Practice parameters for the surgical treatment of ulcerative colitis

Early Pouchitis Is Associated With Crohn's Disease-like Pouch Inflammation in Patients With Ulcerative Colitis

BACKGROUND

Despite the initial diagnosis of ulcerative colitis (UC), approximately 10% to 20% of patients develop Crohn's disease-like pouch inflammation (CDLPI) after restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate whether early pouchitis, defined as pouchitis within the first year after IPAA, is a predictor of CDLPI.

METHODS

This was a retrospective cohort analysis of patients with UC or IBD unclassified (IBDU) who underwent RPC with IPAA at Mount Sinai Hospital between January 2008 and December 2017. The primary outcome was development of CDLPI. Predictors of CDLPI were analyzed via univariable and multivariable Cox regression models.

RESULTS

The analytic cohort comprised 412 patients who underwent at least 1 pouchoscopy procedure between 2009 and 2018. Crohn's disease-like pouch inflammation developed in 57 (13.8%) patients a median interval of 2.1 (interquartile range, 1.1-4.3) years after surgery. On univariable analysis, older age at colectomy (hazard ratio [HR], 0.97; 95% CI, 0.95-0.99) was associated with a reduced risk of CDLPI; although early pouchitis (HR, 2.43; 95% CI, 1.32-4.45) and a greater number of pouchitis episodes (HR, 1.38; 95% CI, 1.17-1.63) were associated with an increased risk. On multivariable analysis, early pouchitis (HR, 2.35; 95% CI, 1.27-4.34) was significantly associated with CDLPI. Time to CDLPI was significantly less in patients who developed early pouchitis compared with those who did not (P = .003).

CONCLUSION

Early pouchitis is significantly associated with subsequent CDLPI development and may be the first indication of enhanced mucosal immune activation in the pouch.

Depression and Anxiety Disorders Impact in the Quality of Life of Patients with Inflammatory Bowel Disease

Objective

Anxiety and depression have a negative influence in the quality of life. The aim of the study was to determinate the levels of sensitivity and specificity of the Anxiety and Hospital Depression Scale (HADS) and compare the quality of life in patients with inflammatory bowel disease (IBD) and depression or anxiety.

Methods

This study included 104 patients with diagnosis of IBD. Each patient received psychiatric intervention with SCID-I (Structured Clinical Interview for DSMIV Axis I Disorders) instrument as a gold standard to stablish the cut-off points of HADS. Quality of life was also evaluated with IBDQ-32. Demographic and clinical variables were collected.

Results

Most of the patients reported a high quality of life (73.1%, n = 76), while 25.0% (n = 26) express a moderate quality of life. The ROC curves for both psychiatric entities showed an adequate discriminative capacity of the HADS-anxiety dimension (AUC = 0.84, 95%CI = 0.76-0.92) with a limited discriminability of the HADS-depression dimension (AUC = 0.58, 95%CI = 0.46-0.70) using the proposed scoring of 8 as a cut-off point.

Conclusions

Anxiety and depression impact negatively in the quality of life in Mexican patients with IBD. The Mexican version of HADS had acceptable internal consistency and external validity, with moderate sensitivity and specificity for clearly identifying clinical cases of anxiety and depression in patients with IBD.

The Management of the Hospitalized Ulcerative Colitis Patient, the Medical-Surgical Conundrum

PURPOSE OF REVIEW

In this study we present the evidence based management for patients hospitalized for UC with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

RECENT FINDINGS

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized ulcerative colitis patients is advocated. The colectomy rate has not changed over the years. Moreover delayed surgery after admission is burden by increase complication and mortality. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and to not prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

Oral delivery of natural active small molecules by polymeric nanoparticles for the treatment of inflammatory bowel diseases

The incidence of inflammatory bowel disease (IBD) is rapidly rising throughout the world. Although tremendous efforts have been made, limited therapeutics are available for IBD management. Natural active small molecules (NASMs), which are a gift of nature to humanity, have been widely used in the prevention and alleviation of IBD; they have numerous advantageous features, including excellent biocompatibility, pharmacological activity, and mass production potential. Oral route is the most common and acceptable approach for drug administration, but the clinical application of NASMs in IBD treatment via oral route has been seriously restricted by their inherent limitations such as high hydrophobicity, instability, and poor bioavailability. With the development of nanotechnology, polymeric nanoparticles (NPs) have provided a promising platform that can efficiently encapsulate versatile NASMs, overcome multiple drug delivery barriers, and orally deliver the loaded NASMs to targeted tissues or cells while enhancing their stability and bioavailability. Thus, NPs can enhance the preventive and therapeutic effects of NASMs against IBD. Herein, we summarize the recent knowledge about polymeric matrix-based carriers, targeting ligands for drug delivery, and NASMs. We also discuss the current challenges and future developmental directions.

Ileal pouch-anal anastomosis in the elderly: A systematic review and meta-analysis

AIM

Despite good overall outcomes in most patients undergoing ileal pouch-anal anastomosis (IPAA), there is still hesitation about performing an IPAA in older patients due to the comorbidity burden and concern about incontinence. The aim of this work was to identify short- and long-term outcomes in older patinets undergoing IPAA to determine the perioperative safety and long-term functional success of IPAA in older patients.

METHOD

A literature search was performed for all publications on IPAA in adults aged ≥50 years that reported short- and long-term outcomes. Data extraction included demographics, 30-day outcomes, long-term functional outcomes and pouch failure. Data were further separated by age group (50-65 and ≥65 years). Outcomes were compared between age groups. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1053 publications reviewed, 13 full papers were included in the analysis. The overall 30-day morbidity and mortality rates were 47.3% and 1.3%, respectively. Thirty-day postoperative rates of small bowel obstruction and pelvic sepsis were 7.6% and 9.9%, respectively. After a median follow-up time of 62 months, rates of pouchitis, incontinence and pouch failure were 13.9%, 17.5% and 7.5%, respectively. There was no statically significant difference in rates of short- or long-term functional outcomes based on age 50-65 versus ≥65 years.

CONCLUSION

Increasing age did not increase the rate of short- or long-term outcomes, including pouch failure. These data suggest that the decision for IPAA construction should not be based on age alone.

The Incisionless Totally Laparoscopic Total Abdominal Colectomy: How I Do It?

Laparoscopic total abdominal colectomy (TAC) is the optimal operative approach for patients with medically refractory inflammatory bowel disease and other benign colon conditions. Minimally invasive techniques for TAC are safe, appropriate, and associated with faster recovery than open surgery. This may be of particular importance in patients who ultimately undergo proctectomy with or without intestinal pouch reconstruction. We describe approaches to the laparoscopic TAC.

The Management of the Hospitalized Ulcerative Colitis Patient: the Medical-Surgical Conundrum

PURPOSE OF REVIEW

In this study, we present the evidence-based management for patients hospitalized for ulcerative colitis (UC) with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

RECENT FINDINGS

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized UC patients is advocated. The colectomy rate has not changed over the years. Moreover, delayed surgery after admission is burden by increase complication and mortality rates. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and not to prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non-responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

Special Considerations for Colorectal Surgery in the Elderly IBD Patient

PURPOSE OF REVIEW

We sought to understand the key aspects to optimize in the perioperative period when treating an elderly surgical patient with inflammatory bowel disease.

RECENT FINDINGS

Addressing preoperative polypharmacy, frailty, and nutrition is important in the elderly population. Understanding intraoperative principles of oncologic risk and pouch formation and the advantages of laparoscopy are key. Postoperative-enhanced recovery pathways and VTE prophylaxis are essential for high-quality care. Preoperative, perioperative, and postoperative factors can greatly impact elderly patients' surgical outcomes.

A User-Friendly Prediction Tool to Identify Colectomy Risk in Patients With Ulcerative Colitis

BACKGROUND

Many patients with ulcerative colitis (UC) fear the potential side effects of immunosuppressive therapies. However, those with medically refractory disease often require total proctocolectomy (TPC) with a permanent ostomy or pouch, which may reduce quality of life. Prior studies have identified TPC predictors; however, no clinically useful prognostic tools exist to guide shared therapeutic decision-making. We therefore sought to develop a prediction tool of future TPC risk in UC patients.

METHODS

In this retrospective study, clinic charts of UC patients were reviewed from January 1, 2017, to December 31, 2017. Cases had TPC performed for refractory UC after January 1, 2008. Controls had no prior UC surgery. Clinical data were assessed 1-12 months preceding TPC or clinic visit for cases and controls, respectively. We randomly selected two-thirds of patients to develop a TPC prediction model using multivariable logistic regression. One-third was reserved for model validation.

RESULTS

We identified 115 cases and 325 controls. TPC predictors included albumin, 9-point Mayo score >5, Mayo endoscopic subscore >1, and corticosteroid use within 6 months. The areas under the receiver operating characteristic curve for the multivariable model were 0.94 (95% confidence interval [CI], 0.92-0.95) and 0.92 (95% CI, 0.89-0.95) for the test and validation cohorts, respectively. The validation cohort demonstrated a significant difference in calculated probability distributions between patients who did and did not have TPC (P < 0.01). We incorporated our model into a web-based application to allow convenient calculation of a patient's TPC risk.

CONCLUSIONS

We created a user-friendly tool to assess TPC risk in UC. Prospective assessment will determine its utility for shared therapeutic decision-making.

Sexual Dysfunction and Fertility Problems in Men with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract that is usually diagnosed in young individuals. Crohn's disease and ulcerative colitis are the 2 principal forms of IBD. Patients with IBD demonstrate varying degrees of disease activity and sometimes need to undergo bowel surgery such as proctocolectomy with ileal pouch-anal anastomosis that involves removal of the entire colon and rectum with consequent sexual dysfunction. Several studies have shown that sulfasalazine, affects male fertility. Additionally, many men with IBD are unable to control their smoking, drinking, and eating habits, which can cause worsening of disease activity and fertility. Therefore, infertility and sexual dysfunction are important issues in young patients diagnosed with IBD because they are related to optimal management of the disease and patients' quality of life. Only a few studies have reported sexual dysfunction and infertility in men with IBD. Therefore, this study reviewed the current literature describing male sexual dysfunction scales and evaluated the causes of sexual dysfunction and infertility in men with IBD.

Surgery in the age of biologics

Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.

Impact of Modern Drug Therapy on Surgery: Ulcerative Colitis

Background

The primary treatment of ulcerative colitis (UC) is conservative, and substantial therapeutic progress has been made in the past few decades. Meanwhile, biologicals have become a mainstay in the treatment for steroid-refractory UC. Despite further development of drug therapy and an increased time span to operation, a significant proportion of patients with UC require surgical intervention. Surgical intervention needs to be carried out in medically refractory cases, imminent or malignant transformation, or complications. This article discusses the impact of modern drug therapy on surgery for UC.

Methods

A selective literature search of PubMed was conducted, taking into account current studies, reviews, meta-analyses, and guidelines. Selected articles were then reviewed in detail and recommendations were drafted based on data and conclusions of the articles.

Results

In recent years, modern drug therapy has changed the timing, approach, and outcomes of surgery for UC. Most of the studies showed a decrease in surgery rates over time while the rate of emergency colectomies remains unchanged. So far, no convincing surgery-sparing effect of newer medications has been established, and it remains debatable if surgery rates have decreased because of improved management for UC in general or due to the introduction of biologicals. The intensified conservative therapy with increasing use of biologics has been accompanied by a trend towards performing a three-step procedure in the last decade. There is a subset of patients with complex refractory disease who most likely benefit from elective surgery as an alternative to prolonged conservative therapies after failure of first-line treatment. The majority of patients after ileal pouch-anal anastomosis can avoid hospitalizations and colitis-related medications with their associated potential adverse effects. In addition, the procedure substantially reduces UC-related symptoms and the risk for dysplasia or cancer. There is a long-term pouch success rate of >90% after 10 and 20 years of follow-up.

Conclusion

Conservative medical therapy in the treatment of UC will continue to develop and the number of approved therapeutics will grow. Surgery should not be considered as the negative endpoint of treatment modalities but as a good alternative to a prolonged conservative therapy for some patients. In conclusion, a close cooperation between the various disciplines in the pre- and postoperative management is essential in order to optimize the timing and outcome of patients with UC.

Outcomes and Management of the Ileal Pouch-Anal Anastomosis in the Elderly

PURPOSE OF REVIEW

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients.

RECENT FINDINGS

Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed. IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.

The Impact of Age at Time of Ileal Pouch Anal Anastomosis on Short and Long-Term Outcomes in Adults

BACKGROUND

There is limited knowledge on ileal pouch anal anastomosis (IPAA) function when performed on patients older than age 50 years. The aim of this study was to determine if surgery on those older than age 50 years impacts short-term complications or long-term function.

METHODS

A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between 2002 and 2013 was conducted. Short-term postoperative complications and long-term function and quality of life were analyzed according to age at pouch formation (age >50 vs age ≤50 years).

RESULTS

A total of 911 patients who underwent IPAA (542 male) were included, with 178 patients (20%) age >50 years and 733 (80%) ≤50 years. Patients >50 years had higher American Society of Anesthesiology score (ASA) scores and increased rates of obesity and dysplasia or cancer at the time of colectomy, and were less often on steroids (all P < 0.01). Over a median follow-up of 5 years, older patients reported increased daytime incontinence (60% vs 37%, P < 0.01) and pad usage (34% vs 11%, P < 0.01) at up to 1.5 years post-IPAA, after which time the groups became similar. Other functional outcomes, including pouch failure and quality of life, were similar between the 2 groups across the follow-up periods.

CONCLUSION

Performing an IPAA on carefully selected patients older than age 50 years has minor, transient differences in pouch function compared with patients younger than age 50 years. Assuming appropriate patient selection, IPAA should continue to be offered to older patients without increased risk of compromised function or of pouch failure.

Rescue Diverting Loop Ileostomy: An Alternative to Emergent Colectomy in the Setting of Severe Acute Refractory IBD-Colitis

BACKGROUND

Severe acute refractory colitis has traditionally been an indication for emergent colectomy in IBD, yet under these circumstances patients are at elevated risk for complications because of their heightened inflammatory state, nutritional deficiencies, and immunocompromised state.

OBJECTIVE

We hypothesized that rescue diverting loop ileostomy may be a viable alternative to emergent colectomy, providing the opportunity for colonic healing and patient optimization before more definitive surgery.

DESIGN

This was a retrospective case series.

SETTINGS

The study was conducted at a single academic center.

PATIENTS

Patients with severe acute medically refractory IBD-related colitis were included.

INTERVENTION

Rescue diverting loop ileostomy was the intervening procedure.

MAIN OUTCOME MEASURES

The primary outcome was avoidance of urgent/emergent colectomy. The secondary outcome was efficacy, defined by 3 clinical aims: 1) reduced steroid dependence or opportunity for bridge to medical rescue, 2) improved nutritional status, and 3) ability to undergo an elective laparoscopic definitive procedure or ileostomy reversal with colon salvage.

RESULTS

Among 33 patients, 14 had Crohn's disease and 19 had ulcerative colitis. Three patients required urgent/emergent colectomy, 2 with ulcerative colitis and 1 with Crohn's disease. Across both disease cohorts, >80% of patients achieved each clinical aim for efficacy: 88% reduced their steroid dependence or were able to bridge to medical rescue, 87% improved their nutritional status, and 82% underwent an elective laparoscopic definitive procedure or ileostomy reversal. A total of 4 patients (11.7%) experienced a postoperative complication following diversion, including 3 surgical site infections and 1 episode of acute kidney injury.

LIMITATIONS

The study was limited by being a single-center, retrospective series.

CONCLUSIONS

Rescue diverting loop ileostomy in the setting of severe, refractory IBD-colitis is a safe and effective alternative to emergent colectomy. This procedure has acceptably low complication rates and affords patients time for medical and nutritional optimization before definitive surgical intervention. See Video Abstract at http://links.lww.com/DCR/A520.

Surgery in ulcerative colitis: When? How?

Ulcerative Colitis (UC) is an idiopathic chronically-remitting inflammatory bowel disorder characterized by a contiguous inflammation of the colonic mucosa affecting the rectum that generally extends proximally in a continuous manner through the entire colon. Patients typically experience intermittent exacerbations, with symptoms characterized by bloody diarrhea associated with urgency and tenesmus. The anatomical extent of mucosal involvement is the most important factor determining disease course and is an important predictor of colectomy. The precise etiology of UC is unknown. However, a combination of genetic predisposition and environmental factors seems to have a key role in the development of the disease. UC usually is mildly active but it can be a life-threatening condition because of colonic and systemic complications, and later in the disease course due to the development of colorectal cancer. Interestingly, even if pathogenetic features detected in patients with sporadic CRC can be also found in UC-related colorectal cancer (UC-CRC), this latter is, usually, driven by an inflammation-driven pathway rising from a non-neoplastic inflammatory epithelium to dysplasia to cancer. Thus, a long-term follow-up with colonoscopy surveillance has been recommended. Approximately 15% of UC patients develop an acute attack of severe colitis, and 30% of these patients require colectomy. The initial treatment strategy in UC typically follows the traditional step-up approach. One third of the patients will not respond to steroid therapy and cyclosporine and infliximab are the most common salvage agents employed in these cases in order to avoid emergent surgery. Unfortunately, although a significant short-term benefit have been observed after infliximab treatment, the colectomy rate have remained stable. Surgery in UC depends on the stage of the disease as well as patient's status and is divided into the following settings: urgent, emergent and elective. Despite many efforts the surgical management of UC remains a significant challenge. A multidisciplinary management of UC is key in order to define the best timing and the best procedure for each patient in an individualized basis.

Predicting Future Elective Colon Resection for Diverticulitis Using Patterns of Health Care Utilization

Background

Recurrent diverticulitis is the most common reason for elective colon surgery and, although professional societies now recommend against early resection, its use continues to rise. Shared decision making decreases use of low-value surgery but identifying which patients are most likely to elect surgery has proven difficult. We hypothesized that Machine Learning algorithms using health care utilization (HCU) data can predict future clinical events including early resection for diverticulitis.

Study Design

We developed models for predicting future surgery among patients with new diagnoses of diverticulitis (2009-2012) from the MarketScan® database. Claims data (diagnosis, procedural, and drug codes) were used to train three Machine Learning algorithms to predict surgery occurring between 52 and 104 weeks following diagnosis.

Results

Of 82,231 patients with incident diverticulitis (age 51 ± 8 years, 52% female), 1.2% went on to elective colon resection. Using maximal training data (152 consecutive weeks of claims), the Gradient Boosting Machine model predicted elective surgery with an area under the curve (AUC) of 75% (95% uncertainty interval [UI] 71-79%). Models trained on less data resulted in less accurate prediction (AUC: 68% [64-74%] using 128 weeks, 57% [53-63%] using 104 weeks). The majority of resections (85%) were identified as low-value.

Conclusion

By applying Machine Learning to HCU data from the time around a diagnosis of diverticulitis, we predicted elective surgery weeks to months in advance, with moderate accuracy. Identifying patients who are most likely to elect surgery for diverticulitis provides an opportunity for effective shared decision making initiatives aimed at reducing the use of costly low-value care.

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

BACKGROUND AND AIMS

Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres.

METHODS

The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate.

RESULTS

In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery.

CONCLUSIONS

Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

Clinical Aspects of Idiopathic Inflammatory Bowel Disease: A Review for Pathologists

CONTEXT

-Idiopathic inflammatory bowel disease manifests with different clinical phenotypes showing varying behavior and risk for neoplasia. The clinical questions that are posed to pathologists differ depending on phase of the disease and the clinical circumstances. Understanding the clinical aspects of the dynamic disease process will enhance the role of pathology in optimizing the care of patients with inflammatory bowel disease.

OBJECTIVE

-To review clinical and surgical aspects of inflammatory bowel disease that are relevant to practicing pathologists.

DATA SOURCES

-The literature was reviewed.

CONCLUSIONS

-Diagnosis and management of inflammatory bowel disease require an integrated evaluation of clinical, endoscopic, radiologic, and pathologic features. Therefore, close interaction between clinicians and pathologists is crucial. Having this team approach improves understanding of the pertinent clinical and surgical aspects of the disease and assists in the recognition of unusual presentation of variants, as well as mimics of idiopathic inflammatory bowel disease, by pathologists.

Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel diseases are common in Europe, with prevalences as high as 1 in 198 persons (ulcerative colitis) and 1 in 310 persons (Crohn's disease).

METHODS

This review is based on pertinent articles retrieved by a search in PubMed and in German and European guidelines and Cochrane reviews of controlled trials.

RESULTS

Typically, the main clinical features of inflammatory bowel diseases are diarrhea, abdominal pain, and, in the case of ulcerative colitis, peranal bleeding. These diseases are due to a complex immunological disturbance with both genetic and environmental causes. A defective mucosal barrier against commensal bowel flora plays a major role in their pathogenesis. The diagnosis is based on laboratory testing, ultrasonography, imaging studies, and, above all, gastrointestinal endoscopy. Most patients with Crohn's disease respond to budesonide or systemic steroids; aminosalicylates are less effective. Refractory exacerbations may be treated with antibodies against tumor necrosis factor (TNF) or, more recently, antibodies against integrin, a protein of the cell membrane. In ulcerative colitis, aminosalicylates are given first; if necessary, steroids or antibodies against TNF-α or integrin are added. Maintenance therapy to prevent further relapses often involves immunosuppression with thiopurines and/or antibodies. Once all conservative treatment options have been exhausted, surgery may be necessary.

CONCLUSION

The treatment of chronic inflammatory bowel diseases requires individually designed therapeutic strategies and the close interdisciplinary collaboration of internists and surgeons.

Surgical management of inflammatory bowel disease in China: a systematic review of two decades

Background/Aims

The past decades have seen increasing incidence and prevalence of inflammatory bowel disease (IBD) in China. This article aimed to summarize the current status and characteristics of surgical management for IBD in China.

Methods

We searched PubMed, Embase, and Chinese databases from January 1, 1990 to July 1, 2014 for all relevant studies on the surgical treatment IBD in China. Eligible studies with sufficient defined variables were further reviewed for primary and secondary outcome measures.

Results

A total of 74 studies comprising 2,007 subjects with Crohn's disease (CD) and 1,085 subjects with ulcerative colitis (UC) were included. The percentage of CD patients misdiagnosed before surgery, including misdiagnosis as appendicitis or UC, was 50.8%±30.9% (578/1,268). The overall postoperative complication rate was 22.3%±13.0% (267/1,501). For studies of UC, the overall postoperative complication rate was 22.2%±27.9% (176/725). In large research centers (n>50 surgical cases), the rates of emergency operations for CD (P=0.032) and in-hospital mortalities resulting from both CD and UC were much lower than those in smaller research centers (n≤50 surgical cases) (P=0.026 and P <0.001, respectively). Regarding the changes in CD and UC surgery over time, postoperative complications (P=0.045 for CD; P=0.020 for UC) and postoperative in-hospital mortality (P=0.0002 for CD; P=0.0160 for UC) both significantly improved after the year 2010.

Conclusions

The surgical management of IBD in China has improved over time. However, the rates of misdiagnosis and postoperative complications over the past two decades have remained high. Large research centers were found to have relatively better capacity for surgical management than the smaller ones. Higher quality prospective studies are needed in China.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: A narrative review

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) is the gold standard surgical treatment for ulcerative colitis. However, despite the widespread use of RP-IPAA, many aspects of this treatment still remain controversial, such as the approach (open or laparoscopic), number of stages in the surgery, type of pouch, and construction type (hand-sewn or stapled ileal pouch-anal anastomosis). The present narrative review aims to discuss current evidence on the short-, mid-, and long-term results of each of these technical alternatives as well as their benefits and disadvantages. A review of the MEDLINE, EMBASE, and Ovid databases was performed to identify studies published through March 2016. Few large, randomized, controlled studies have been conducted, which limits the conclusions that can be drawn regarding controversial issues. The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases. Regarding 2- and 3-stage RP-IPAA, patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables, making any comparisons extremely difficult. The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly, although the J pouch is generally preferred by surgeons. Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages, and there is no clear benefit of one technique over the other.

Hepatocyte growth factor, hepatocyte growth factor activator and arginine in a rat fulminant colitis model

Introduction

Dextran sodium sulfate (DSS) is commonly used to induce a murine fulminant colitis model. Hepatocyte growth factor (HGF) has been shown to decrease the symptoms of inflammatory bowel disease (IBD) but the effect of its activator, HGFA, is not well characterized. Arginine reduces effects of oxidative stress but its effect on IBD is not well known. The primary aim is to determine whether HGF and HGFA, or arginine will decrease IBD symptoms such as pain and diarrhea in a DSS-induced fulminant colitis murine model.

Methods

A severe colitis was induced in young, male Fischer 344 rats with 4% (w/v) DSS oral solution for seven days; rats were sacrificed on day 10. Rats were divided into five groups of 8 animals: control, HGF (700 mcg/kg/dose), HGF and HGFA (10 mcg/dose), HGF and arginine, and high dose HGF (2800 mcg/kg/dose). Main clinical outcomes were pain, diarrhea and weight loss. Blinded pathologists scored the terminal ileum and distal colon.

Results

DSS reliably induced severe active colitis in 90% of animals (n = 36/40). There were no differences in injury scores between control and treatment animals. HGF led to 1.38 fewer days in pain (p = 0.036), while arginine led to 1.88 fewer days of diarrhea (P = 0.017) compared to controls. 88% of HGFA-treated rats started regaining weight (P < 0.001).

Discussion/Conclusion

Although treatment was unable to reverse fulminant disease, HGF and arginine were associated with decreased days of pain and diarrhea. These clinical interventions may reduce associated symptoms for severe IBD patients, even when urgent surgical intervention remains the only viable option.

•

We developed a fulminant colitis model in adolescent rats.

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The fulminant colitis model reproduces inflammatory bowel disease in humans.

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The rats were treated with hepatocyte growth factor, its activator, and arginine.

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The HGF treated rats had fewer days of pain.

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The arginine treated rats had fewer days of diarrhea.

Noninvasive evaluation of active pan-ulcerative colitis with multiple strictures using Fluorine-18-Fluorodeoxyglucose positron emission tomography/computed tomography

Ulcerative colitis (UC) is an inflammatory bowel disease characterized by waxing and waning inflammation that changes in severity and extent and may progress to neoplasia, especially in the presence of strictures. When patients have nonnegotiable strictures or severe inflammation with ulcers, colonoscopy is difficult and carries the risk of perforation. The authors present a patient with pan-UC with multiple strictures, in whom fluorodeoxyglucose positron emission tomography/computed tomography was used to noninvasively evaluate the extent and severity of the disease.

Elderly patients and inflammatory bowel disease

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing globally. Coupled with an ageing population, the number of older patients with IBD is set to increase. The clinical features and therapeutic options in young and elderly patients are comparable but there are some significant differences. The wide differential diagnosis of IBD in elderly patients may result in a delay in diagnosis. The relative dearth of data specific to elderly IBD patients often resulting from their exclusion from pivotal clinical trials and the lack of consensus guidelines have made clinical decisions somewhat challenging. In addition, age specific concerns such as co-morbidity; loco-motor and cognitive function, poly-pharmacy and its consequences need to be taken into account. In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this vulnerable group and set appropriate boundaries maximising benefit and minimising harm. Meanwhile, clinicians need to make personalised decisions but as evidence based as possible in the holistic, considered and optimal management of IBD in elderly patients. In this review we will cover the clinical features and therapeutic options of IBD in the elderly; as well as addressing common questions and challenges posed by its management.

Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review

AIM

Ileal pouch-anal anastomosis (IPAA) is performed in ulcerative colitis or familial adenomatous polyposis with a view to restoration of GI continuity and prevention of permanent faecal diversion. Debate exists as to its safety in older patients. This review aims to assess functional outcomes and safety of restorative proctocolectomy (RPC) in older compared to younger patients.

METHODS

Literature search was performed for age-stratified studies which assessed functional outcomes of IPAA. Twelve papers were included overall. Patients were categorized into 'older' and 'younger' groups. Analysis was split into three separate parts: 1. Age cut-off of 50 ± 5 years (with sensitivity analysis); 2. Age cut-off of 65 ± years; 3. Long-term outcomes (>10 years).

RESULTS

With an age cut-off of 50 years (4327 versus 513 patients), complication rates were comparable with the exception of an increased rate of small-bowel obstruction in the younger patients (p = 0.034). At 1 year, 24-h stool frequency was significantly higher in the older patient group (p < 0.0001). Daytime (p < 0.0001) and night-time (p < 0.0001) incontinence rates were also significantly higher in older patients. Overall, function deteriorated with time across all ages; however, after 10 years, there was no significant difference in incontinence rates between age groups. Dehydration and electrolyte loss was a significant problem in patients over 65 (p < 0.0001). Despite differences in postoperative function, quality of life was comparable between groups; however, only a few studies reported quality of life data.

CONCLUSION

IPAA is safe in older patients, although treating clinicians should bear in mind the increased risk of dehydration. Postoperative function is worse in older patients, but seems to level out with time and does not appear to significantly impact on overall quality of life and patient satisfaction. Assessment for suitability for RPC should not be based on chronological age in isolation. It is imperative that the correct support is given to older patients with worsened postoperative function in order to maintain patient satisfaction and adequate quality of life.

Optimal management of steroid-dependent ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory condition that is variable in both extent and severity of disease as well as response to therapy. Corticosteroids (CSs) were the first drugs used in the management of UC and are still used for induction of remission. However, because of their extensive side-effect profile, they are not utilized for maintenance of remission. In view of this, CS-free remission has become an important end point while evaluating therapeutic agents used in the management of UC. This review highlights the results of various studies conducted to evaluate the efficacy of different medications to attain CS-free remission in the setting of active UC. The drugs reviewed include established agents such as thiopurines, methotrexate, infliximab, adalimumab, vedolizumab, golimumab, and newer experimental agents, and if all else fails, colectomy will be performed. The efficacy of these drugs is evaluated individually. Our aim is to provide a synopsis of the work done in this field to date.

Severity of inflammation as a risk factor for ileo-anal anastomotic leak after a pouch procedure in ulcerative colitis

PURPOSE

The pelvic pouch procedure (PPP) carries significant post-operative complication risks including a 4-14 % risk of ileo-anal anastomotic (IAA) leak [1-4]. The aim of this study is to evaluate the severity of disease at the distal resection margin as an independent risk factor for an IAA leak following the PPP for patients with ulcerative colitis (UC).

METHODS

A retrospective matched case-control study was undertaken. The distal margin of each subject's specimen was reviewed by a blinded pathologist and the degree of inflammation was scored using a modified histological activity index (mHAI)--a 0 to 5 graded scale with HAI of 5 representing ulcerations >25 % the depth of bowel wall.

RESULTS

Forty-nine patients with perioperative IAA leaks (mean 11 days ±0.92) were identified and matched for gender, age and year of surgery. The case cohort had 33 males (67 %) of mean age at time of surgery of 36.3 years (±1.42). The severity of distal inflammation did not increase the risk of IAA leak. The presence of a diverting ileostomy was associated with a decreased incidence of an IAA leak (p = 0.01).

CONCLUSION

Studies with greater power will be required to evaluate the association (if any) between histological severity of UC at the distal margin of a PPP procedure and IAA leak rate. This risk factor could influence preoperative management and post-operative outcome in patients requiring the PPP.

Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

AIM

The aim was to study the feasibility of the laparoscopic approach in the management of ulcerative colitis, to assess the functional results at 1-year and to review of literature on the topic.

MATERIALS AND METHODS

All patients presenting for surgical management of histopathologically proven ulcerative colitis during the study period were included in the study. All patients presenting in a non-emergency setting were offered a two-stage procedure (Group A). The first-stage consisted of laparoscopic total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) with a diverting split end ileostomy. Ileostomy was closed in the second stage. For patients presenting in acute setting (Group B), the first-stage consisted of laparoscopic TPC with end ileostomy followed by IPAA with diverting split end ileostomy in the second-stage and finally ileostomy closure in the third-stage. The technique is described.

RESULTS

A total of 31 cases underwent laparoscopic TPC-IPAA, of which 28 belonged to Group A and 3 were included in Group B. All surgeries were successfully completed laparoscopically without need for conversion. The average operating time was 375 min in Group A (range: 270-500 min) and 390 min in Group B (range: 250-480 min). Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days). Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil.

CONCLUSIONS

Laparoscopic TPC-IPAA is feasible in acute as well as non-acute setting in patients needing surgical management of ulcerative colitis.

The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery

OBJECTIVE

Assess the impact of preoperative serum antitumor necrosis factor-α (anti-TNFα) drug levels on 30-day postoperative morbidity in inflammatory bowel disease (IBD) patients.

BACKGROUND

Studies on the association of anti-TNFα drugs and postoperative outcomes in IBD are conflicting due to variable pharmacokinetics of anti-TNFα drugs. It remains to be seen whether preoperative serum anti-TNFα drug levels correlate with postoperative morbidity.

METHODS

Thirty-day postoperative outcomes of consecutive IBD surgical patients with serum drawn within 7 days preoperatively were studied. The total serum level of 3 anti-TNFα drugs (infliximab, adalimumab, and certolizumab) was measured, with ≥ 0.98 μg/mL considered as detected. Data were also reviewed according to a clinical cutoff value of 3 μg/mL.

RESULTS

A total of 217 patients [123 with Crohn disease (CD) and 94 with ulcerative colitis (UC)] were analyzed; 75 of 150 (50%) treated with anti-TNFα therapy did not have detected levels at the time of surgery. In the UC cohort, adverse postoperative outcome rates between the undetectable and detectable groups were similar when stratified according to type of UC surgery. In the CD cohort, there was a higher but statistically insignificant rate of adverse outcomes in the detectable versus undetectable groups. Using a cut off level of 3 μg/mL, postoperative morbidity (odds ratio [OR] = 2.5, P = 0.03) and infectious complications (OR = 3.0, P = 0.03) were significantly higher in the ≥ 3 μg/mL group. There were higher rates of postoperative morbidity (P = 0.047) and hospital readmissions (P = 0.04) in the ≥ 8 μg/mL compared with <3 μg/mL group.

CONCLUSIONS

Increasing preoperative serum anti-TNFα drug levels are associated with adverse postoperative outcomes in CD but not UC patients.

The impact of timing and duration of thiopurine treatment on colectomy in ulcerative colitis: a national population-based study of incident cases between 1989-2009

BACKGROUND

The role of thiopurines in altering the risk of colectomy in ulcerative colitis (UC) remains unclear.

AIMS

To examine predictors of colectomy in UC and determine the impact of thiopurines on the risk of colectomy.

METHODS

We constructed a population-based cohort of incident cases of UC in the United Kingdom between 1989 and 2009. We determined trends in thiopurine usage and colectomy for three defined cohorts: era 1 (1989-1995), era 2 (1996-2002), era 3 (2003-2009). We used Cox regression to determine predictors of colectomy and quantified the impact of duration and timing of thiopurine use on the risk of colectomy.

RESULTS

We identified 8673 incident cases of UC. 5-year colectomy rates increased from 4.2%, 5.1% to 6.9% (P = 0.001) for era 1, era 2 and era 3, respectively, despite increasing thiopurine use. This was not significant after adjustment for predictors of colectomy (P = 0.06). There was a higher risk of colectomy in men (HR 1.44, 95% CI: 1.19-1.73), those diagnosed at an early age (HR 1.35, 95% CI: 1.04-1.75; 16-24 vs. 25-64) and early steroid users (HR 1.94, 95% CI: 1.59-2.37). 5-ASA users were less likely to require a colectomy (HR 0.35, 95% CI: 0.28-0.44). Amongst thiopurine users, those treated for greater than 12 months had a 71% reduction in risk of colectomy (HR 0.29, 95% CI: 0.21-0.40). Early thiopurines offered no additional benefit.

CONCLUSIONS

Thiopurine exposure for greater than 12 months reduces the likelihood of colectomy by 71%. Young men and those requiring steroids within 3 months of diagnosis are at greatest risk of colectomy, and most likely to benefit from sustained thiopurine use.

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE

Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients.

METHODS

Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups.

RESULTS

Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002).

CONCLUSIONS

The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Mortality after total colectomy in 3084 patients with inflammatory bowel disease: a population-based cohort study

BACKGROUND

A high post-operative mortality has been reported following colectomy in patients with inflammatory bowel disease (IBD), especially in some patient groups.

AIMS

To investigate the 40-day mortality following colectomy in patients with IBD. The secondary aim was to assess whether colectomised IBD patients have an increased mortality compared to the general population.

METHODS

This is a population-based register study of all patients with IBD in Sweden who underwent total colectomy in 2000-2010. The cohort was identified using international classification codes for ulcerative colitis (UC) and Crohn's disease (CD). Patients registered with both UC and CD before colectomy (UCCD) were analysed separately. Each patient was followed-up to the date of death, migration or 31st of December 2010, whichever came first. Kaplan-Meier survival curves, Cox proportional hazards models and relative mortality rates were used to describe mortality.

RESULTS

In the cohort of 3084 patients, 2424 were diagnosed with UC, 326 with CD and 334 with UCCD. The 40-day, 1-year and 3-year mortality was 1.3%, 3.1% and 6.0%, respectively. The highest 40-day mortality was seen in patients ≥59 years of age (4.4%). Colectomy at the primary hospitalisation for IBD did not significantly increase the risk of post-operative mortality, nor did hospital volume. The relative survival after 3 years was 0.99, 0.98, 0.97 and 0.90 in those <30, 30-43, 44-58 and ≥59 years old, respectively.

CONCLUSION

The 40-day mortality following total colectomy in IBD patients in Sweden is low, except in patients ≥59 years old.

Systematic review of the effectiveness of biological therapy for active moderate to severe ulcerative colitis

BACKGROUND AND AIM

The aim of this systematic review was to evaluate the efficacy and safety of biological agents (vedolizumab, abatacept, visilizumab, golimumab) in patients with active moderate to severe ulcerative colitis.

METHODS

This paper was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The systematic literature search was performed in PubMed, Embase, Cochrane Library, and other databases until December 27, 2013 to identify randomized controlled trials fulfilling the established inclusion criteria for this review.

RESULTS

Eight randomized controlled trials were included in the systematic review. Vedolizumab was significantly more effective compared with placebo (P < 0.05) increasing the percentage of patients with a clinical response, clinical remission and mucosal healing in the induction phase, and patients with a clinical remission and mucosal healing in the maintenance phase. Similarly, golimumab was significantly more effective than placebo (P < 0.05) regarding the percentage of patients with a clinical response and mucosal healing in the induction phase, and patients with a clinical response, clinical remission, and mucosal healing in the maintenance phase. The safety of these two biological agents was comparable with placebo during the treatment (P > 0.05). However, the efficacy of visilizumab or abatacept was related to the higher risk of treatment failure and a worse safety profile than placebo.

CONCLUSIONS

The results of the systematic review demonstrated that the efficacy and safety of particular biological agents are differentiated. Vedolizumab and golimumab occurred more effective, and comparably as safe as placebo in patients with active moderate to severe ulcerative colitis increasing the number of available therapeutic options.

Current approaches to the management of new-onset ulcerative colitis

Ulcerative colitis (UC) is an idiopathic, inflammatory gastrointestinal disease of the colon. As a chronic condition, UC follows a relapsing and remitting course with medical maintenance during periods of quiescent disease and appropriate escalation of therapy during times of flare. Initial treatment strategies must not only take into account current clinical presentation (with specific regard for extent and severity of disease activity) but must also take into consideration treatment options for the long-term. The following review offers an approach to new-onset UC with a focus on early treatment strategies. An introduction to the disease entity is provided along with an approach to initial diagnosis. Stratification of patients based on clinical parameters, disease extent, and severity of illness is paramount to determining course of therapy. Frequent assessments are required to determine clinical response, and treatment intensification may be warranted if expected improvement goals are not appropriately reached. Mild-to- moderate UC can be managed with aminosalicylates, mesalamine, and topical corticosteroids with oral corticosteroids reserved for unresponsive cases. Moderate-to-severe UC generally requires oral or intravenous corticosteroids in the short-term with consideration of long-term management options such as biologic agents (as initial therapy or in transition from steroids) or thiopurines (as bridging therapy). Patients with severe or fulminant UC who are recalcitrant to medical therapy or who develop disease complications (such as toxic megacolon) should be considered for colectomy. Early surgical referral in severe or refractory UC is crucial, and colectomy may be a life-saving procedure. The authors provide a comprehensive evidence-based approach to current treatment options for new-onset UC with discussion of long-term therapeutic efficacy and safety, patient-centered perspectives including quality of life and medication compliance, and future directions in related inflammatory bowel disease care.

Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties

Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.

Systematic review with meta-analysis: inflammatory bowel disease in the elderly

BACKGROUND

Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.

AIM

To critically review available data regarding the care of elderly IBD patients.

METHODS

Bibliographic searches (MEDLINE) up to June 2013.

RESULTS

Approximately 10-15% of cases of IBD are diagnosed in patients aged >60 years, and 10-30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis. The clinical features of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.

CONCLUSIONS

Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.

Does intramesorectal proctectomy with rectal eversion affect postoperative complications compared to standard total mesorectal excision in patients with ulcerative colitis?

INTRODUCTION

Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal proctectomy with concomitant rectal eversion (IMP/RE) or total mesorectal excision (TME). No data exists comparing the outcomes of the two techniques.

METHODS

All UC patients undergoing J-pouch surgery at a single institution over 10.5 years were included. Postoperative complications with IMP/RE vs. TME were analyzed using univariable and multivariable statistics.

RESULTS

One hundred nineteen of 201 (59 %) patients underwent IMP/RE. Demographic and disease characteristics were similar between groups. On univariable analysis, IMP/RE had fewer total perioperative complications than TME (p = 0.02), but no differences in postoperative length of stay or readmissions. Multivariable regression accounting for patient age, comorbidities, disease severity, preoperative medications, operative technique, and follow-up time (mean 5.5 ± 0.2 years) suggested that both anastomotic leak rate (OR 0.32; p = 0.04) and overall postoperative complications (2.10 ± 0.17 vs. 2.60 ± 0.20; p = 0.05) were lower in the IMP/RE group.

CONCLUSIONS

IMP/RE may be associated with fewer overall postoperative complications compared to TME. However, further studies on functional and long-term outcomes are needed.

The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: A review of current evidence

Up to 35% of patients with ulcerative colitis will require surgery during the course of their disease. Nowadays, a total colectomy with ileal pouch-anal anastomosis is the preferred procedure, which can be performed open or via laparoscopic approach. Since the early '90s, minimally invasive techniques have gained popularity, but the extend of restorative procedures in these patients has restricted the use of laparoscopic approaches mainly to elective procedures in specialised centres. This review discusses the benefits and disadvantages of laparoscopic surgery when compared to open surgery. It presents the current evidence on short-term and long-term post-operative results, functional outcome, fecundity, and costs, for both elective and emergency indications. In addition, the value of new techniques (including single port surgery) and alternative laparoscopic approaches (e.g. ileo-rectal anastomosis, Kock-pouch and appendectomy) will be discussed.

The impact of thiopurines on surgical outcomes in inflammatory bowel disease: do they make a difference?

Ulcerative colitis and Crohn's disease together are known as inflammatory bowel disease (IBD). Surgery is considered for more severe disease and is a dreaded consequence for patients. Thiopurines have proven efficacy in the induction and maintenance of remission of IBD, but the long-term need for surgery remains uncertain with conflicting results from the available studies. The timing and duration of thiopurines also appears to play a pivotal role in the management of these conditions and may also affect the need for surgery. Data from Denmark, Canada, Hungary and the UK appear to suggest a reduction in surgery rates prior to the introduction of anti-tumor necrosis factor (TNF) therapy. The authors aim to review the more recent literature evaluating the surgery rates in IBD and changes in disease trends over time. We ask whether increasing thiopurine prescribing has had an effect on the surgery rates in the era of biologic therapy and whether more aggressive treatment approaches have altered the natural history of IBD.

Operative strategy modifies risk of pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy

BACKGROUND

Whether preoperative biological therapy increases postoperative complications after restorative proctocolectomy remains controversial.

OBJECTIVE

This study aims to evaluate the influence of preoperative use of biologics on outcomes after restorative proctocolectomy and to assess whether a staged approach modifies any negative influence of these medications.

SETTING

The study was conducted at a single tertiary institution.

DESIGN AND PATIENTS

Patients who were operated on for medically refractory ulcerative or indeterminate colitis were identified and classified by initial surgery, whether subtotal colectomy or total proctocolectomy, then categorized into biologics user and nonuser groups. Demographics, perioperative data, postoperative complications, pouch function, and quality of life were collected.

OUTCOME MEASURE

Cumulative 1-year complication rates were estimated by using the Kaplan-Meier curve, and independent predictors for infectious complications were identified by using Cox proportional hazards regression models.

RESULTS

From 2006 to 2010, 407 and 181 patients underwent initial subtotal colectomy with end ileostomy or total proctocolectomy with IPAA. For the 181 patients who underwent total proctocolectomy straightaway, pre- and perioperative data were comparable for biologics users (n = 25) and nonusers (n = 156). Cumulative 1-year pelvic sepsis rate was significantly greater in patients on biologics (32% vs 16%, p = 0.012). Multivariate analysis demonstrated that preoperative anti-tumor necrosis factor therapy (HR, 2.62; p = 0.027) was an independent risk factor for postoperative pelvic sepsis after total proctocolectomy. After subtotal colectomy, no differences occurred in both 30-day and cumulative 1-year postoperative complications between biologics users (n = 142) and nonusers (n = 265). Outcomes were also similar when biologics users (n = 88) and nonusers (n = 164) underwent subsequent completion proctectomy with ileal pouch creation after initial colectomy.

LIMITATIONS

The retrospective nature of this study and physician's preference were limitations.

CONCLUSIONS

Preoperative exposure to biologics is associated with an increased risk of pelvic sepsis after total proctocolectomy with IPAA. This risk is mitigated by the performance of an initial subtotal colectomy.

Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies

BACKGROUND & AIMS

The inflammatory bowel diseases (IBDs) are chronic diseases that often require surgery. However, the risk of requirement of surgery over time has not been well characterized. We performed a systematic review and meta-analysis to establish the cumulative risk of surgery among patients with IBD and evaluated how this risk has changed over time.

METHODS

We searched Medline, EMBASE, PubMed, and conference proceedings (2009-2012) on May 8, 2013, for terms related to IBD and intestinal surgery. Two reviewers screened 8338 unique citations to identify 486 for full-text review. The analysis included population-based studies published as articles (n = 26) and abstracts (n = 4) that reported risks of surgery at 1, 5, or 10 years after a diagnosis of Crohn's disease and/or ulcerative colitis. The trend in risk of surgery over time was analyzed by meta-regression using mixed-effect models.

RESULTS

Based on all population-based studies, the risk of surgery 1, 5, and 10 years after diagnosis of Crohn's disease was 16.3% (95% confidence interval [CI], 11.4%-23.2%), 33.3% (95% CI, 26.3%-42.1%), and 46.6% (95% CI, 37.7%-57.7%), respectively. The risk of surgery 1, 5, and 10 years after diagnosis of ulcerative colitis was 4.9% (95% CI, 3.8%-6.3%), 11.6% (95% CI, 9.3%-14.4%), and 15.6% (95% CI, 12.5%-19.6%), respectively. The risk of surgery 1, 5, and 10 years after diagnosis of Crohn's disease and 1 and 10 years after diagnosis of ulcerative colitis has decreased significantly over the past 6 decades (P < .05).

CONCLUSIONS

Based on systematic review and meta-analysis of population-based studies, the risk of intestinal surgery among patients with IBD has decreased over the past 6 decades.

Total abdominal colectomy for severe ulcerative colitis: does the laparoscopic approach really have benefit?

BACKGROUND

It is still unknown to what extent the reported morbidity and recovery benefits of laparoscopic total abdominal colectomy (TAC) for severe ulcerative colitis (UC) are associated with patient selection bias. This study aimed to evaluate whether laparoscopic TAC has any advantages over open surgery after control for perioperative confounding factors.

METHODS

Patients undergoing TAC for UC during 2006-2010 were identified. Demographics, disease characteristics, and perioperative outcomes were compared between laparoscopic and open TAC. Postoperative recovery and 30-day complications were further assessed by covariate-adjusted multivariate regression models. The outcomes of different laparoscopic techniques were compared. A subgroup analysis including surgeons who routinely used both laparoscopic and open techniques was also performed.

RESULTS

Of the 412 eligible patients, the 197 patients undergoing laparoscopic TAC were significantly younger and had a decreased Charlson Comorbidity Index and ASA score, increased hemoglobin and serum albumin levels, and a smaller proportion of extensive colitis and urgent cases. Unadjusted analyses showed that intraoperative morbidity, postoperative mortality, and rates for readmission and reoperation were similar. Laparoscopic TAC was associated with a longer operative time but a decrease in blood loss, overall morbidity, ileus, and thromboembolism, as well as a faster return to bowel function and a shorter hospital stay. After covariate adjustments, laparoscopic surgery remained associated with a reduction in the time to stoma function, incidence of postoperative ileus, and hospital stay compared with open TAC. The rates of postoperative morbidity, readmission, and reoperation did not differ regardless whether the conventional multitrocar technique, hand-assisted procedure, or single-incision technique was used. Laparoscopic TAC among surgeons using both open and laparoscopic techniques was associated with recovery benefits similar to those observed in the overall study population.

CONCLUSION

The data suggest that laparoscopic TAC retains recovery advantages over open surgery even after adjustments for confounders.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.