort study

BACKGROUND/AIMS

Crohn's disease (CD) has a progressive nature and commonly perianal involvement. The aim of this study is to assess the prevalence, surgical treatment, and outcome of perianal fistulizing CD with associated risk factors in a large Chinese cohort.

METHODS

Hospitalized patients diagnosed with CD in our center were consecutively enrolled between January 2000 and December 2018. Transition of disease behavior was classified according to the presence or absence of penetrating behavior (B3 in the Montreal classification) at diagnosis and at a median follow-up of 102 months.

RESULTS

A total of 504 patients were included, of whom 207 (41.1%) were classified as B3 and 348 (69.0%) as L2/3 at follow-up. Transition of behavior to B3 was observed in 86 patients (17.1%). The incidence of perianal fistulizing lesions was 10.9% at 10 years with a final prevalence of 27.0% (n = 136) at the end of follow-up. Multivariate Cox regression identified independent risks of perianal fistulizing lesions for persistent B3 (hazard ratio, 4.72; 95% confidence interval, 1.91-11.66) and behavior transition of progressed to B3 (hazard ratio, 9.90; 95% confidence interval, 4.60-21.33). Perianal surgical treatments were performed in 104 patients (20.6%). Thirty-six cases (7.1%) were refractory, and it is independently associated with behavior of persistent B3 (P= 0.011).

CONCLUSIONS

Perianal fistulizing lesions occurred frequently in Chinese CD patients. Its incidence and refractory outcome were closely associated with the penetrating CD behavior. An additional risk of perianal fistulizing lesions was indicated for CD patients with behavior of progressing to B3, suggesting further attention.

Anti-TNF Agents and New Biological Agents (Vedolizumab and Ustekinumab) in the Prevention and Treatment of Postoperative Recurrence After Surgery in Crohn's Disease

Surgery for Crohn's disease (CD) is not curative, as postoperative recurrence (POR) after ileocolonic resection is the rule in the absence of prophylactic treatment. In the present article, we critically review available data on the role of anti-tumour necrosis factor (TNF) agents and new biologics (including vedolizumab and ustekinumab) in the prevention and treatment of POR after surgery in CD. Several studies (summarised in various meta-analyses) have confirmed the efficacy of anti-TNFs in the prevention of POR. We identified 37 studies, including 1863 CD patients, with mean endoscopic POR at 6-12 months of 29%. Only few randomised controlled trials (RCTs) have directly compared thiopurines and anti-TNFs, with controversial results, although the superiority of the latter is supported by several meta-analyses. Infliximab and adalimumab seem equally effective. The combination of anti-TNFs and immunosuppressives should be considered in patients previously exposed to anti-TNFs. Several studies have shown that anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. In fact, the use of the same anti-TNF before and after surgery might be effective for the prevention of POR. Prophylactic anti-TNF treatment, once started, should be continued long term. Anti-TNFs are also effective for the treatment of established POR. Retreatment with anti-TNFs for POR is a valid strategy even after their preoperative failure. In six studies (including 156 patients) evaluating vedolizumab, mean endoscopic POR at 6-12 months was 41%. The non-randomised comparison of anti-TNFs and vedolizumab has provided controversial results. One placebo-controlled RCT confirmed that vedolizumab is quite effective in preventing POR in CD patients with increased risk of recurrence. Seven studies (including 162 patients) evaluated ustekinumab, with a mean endoscopic POR at 6-12 months of 41%. The comparative efficacy of ustekinumab and anti-TNFs is still unclear. Ustekinumab and vedolizumab seem to be equally effective, although the experience is very limited. In conclusion, to date, anti-TNFs are the most effective agents in preventing and treating POR in CD. Anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. Vedolizumab seems to be quite effective in the prevention of POR in patients with increased risk of recurrence. Ustekinumab is probably also effective in the postoperative setting, although the comparative efficacy with anti-TNFs or vedolizumab is still unclear.

Secondary Indicators for an Evaluation and Guidance System for Quality of Care in Inflammatory Bowel Disease Centers: A Critical Review of the Inflammatory Bowel Disease Quality of Care Center

The number of patients with inflammatory bowel disease (IBD) has increased remarkably in recent years. However, the level of health care for IBD patients varies greatly among regions of China. Standardization of health care for IBD patients is essential to improve quality of care (QoC). The mission of the IBD Quality Care Evaluation Center (IBDQCC) is to establish indicators for QoC. Since 2017, the IBDQCC has developed structure, process, and outcome indicators with the steering committee of IBD specialists and methodologists; 28 core and 13 secondary IBD QoC indicators were selected using a Delphi method. Applications for certification of IBD quality care units were made voluntarily and preliminarily screened through the IBDQCC committee. Regional units had to meet all core indicators, and units of excellence were required to meet all core indicators together with an additional 50% of secondary indicators. As of 2019 and 2020, 69 IBD units (all from tertiary referral hospitals) have been certified as regional IBD units in China. The certification of excellence of the IBD units is currently undergoing auditing. The awareness of and appreciation for QoC in IBD is increasing in China, especially through the quality control evaluation program initiated by the IBDQCC, with a higher number of IBD units applying for the next round of certification. Although secondary indicators seem to play relatively minor roles in QoC, they suggest additional requirements for high-level centers.

Capsule Endoscopy Is Useful for Postoperative Tight Control Management in Patients with Crohn's Disease

BACKGROUND

In Crohn's disease, postoperative endoscopic activity of small bowel lesions outside the scope of ileocolonoscopy has been insufficiently studied.

AIMS

We aimed to assess this postoperative activity using capsule endoscopy (CE) and analyze the association between treatment optimization based on CE findings and the long-term course.

METHODS

In patients who underwent intestinal resection, we performed CE and assessed the endoscopic activity using the Lewis score within 3 months postoperatively (1st CE) and during follow-up. Postoperative treatments were adjusted according to clinical symptoms or CE findings (severity of 1st CE or worsening of follow-up CEs). Hospitalization, repeat surgery, or endoscopic dilation defined the primary outcome.

RESULTS

Among the CE group (N = 48), 85.7% (1st CE) and 79.2% (2nd CE) exhibited endoscopic activities indicating residual or recurrent lesions. Postoperative treatments were adjusted according to clinical symptoms in the non-CE group (N = 57) and clinical symptoms or CE findings in the CE group. Compared to the non-CE group, the CE group had significantly fewer primary outcomes. Patients with treatment adjustments based on CE findings had even lower primary outcome rate. Multivariate analysis identified the CE group as an independent protective factor (hazard ratio = 0.45, 95% confidence interval = 0.20-0.96). Treatment adjustments based on CE findings showed a stronger protective effect (0.30, 0.10-0.75).

CONCLUSIONS

Postoperative repeated CE enabled us to assess residual and recurrent lesions accurately before clinical symptoms appeared. The regular assessment of endoscopic activity and subsequent treatment optimization have the potential for improving postoperative course.

Changes in disease behaviour and location and factor analysis in patients with Crohn's disease undergoing repeated-resections

AIM

Crohn's disease affects the entire gastrointestinal tract and is accompanied by changes in disease location and behaviour. We aimed to analyse changes and the factors in patients with Crohn's disease undergoing intestinal repeated-resection.

METHODS

We included and retrospectively analyzed patients with Crohn's disease who received ≥2 bowel surgeries from a tertiary inflammatory bowel disease centre from January 2008 to December 2019. The Montreal classification was used to describe the disease site and behaviour. Factors were assessed by univariate and multivariate analysis.

RESULTS

A total of 339 patients were included of whom 94 patients received ≥3 bowel resections. The median patient's age at the second and third surgery was 36.4 and 39.6, respectively. Repeated-resection most commonly occurred in the original surgical site. However, disease behaviour progressed with the number of surgical interventions and disease duration, especially for patients with B1 phenotype. Patients with L1 Crohn's disease at a primary resection that progressed to L2 Crohn's disease at a second surgical resection required a resection earlier than patients whose disease remained in L1 or progressed to L3 Crohn's disease. Multivariate analysis showed that history of appendectomy was a predictor of progression from L1 to L3 Crohn's disease at a second surgical resection, while treatment with azathioprine (AZA) may be a protective factor that abated the risk of progression from L1 to L3 Crohn's disease.

CONCLUSION

The original resection site is the most common location for recurrence in patients with Crohn's disease, but disease behaviour progresses with the number of surgeries and disease duration. L1 Crohn's disease patients with a history of appendectomy have a higher risk to progress to L3 Crohn's disease at a second surgical resection, while the AZA may be a protective factor that reduces the risk of progression from L1 to L3.

Risk Factors for Postoperative Recurrence in Korean Patients with Crohn's Disease

Background/Aims

A considerable number of patients with Crohn’s disease still need intestinal resection surgery. Postoperative recurrence is an important issue in Crohn’s disease management, including the selection of high-risk patients. Eastern Asian patients showed several differences from Caucasian patients. Therefore, we investigated the postoperative surgical recurrence outcome and identified risk factors in Korean patients.

Methods

Clinical data of 372 patients with Crohn’s disease who underwent first intestinal resection between January 2004 and August 2014 at 14 hospitals in Korea were retrospectively reviewed.

Results

Over the follow-up period, 50 patients (17.1%) showed surgical recurrence. The cumulative surgical recurrence rate was 6.5% at 1 year and 15.4% at 7 years. Age under 16 (p=0.011; hazard ratio [HR], 5.136; 95% confidence interval [CI], 1.576 to 16.731), colonic involvement (p=0.023; HR , 2.011; 95% CI, 1.102 to 3.670), and the presence of perianal disease at surgery (p=0.008; HR, 2.239; 95% CI, 1.236 to 4.059) were independent risk factors associated with surgical recurrence. Postoperative thiopurine treatment (p=0.002; HR, 0.393; 95% CI, 0.218 to 0.710) was a protective factor for surgical recurrence.

Conclusions

Among the disease characteristics at surgery, younger age, colonic location, and perianal lesions were independent risk factors for surgical recurrence. Postoperative thiopurine treatment significantly reduced the incidence of surgical recurrence.

The advanced lung cancer inflammation index predicts outcomes in patients with Crohn's disease after surgical resection

AIM

Precise biomarkers for predicting prognosis could help to identify high-risk Crohn's disease (CD) patients to facilitate better follow-up during the postoperative course. In this study, the primary aim is the identification of the most reliable nutrition marker that predicts surgical relapse in CD patients.

METHOD

We first evaluated the predictive value of various nutrition markers for postoperative surgical relapse in CD patients and identified the advanced lung cancer inflammation index (ALI) as a promising biomarker. Then, we assessed the clinical significance of preoperative ALI in CD patients using two cohorts.

RESULTS

Preoperative ALI showed the highest correlation with reoperation rate compared with other nutritional parameters in CD patients receiving surgical resection (sensitivity 53%, specificity 86%, area under the curve 0.71). Lower levels of preoperative ALI were significantly correlated with the presence of perianal disease. A lower level of preoperative ALI was an independent prognostic factor for reoperation rate after an intestinal resection (hazard ratio 3.37, 95% CI 1.38-10.12, P = 0.006), and the prognostic impact of preoperative ALI was successfully validated in an independent cohort using the same cut-off value.

CONCLUSION

Preoperative ALI might be useful for postoperative management of CD patients.

Elemental diet therapy plays a significant role in preventing surgical recurrence of Crohn's disease in the era of biologics

PURPOSE

Most patients with Crohn's disease (CD) experience surgical recurrence. In this era of novel therapies, we conducted this study to clarify which treatments effectively decrease the risk of surgical recurrence in patients with CD.

METHODS

The subjects of this retrospective study were 37 patients with CD. We created cumulative surgery rate curves and performed univariate and multivariate analyses.

RESULTS

Univariate analysis revealed that patients who consumed an elemental diet (ED; ≥ 900 kcal/day), anti-tumor necrosis factor-alpha, and thiopurines had a significantly better prognosis than those who did not (p = 0.011, p = 0.025, and p = 0.0080, respectively). Multivariate analysis revealed that ED therapy and thiopurines were independent significant factors for controlling surgical recurrence (p = 0.046 and p = 0.032, respectively). Additional analyses showed that the most promising ED therapeutic dose was ≥ 1200 kcal/day, while an ED therapeutic dose of ≥ 900 kcal/day was acceptable.

CONCLUSIONS

Although univariate analyses revealed that all three treatment strategies had significant effects on surgical recurrence in patients with CD, multivariate analysis revealed that only ED therapy was significantly associated with surgical recurrence rates. Thus, ED therapy plays an important role in the management of CD, even in the era of biological therapies.

No Association between staging operation and the 5-Year Risk of Reoperation in Patients with Crohn's Disease

The aim of this study was to investigate the impact of staging operation on the risk of reoperation in patients with CD who underwent primary bowel resection. This was a retrospective study of 980 patients with CD who were hospitalized in Jinling Hospital Affiliated to Nanjing Medical University between January 1, 2001, and October 1, 2016. The patients were grouped according to staging operation (n = 64) and one-stage operation (n = 148). Postoperative intestinal function recovery time, postoperative short-term complications, and reoperation rates were compared between the two groups. There was significant difference in disease behavior between the staging operation group and the one-stage operation group. There was no significant difference in postoperative tolerance of enteral nutrition among groups (P > 0.05). Obvious differences were found in the comparison of the first time of exhaustion, defecation after operation, postoperative length of stay and postoperative complications among groups (all P < 0.05). There was no difference in the 5-year cumulative reoperation-free rates between the two groups (P > 0.05). In conclusion, surgical intervention at proper time and appropriate operation during operation are essential for patients with CD. It is believed that staging operation with ostomy followed by intestinal anastomosis is feasible when there are more than two risk factors for postoperative intra-abdominal infectious complications.