Crohn's disease: a population-based study of surgery in the age of biological therapy

Association of early therapeutic drug monitoring of adalimumab with biologic remission and drug survival in Crohn's Disease

Background

Therapeutic drug monitoring of adalimumab (ADA) is still controversial.

Objectives

To study the association between ADA trough levels in the early stages of treatment with biological remission (BR) and drug survival in Crohn's disease (CD).

Design

Retrospective cohort study.

Methods

Patients treated with ADA with available trough levels at weeks 2 and 6 (after the first induction and maintenance dose, respectively) were included. Fecal calprotectin (Fcal) and C-reactive protein (CRP) were registered at baseline, week 24, and week 52. BR was defined as Fcal <200 µg/g and CRP <5 mg/dl. Treatment survival and the need for dose escalation were assessed at week 52. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic accuracy of ADA cutoff levels for BR. Quartile-specific comparisons were performed to evaluate differences in the proportion of patients achieving BR at weeks 24 and 52, drug survival, and dose escalation.

Results

In all, 112 patients were included. ADA trough levels at week 6 were higher in patients achieving BR at week 24 (12.32 μg/ml vs 10.3 μg/ml, p = 0.0008), week 52 (12.3 μg/ml vs 10.8 μg/ml, p = 0.035), and in patients with 1-year treatment persistence (12.17 μg/ml vs 9.7 μg/ml, p = 0.03), but lower in patients requiring maintenance intensification (9.7 μg/ml vs 12.2 µg/ml, p < 0.0001). ADA week 6 trough levels >12.27 μg/ml predicted BR at week 24 with 79.7% specificity and 79.5% positive predictive value. Patients in the third quartile (Q3) and fourth quartile (Q4) of ADA levels at week 6 exhibited higher rates of BR at week 24, BR at week 52, 1-year drug survival, and less need for dose escalation (all p-values <0.05). In logistic regression, Q3 and Q4 of week 6 levels were significantly associated with BR at week 24 (p = 0.02 and p = 0.001); and week 6 Q4 with BR at week 52 (p = 0.02), treatment persistence (p = 0.03), and lower dose escalation (p = 0.004). ADA trough levels at week 2 did not show similar associations.

Conclusion

ADA trough levels at week 6 are associated with BR at weeks 24 and 52, drug survival, and need for dose escalation in CD. However, ADA concentrations at week 2 failed to yield similar results.

Characteristics and Outcomes of Over a Million Patients with Inflammatory Bowel Disease in Seven Countries: Multinational Cohort Study and Open Data Resource

BACKGROUND AND AIMS

Observational healthcare data are an important tool for delineating patients' inflammatory bowel disease (IBD) journey in real-world settings. However, studies that characterize IBD cohorts typically rely on a single resource, apply diverse eligibility criteria, and extract variable sets of attributes, making comparison between cohorts challenging. We aim to longitudinally describe and compare IBD patient cohorts across multiple geographic regions, employing unified data and analysis framework.

METHODS

We conducted a descriptive cohort study, using routinely collected healthcare data, from a federated network of data partners in sixteen databases from seven countries (USA, UK, France, Germany, Japan, Korea, and Australia); and computed the prevalence of thousands of attributes, across multiple baseline and follow-up time windows, for full disease cohorts and various strata.

RESULTS

Characterizing the disease trajectory of 462,502 Crohn's disease (CD) and 589,118 ulcerative colitis (UC) subjects, we observed a decline over time in the average age at CD diagnosis in Europe and North America but less pronounced shifts in Japan and Korea; an uptick in the proportion of patients with anxiety diagnosis prior to CD diagnosis in European and US datasets; and stable rates of segmental colonic and small bowel resections within one and three years following UC and CD diagnosis, respectively, in most US databases.

CONCLUSIONS

The study provides a comprehensive characterization of IBD patient cohorts from various countries including insights into disease trends, demographics, and pre-diagnosis symptoms. All characteristics and outcomes are publicly available, providing an unprecedented, comprehensive open resource for clinicians and researchers.

Nutritional Management in Stricturing Crohn's Disease: A Pilot Study

BACKGROUND

More than half of patients with Crohn's disease develop intestinal fibrosis induced intestinal obstruction with debilitating symptoms throughout their disease course. The incidence of stricture formation in CD has remained unchanged over the last several decades. Factors promoting intestinal fibrosis are currently unclear, but diet may represent an underestimated risk factor for intestinal fibrosis by modification of both the host immune response and intestinal microbial composition. Evaluating the impact of diet on the course of IBD is very complex. Sarcopenia is a common problem in IBD patients and correlates with an increased rate of disease. Skeletal muscle index (SMI) is an important parameter to measure sarcopenia and is an easily accessible tool for evaluating the likelihood of complications in individuals with CD.

METHODS

Using a randomized and controlled pilot design, we aimed to investigate the efficacy of 12 months of short-term dietary intervention based on essential amino acid (EAA) and sodium butyrate (NaB) supplementation in the management of stricturing Crohn's disease patients.

RESULTS

After the treatment in the diet EAA/NaB group, we revealed a statistically significant improvement of muscle mass (61.49 ± 5.47 vs. control 86 ± 10.70, p = 0.01) and SMI index (9.97 ± 1.79 vs. control 7.60 ± 2.29, p = 0.02). In addition, the measurement of skeletal muscle mass in CD patients has been suggested to be crucial for predicting the disease course. Indeed, after one year, surgery was required in 4/10 control group patients (40%) and 1/10 study group (10%) patients, underlining the importance of body composition alterations and adequate dietary intake in the management of these patients.

CONCLUSIONS

Further prospective studies are needed to confirm these results; nonetheless this nutritional approach could become an integral part in the treatment of stricturing CD patients to improve disease outcomes and increase the quality of life in these patients.

Perioperative Enhanced Recovery Concepts Significantly Improve Postoperative Outcome in Patients with Crohn`s Disease

BACKGROUND AND AIMS

Despite recent advancements in medical and surgical techniques in patients suffering from Crohn`s disease [CD], postoperative morbidity remains relevant due to a long-standing, non-curable disease burden. As demonstrated for oncological patients, perioperative enhanced recovery concepts provide great potential to improve postoperative outcome. However, robust evidence about the effect of perioperative enhanced recovery concepts in the specific cohort of CD patients is lacking.

METHODS

In a prospective, single-centre study, all patients receiving ileocaecal resection due to CD between 2020 and 2023 were included. A specific, perioperative, enhanced recovery concept [ERC] was implemented and patients were divided into two groups [before and after implementation]. The primary outcome focused on postoperative complications as measured by the Comprehensive Complication Index [CCI], secondary endpoints were severe complications, length of hospital stay, and rates of re-admission.

RESULTS

Of 83 patients analysed, 33 patients participated in the enhanced recovery programme [post-ERC]. Whereas patient characteristics were comparable between both groups, ERC resulted in significantly decreased rates of overall and severe postoperative complications [CCI: 21.4 versus 8.4, p = 0.0036; Clavien Dindo > 2: 38% versus 3.1%, p = 0.0002]. Additionally, post-ERC-patients were ready earlier for discharge [5 days versus 6.5 days, p = 0.001] and rates of re-admission were significantly lower [3.1% versus 20%, p = 0.03]. In a multivariate analysis, the recovery concept was identified as independent factor to reduce severe postoperative complications [p = 0.019].

CONCLUSION

A specific, perioperative, enhanced recovery concept significantly improves the postoperative outcome of patients suffering from Crohn`s disease.

Progression of Crohn's Disease in Newly Diagnosed Patients: Results from an Observational Study Using US Claims Data

BACKGROUND

Patients with Crohn's disease (CD) experience disease progression over time, including strictures/stenoses, penetrating fistulae, and abscesses.

AIMS

This retrospective US population-based study aimed to characterize CD progression in newly diagnosed patients.

METHODS

Patient-level data from the Optum® Market Clarity database from January 1, 2016, to June 30, 2020, were used. The study comprised a 12-month baseline period (pre-diagnosis), an index date (diagnosis date), and a follow-up period. The risk of, and time to, CD progression since CD diagnosis, dispensed treatment changes following CD progression, and healthcare resource utilization before and after CD progression were assessed.

RESULTS

Overall, 6804 newly diagnosed patients were included. Of these, 1714 (25.2%) experienced CD progression as follows: 19.3% (1183/6117) in the first 6 months, 21.6% (1188/5503) by 1 year, 24.6% (953/3875) by 2 years, and 26.6% (444/1668) by 3 years. Intestinal obstruction/stenosis was more common than fistula or abscess. Among patients with CD progression, the median (interquartile range) estimated time to progression was 2 (0-140) days; the shortest time to progression was seen with a first intestinal obstruction/stenosis (0 [0-137] days). The frequency of several dispensed treatments increased following CD progression. Among patients who experienced progression, CD-related inpatient hospital admissions/visits increased from 436 of 1714 patients (25.4%) in the month before progression to 965 (56.3%) in the month after progression.

CONCLUSIONS

Over one quarter of patients with newly diagnosed CD experienced CD progression and complications within 3 years of diagnosis, highlighting the importance of monitoring for progression and early intervention to limit progression.

Epidemiological investigation of different types of Crohn's disease patients undergoing first abdominal surgery in the era of biological agents: a population-based cohort study

BACKGROUND

Before the era of biological agents, most Crohn's disease patients required at least one intestinal resection surgery after diagnosis. However, clinical data regarding the abdominal surgery rates for Crohn's disease patients in the era of biological agents is not yet fully clear and needs to be updated.

MATERIALS AND METHODS

We retrospectively collected clinical data from 1115 Crohn's disease patients diagnosed and treated medically at The Second Xiangya Hospital of Central South University from January 2016 to January 2024. Using abdominal intestinal resection surgery as a clinical outcome, propensity score matching was employed to eliminate confounding factors. We explored the timing and proportion of abdominal surgery in patients with different Montreal classifications of Crohn's disease during the natural course of the disease, as well as the impact of the duration of the natural course and the use of biological agents on surgical outcomes.

RESULTS

Montreal classification type B had the greatest impact on Crohn's disease surgery, especially with a higher proportion of type B3 patients undergoing surgery. Type A1 Crohn's disease patients underwent surgery earlier than types A2 and A3. The occurrence of behavior changes (B Change) during the natural course of the disease is a poor prognostic signal, indicating a significantly increased likelihood of surgery. The duration of the natural course from the onset of gastrointestinal symptoms to diagnosis and clinical observation outcomes did not directly affect the likelihood of surgery in Crohn's disease patients. Compared with Crohn's disease patients who did not receive biological agents, the surgery rate was significantly lower in patients who used biological agents. Additionally, Crohn's disease patients who received biological agents within 1 month of diagnosis had a significantly lower likelihood of undergoing surgical intervention. Moreover, Crohn's disease patients who received biological agent treatment within 19 months of the onset of gastrointestinal symptoms also had a significantly lower likelihood of undergoing surgery than other Crohn's disease patients.

CONCLUSIONS

In the era of biological agents, the risk of surgical intervention varies among Crohn's disease patients with different Montreal classifications, particularly when there is type B3 disease or a B Change. Clinicians should pay closer attention to surgical indications in such cases. For Crohn's disease patients, shortening the natural course before diagnosis and early use of biological agents after diagnosis can significantly reduce the risk of abdominal surgery.

Outcomes after right-sided colon surgery in Crohn's disease versus cancer

BACKGROUND

Surgery for Crohn's disease (CD) is considered to have more complications due to the underlying inflammation, immunosuppression, and malnutrition. We sought to study the outcomes of right-sided colonic resection in patients with CD and patients with cancer at a high-volume tertiary center utilizing a standardized perioperative protocol.

METHODS

This is a retrospective study of outcomes for all patients with CD or patients undergoing ileocolic resection or right hemicolectomy with ileocolic anastomosis at a single institution from 2013 to 2022. Patients were excluded if they simultaneously underwent another procedure or ostomy creation. Data were analyzed using Wilcoxon rank-sum and chi-squared tests for univariate analyses, and logistic and linear regressions for multivariate analyses.

RESULTS

In total 141 patients with CD and 589 patients with cancer were included. Patients with CD were significantly younger with lower body mass index and less likely to have comorbidities, including diabetes and hypertension. Patients with CD were less likely to have a smoking history or prior abdominal surgery, but more likely to be on steroids. Both groups had similar rates of laparoscopy, intraoperative complications, and blood loss. Despite the preoperative and intraoperative differences, both patients with CD and patients with cancer had similar lengths of stay (LOS), readmission, reoperation, and mortality rates. None of the surgical outcomes differed significantly between the two groups. On multivariate analysis, CD diagnosis was not associated with reoperation, readmission, mortality, or LOS while controlling for other characteristics.

CONCLUSIONS

With the use of standardized perioperative protocols, surgery for CD at a high-volume center with expertise in CD can be performed with comparable results to other indications like cancer.

National 30-Day Readmission Trends in IBD 2014-2020-Are We Aiming for Improvement?

Background: Inflammatory bowel disease (IBD) prevalence in Eastern Europe is increasing. The 30-day readmission rate is a crucial quality metric in healthcare, reflecting the effectiveness of initial treatment and the continuity of care post-discharge; however, such parameters are rarely analyzed. The aim of this study was to explore the trends in 30-day readmissions among patients with inflammatory bowel disease in Latvia between 2014 and 2020. Methods: This is a retrospective trends study in IBD-ulcerative colitis and Crohn's disease (UC and CD)-patients in Latvia between 2014 and 2020, involving all IBD patients identified in the National Health service database in the International Classification of Diseases-10 (ICD) classification (K50.X and K51.X) and having at least one prescription for IBD diagnoses. We assessed all IBD-related hospitalizations (discharge ICD codes K50X and K51X), as well as hospitalizations potentially related to IBD comorbidities. We analyzed hospitalization trends and obtained the 30 day all-cause readmission rate, disease specific readmission rate and readmission proportion for specific calendar years. Trends in readmissions and the mean length of stay (LOS) for CD and UC were calculated. Results: Despite a decrease in admission rates observed in 2020, the total number of readmissions for CD and UC has increased. Female patients prevailed through the study period and were significantly older than male patients in both the CD and UC groups, p < 0.05. We noted that there was no trend for 30 day all-cause readmission rate for CD (p > 0.05); however, there was a statistically significant trend for 30 day all-cause readmission for UC patients (p-trend = 0.018) in the period from 2014 to 2019. There was a statistically significant trend for CD-specific readmission rate (p < 0.05); however, no statistically significant trend was observed for UC-specific readmission (p > 0.05). An exploratory analysis did not reveal any statistically significant differences between treated and not-treated IBD patients (p > 0.05). The increasing trend is statistically significant over the period 2014-2018 (p < 0.05); however, the trend interrupts in 2020, which can be associated with the COVID-19 global pandemic and the related changes in admission flows where the gastroenterology capacity was reallocated to accommodate increasing numbers of COVID-19 patients. More studies are needed to evaluate the long-term impact of COVID-19 pandemic and 30-day readmissions. No significant dynamics were observed in the mean total hospitalization costs over the 2014-2020 period.

Relationship between histopathological findings, clinical severity and the need for surgery in patients with Crohn's disease

INTRODUCTION

Defining histological variables that make it possible to establish the activity of Crohn's disease (CD) and predict the patients who may present a higher risk of clinical complications and surgical interventions could lead to timely adjustments in medical therapy and elective surgeries that represent a lower risk of complications. The purpose of the study is to determine the relation between the histopathological findings using the Naini and Cortina (N&C) score, the clinical severity, and the indication for surgery in a group of patients with CD.

MATERIALS AND METHODS

Descriptive, retrospective, cross-sectional study of 44 patients diagnosed with CD, treated at the San Vicente Fundación University Hospital in Medellín, Colombia, between 2010 and 2022.

RESULTS

Of the 44 patients, 36 ileum samples and 34 colon samples were obtained. Of the patients with inflammatory behavior, 87.5% did not have surgical intervention (P=.022), a value that remained significant in the ileum subgroup (P=.0058). 91.3% of the patients with ileal involvement did not develop perianal disease (P=.01). Granulomas only occurred in two patients with a colon sample (5.8%). In the histological score of N&C both in the ileum and in the colon, no statistically significant differences were obtained in relation to the surgical outcome (P=.34 and P=.054, respectively).

CONCLUSION

The histological index of N&C was not a predictor in Crohn's disease (CD) related to the surgical outcome.

Postoperative outcomes of surgical delay in inflammatory bowel disease patients: a multicenter cohort study

Postponement of surgical inflammatory bowel disease (IBD) care may lead to disease progression. This study aims to determine the influence of delayed surgical IBD procedures on clinical outcomes. This multicenter retrospective cohort study included IBD patients who underwent a surgical procedure during the Coronavirus disease 2019 (COVID-19) pandemic from March 16, 2020, to December 31, 2020, and were compared to a pre-COVID-19 cohort. The primary endpoint was determining the number of (major) postoperative complications. Secondary endpoints were the time interval between surgical indication and performance of the surgical procedure and the risk factors of postoperative complications using multivariate analysis. Eighty-one IBD patients who underwent a surgical procedure were included. The median time interval between surgical indication and performance of the surgical procedure did not differ between the COVID-19 and pre-COVID-19 cohorts (34 vs. 33.5 days, p = 0.867). Multivariate analysis revealed a longer time interval between surgical indication and surgical procedure significantly correlated with the risk of developing postoperative complications [odds ratio (OR) 1.03, p = 0.034]. Moreover, previous surgery was identified as an independent predictor (OR 4.25, p = 0.018) for an increased risk of developing major postoperative complications. There was no significant surgical delay for patients with IBD in the COVID-19 pandemic cohort compared to the pre-pandemic cohort. However, a longer time interval between surgical indication and surgical procedure significantly correlated with the risk of developing postoperative complications. In the event of future scarcity in healthcare, efforts should be made to continue surgical procedures in IBD patients.

Inhibition of Transmural Inflammation in Crohn's Disease by Orally Administered Tumor Necrosis Factor-Alpha Deoxyribozymes-Loaded Pyroptosis Nanoinhibitors

Crohn's disease (CD) is a refractory chronic inflammatory bowel disease (IBD) with unknown etiology. Transmural inflammation, involving the intestine and mesentery, represents a characteristic pathological feature of CD and serves as a critical contributor to its intractability. Here, this study describes an oral pyroptosis nanoinhibitor loaded with tumor necrosis factor-α (TNF-α) deoxyribozymes (DNAzymes) (DNAzymes@degradable silicon nanoparticles@Mannose, Dz@MDSN), which can target macrophages at the site of inflammation and respond to reactive oxygen species (ROS) to release drugs. Dz@MDSN can not only break the inflammatory cycle in macrophages by degrading TNF-α mRNA but also reduce the production of ROS mainly from macrophages. Moreover, Dz@MDSN inhibits excessive pyroptosis in epithelial cells through ROS clearance, thereby repairing the intestinal barrier and reducing the translocation of intestinal bacteria to the mesentery. Consequently, these combined actions synergistically contribute to the suppression of inflammation within both the intestine and the mesentery. This study likely represents the first successful attempt in the field of utilizing nanomaterials to achieve transmural healing for CD, which also provides a promising treatment strategy for CD patients.

Development and validation of a scale to measure the care needs of Crohn's disease patients: a mixed-methods study

BACKGROUND

Crohn's disease (CD) patients require varying levels of supportive care. In order to facilitate caregivers and nurses in precisely evaluating the caregiving requirements of these patients, we developed the CD-specific Care Needs Scale (CD-CNS).

METHODS

This study employed a mixed-methods approach, integrating qualitative and quantitative methodologies. The initial items of the scale were developed through qualitative interviews, Delphi expert consultation, and literature review, while the final items were refined through clinical testing. Qualitative interviews were conducted based on the supportive care needs framework and Maslow's hierarchy of needs, and scale items were constructed through a literature search and qualitative interviews. The initial version of the scale with 45 items was obtained after the items were verified and modified by expert consultation. A total of 250 CD patients admitted to the gastroenterology department of a hospital in China were selected for verification of the initial version of the scale. A self-designed general questionnaire was used to obtain patients' medical history and sociodemographic data, and the Chinese version of the Inflammatory Bowel Disease Questionnaire (IBDQ) was used as the criterion. Exploratory factor analysis (EFA) was performed on the CD-CNS to evaluate the dimensions, factor structure, reliability, criterion validity, and construct validity.

RESULTS

EFA identified 5 dimensions and retained 27 items with strong internal consistency reliability (α = 0.940). The Cronbach's α coefficients for each dimension ranged from 0.824 to 0.921. Criterion validity was assessed using Spearman's coefficient, which demonstrated a significant correlation with the IBDQ (P < 0.050). The test-retest reliability for each dimension after two weeks ranged from 0.655 to 0.895.

CONCLUSIONS

We developed and validated a new scale that can be used to assess the care needs of CD patients. This new tool can guide the specific supportive care of CD patients.

TRIAL REGISTRATION

This study was reviewed and approved by the Ethics Committee of the Second Hospital of Nanjing (2021-LS-ky-022). The study was duly registered and approved online through the Trial Center of the Second Hospital of Nanjing in 2021. Confidentiality was ensured by anonymizing all the data. The entire study process was conducted under the supervision of the Ethics Committee of Nanjing Second Hospital. Informed consent was obtained from the patients, and each patient volunteered and agreed to participate.

Impact of Biologics and Small-Molecule Agents on Postoperative Complications in IBD: A Systematic Review

BACKGROUND

Patients with IBD may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. The question of the impact of biologic use on postoperative complications is a topic of active investigation.

OBJECTIVE

A systematic literature review was performed to describe the current state of knowledge of the impact of perioperative biologic and tofacitinib use on postoperative complications in patients with IBD.

DATA SOURCES

PubMed and Cochrane databases were searched.

STUDY SELECTION

Studies between January 2000 and January 2023, in any language, were searched, followed by a snowball search identifying further studies in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Articles regarding pediatric or endoscopic management were excluded.

INTERVENTIONS

Preoperative or perioperative exposure to biologics in IBD was included.

MAIN OUTCOME MEASURES

Infectious and noninfectious complications, including anastomotic leaks, surgical site infections, urinary tract infections, pneumonia, sepsis, septic shock, postoperative length of stay, readmission, and reoperation, were the main outcomes measured.

RESULTS

A total of 28 studies were included for analysis in this review, including 7 meta-analyses or systematic reviews and 5 randomized studies. Snowball search identified 11 additional studies providing topical information. Overall, tumor necrosis factor inhibitors likely do not increase the risk of postoperative adverse outcomes, while data on other biologics and small-molecule agents are emerging.

LIMITATIONS

This is a qualitative review including all study types. The varied nature of study types precludes quantitative comparison.

CONCLUSIONS

Although steroids increase postoperative infectious and noninfectious complications, tumor necrosis factor inhibitors do not appear to increase postoperative infectious and noninfectious complications. There is a need for further perioperative data for other agents. See video from symposium .

Positive resection margins in Crohn's disease are a relevant risk factor for postoperative disease recurrence

Postoperative disease recurrence in Crohn's disease represents a relevant issue despite recent advancements in surgical and medical therapies. Additional criteria are necessary to improve the identification of patients at risk and to enable selective therapeutic approaches. The role of resection margins on disease recurrence remains unclear and general recommendations are lacking. A single-center retrospective analysis was performed including all patients who received ileocecal resection due to Crohn's disease. Resection margins were analyzed by two independent pathologists and defined by histopathological criteria based on previous consensus reports. 158 patients were included for analysis with a median follow up of 35 months. While postoperative morbidity was not affected, positive resection margins resulted in significantly increased rates of severe endoscopic recurrence at 6 months (2.0% versus 15.6%, p = 0.02) and overall (4.2% versus 19.6%, p = 0.001), which resulted in significantly increased numbers of surgical recurrence (0% versus 4.5%, p = 0.04). Additionally, positive margins were identified as independent risk factor for severe endoscopic disease recurrence in a multivariate analysis. Based on that, positive margins represent an independent risk factor for postoperative endoscopic and surgical disease recurrence. Prospective studies are required to determine whether extended resection or postoperative medical prophylaxis is beneficial for patients with positive resection margins.

Fractal analysis of extracellular matrix for observer-independent quantification of intestinal fibrosis in Crohn's disease

Prevention of intestinal fibrosis remains an unresolved problem in the treatment of Crohn's disease (CD), as specific antifibrotic therapies are not yet available. Appropriate analysis of fibrosis severity is essential for assessing the therapeutic efficacy of potential antifibrotic drugs. The aim of this study was to develop an observer-independent method to quantify intestinal fibrosis in surgical specimens from patients with CD using structural analysis of the extracellular matrix (ECM). We performed fractal analysis in fibrotic and control histological sections of patients with surgery for CD (n = 28). To specifically assess the structure of the collagen matrix, polarized light microscopy was used. A score to quantify collagen fiber alignment and the color of the polarized light was established. Fractal dimension as a measure for the structural complexity correlated significantly with the histological fibrosis score whereas lacunarity as a measure for the compactness of the ECM showed a negative correlation. Polarized light microscopy to visualize the collagen network underlined the structural changes in the ECM network in advanced fibrosis. In conclusion, observer-independent quantification of the structural complexity of the ECM by fractal analysis is a suitable method to quantify the degree of intestinal fibrosis in histological samples from patients with CD.

The long-term effect on surgery-free survival of biological compared to conventional therapy in Crohn's disease in real world-data: a retrospective study

BACKGROUND

The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and, in particular, that it could lead to a significant reduction in surgery in the short and long term. This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn's disease (CD) who were never with the surgical option.

METHODS

This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L'Aquila. Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group. Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population.

RESULTS

Two hundred three CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Meier survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p = 0.03). However, after propensity matching analysis, conducted on 143 patients, no significant difference was found in surgery-free survival (p = 0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p = 0.02; Hazard Ratio 2.9; CI 1.01-8.54) while no significant difference was found between the biologic and conventional post-biologic groups (p = 0.15; Hazard Ratio 2.1; CI 0.69-6.44).

CONCLUSION

This study shows that the introduction of biological therapy has only a slight impact on the eventual occurrence of surgery in CD patients over a long observation period. Nevertheless, biological therapy appears to delay the first intestinal resection.

Early Initiation of Adalimumab Significantly Diminishes Postoperative Crohn's Disease Endoscopic Recurrence and Is Superior to 6-Mercaptopurine Therapy: An Open-Label, Randomized Controlled Study

Postoperative recurrence (POR) is the rule in patients with Crohn's disease (CD), mitigated with prophylactic therapy. The evidence for therapeutic choice and timing of intervention is lacking. We aimed to compare the rates of POR in patients treated early with prophylactic 6-mercaptopurine (6-MP) or adalimumab. We conducted a prospective single-center randomized open-label clinical study in which patients in surgical remission following their first ileocecectomy were randomized to receive early treatment with 6-MP or adalimumab. Patients were followed up clinically every 3 months and underwent endoscopy at weeks 32 and 58 postoperatively. The primary endpoint was endoscopic recurrence (ePOR) at 1 year (week 58), defined as a Rutgeerts score ≥ i2. We enrolled 35 patients (25 males, mean age 35 ± 1.4 years, median disease duration 5 ± 6.1 years) following ileocecectomy. Of these, seven (20%) were current smokers and nine (26%) biologics-experienced. Patients allocated to adalimumab had significantly less ePOR than patients treated with 6MP at week 32 (21% vs. 69%, p = 0.004) and 58 (47% vs. 75%), (p = 0.03, HR = 0.39, 95% CI = 0.16-0.93). POR was associated with an increased diameter of the resected small bowel surgical specimen, lower baseline body mass index (BMI), increased week 18 fecal calprotectin, increased week 18 serum alanine aminotransferase and decreased week 18 hemoglobin level. Adalimumab was more effective than 6-MP in preventing ePOR. Increased operative small bowel diameter and lower postoperative BMI were associated with ePOR. At eighteen weeks, serum hemoglobin, ALT and fecal calprotectin levels were predictive of endoscopic disease recurrence. (ClinicalTrials.gov ID NCT01629628).

Mathematical Models Including microRNA Levels of Mesenteric Adipose Tissue May Predict Postoperative Relapse in Crohn's Disease Patients

Background and Aims

Recent evidence suggests that the mesenteric adipose tissue (MAT) near the affected intestine may play a role in Crohn's disease (CD) pathophysiology. Modulation of several transcripts has already been identified in the MAT of CD in the literature. Therefore, our aim was to validate the microRNA (miRNA) transcript levels and their target genes in the MAT of active CD patients and correlate them with clinical and epidemiological data.

Methods

Samples from the MAT of surgical specimens from 25 active CD patients were obtained. The control group comprised fifteen patients who underwent surgery for other diseases, except inflammatory bowel diseases. Transcriptional levels of miRNA and their target genes were assessed by quantitative real-time polymerase chain reaction. The correlation between transcripts and clinical characteristics was obtained using multiple linear regression. The mathematical models (M) underwent a statistical filter to ensure robustness and reliability (P value < .05; adjusted R-squared (Rˆ2)> .99; correct predictions of more than 60%).

Results

miRNA-650 and miRNA-29c were upregulated in the MAT of CD compared to the control group (P < .0001 and P = .0032, respectively), besides presenting decreased levels of their target genes. Two were target genes of the miRNA-650: glutamine-fructose-6-phosphate transaminase 2 (P = .012) and aldehyde dehydrogenase 4 family (P = .0035); and 4 were targets of the miRNA-29c: cell death-inducing DFFA-like effector c (P = .001), E2F transcription factor-1 (P = .007), hypoxia-inducible factor 3 subunit alpha (P = .0029), and pyruvate dehydrogenase kinase 4 (P = .0054). We found 2 M with statistical strength and robustness. The performance test identified one model with 100% accuracy for predicting the month of recurrence and determining patients with less risk of early relapse after surgery.

Conclusion

We demonstrate that miRNA-650 and miRNA-29c and some of their target genes, besides clinical and epidemiological variables, may be useful in a model to predict when disease relapse may occur in CD patients who underwent surgery. These findings constitute a potential tool to guide postoperative clinical management.

Temporal trends in surgery for Crohn's disease: a ten-year single-center retrospective study

PURPOSE

Crohn's disease (CD) is a chronic inflammatory bowel disease that requires surgery in many cases. The aim of this article is to present the experience of a referral center regarding surgical interventions for CD, while also exploring the transformations that have occurred over 10 years.

METHODS

The data of patients underwent abdominal surgery for CD between 2013 and 2022 were collected prospectively. Data were compared between two periods (2013-2017 and 2018-2022). Temporal trends were assessed with the Mann-Kendall trend test.

RESULTS

A total of 1059 individuals underwent 1176 surgical procedures, of which 67.1% were male. The median age of patients at the time of surgery was 36.0 years, and an overall increasing trend was observed in surgical volume (z = 3.04; p = 0.002). The proportion of patients treated with biologics increased from the first period (2013-2017) to the second (2018-2022), rising from 19.2% to 33.5% (p < 0.001). In the second stage, the proportion of patients who underwent surgery for abscesses or fistulas increased (47.8% vs. 40.0%, p = 0.028), while the percentage of emergency surgeries declined (3.0% vs. 7.1%, p = 0.001). Furthermore, there was a rise in the proportion of laparoscopic surgeries (76.5% vs. 63.7%, p < 0.001), coupled with a decrease in stoma rates (15.4% vs. 30.5%, p < 0.001) and postoperative complications (23.0% vs. 30.5%, p = 0.007).

CONCLUSION

The frequency of biologics use in CD surgery have increased over time, and the proportion of penetrating patients has grown. Minimally invasive surgical methods have become the norm, and surgical outcomes have markedly enhanced, evidenced by a substantial reduction in both stoma rates and complication rates.

Prophylactic Treatment with Vedolizumab in the Prevention of Postoperative Recurrence (POR) in High-Risk Crohn's Patients

About 50% of Crohn's Disease (CD) patients undergo an intestinal resection during their lifetime. Although the patients experience a fairly long period of well-being after the intestinal resection, they presented a postoperative recurrence (POR) in 40% of cases within 5 years. In this case series, we aimed to evaluate the incidence of POR in CD patients with high risk for early POR, prophylactically treated with Vedolizumab. All consecutive CD patients (followed from 2017 to 2020) who underwent ileocolonic resection after the loss of response at anti-Tumor Necrosis Factor α (anti-TNFα) and with one or more risk factors for early POR were included. POR was defined as a Rutgeerts score (Ri) > 1 at the colonoscopic evaluation. All the included patients underwent a Magnetic resonance enterography (MRE) at least one year after the surgical resection. Six patients (4 Female; 2 Males) were included. At the first endoscopic evaluation, all patients were in endoscopic remission (5 patients Ri 0; 1 patient Ri 1). No stenosis nor other intestinal wall changes or complications were observed at MRE. Five patients underwent colonoscopy over two years of follow-up (median: 32 months; range 25-33). The Ri score was 0 in four patients, while the fifth patient showed severe endoscopic relapse. The same patient presented a clinical relapse (Harvey-Bradshaw index = 10) with a flare of disease in the colonic mucosa. These data suggest that early post-operative treatment with Vedolizumab could be a valuable strategy to be submitted to a prospective controlled trial for preventing POR.

Burden of disease among patients with prevalent Crohn's disease: results from a large German sickness fund

PURPOSE

The aim of this study was to investigate the burden of disease among a real-world cohort of patients with prevalent Crohn's disease (CD) in Germany.

METHODS

We conducted a retrospective cohort analysis using administrative claims data from the German AOK PLUS health insurance fund. Continuously insured patients with a CD diagnosis between 01 October 2014 and 31 December 2018 were selected and followed for at least 12 months or longer until death or end of data availability on 31 December 2019. Medication use (biologics, immunosuppressants (IMS), steroids, 5-aminosalicylic acid) was assessed sequentially in the follow-up period. Among patients with no IMS or biologics (advanced therapy), we investigated indicators of active disease and corticosteroid use.

RESULTS

Overall, 9284 prevalent CD patients were identified. Within the study period, 14.7% of CD patients were treated with biologics and 11.6% received IMS. Approximately 47% of all prevalent CD patients had mild disease, defined as no advanced therapy and signs of disease activity. Of 6836 (73.6%) patients who did not receive advanced therapy in the follow-up period, 36.3% showed signs of active disease; 40.1% used corticosteroids (including oral budesonide), with 9.9% exhibiting steroid dependency (≥ 1 prescription every 3 months for at least 12 months) in the available follow-up.

CONCLUSIONS

This study suggests that there remains a large burden of disease among patients who do not receive IMS or biologics in the real world in Germany. A revision of treatment algorithms of patients in this setting according to the latest guidelines may improve patient outcomes.

Percutaneous Drainage vs. Surgery as Definitive Treatment for Anastomotic Leak after Intestinal Resection in Patients with Crohn's Disease

BACKGROUND

Anastomotic leak (AL) remains one of the most relevant complications after intestinal resection for Crohn's disease (CD). While surgery has always been considered the standard treatment for perianastomotic collection, percutaneous drainage (PD) has been proposed as a potential alternative.

METHODS

Retrospective study in consecutive patients treated with either PD or surgery for AL after intestinal resection for CD between 2004 and 2022. AL was defined as a perianastomotic fluid collection confirmed by radiological findings. Patients with generalized peritonitis or clinical instability were excluded.

PRIMARY AIM

To compare the success rate of PD vs. surgery. Secondary aims: To compare the outcomes at 90 days after the procedures; to identify the variables associated with the indication for PD.

RESULTS

A total of 47 patients were included, of which 25 (53%) underwent PD and 22 (47%) surgery. The success rate was 84% in the PD and 95% in the surgery group (p = 0.20). There were no significant differences between the PD and surgery group in postoperative medical and surgical complications, discharge, readmission or reoperation rates at 90 days. PD was more likely to be performed in patients with later diagnosis of AL (OR 1.25, 95% CI 1.03-1.53, p = 0.027), undergoing ileo-colic anastomosis alone (OR 3.72, 95% CI 2.29-12.45, p = 0.034) and treated after 2016 (OR 6.36, 95% CI 1.04-39.03, p = 0.046).

CONCLUSION

The present study suggests that PD is a safe and effective procedure to treat anastomotic leak and perianastomotic collection in CD patients. PD should be indicated in all eligible patients as an effective alternative to surgery.

Timing of individualized surgical intervention in Crohn’s disease

Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with an increasing incidence worldwide. Comprehensive therapy for CD focuses on symptom control and healing the intestinal mucosa to improve the quality of life and prevent complications. Surgical intervention plays a vital role in comprehensive therapy. However, deciding the optimal timing for surgical intervention has long been a focus of controversy. This review provides insights into the timing of surgery for CD and guides clinicians in daily treatment.

Incidence and impact of venous thromboembolism in hospitalized patients with Crohn's disease

BACKGROUND

Crohn's disease (CD) is associated with an increased risk for venous thromboembolism (VTE). Beside higher VTE risk, data on impact of VTE on survival and risk factors for the occurrence of VTE in CD are sparse.

METHODS

The German nationwide inpatient sample was screened for patients admitted due to CD (ICD-code K50). CD hospitalizations were stratified for VTE and risk-factors for VTE and impact of VTE on in-hospital case-fatality rate were investigated.

RESULTS

Overall, 333,975 hospitalizations of patients due to CD were counted in Germany (median age 38.0 [IQR 24.0-52.0] years, 56.0 % females) during the observational period 2005-2018. VTE rate increased slightly from 0.6 % (2005) to 0.7 % (2018) (β 0.000097 [95%CI 0.000027 to 0.000167], P = 0.007) 2005-2018 and with age-decade (β 0.0017 [95%CI 0.0016 to 0.0019], P < 0.001). In total, 0.7 % (2295) of the CD inpatients had a VTE event. Patients with VTE were in median 12 years older (49.0 [34.0-62.0] vs. 37.0 [24.0-52.0] years, P < 0.001) and colon-involvement was in those patients more prevalent (32.0 % vs.27.7 %, P < 0.001). Age ≥ 70 years, obesity, colon-involvement, cancer, surgery, thrombophilia, and heart failure were strongly associated with higher risk of VTE in CD patients. In-hospital death occurred 15-times more often in CD with VTE than without (4.5 % vs. 0.3 %, P < 0.001). VTE was independently associated with increased in-hospital case-fatality rate (OR 9.31 [95%CI 7.54-11.50], P < 0.001).

CONCLUSIONS

VTE is a life-threatening event in hospitalized CD patients associated with 9.3-fold increased case-fatality rate. Older age, obesity, colon involvement, cancer, surgery, thrombophilia and heart failure were strong risk factors for VTE in CD.

Assessment of influencing factors of hospitalization expenses for Crohn's disease patients: Based on LASSO and linear mixed model

Aims

Crohn's disease (CD) is a global disease that is dramatically increasing. This study aimed to identify the primary drivers of hospitalization expenses for CD patients to provide guidance on the allocation and control of health care costs.

Methods

This study retrospectively collected the homepage data of the electronic medical records of CD patients in two tertiary hospitals in Zhejiang Province, China, from January 2016 to December 2021. The influencing factors of hospitalization expenses for CD were analyzed. A linear mixed model with least absolute shrinkage (LASSO-LMM) was used to develop a predictive model for hospitalization expenses for CD patients.

Results

A total of 4,437 CD patients were analyzed in this study. CD patients' age, length of hospital stay, admission route, comorbidities, and main treatment were found to be statistically significant variables for CD patients' hospitalization expenses. The AIC and BIC of LASSO-LMM model were 319.033 and 306.241, respectively. Patients who were older, had a longer hospital stay, and had comorbidities had higher hospitalization expenses. The hospitalization expenses of outpatients were lower than those of emergency patients. The weight of surgical treatment was the highest among three treatments (0.602).

Conclusions

Identifying and examining factors that influence hospitalization expenses for CD patients can help to control healthcare expenditures. Treatment mode was the most important impact on CD hospitalization expenses. Medical security departments can consider implement personalized and precise hospitalization expense compensation scheme base on LASSO-LMM prediction model in the future.