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Ovesen PD, Attauabi M, Ilvemark JFKF, Wewer MD, Warren DJ, Burisch J, Klaasen RA, Bolstad N, Steenholdt C, Seidelin JB. Effects of prednisolone tapering on effectiveness of infliximab in patients with ulcerative colitis: data from a retrospective cohort. BMJ Open Gastroenterol 2024; 11:e001343. [PMID: 38719549 PMCID: PMC11085681 DOI: 10.1136/bmjgast-2024-001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVE The influence of concomitant prednisolone on clinical outcomes and safety in infliximab-treated ulcerative colitis (UC) patients is unknown. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES A retrospective cohort study was performed, including 147 UC patients treated with infliximab at a tertiary inflammatory bowel disease (IBD) centre. Primary outcome was corticosteroid-free clinical remission (CFCR) at week 14 and week 52. Patients were grouped according to prednisolone tapering regimens: standard (≤5 mg/week), fast (>5 mg/week), direct discontinuation or no prednisolone. Patients intolerant to corticosteroids and patients stopping corticosteroids in preparation for surgery including colectomy during their initial admission were excluded. RESULTS There was no overall association between prednisolone exposure or no exposure and CFCR at weeks 14 or 52 of infliximab. The proportion of patients with C reactive protein ≤5 mg/L was higher in the standard tapering at week 14 as compared with faster regimens or no prednisolone. In subgroup analyses, the standard tapering was associated with a higher rate of CFCR at week 14 compared with the fast-tapering regimen in patients receiving ≥40 mg prednisolone at initiation of infliximab (64.3% vs 26.3%, p=0.04) and among patients admitted with acute severe UC (66.6% vs 23.5%, p<0.05). Similar data were seen at week 52. Prednisolone did not affect infliximab trough levels but increased infection rates (10/77 vs 2/70, p=0.03), in particular C. difficile infection. CONCLUSION In UC patients with limited disease burden, prednisolone did not affect effectiveness of infliximab. However, patients with increased disease burden seem to benefit from corticosteroid combination therapy.
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Affiliation(s)
- Pernille Dige Ovesen
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital-Herlev and Gentofte, Herlev Hospital, Copenhagen, Denmark
| | - Mohamed Attauabi
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital-Herlev and Gentofte, Herlev Hospital, Copenhagen, Denmark
| | - Johan F K F Ilvemark
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital-Herlev and Gentofte, Herlev Hospital, Copenhagen, Denmark
| | | | - David J Warren
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Johan Burisch
- Gastrounit, Hvidovre Hospital Gastro Unit, Hvidovre, Denmark
| | - Rolf A Klaasen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Casper Steenholdt
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital-Herlev and Gentofte, Herlev Hospital, Copenhagen, Denmark
| | - Jakob Benedict Seidelin
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital-Herlev and Gentofte, Herlev Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
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Mukhtar MS, Mosli MH. Selecting first-line advanced therapy for ulcerative colitis: A clinical application of personalized medicine. Saudi J Gastroenterol 2024; 30:126-137. [PMID: 38597333 DOI: 10.4103/sjg.sjg_427_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/13/2024] [Indexed: 04/11/2024] Open
Abstract
Ulcerative colitis (UC) is a chronic autoimmune inflammatory disease that affects the colon, leading to symptoms of bloody diarrhea, abdominal cramps, and urgency. The treatment of UC has evolved over the past few decades from locally active anti-inflammatory compounds to more selective therapies that target specific arrays of the immune system. The challenge of selecting the first advanced therapy became apparent in this rapidly expanding landscape of medications. No current investigational tools, such as genetic, immunologic, or biological markers, can guide the identification of the safest and most effective therapeutic option for each patient. Hence, physicians must carefully assess patient/disease characteristics and match them with the most suitable drug through a clinically driven assessment. In this paper, we outline patient and drug characteristics that play a role in selecting first-line advanced therapies for UC and propose an algorithm for selection.
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Affiliation(s)
- Mariam S Mukhtar
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mahmoud H Mosli
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
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Stephens IJB, Murphy B, Burns L, McCawley N, McNamara DA, Burke JP. Contemporary perioperative outcomes after total abdominal colectomy for ulcerative colitis in a tertiary referral centre. Eur J Gastroenterol Hepatol 2024; 36:578-583. [PMID: 38489595 DOI: 10.1097/meg.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Colectomy for ulcerative colitis (UC) is common despite therapeutic advances. Post-operative morbidity and mortality demonstrate an association between hospital volumes and outcomes. This single-centre retrospective study examines outcomes after emergency colectomy for UC. METHODS Patient demographics, perioperative variables and outcomes were collected in Beaumont Hospital between 2010 and 2023. Univariant analysis was used to assess relationships between perioperative variables and morbidity and length of stay (LOS). RESULTS A total of 115 patients underwent total abdominal colectomy with end ileostomy for UC, 8.7 (±3.8) per annum. Indications were refractory acute severe colitis (88.7%), toxic megacolon (6.1%), perforation (4.3%), or obstruction (0.9%). Over 80% of cases were performed laparoscopically. Pre-operative steroid (93%) and biologic (77.4%) use was common. Median post-operative LOS was 8 days (interquartile range 6-12). There were no 30-day mortalities, and 30-day post-operative morbidity was 38.3%. There was no association between time to colectomy ( P = 0.85) or biologic use ( P = 0.24) and morbidity. Increasing age was associated with prolonged LOS ( P = 0.01). Laparoscopic approach (7 vs. 12 days P =0.01, 36.8% vs. 45% P = 0.66) was associated with reduced LOS and morbidity. CONCLUSION This study highlights contemporary outcomes after emergency colectomy for UC at a specialist high-volume, tertiary referral centre, and superior outcomes after laparoscopic surgery in the biologic era.
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Affiliation(s)
- Ian J B Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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Ng AP, Chervu N, Porter G, Mallick S, Le N, Benharash P, Lee H. Cost variation of nonelective surgery for ulcerative colitis across the United States. J Gastrointest Surg 2024; 28:488-493. [PMID: 38583900 DOI: 10.1016/j.gassur.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/07/2024] [Accepted: 01/27/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although clinical outcomes of surgery for ulcerative colitis (UC) have improved in the modern biologic era, expenditures continue to increase. A contemporary cost analysis of UC operative care is lacking. The present study aimed to characterize risk factors and center-level variation in hospitalization costs after nonelective resection for UC. METHODS All adults with UC in the 2016-2020 Nationwide Readmissions Database undergoing nonelective colectomy or rectal resection were identified. Mixed-effects models were developed to evaluate patient and hospital factors associated with costs. Random effects were estimated and used to rank hospitals by increasing risk-adjusted center-level costs. High-cost hospitals (HCHs) in the top decile of expenditure were identified, and their association with select outcomes was subsequently assessed. RESULTS An estimated 10,280 patients met study criteria with median index hospitalization costs of $40,300 (IQR, $26,400-$65,000). Increased time to surgery was significantly associated with a +$2500 increment in costs per day. Compared with low-volume hospitals, medium- and high-volume centers demonstrated a -$5900 and -$8200 reduction in costs, respectively. Approximately 19.2% of variability in costs was attributable to interhospital differences rather than patient factors. Although mortality and readmission rates were similar, HCH status was significantly associated with increased complications (adjusted odds ratio [AOR], 1.39), length of stay (+10.1 days), and nonhome discharge (AOR, 1.78). CONCLUSION The present work identified significant hospital-level variation in the costs of nonelective operations for UC. Further efforts to optimize time to surgery and regionalize care to higher-volume centers may improve the value of UC surgical care in the United States.
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Affiliation(s)
- Ayesha P Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Giselle Porter
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Nguyen Le
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, United States.
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Vuyyuru SK, Jairath V. Unresolved challenges in acute severe ulcerative colitis. Indian J Gastroenterol 2024; 43:9-14. [PMID: 38189896 DOI: 10.1007/s12664-023-01503-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
| | - Vipul Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
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AbdelMeguid AMA, Whitehead E, Sebastian S. Modern practical management of acute severe colitis. Indian J Gastroenterol 2024; 43:78-92. [PMID: 38407787 DOI: 10.1007/s12664-024-01522-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/28/2023] [Indexed: 02/27/2024]
Abstract
Acute severe ulcerative colitis (ASUC) is one of life-threatening complications that occur in one-fifth of ulcerative colitis (UC) patients with significant morbidity and an estimated mortality rate up to 1%. There are no validated clinical scoring systems for ASUC. Intravenous corticosteroids remain the cornerstone for the management of ASUC patients However, one-third of patients are steroid refractory and require colectomy in the pre-biologic era or salvage therapy in the post-biologic era. The currently available predictors of non-response to steroids and salvages therapy are sub-optimal. Furthermore, there is a need for the development of clear outcome measures for ASUC patients. Although infliximab and cyclosporin are both effective as salvage therapy, they still carry a rate of treatment failure. Hence, there is an unmet need to explore alternative therapeutic options before colectomy particularly in prior infliximab-exposed patients. This may include the introduction of small molecules with rapid onset of action as a salvage or sequential therapy and the use of slow-onset other biological therapy after "bridging" with cyclosporine. In this article, we explore the current best evidence-based practice and detail the gaps in knowledge in the management of ASUC.
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Affiliation(s)
| | - Emma Whitehead
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK
| | - Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK.
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Ihara K, Nakamura T, Takayanagi M, Fujita J, Maeda Y, Nishi Y, Shibuya N, Hachiya H, Ishizuka M, Tominaga K, Kojima K, Irisawa A. Risk Factors for Stoma Outlet Obstruction after Proctocolectomy for Ulcerative Colitis. J Anus Rectum Colon 2024; 8:18-23. [PMID: 38313747 PMCID: PMC10831979 DOI: 10.23922/jarc.2023-018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/19/2023] [Indexed: 02/06/2024] Open
Abstract
Objectives Stoma outlet obstruction (SOO) occurs with an incidence of approximately 40% after proctocolectomy for Ulcerative colitis (UC) with diverting ileostomy. This study aimed to identify the risk factors for SOO after proctocolectomy with diverting ileostomy for patients with UC. Methods We reviewed the data of 68 patients with UC who underwent proctocolectomy and diverting ileostomy between April 2006 and September 2021. These cases were analyzed on the basis of clinicopathological and anatomical factors. SOO was defined as small bowel obstruction displaying symptoms of intestinal obstruction, such as abdominal distention, abdominal pain, insertion of a tube through the stoma. Results The study included 38 (56%) men and 30 (44%) women with a median age of 42 years (range, 21-80). SOO categorized as at least Clavien-Dindo grade II occurred in 11 (16%) patients. Six patients required earlier stoma closure than scheduled. Compared with patients without SOO, patients with SOO had a significantly higher total steroid dose from the onset of UC to surgery (p = 0.02), a small amount of intraabdominal fat (p = 0.04), and a higher rate of laparoscopic surgery (p < 0.01). Conclusions A high preoperative steroid dose, a small amount of intraabdominal fat and laparoscopic surgery were identified as risk factors for SOO. Early detection and treatment for SOO are important for patients at risk.
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Affiliation(s)
- Keisuke Ihara
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Takatoshi Nakamura
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Masashi Takayanagi
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Junki Fujita
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Yasunori Maeda
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Yusuke Nishi
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Norisuke Shibuya
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Hiroyuki Hachiya
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Mitsuru Ishizuka
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Keiichi Tominaga
- Department of Gastroenterology, Dokkyo Medical University, Shimotsuga, Japan
| | - Kazuyuki Kojima
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Atsushi Irisawa
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Gastroenterology, Dokkyo Medical University, Shimotsuga, Japan
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia. ANZ J Surg 2023; 93:2928-2938. [PMID: 37795917 DOI: 10.1111/ans.18713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. METHODS A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014). RESULTS A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007. CONCLUSIONS The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Sobrado LF, Mori FNC, Facanali CBG, Camargo MGM, Nahas SC, Sobrado CW. RISK FACTORS FOR EARLY POSTOPERATIVE COMPLICATIONS IN ACUTE COLITIS IN THE ERA OF BIOLOGIC THERAPY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1770. [PMID: 37878974 PMCID: PMC10595074 DOI: 10.1590/0102-672020230052e1770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/30/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Despite major advances in the clinical treatment of inflammatory bowel disease, some patients still present with acute colitis and require emergency surgery. AIMS To evaluate the risk factors for early postoperative complications in patients undergoing surgery for acute colitis in the era of biologic therapy. METHODS Patients with inflammatory bowel disease admitted for acute colitis who underwent total colectomy at a single tertiary hospital from 2012 to 2022 were evaluated. Postoperative complications were graded according to Clavien-Dindo classification (CDC). Patients with more severe complications (CDC≥2) were compared with those with less severe complications (CDC<2). RESULTS A total of 46 patients underwent surgery. The indications were: failure of clinical treatment (n=34), patients' or surgeon's preference (n=5), hemorrhage (n=3), toxic megacolon (n=2), and bowel perforation (n=2). There were eight reoperations, 60.9% of postoperative complications classified as CDC≥2, and three deaths. In univariate analyses, preoperative antibiotics use, ulcerative colitis diagnosis, lower albumin levels at admission, and preoperative hospital stay longer than seven days were associated with more severe postoperative complications. CONCLUSIONS Emergency surgery for acute colitis was associated with a high incidence of postoperative complications. Preoperative use of antibiotics, ulcerative colitis, lower albumin levels at admission, and delaying surgery for more than seven days were associated with more severe early postoperative complications. The use of biologics was not associated with worse outcomes.
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Affiliation(s)
- Lucas Faraco Sobrado
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Fernando Noboru Cabral Mori
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | | | - Mariane Gouvea Monteiro Camargo
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Sérgio Carlos Nahas
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Carlos Walter Sobrado
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
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Weinstein CLJ, Meehan AG, Govoni M, Lin J, Reinisch W. Low Occurrence of Colectomy With Long-Term (up to 4 Years) Golimumab Treatment in Patients With Moderate-to-Severe Active Ulcerative Colitis: Data From the PURSUIT Maintenance and Long-Term Extension Studies. CROHN'S & COLITIS 360 2023; 5:otad044. [PMID: 37691729 PMCID: PMC10492447 DOI: 10.1093/crocol/otad044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 09/12/2023] Open
Abstract
Background This analysis evaluated the incidence of all-cause colectomies (total or partial) among patients with moderate-to-severe active ulcerative colitis (UC) in the golimumab (GLM) Program of Ulcerative Colitis Utilizing an Investigational Treatment (PURSUIT)-maintenance (-M) and long-term extension (-LTE) studies. Methods Eligible PURSUIT-M trial participants completed a 6-week GLM induction trial without requiring colectomy. Responders to GLM induction were randomized 1:1:1 to GLM 50 mg, GLM 100 mg, or placebo (PBO) maintenance for up to 1 year, administered every 4 weeks (q4w). Nonresponders to GLM or PBO induction received GLM 100 mg; responders to PBO induction received PBO (each administered q4w for up to 1 year). Participants who completed PURSUIT-M were eligible to continue their treatment in the 3-year PURSUIT-LTE study. Results A total of 60 (4.9%) colectomies were reported among the 1228 patients who enrolled in the 1-year PURSUIT-M study, which included 672 participants who continued into the 3-year PURSUIT-LTE LTE study (of which 666 were treated). The colectomy rate during the 3-year extension was lower than that observed during the maintenance phase of the study (9/666 [1.4%] compared to 51/1228 [4.2%]). The majority (43/60 [71.7%]) of the reported colectomies occurred in patients who had not responded to induction therapy and who tended to have had more severe disease characteristics at baseline. Conclusions This retrospective evaluation of colectomy data from the PURSUIT-M and -LTE studies in patients with moderate-to-severe active UC demonstrated a low (<5%) occurrence of colectomy with long-term (up to 4 years) GLM treatment. PURSUIT-M (NCT00488631; EudraCT, 2006-003399-37).
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Affiliation(s)
| | | | | | | | - Walter Reinisch
- Universitätsklinik für Innere Medizin III, Gastroenterology & Hepatology, Vienna, Austria
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Sharma S, Li DK, Levine LJ, Chaar A, McMillan C, Gaidos JKJ, Proctor DD, Al-Bawardy B. Early Flexible Sigmoidoscopy Improves Clinical Outcomes in Acute Severe Ulcerative Colitis. CROHN'S & COLITIS 360 2023; 5:otad032. [PMID: 37323477 PMCID: PMC10263117 DOI: 10.1093/crocol/otad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Indexed: 06/17/2023] Open
Abstract
Objectives Guidelines recommend performing a flexible sigmoidoscopy in patients hospitalized with acute severe ulcerative colitis (ASUC). However, it is unclear if time to sigmoidoscopy affects relevant clinical outcomes. We aimed to assess the impact of early sigmoidoscopy on clinical outcomes using a well-characterized cohort of patients with ASUC. Methods This is a single-center, retrospective study of all patients hospitalized with ASUC from January 1, 2012 to November 1, 2021. Early sigmoidoscopy was defined as occurring within 72 hours of admission while delayed sigmoidoscopy was defined as occurring >72 hours after admission. Primary outcomes were cumulative days of intravenous (IV) corticosteroid (CS) use, length of hospital stay, and colectomy rates. Secondary outcomes were time to infliximab (IFX) rescue and inpatient opioid medication use. Results A total of 112 patients hospitalized with ASUC who underwent sigmoidoscopy were included in the analysis. Eighty-seven patients (78%) had early sigmoidoscopy and 25 (22%) had delayed sigmoidoscopy. Patients in the early sigmoidoscopy group were exposed to significantly fewer days of IV CS (4.5 vs 9.2 days; P < .001), had shorter hospital stays (6.4 vs 19.3 days; P < .001), and shorter time to IFX rescue (3.5 vs 6.4 days; P = .004). Rates of colectomy in the early and delayed sigmoidoscopy groups were 17% versus 28%, respectively (P = .23). Longer time to sigmoidoscopy was associated with a 16% increased risk of colectomy (HR = 1.16, P = .002). Conclusions In this well-characterized cohort, early sigmoidoscopy in ASUC was associated with favorable clinical outcomes. These findings highlight the benefits of early sigmoidoscopy in patients with ASUC. Larger prospective studies are needed to corroborate these findings.
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Affiliation(s)
- Shreyak Sharma
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Darrick K Li
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Louis J Levine
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Abdelkader Chaar
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Jill K J Gaidos
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Deborah D Proctor
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Badr Al-Bawardy
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Gordon BL, Battat R. Therapeutic Drug Monitoring of Infliximab in Acute Severe Ulcerative Colitis. J Clin Med 2023; 12:jcm12103378. [PMID: 37240484 DOI: 10.3390/jcm12103378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Therapeutic drug monitoring (TDM) is a useful strategy in ulcerative colitis (UC). Nearly a quarter of UC patients will experience acute severe UC (ASUC) in their lifetime, including 30% who will fail first-line corticosteroid therapy. Steroid-refractory ASUC patients require salvage therapy with infliximab, cyclosporine, or colectomy. Fewer data are available for the use of TDM of infliximab in ASUC. The pharmacokinetics of ASUC make TDM in this population more complex. High inflammatory burden is associated with increased infliximab clearance, which is associated with lower infliximab drug concentrations. Observational data support the association between increased serum infliximab concentrations, lower clearance, and favorable clinical and endoscopic outcomes, as well as decreased rates of colectomy. Data regarding the benefit of accelerated or intensified dosing strategies of infliximab-as well as target drug concentration thresholds-in ASUC patients remain more equivocal, though limited by their observational nature. Studies are underway to further evaluate optimal dosing and TDM targets in this population. This review examines the evidence for TDM in patients with ASUC, with a focus on infliximab.
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Affiliation(s)
- Benjamin L Gordon
- Division of Gastroenterology and Hepatology, New York-Presbyterian/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Robert Battat
- Center for Clinical and Translational Research in Inflammatory Bowel Diseases, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2X 0A9, Canada
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Nakase H. Acute Severe Ulcerative Colitis: Optimal Strategies for Drug Therapy. Gut Liver 2023; 17:49-57. [PMID: 36375793 PMCID: PMC9840911 DOI: 10.5009/gnl220017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/01/2022] [Accepted: 04/14/2022] [Indexed: 11/16/2022] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity (30% to 40%). Patients with ASUC require hospitalization for prompt medical treatment, and colectomy is considered if medical therapy fails. Corticosteroids remain the primary initial therapy, although one-third of patients do not respond to treatment. Clinical data have indicated that cyclosporine, tacrolimus, and infliximab can be used to treat patients with ASUC who do not respond to intravenous corticosteroids. The effectiveness and safety of sequential therapy have recently been reported; however, the data are not convincing. Importantly, timely decision-making with rescue therapy or surgical treatment is critical to manage ASUC without compromising the health or safety of the patients. In addition, risk stratification and the use of predictive clinical parameters have improved the clinical outcome.of ASUC. Multidisciplinary teams that include inflammatory bowel disease experts, colorectal surgeons, and other medical staff contribute to the better management of patients with ASUC. In this review, we introduce current evidence and present a clinical approach to manage ASUC.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan,Corresponding AuthorHiroshi Nakase, ORCIDhttps://orcid.org/0000-0003-2848-6586, E-mail
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14
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Ostrowski S, Croft A. Viral Enteric Infections in Acute Severe Ulcerative Colitis. J Crohns Colitis 2022; 16:1335-1339. [PMID: 35165696 DOI: 10.1093/ecco-jcc/jjac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/29/2022] [Accepted: 02/13/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Excluding superimposed enteric infection is critical in the management of acute severe ulcerative colitis [ASUC]. Whilst infection with Clostridium difficile and cytomegalovirus have been shown to increase colectomy and mortality rates, no data exist regarding the impact of common viral enteropathogens in ASUC. Our aim was to determine if viral enteric infection in ASUC alters the severity or outcomes of these episodes. METHODS This was a retrospective review of cases presenting to a large tertiary centre. Data were obtained from an in-house, prospectively maintained inflammatory bowel disease database. We identified all ASUC cases treated between October 2015 and January 2021 and compared those testing positive for adenovirus 40/41, human rotavirus or norovirus GI by faecal multiplex polymerase chain reaction [PCR] to those testing negative. RESULTS We identified 147 patients with ASUC and faecal multiplex PCR testing for viral pathogens. In total, 22/147 patients [14.9%] tested positive, two of whom tested positive for two viruses. The infected and non-infected cohorts did not differ significantly with regard to admission C-reactive protein [81.7 vs 76.6, p = 0.77], Mayo endoscopic subscore [2.4 vs 2.3, p = 0.43], length of hospital admission [7.9 vs 7.9 p = 0.99], requirement for rescue therapy [59% vs 56%, p = 0.75] or colectomy rate [4.5% vs 4.1%, p = 0.69]. CONCLUSIONS Infection with viral enteropathogens was common in our ASUC cohort, but did not appear to affect disease severity at presentation, the need for rescue therapy or the success rate of rescue therapy.
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Affiliation(s)
- Szymon Ostrowski
- Royal Brisbane and Women's Hospital, Department of Gastroenterology and Hepatology, Butterfield St., Herston, QLD 4029, Australia.,Mater Hospital Brisbane, Department of Gastroenterology and Hepatology, Raymond Terrace, South Brisbane, QLD 4101, Australia
| | - Anthony Croft
- Royal Brisbane and Women's Hospital, Department of Gastroenterology and Hepatology, Butterfield St., Herston, QLD 4029, Australia.,University of Queensland, St Lucia, QLD 4072, Australia
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Emergent and Urgent Surgery for Ulcerative Colitis in the United States in the Minimally Invasive and Biologic Era. Dis Colon Rectum 2022; 65:1025-1033. [PMID: 34897209 DOI: 10.1097/dcr.0000000000002109] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although the overall adoption of minimally invasive surgery in the nonemergent management of ulcerative colitis is established, little is known about its utilization in emergency settings. OBJECTIVE The goal of this study was to assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis. DESIGN This was a retrospective analysis study. SETTINGS Data were collected from the American College of Surgeons National Quality Improvement Program database. PATIENTS All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included. MAIN OUTCOME MEASURES Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery. RESULTS A total of 2219 patients were identified. Of those, 1515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p < 0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018; p = 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1058/1515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p < 0.0001) and emergent (0% in 2005 to 42% in 2018; p < 0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of surgical, septic, and overall complications, and prolonged hospitalization. LIMITATIONS This study was limited by its retrospective nature of the analysis. CONCLUSION Based on a nationwide analysis from the United States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis. Although the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847 . CIRUGA DE URGENCIA Y EMERGENCIA PARA LA COLITIS ULCEROSA EN LOS ESTADOS UNIDOS EN LA ERA MNIMAMENTE INVASIVA Y DE TERAPIA BIOLGICA ANTECEDENTES:Si bien se ha establecido la adopción generalizada de la cirugía mínimamente invasiva en el tratamiento electivo de la colitis ulcerosa, se sabe poco sobre su utilización en situaciones de emergencia.OBJETIVO:Evaluar las tasas de cirugía de urgencia a lo largo del tiempo en la era de las terapias biológicas emergentes y destacar la práctica actual en los Estados Unidos con respecto a la utilización de la cirugía mínimamente invasiva para las indicaciones de urgencia y emergencia de la colitis ulcerosa.DISEÑO:Análisis retrospectivo.AJUSTES:Base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes adultos que se sometieron a colectomía de emergencia o urgencia por colitis ulcerosa.MEDIDAS DE RESULTADO:Se evaluaron las tasas de operaciones de emergencia a lo largo del tiempo y las tendencias de utilización de la cirugía mínimamente invasiva en entornos de urgencia y emergencia. Se compararon las tasas de complicaciones generales, quirúrgicas y médicas de 30 días no ajustadas y ajustadas entre la cirugía abierta y la mínimamente invasiva.RESULTADOS:Se identificaron un total de 2.219 pacientes. De ellos, 1.515 pacientes (68,3%) fueron intervenidos de urgencia y 704 (31,7%) de emergencia. Los casos emergentes disminuyeron con el tiempo (21% en 2006 a 8% en 2018; p <0,0001). Sin embargo, la tasa de cirugías urgentes no ha cambiado significativamente (42% en 2011 a 46% en 2018, p = 0,44). Se ofreció cirugía mínimamente invasiva al 70% de los pacientes del grupo urgente (1.058 / 1.515) y al 22,6% de las emergencias (159/704). En general, la cirugía mínimamente invasiva se utilizó cada vez más durante el período de estudio en grupos urgentes (38% en 2011 a 71% en 2018; p <0,0001) y emergentes (0% en 2005 a 42% en 2018; p <0,0001). En comparación con la cirugía mínimamente invasiva, la cirugía abierta se asoció con un mayor riesgo de complicaciones generales, quirúrgicas, sépticas y hospitalización prolongada.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIÓNES:Basado en un análisis nacional de los Estados Unidos, la cirugía mínimamente invasiva se ha implementado de manera creciente y segura para las indicaciones emergentes y urgentes de la colitis ulcerosa. Si bien la suma de casos emergentes y urgentes permaneció igual durante el período de estudio, los casos de emergencia disminuyeron significativamente, lo que puede estar relacionado con mejores opciones de tratamiento médico y un enfoque de equipo colaborativo y especializado. Consulte Video Resumen en http://links.lww.com/DCR/B847 . (Traducción-Dr. Felipe Bellolio ).
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Kwon Y, Kim ES, Choe YH, Kim MJ. How has the disease course of pediatric ulcerative colitis changed throughout the biologics era? A comparison with the IBSEN study. World J Gastroenterol 2022; 28:3666-3681. [PMID: 36161040 PMCID: PMC9372802 DOI: 10.3748/wjg.v28.i28.3666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/29/2021] [Accepted: 06/30/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In Korea, infliximab was approved for use in children with ulcerative colitis (UC) in October 2012.
AIM To compare the clinical course of UC before and after the introduction of biological agents, and to compare with the IBSEN study.
METHODS Patients under 18 years of age, who were diagnosed with UC and followed from January 2003 to October 2020, were included in the study. Group A (n = 48) was followed for at least 2 years between January 2003 and October 2012, and Group B (n = 62) was followed for at least 2 years between November 2012 and October 2020. We compared endoscopic remission, drug composition, relapse rate, steroid-free period, and the quality of life of each group. We plotted the clinical course of the included patients using the pediatric UC activity index score, and compared our patients with those in the IBSEN study.
RESULTS After 2 years of treatment, colonoscopy evaluation revealed different outcomes in the two treatment groups. Remission was confirmed in 14 patients (29.2%) of Group A, and in 31 patients (50.0%) of Group B (P < 0.012). The median cumulative corticosteroid-free period was 3.0 years in Group A and 4.4 years in Group B. Steroid-free period of Group B was significantly longer than that of Group A (P < 0.001). There was a statistically significant difference between the two groups in evaluation of the relapse rate during the observation period (P < 0.001). The plotted clinical course graphs of Group A showed similar proportions to the graphs in the IBSEN study. However, in Group B, the proportion of patients corresponding to curve 1 (remission or mild severity after initial high activity) was high at 76% (47/62).
CONCLUSION The incidence of relapse has decreased and the steroid-free period has increased after the introduction of the biological agent. The clinical course also showed a different pattern from that of IBSEN study. The active use of biological agents may change the long-term disease course in moderate to severe pediatric UC.
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Affiliation(s)
- Yiyoung Kwon
- Department of Pediatrics, Samsung Medical Center, Seoul 06351, South Korea
| | - Eun Sil Kim
- Department of Pediatrics, Kangbuk Samsung Medical Center, Seoul 03181, South Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Seoul 06351, South Korea
| | - Mi Jin Kim
- Department of Pediatrics, Samsung Medical Center, Seoul 06351, South Korea
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17
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Sahu P, Jain S, Kedia S, Vuyyuru SK, Sahni P, Sharma R, Panwar R, Das P, Gupta V, Makharia G, Travis S, Ahuja V. Prospective validation of AIIMS index as a predictor of steroid failure in patients with acute severe ulcerative colitis. Indian J Gastroenterol 2022; 41:273-283. [PMID: 35474175 DOI: 10.1007/s12664-021-01217-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Optimal outcomes in acute severe ulcerative colitis (ASUC) are related to time-bound management based upon early prediction of response to intravenous (IV) steroids. In an earlier study, we described the All India Institute of Medical Sciences (AIIMS) index (baseline Ulcerative Colitis Endoscopic Index of Severity [UCEIS] ≥ 7 and day 3 fecal calprotectin [FCP] > 1000 μg/g) for predicting failure of IV steroids. The current study is designed to validate this index in a prospective cohort. METHODS IV steroid-naïve patients with ASUC, satisfying Truelove and Witts' criteria, hospitalized from August 2018 to July 2019 were included. Patients' assessment included baseline sigmoidoscopy, day 1 and 3 FCP, hemogram, biochemistry and day 3 C-reactive protein. All patients received IV steroids, and the primary outcome was steroid failure, defined as the need for colectomy or rescue therapy with cyclosporine (CYC)/infliximab (IFX) during admission. RESULTS Of the 47 patients, eight were excluded (four received steroids outside, two were directly taken for surgery/infliximab therapy, one had toxic megacolon, and one had infectious colitis), and 39 patients were included (mean age: 36.1 ± 12.6 years, male: 31%). Fifteen patients (38%) failed IV steroid and required rescue therapy (IFX: 9, CYC: 2, Colectomy: 3, IFX followed by colectomy: 1). On univariate analysis, UCEIS ≥ 7 at baseline (p = 0.006), day 1 FCP (p = 0.03), day 3 FCP > 1000 μg/g (p = 0.001), Oxford criteria (p = 0.04) and AIIMS index (p < 0.001) were significantly different between steroid responders and steroid failures. On multivariate analysis, day 3 FCP > 1000 μg/g (odds ratio (odds ratio (OR)= 6.4;(95% CI =2.2-196.1) and baseline UCEIS ≥ 7 (OR) = 10.1;(95% CI = 2.1-80.2) were independent predictors. The AIIMS index predicted steroid failure with a better specificity (100% vs. 83%, p = 0.04) and positive predictive value (100% vs. 64%, p = 0.03) than Oxford criteria. CONCLUSION AIIMS index has been validated in 39 prospective ASUC patients as an effective early predictor of steroid failure (sensitivity = 53%, specificity = 100%).
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Affiliation(s)
- Pabitra Sahu
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saransh Jain
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sudheer K Vuyyuru
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Rajesh Panwar
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Vipin Gupta
- Translational, Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, USA
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Simon Travis
- Translational, Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, USA
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Lactiplantibacillus plantarum attenuates 2,4,6-trinitrobenzenesulfonic acid-induced ulcerative colitis in rats by regulating the inflammatory response, T helper 17 immune response, and intestinal permeability. Biologia (Bratisl) 2022. [DOI: 10.1007/s11756-022-01111-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Kuwabara H, Kimura H, Kunisaki R, Tatsumi K, Koganei K, Sugita A, Katsumata K, Tsuchida A, Endo I. Postoperative complications, bowel function, and prognosis in restorative proctocolectomy for ulcerative colitis-a single-center observational study of 320 patients. Int J Colorectal Dis 2022; 37:563-572. [PMID: 34751417 DOI: 10.1007/s00384-021-04059-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine the selection criteria, postoperative complications, bowel function, and prognosis of stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA for ulcerative colitis (UC). METHODS We defined our surgical indications and strategy, and compared the postoperative complications, bowel function, and prognoses between patients who underwent stapled and hand-sewn IPAA for UC at the Yokohama City University Medical Center between 2004 and 2017. RESULTS Among 320 patients enrolled, 298 patients underwent stapled IPAA while 22 underwent hand-sewn IPAA. There was no significant difference in the postoperative complications between the two groups. Regarding postoperative bowel function, stapled IPAA caused significantly less soiling (stapled vs hand-sewn: 9.1% vs 41.0%, odds ratio (OR) = 0.14, p < 0.0002), spotting (stapled vs hand-sewn: 23.2% vs 63.6%, OR = 0.17, p < 0.0001), and difficulty in distinguishing feces from flatus (stapled vs hand-sewn: 39.9% vs 63.6%, OR = 0.36, p < 0.026). No postoperative neoplasia was observed at the final follow-up in all patients. CONCLUSION In this study, there was no clear difference in the postoperative complications between stapled and hand-sewn IPAA, but stapled IPAA resulted in better postoperative bowel function. Postoperative oncogenesis from the residual mucosa is rare. However, future cancer risk remains; thus, careful follow-up is required.
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Affiliation(s)
- Hiroshi Kuwabara
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku Ward, Tokyo, 160-0012, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Kenji Tatsumi
- Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawa Nishimachi, Kanagawa Ward, Yokohama, Kanagawa, 221-0855, Japan
| | - Kazutaka Koganei
- Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawa Nishimachi, Kanagawa Ward, Yokohama, Kanagawa, 221-0855, Japan
| | - Akira Sugita
- Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawa Nishimachi, Kanagawa Ward, Yokohama, Kanagawa, 221-0855, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku Ward, Tokyo, 160-0012, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku Ward, Tokyo, 160-0012, Japan
| | - Itaru Endo
- Department of Gastrointestinal Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa Ward, Yokohama, 236-0004, Japan
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20
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Spinelli A, Bonovas S, Burisch J, Kucharzik T, Adamina M, Annese V, Bachmann O, Bettenworth D, Chaparro M, Czuber-Dochan W, Eder P, Ellul P, Fidalgo C, Fiorino G, Gionchetti P, Gisbert JP, Gordon H, Hedin C, Holubar S, Iacucci M, Karmiris K, Katsanos K, Kopylov U, Lakatos PL, Lytras T, Lyutakov I, Noor N, Pellino G, Piovani D, Savarino E, Selvaggi F, Verstockt B, Doherty G, Raine T, Panis Y. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment. J Crohns Colitis 2022; 16:179-189. [PMID: 34635910 DOI: 10.1093/ecco-jcc/jjab177] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, and Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johan Burisch
- Gastrounit, Medical Division, and Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Lüneburg, Germany
| | - Michel Adamina
- Department of Surgery, Clinic of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Zurich.,Department of Biomedical Engineering, Clinical Research and Artificial Intelligence in Surgery, Faculty of Medicine, University of Basel, Allschwil, Switzerland
| | - Vito Annese
- Department of Gastroenterology, Fakeeh University Hospital, Dubai, UAE
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim.,Hannover Medical School, Hannover, Germany
| | - Dominik Bettenworth
- University Hospital Munster, Department of Medicine B - Gastroenterology and Hepatology, Munster, Germany
| | - Maria Chaparro
- Gastroenterology Unit, IIS-IP, Universidad Autónoma de Madrid [UAM], CIBEREHD, Madrid, Spain
| | - Wladyslawa Czuber-Dochan
- King's College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznań University of Medical Sciences, and Heliodor Święcicki University Hospital, Poznań, Poland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Catarina Fidalgo
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, and IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Paolo Gionchetti
- IBD Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna DIMEC, University of Bologna, Bologna, Italy
| | - Javier P Gisbert
- Gastroenterology Unit, IIS-IP, Universidad Autónoma de Madrid [UAM], CIBEREHD, Madrid, Spain
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, and Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, and Division of Gastroenterology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, and Sackler Medical School, Tel Aviv, Israel
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC, Canada.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Theodore Lytras
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Ivan Lyutakov
- Department of Gastroenterology, University Hospital 'Tsaritsa Yoanna - ISUL', Medical University Sofia, Sofia, Bulgaria
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy, and Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy and Université of Paris, France
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21
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Verma A, Varma S, Freedberg DE, Axelrad JE. A Simple Emergency Department-Based Score Predicts Complex Hospitalization in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:629-638. [PMID: 33606139 PMCID: PMC8373997 DOI: 10.1007/s10620-021-06877-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/24/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Thirty percent of inflammatory bowel disease (IBD) patients hospitalized with flare require salvage therapy or surgery. Additionally, 40% experience length of stay (LOS) > 7 days. No emergency department (ED)-based indices exist to predict these adverse outcomes at admission for IBD flare. We examined whether clinical, laboratory, and endoscopic markers at presentation predicted prolonged LOS, inpatient colectomy, or salvage therapy in IBD patients admitted with flare. METHODS Patients with ulcerative colitis (UC) or colonic involvement of Crohn's disease (CD) hospitalized with flare and tested for Clostridioides difficile infection (CDI) between 2010 and 2020 at two urban academic centers were studied. The primary outcome was complex hospitalization, defined as: LOS > 7 days, inpatient colectomy, or inpatient infliximab or cyclosporine. A nested k-fold cross-validation identified predictive factors of complex hospitalization. RESULTS Of 164 IBD admissions, 34% (56) were complex. Predictive factors included: tachycardia in ED triage (odds ratio [OR] 3.35; confidence interval [CI] 1.79-4.91), hypotension in ED triage (3.45; 1.79-5.11), hypoalbuminemia at presentation (2.54; 1.15-3.93), CDI (2.62; 1.02-4.22), and endoscopic colitis (4.75; 1.75-5.15). An ED presentation score utilizing tachycardia and hypoalbuminemia predicted complex hospitalization (area under curve 0.744; CI 0.671-0.816). Forty-four of 48 (91.7%) patients with a presentation score of 0 (heart rate < 99 and albumin ≥ 3.4 g/dL) had noncomplex hospitalization. CONCLUSIONS Over 90% of IBD patients hospitalized with flare with an ED presentation score of 0 did not require salvage therapy, inpatient colectomy, or experience prolonged LOS. A simple ED-based score may provide prognosis at a juncture of uncertainty in patient care.
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Affiliation(s)
- Abhishek Verma
- Department of Medicine, NYU Langone Health, New York, NY 10016, USA
| | - Sanskriti Varma
- Department of Medicine, New York Presbyterian Columbia University Medical Center, New York, NY, 10032, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA
| | - Jordan E Axelrad
- Division of Gastroenterology, NYU Langone Health, Inflammatory Bowel Disease Center at NYU Langone Health, New York, NY 10016, USA
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22
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Carvello M, Watfah J, Spinelli A. The Management of the Hospitalized Ulcerative Colitis Patient, the Medical-Surgical Conundrum. Curr Gastroenterol Rep 2021; 23:25. [PMID: 34716521 DOI: 10.1007/s11894-021-00820-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Joseph Watfah
- Department of General Surgery, Northwick Park Hospital, London, UK
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
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23
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Lim MH, Lord AR, Simms LA, Hanigan K, Edmundson A, Rickard MJ, Stitz R, Clark DA, Radford-Smith GL. Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Australian Institution's Experience. Ann Coloproctol 2021; 37:318-325. [PMID: 32972106 PMCID: PMC8566152 DOI: 10.3393/ac.2020.08.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/16/2020] [Accepted: 08/26/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE We report outcomes and evaluate patient factors and the impact of surgical evolution on outcomes in consecutive ulcerative colitis patients who had restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) at an Australian institution over 26 years. METHODS Data including clinical characteristics, preoperative medical therapy, and surgical outcomes were collected. We divided eligible patients into 3 period arms (period 1, 1990 to 1999; period 2, 2000 to 2009; period 3, 2010 to 2016). Outcomes of interest were IPAA leak and pouch failure. RESULTS A total of 212 patients were included. Median follow-up was 50 (interquartile range, 17 to 120) months. Rates of early and late complications were 34.9% and 52.0%, respectively. Early complications included wound infection (9.4%), pelvic sepsis (8.0%), and small bowel obstruction (6.6%) while late complications included small bowel obstruction (18.9%), anal stenosis (16.8%), and pouch fistula (13.3%). Overall, IPAA leak rate was 6.1% and pouch failure rate was 4.8%. Eighty-three patients (42.3%) experienced pouchitis. Over time, we observed an increase in patient exposure to thiopurine (P=0.0025), cyclosporin (P=0.0002), and anti-tumor necrosis factor (P<0.00001) coupled with a shift to laparoscopic technique (P<0.00001), stapled IPAA (P<0.00001), J pouch configuration (P<0.00001), a modified 2-stage procedure (P=0.00012), and a decline in defunctioning ileostomy rate at time of IPAA (P=0.00002). Apart from pouchitis, there was no significant difference in surgical and chronic inflammatory pouch outcomes with time. CONCLUSION Despite greater patient exposure to immunomodulatory and biologic therapy before surgery coupled with a significant change in surgical techniques, surgical and chronic inflammatory pouch outcome rates have remained stable.
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Affiliation(s)
- Ming Han Lim
- Department of Gastroenterology & Hepatology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Anton R. Lord
- Gut Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Lisa A. Simms
- Gut Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Katherine Hanigan
- Gut Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Matthew J.F.X. Rickard
- Division of Colorectal Surgery, Department of Surgery, Concord Repatriation General Hospital, Sydney, Australia
- Discipline of Surgery, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Russell Stitz
- Department of Colorectal Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - David A. Clark
- Discipline of Surgery, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Colorectal Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Graham L. Radford-Smith
- Department of Gastroenterology & Hepatology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- Gut Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
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24
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Soriano CR, Powell CR, Chiorean MV, Simianu VV. Role of hospitalization for inflammatory bowel disease in the post-biologic era. World J Clin Cases 2021; 9:7632-7642. [PMID: 34621815 PMCID: PMC8462259 DOI: 10.12998/wjcc.v9.i26.7632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Charleston R Powell
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA 98109, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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25
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Blesl A, Binder L, Högenauer C, Wenzl H, Borenich A, Pregartner G, Berghold A, Mestel S, Kump P, Baumann‐Durchschein F, Petritsch W. Limited long-term treatment persistence of first anti-TNF therapy in 538 patients with inflammatory bowel diseases: a 20-year real-world study. Aliment Pharmacol Ther 2021; 54:667-677. [PMID: 34151449 PMCID: PMC8453765 DOI: 10.1111/apt.16478] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/12/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anti-TNF antibodies were the first biologic treatment option for patients with inflammatory bowel diseases. AIMS To assess length of treatment persistence of first anti-TNF therapy and influencing factors used in the standard care of patients with inflammatory bowel diseases. METHODS Single-centre, retrospective study from a register including patients who received anti-TNF therapy in the last 20 years at the study centre. Kaplan-Meier analysis with log-rank test was used to describe treatment persistence. With multivariable Cox regression analysis, risk factors for treatment failure were investigated. RESULTS Five hundred thirty-eight patients (CD, Crohn's disease: 367, UC, ulcerative colitis: 147, inflammatory bowel disease unclassified: 24) with a median follow-up of 8.1 years were included. Median (95% confidence interval) treatment persistence in the total cohort was 2.3 years (28 [22, 38] months), and nearly half of patients withdrew from treatment within 2 years. Male patients were treated longer than females (male: 37 [25, 48] months, female: 23 [14, 33] months, P = 0.002). Treatment persistence was longer in CD compared to UC (CD: 39 [30, 50] months, UC: 13 [9, 19] months, P < 0.001), and patients with CD remained longer on adalimumab than on infliximab treatment (adalimumab: 67 [55, 95] months, infliximab: 19 [14, 31] months, P < 0.001). Treatment failure (52%) and side effects (25%) were the most common reasons for withdrawal from therapy; 14% withdrew due to remission. Female sex was identified as independent predictor for treatment failure in UC (hazard ratio [CI]: 1.73 [1.02-2.92], P = 0.04). CONCLUSION Long-term treatment persistence of first anti-TNF therapy was limited in patients with inflammatory bowel diseases, primarily due to treatment failure and side effects.
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Affiliation(s)
- Andreas Blesl
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | - Lukas Binder
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | - Christoph Högenauer
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria,BiotechmedGrazAustria
| | - Heimo Wenzl
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | - Andrea Borenich
- Institute for Medical Informatics, Statistics and DocumentationMedical University of GrazGrazAustria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and DocumentationMedical University of GrazGrazAustria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and DocumentationMedical University of GrazGrazAustria
| | - Sigrid Mestel
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | - Patrizia Kump
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | | | - Wolfgang Petritsch
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
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26
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Preoperative Neutrophil-to-Lymphocyte Ratio Is Correlated with Severe Postoperative Complications After Emergency Surgery for Ulcerative Colitis. Int Surg 2021. [DOI: 10.9738/intsurg-d-16-00216.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction
The incidence of postoperative severe complications is reported to be high in patients undergoing emergency surgery for severe ulcerative colitis (UC). It has also been reported that the preoperative inflammatory status is associated with the frequency of postoperative complications. The neutrophil-to-lymphocyte ratio (NLR) is a simple and useful parameter for determining the inflammatory status.
Methods
In the present study, we retrospectively investigated the correlation between the NLR and the incidence of severe postoperative complications in patients undergoing emergency surgery for severe UC. A total of 105 UC patients who underwent emergency or semi-emergency surgery were enrolled. Various clinical factors and NLR values were evaluated to identify the risk factors for severe complications. Postoperative complications were stratified by their severity according to the Clavien-Dindo Classification (CD). A postoperative complication of CD IIIb or higher was defined as severe postoperative complications. The incidence of severe complications was 16.2%.
Results
A multivariate analysis revealed the ASA score, toxic megacolon, and NLR to be independent risk factors for severe postoperative complications.
Conclusions
The results of this retrospective study suggest that the NLR is an independent risk factor for severe postoperative complications in patients undergoing emergency surgery for UC.
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27
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Ge X, Jiang L, Yu W, Wu Y, Liu W, Qi W, Cao Q, Bai R, Zhou W. The importance of sarcopenia as a prognostic predictor of the clinical course in acute severe ulcerative colitis patients. Dig Liver Dis 2021; 53:965-971. [PMID: 33934998 DOI: 10.1016/j.dld.2021.03.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Acute severe ulcerative colitis (ASUC) is a life-threatening condition that requires timely referral for therapy. Sarcopenia has been associated with clinical outcomes of inflammatory bowel disease (IBD). This study investigated the role of sarcopenia in predicting the clinical course of ASUC. METHODS This retrospective cohort study included ASUC patients with abdominal CT scans. Univariate and multivariable regression analyses were performed to identify a practical predictive index for the clinical course of ASUC. RESULTS Of 233 included patients, 151 had intravenous corticosteroid (IVS) failure, among whom 32 received surgery without medical rescue therapy. Fifty patients underwent colectomy after medical rescue therapy failure. Of these 82 surgical patients, 42 suffered postoperative complications. Multivariable regression analysis showed that sarcopenia remained an independent risk factor for IVS failure (OR=2.969; 95% CI, 1.547-5.701; p = 0.001), colectomy after medical rescue therapy failure (OR=3.411; 95% CI, 1.147-10.141; p = 0.027), and postoperative complications after colectomy (OR=4.157; 95% CI, 1.364-12.667; p = 0.012). During follow-up, patients with colectomy after first-line treatment had a lower comprehensive complication index and better health-related quality of life. CONCLUSION Sarcopenia is useful in predicting the clinical course and postoperative outcomes of ASUC.
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Affiliation(s)
- Xiaolong Ge
- Department of General Surgery, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China
| | - Liping Jiang
- Department of Medicine, Guangxi Medical College, Nanning, GuangXi 530023, China
| | - Weihua Yu
- Department of General Surgery, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China
| | - Yan Wu
- Department of Gastroenterology, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Wei Liu
- Department of General Surgery, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China
| | - Weilin Qi
- Department of General Surgery, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China
| | - Qian Cao
- Department of Gastroenterology, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Rongpan Bai
- Department of General Surgery, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China.
| | - Wei Zhou
- Department of General Surgery, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China.
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28
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The Role of Biomarkers in Surgery for Ulcerative Colitis: A Review. J Clin Med 2021; 10:jcm10153362. [PMID: 34362144 PMCID: PMC8348722 DOI: 10.3390/jcm10153362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/25/2021] [Accepted: 07/28/2021] [Indexed: 12/19/2022] Open
Abstract
Ulcerative colitis (UC) is an inflammatory condition that generally affects the rectum and extends proximally into the colon in a continuous, distal-to-proximal pattern. Surgical resection (total proctocolectomy) is the only cure for UC and is often necessary in managing complicated or refractory disease. However, recent advances in biologically targeted therapies have resulted in improved disease control, and surgery is required in only a fraction of cases. This ever-increasing array of options for medical management has added complexity to surgical decision-making. In some circumstances, the added time required to ensure failure of medical therapy can delay colectomy in patients who will ultimately need it. Indeed, many patients with severe disease undergo trials of multiple medical therapies prior to considering surgery. In severe cases of UC, continued medical management has been associated with a delay to surgical intervention and higher rates of morbidity and mortality. Biomarkers represent a burgeoning field of research, particularly in inflammatory bowel disease and cancer. This review seeks to highlight the different possible settings for surgery in UC and the role various biomarkers might play in each.
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29
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Luo L, Qing L, Yao C, Liu D, Li Y, Li T, Feng P. Efficacy and safety of hyperbaric oxygen therapy for moderate-to-severe ulcerative colitis: a protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e047543. [PMID: 34183344 PMCID: PMC8240565 DOI: 10.1136/bmjopen-2020-047543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/27/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Ulcerative colitis (UC) is a type of inflammatory bowel disease, and 62% of patients with UC felt that it is difficult for them to live a normal life. Furthermore, some researches have shown that about 15% of patients with UC undergo at least one extreme clinical course in their lifetime, and 10%-30% of patients with UC oblige colectomy. Although many investigations have demonstrated that HBO2 has a beneficial impact on UC treatment, a systematic review and meta-analysis are unavailable. Therefore, a meta-analysis is essential to assess the efficacy and safety of HBO2 in treating UC. METHODS AND ANALYSIS A systematic search plan will be performed in the following seven databases with a restriction of time from inception to September 2020 to filter the eligible studies: PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal Database (VIP) and Chinese Biomedical Database WanFang. Other related resources will be also searched. Two independent reviewers will choose eligible researches and extract data. The risk of bias will be evaluated based on Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Scale. Eventually, a systematic review and meta-analysis will be performed via the Review Manager V.5.3 statistical software and STATA V.14.0 software. ETHICS AND DISSEMINATION This study will not involve the individual patient and any ethical problems since its outcomes are based on published data. Therefore, no ethical review and approval are required. We plan to publish the study in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020210244.
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Affiliation(s)
- Lihong Luo
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Lei Qing
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Chengjiao Yao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Dongying Liu
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yilin Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Tinglin Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Peimin Feng
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
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30
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De Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, Sartelli M, Biffl WL, Ansaloni L, Coccolini F, Chiarugi M, De’Angelis N, Moore EE, Kluger Y, Abu-Zidan F, Sakakushev B, Coimbra R, Celentano V, Wani I, Pintar T, Sganga G, Di Carlo I, Tartaglia D, Pikoulis M, Cardi M, De Moya MA, Leppaniemi A, Kirkpatrick A, Agnoletti V, Poggioli G, Carcoforo P, Baiocchi GL, Catena F. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg 2021; 16:23. [PMID: 33971899 PMCID: PMC8111988 DOI: 10.1186/s13017-021-00362-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. METHOD A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. CONCLUSIONS Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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Affiliation(s)
- Belinda De Simone
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elie Chouillard
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
| | - Frank Hoentjen
- RIMLS - Radboud Institute for Molecular Life Sciences, Radboud University-Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Antonio Tarasconi
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Walter L. Biffl
- Scripps Memorial Hospital La Jolla, San Diego, California USA
| | - Luca Ansaloni
- Department of Surgery, University Hospital of Pavia, Pavia, Italy
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Nicola De’Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Acquaviva delle Fonti (Bari), Italy
| | - Ernest E. Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | - Valerio Celentano
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Hampshire, UK
| | - Imtiaz Wani
- Government Gousia Hospital-Srinagar, Directorate of Health Services-Kashmir, Srinagar, Kashmir India
| | - Tadeja Pintar
- Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Gabriele Sganga
- Department of Emergency Surgery, “A. Gemelli Hospital”, Catholic University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Dario Tartaglia
- Emergency Surgery Unit & Trauma Center, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National & Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Maurizio Cardi
- Department of Oncological Surgery “P.Valdoni”, Sapienza University, Rome, Italy
| | - Marc A. De Moya
- Trauma/Acute Care Surgery Department, Medical College of Wisconsin/Froedtert Trauma Center, Wauwatosa, Wisconsin USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Gilberto Poggioli
- Department of Surgical Sciences, Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Paolo Carcoforo
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | | | - Fausto Catena
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
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31
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Festa S, Scribano ML, Pugliese D, Bezzio C, Principi M, Ribaldone DG, Allocca M, Mocci G, Bodini G, Spagnuolo R, Vernia P, Mazzuoli S, Costa F, Barberio B, Cosintino R, Zerboni G, Aratari A, Armuzzi A, Papi C. Long-term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study. United European Gastroenterol J 2021; 9:507-516. [PMID: 33259773 PMCID: PMC8259429 DOI: 10.1177/2050640620977405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/05/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The long-term course of ulcerative colitis after a severe attack is poorly understood. Second-line rescue therapy with cyclosporine or infliximab is effective for reducing short-term colectomy but the impact in the long-term is controversial. OBJECTIVE The purpose of this study was to evaluate the long-term course of acute severe ulcerative colitis patients who avoid early colectomy either because of response to steroids or rescue therapy. METHODS This was a multicentre retrospective cohort study of adult patients with acute severe ulcerative colitis admitted to Italian inflammatory bowel disease referral centres from 2005 to 2017. All patients received intravenous steroids, and those who did not respond received either rescue therapy or colectomy. For patients who avoided early colectomy (within 3 months from the index attack), we recorded the date of colectomy, last follow-up visit or death. The primary end-point was long-term colectomy rate in patients avoiding early colectomy. RESULTS From the included 372 patients with acute severe ulcerative colitis, 337 (90.6%) avoided early colectomy. From those, 60.5% were responsive to steroids and 39.5% to the rescue therapy. Median follow-up was 44 months (interquartile range, 21-85). Colectomy-free survival probability was 93.5%, 81.5% and 79.4% at 1, 3 and 5 years, respectively. Colectomy risk was higher among rescue therapy users than in steroid-responders (log-rank test, p = 0.02). At multivariate analysis response to steroids was independently associated with a lower risk of long-term colectomy (adjusted odds ratio = 0.5; 95% confidence interval, 0.2-0.8), while previous exposure to antitumour necrosis factor-α agents was associated with an increased risk (adjusted odds ratio = 3.0; 95% confidence interval, 1.5-5.7). Approximately 50% of patients required additional therapy or new hospitalisation within 5 years due to a recurrent flare. Death occurred in three patients (0.9%). CONCLUSIONS Patients with acute severe ulcerative colitis avoiding early colectomy are at risk of long-term colectomy, especially if previously exposed to antitumour necrosis factor-α agents or if rescue therapy during the acute attack was required because of steroid refractoriness.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Giorgia Bodini
- Department of Internal MedicineUniversity of GenoaGenoaItaly
| | | | - Piero Vernia
- Division of GastroenterologySapienza University of RomeRomeItaly
| | - Silvia Mazzuoli
- Gastroenterology UnitMonsignor Raffaele Dimiccoli HospitalBarlettaItaly
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32
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Holvoet T, Lobaton T, Hindryckx P. Optimal Management of Acute Severe Ulcerative Colitis (ASUC): Challenges and Solutions. Clin Exp Gastroenterol 2021; 14:71-81. [PMID: 33727846 PMCID: PMC7955027 DOI: 10.2147/ceg.s197719] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/14/2020] [Indexed: 12/25/2022] Open
Abstract
Acute severe colitis is a severe complication of ulcerative colitis, affecting approximately 20% of patients. For physicians, it remains a challenging condition to treat. Current treatment algorithms have diminished the mortality associated with acute severe ulcerative colitis (ASUC), but colectomy rates remain high (approximately 30%) despite advances in therapy. Colectomy in ASUC is particularly associated with important postoperative complications and morbidity. In this review, reasons for the inability to improve care and avoid evolution to colectomy for ASUC are explored and solutions that might lead to a better management of the disease are investigated.
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Affiliation(s)
- Tom Holvoet
- Department of Gastroenterology, AZ Nikolaas, Sint-Niklaas, Belgium.,Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Triana Lobaton
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Pieter Hindryckx
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
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33
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Con D, Andrew B, Nicolaides S, van Langenberg DR, Vasudevan A. Biomarker dynamics during infliximab salvage for acute severe ulcerative colitis: C-reactive protein (CRP)-lymphocyte ratio and CRP-albumin ratio are useful in predicting colectomy. Intest Res 2021; 20:101-113. [PMID: 33902267 PMCID: PMC8831766 DOI: 10.5217/ir.2020.00146] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background/Aims The residual risk of colectomy after infliximab salvage in steroid-refractory acute severe ulcerative colitis (ASUC) is required to inform the need for subsequent maintenance biologic therapy. The aim of this study was to determine the dynamic response of common serum biomarkers to infliximab salvage and assess their utility in predicting subsequent colectomy. Methods A retrospective single-center cohort study was conducted on all patients who received infliximab salvage for steroid-refractory ASUC between January 1, 2010, and July 31, 2019. Biomarkers were assessed on admission and days 1 and 3 post infliximab, and included C-reactive protein (CRP)-albumin-ratio (CAR), CRP-lymphocyte-ratio (CLR), platelet-lymphocyte-ratio (PLR) and neutrophil-lymphocyte-ratio (NLR). Results Of 94 patients (median age, 35 years; 67% of male), 20% required colectomy at 12 months. Biomarkers on day 3 post-infliximab best differentiated nonresponders, who had higher CRP, lower albumin and lower lymphocyte count (each P < 0.05). Day 3 predictive performance (area under the curve) for 12-month colectomy was best for CAR (0.871) and CLR (0.874), which were similar to Lindgren (0.829; P > 0.05) but superior to Mayo (0.726), partial Mayo (0.719), PLR (0.719), Ho index (0.714), NLR (0.675), Travis score (0.657) and endoscopic Mayo (0.609) (each P < 0.05). A day 3 CAR cutoff of 0.47 mg/g had 79% sensitivity, 80% specificity, 94% negative predictive value (NPV) to predict colectomy; while a day 3 CLR cutoff of 6.0 mg/109 had 84% sensitivity, 84% specificity, 96% NPV. Conclusions CAR and CLR measured on day 3 post infliximab salvage for steroid-refractory ASUC represent simple and routinely performed biomarkers that appear to be strong predictors of colectomy. Prospective studies are required to confirm the utility of these predictive scores.
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Affiliation(s)
- Danny Con
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Bridgette Andrew
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Steven Nicolaides
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
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Aloi M, Bramuzzo M, Norsa L, Arrigo S, Distante M, Miele E, Romano C, Giobbi C, Panceri R, Cucchiara S, Alvisi P. Disease Activity Patterns in the First 5 Years After Diagnosis in Children With Ulcerative Colitis: A Population-Based Study. J Crohns Colitis 2021; 15:367-374. [PMID: 33022055 DOI: 10.1093/ecco-jcc/jjaa203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to define clusters of activity in a population-based cohort during the first 5 years after diagnosis in children with ulcerative colitis [UC] and to identify early prognostic risk factors. METHODS All UC patients from the SIGENP IBD registry with a complete follow-up of at least 5 years were included. Active disease was defined every 6 months in the presence of at least one of the following: clinical activity [Paediatric Ulcerative Colitis Activity Index ≥ 35]; endoscopic activity [Mayo score ≥ 1]; faecal calprotectin > 250 µg/g; hospitalization; surgery; or treatment escalation. Formula-based clusters were generated based on four published questionnaire-based activity patterns in adults, plus one additional cluster. RESULTS In total, 226 patients were identified. Forty-two [19%] had moderate-severe chronically active disease, 31 [14%] chronic-intermittent, 75 [33%] quiescent, 54 [24%] active disease in the first 2 years after the diagnosis, then sustained remission, and 24 [11%] a remission in the first 2 years then an active disease. Mild disease onset along with a lower clinical severity not requiring the use of corticosteroids at 6 months were related to a quiescent disease course at the next follow-up (logistic model area under the curve 0.86 [95% confidence interval 0.78-0.94]; positive predictive value 67%; negative predictive value 70%). Eight per cent of patients needed surgery, none in the quiescent group [p = 0.04]. CONCLUSIONS More than one-third of children with UC present with a chronically active or intermittent course during the first 5 years of follow-up. A significant group of patients has active disease in the first 2 years and then sustained remission. Interestingly, after initial treatment, one-third of patients have well-controlled disease throughout.
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Affiliation(s)
- M Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - M Bramuzzo
- Institute for Maternal and Child Health IRCCS 'Burlo Garofalo', Trieste, Italy
| | - L Norsa
- Pediatric Hepatology Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - S Arrigo
- Pediatric Gastroenterology Unit, Institute 'Giannina Gaslini', Genoa, Italy
| | - M Distante
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - C Romano
- Pediatric Gastroenterology and Endoscopy, University of Messina, Messina, Italy
| | - C Giobbi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - R Panceri
- Department of Pediatrics, University of Milano-Bicocca Fond., MBBM/Hosp., San Gerardo Monza, Italy
| | - S Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - P Alvisi
- Pediatric Department, Maggiore Hospital, Bologna, Italy
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35
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Worley G, Almoudaris A, Bassett P, Segal J, Akbar A, Ghosh S, Aylin P, Faiz O. Colectomy rates for ulcerative colitis in England 2003-2016. Aliment Pharmacol Ther 2021; 53:484-498. [PMID: 33264468 DOI: 10.1111/apt.16202] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/04/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Temporal trends in colectomy rate for ulcerative colitis (UC) are particularly relevant in the current era of published IBD standards and changing approach to salvage of acute severe disease. AIMS To investigate temporal trends in colectomy for UC using English population data. METHODS The Hospital Episode Statistics (HES) were interrogated between 2003-2016 with two patient groups investigated independently. An 'emergency' cohort: emergency UC admission ≥ three days, age ≥18 and a 'total population' cohort: all English patients undergoing colectomy for UC. Mixed methods analyses were utilised. RESULTS Emergency cohort: 37 981 patients, 49% female, median age 46. The one- and three-year incidence of colectomy after acute admission was 0.17 and 0.21. Interrupted time series (ITS) analysis suggested reductions in colectomy rate of 4% per year after 2008 at 30 and 90 days following emergency admission, with no significant reduction ≥1 year. Mortality and laparoscopy rates improved when avoiding colectomy at index and emergency admissions; however, the proportion of emergency colectomies after salvage at index admission significantly increased during the study period. Total population cohort: 17 580 patients underwent colectomy for UC between 2003 and 2016, demonstrating a 3.1% annual reduction in total and elective colectomies after 2008, but no reduction in emergency colectomies. CONCLUSION Reductions in short-term colectomy rates after emergency admission for UC do not persist beyond one year. Emergency colectomy rates remain unchanged. Reduced rates are probably due to multi-modal improvements in IBD care. A lack of data regarding disease severity precludes further interpretation of appropriate medical salvage and timely surgery.
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Affiliation(s)
- Guy Worley
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Alex Almoudaris
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Paul Bassett
- St Mark's Hospital and Academic Institute, London, UK.,Statsconsultancy Ltd, Bucks, UK
| | - Jonathan Segal
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Ayesha Akbar
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital and Academic Institute, London, UK
| | - Subrata Ghosh
- Institute of Translational Medicine, NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Omar Faiz
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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36
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Tiu SPT, Hajirawala LN, Leonardi C, Davis KG, Orangio GR, Barton JS. Delayed Surgery Does Not Increase Risk in Urgent Colectomy for Ulcerative Colitis. Am Surg 2020; 87:880-884. [PMID: 33280393 DOI: 10.1177/0003134820971576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medical management is the cornerstone of therapy for ulcerative colitis (UC). In the setting of fulminant disease, hospitalized patients may undergo medical rescue therapy (MRT) or urgent surgery. We hypothesized that delayed attempts at MRT result in increased morbidity and mortality following urgent surgery for UC. OBJECTIVE The aim is to assess the outcomes for patients requiring urgent, inpatient surgery for UC in a prompt or delayed fashion. DESIGN The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) general and colectomy-specific databases from 2013 to 2016 were queried. Urgent surgery was defined as nonelective, nonemergency surgery. Patients were divided into prompt and delayed groups based on time from admission to surgery of <48 hours or >48 hours. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. SETTING The ACS NSQIP database from 2013 to 2016 was evaluated. PATIENTS Adult patients undergoing nonelective, nonemergency colectomy for UC. MAIN OUTCOME MEASURES 30-day morbidity and mortality. RESULTS 921 patients underwent urgent inpatient surgery for UC. In univariate analysis, there was no significant difference between prompt and delayed surgery for wound infection, sepsis, return to operating room, or readmission. LIMITATIONS Retrospective study of a quality improvement database. Patients who underwent successful MRT did not receive surgery, so are not included in the database. CONCLUSIONS Delaying surgery to further attempt MRT does not alter short-term outcomes and may allow conversion to elective future surgery. Contrarily, medical optimization does not improve short-term outcomes.
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Affiliation(s)
- Simon Peter T Tiu
- Department of Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Luv N Hajirawala
- Department of Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Claudia Leonardi
- Behavioral and Community Health Sciences, School of Public Health, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Kurt G Davis
- Department of Surgery, Section of Colorectal Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Guy R Orangio
- Department of Surgery, Section of Colorectal Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Jeffrey S Barton
- Department of Surgery, Section of Colorectal Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
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37
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Burns EM, Poulton T, Deputy M, Pinkney T, Guy R. An audit of process and outcome for emergency colectomy in England and Wales. Colorectal Dis 2020; 22:2133-2139. [PMID: 32936991 DOI: 10.1111/codi.15367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/22/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022]
Abstract
AIM The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales. METHOD The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65 years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed. RESULTS In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5 days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10 days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age > 55 years [OR 3.59 (1.05-12.21), P = 0.041], female gender [OR 2.88 (1.27-6.52), P = 0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P = 0.007] were associated with increased mortality. CONCLUSION There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.
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Affiliation(s)
- E M Burns
- St Mark's Hospital and Academic Institute, London, UK.,Department of Cancer and Surgery, Imperial College London, London, UK
| | - T Poulton
- Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK
| | - M Deputy
- St Mark's Hospital and Academic Institute, London, UK.,Department of Cancer and Surgery, Imperial College London, London, UK
| | - T Pinkney
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - R Guy
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
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Alkhatry M, Al-Rifai A, Annese V, Georgopoulos F, Jazzar AN, Khassouan AM, Koutoubi Z, Nathwani R, Taha MS, Limdi JK. First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus. World J Gastroenterol 2020; 26:6710-6769. [PMID: 33268959 PMCID: PMC7684461 DOI: 10.3748/wjg.v26.i43.6710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis and Crohn’s disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.
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Affiliation(s)
- Maryam Alkhatry
- Gastroenterology and Endoscopy Department, Ibrahim Bin Hamad Obaid Allah Hospital, Ministry of Health and Prevention, Ras Al Khaiman, United Arab Emirates
| | - Ahmad Al-Rifai
- Department of Gastroenterology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic, Dubai, United Arab Emirates
- Department of Gastroenterology and Endoscopy, American Hospital, Dubai, United Arab Emirates
| | | | - Ahmad N Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ahmed M Khassouan
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Zaher Koutoubi
- Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Rahul Nathwani
- Department of Gastroenterology, Mediclinic City Hospital, Dubai, United Arab Emirates
- Department of Gastroenterology, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Mazen S Taha
- Gastroenterology and Hepatology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Jimmy K Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester M8 5RB, United Kingdom
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Pellino G, Reif de Paula T, Lawlor G, Keller DS. Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program. Tech Coloproctol 2020:10.1007/s10151-020-02327-1. [PMID: 32803500 DOI: 10.1007/s10151-020-02327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. RESULTS Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. CONCLUSIONS In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.
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Affiliation(s)
- G Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
- Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - T Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - G Lawlor
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.
- Division of Colon and Rectal Surgery, Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor Herbert Irving Pavilion, New York, NY, 10032, USA.
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40
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Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program. Tech Coloproctol 2020; 24:1255-1262. [DOI: 10.1007/s10151-020-02315-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023]
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41
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Barnes EL, Jiang Y, Kappelman MD, Long MD, Sandler RS, Kinlaw AC, Herfarth HH. Decreasing Colectomy Rate for Ulcerative Colitis in the United States Between 2007 and 2016: A Time Trend Analysis. Inflamm Bowel Dis 2020; 26:1225-1231. [PMID: 31634390 PMCID: PMC7365804 DOI: 10.1093/ibd/izz247] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Improved treatment approaches for ulcerative colitis (UC), including novel medications, might reduce the need for colectomy. We performed a retrospective cohort study of adult patients (age 18-64) with UC in the United States to examine time trends for colectomy and biologic use from 2007 to 2016. METHODS We estimated quarterly rates for colectomy and biologic use using the IQVIA Legacy PharMetrics Adjudicated Claims Database. We used interrupted time series methods with segmented regression to assess time trends with 95% confidence intervals (CIs) for biologic use and colectomy before and after the emergence of newly available biologic therapies in 2014. RESULTS Among 93,930 patients with UC, 2275 (2.4%) underwent colectomy from 2007 to 2016. Biologic use rates increased significantly from 2007 to 2016, from 131 per 1000 person-years in 2007 (95% CI, 121 to 140) to 589 per 1000 person-years in 2016 (95% CI, 575 to 604; P < 0.001). Colectomy rates decreased significantly between 2007 and 2016, from 7.8 per 1000 person-years (95% CI, 7.4 to 8.2) to 4.2 per 1000 person-years in 2016 (95% CI, 3.2 to 5.1; P < 0.001). An interruption in 2014 was associated with a positive trend deflection for biologic use (+72 treatments per 1000 person-years per year (95% CI, 61 to 83) and a negative trend deflection for colectomy (-0.76 per 1000 person-years per year; 95% CI, -1.47 to -0.05). CONCLUSIONS Among commercially insured patients in the United States from 2007 to 2016, biologic use rates increased, colectomy rates decreased, and both trends were impacted by the interruption in 2014. These findings suggest that new biologic therapies may have contributed to decreased colectomy rates.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Address correspondence to: Edward L. Barnes, MD, MPH, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB #7080, Chapel Hill, NC 27599-7080 ()
| | - Yue Jiang
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Division of Pediatric Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alan C Kinlaw
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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42
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Murphy B, Kavanagh DO, Winter DC. Modern surgery for ulcerative colitis. Updates Surg 2020; 72:325-333. [DOI: 10.1007/s13304-020-00719-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 02/04/2020] [Indexed: 12/12/2022]
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Carvello M, Watfah J, Włodarczyk M, Spinelli A. The Management of the Hospitalized Ulcerative Colitis Patient: the Medical-Surgical Conundrum. Curr Gastroenterol Rep 2020; 22:11. [PMID: 32040642 DOI: 10.1007/s11894-020-0750-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Michele Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Joseph Watfah
- Department of General Surgery, Northwick Park Hospital, London, UK
| | - Marcin Włodarczyk
- Department of General and Colorectal Surgery, Medical University of Lodz, Haller 1 Sq, 90-364, Lodz, Poland
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
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44
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Dong C, Metzger M, Holsbø E, Perduca V, Carbonnel F. Systematic review with meta-analysis: mortality in acute severe ulcerative colitis. Aliment Pharmacol Ther 2020; 51:8-33. [PMID: 31821584 DOI: 10.1111/apt.15592] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 11/07/2019] [Accepted: 11/05/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a life-threatening condition. Mortality in ASUC decreased in published series but there is uncertainty as to whether this also applies to the real-life setting. AIM To perform a systematic review and meta-analysis of mortality in ASUC in studies from referral centres and in population-based studies, separately and combined. A second aim was to identify risk factors of mortality in ASUC. METHODS We searched pubmed and embase from 1998 to 2016, to identify studies that reported 3-month or 12-month mortalities of acute UC in adult patients treated in referral centres, and in population-based studies. RESULTS Six population-based studies with 741 743 patients and 47 referral centre-based studies with 2556 patients were included. The pooled 3-month and 12-month mortalities were respectively 0.84% and 1.01%. Advanced age was significantly associated with both 3 month and 12 month mortalities (OR = 1.15 per year, 95% CI: 1.10-1.20 and OR = 1.19 per year, 95% CI: 1.15-1.23 respectively). The pooled 3-month and 12-month mortalities were 0.78% and 0.85% in studies with median age of less than 50 and 2.81% and 4.17% in studies with median age of 50 or more, respectively. After adjustment for age, 3-month and 12-month mortalities did not differ between population-based and referral centre-based studies. CONCLUSIONS Mortality in acute severe ulcerative colitis is approximately 1%; it is higher in older patients. Efforts should be made to improve the care of elderly patients with severe UC.
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Affiliation(s)
- Catherine Dong
- Hôpital de Bicêtre, Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Marie Metzger
- Inserm U1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Villejuif, France
| | - Einar Holsbø
- Department of Computer Science, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Vittorio Perduca
- Inserm U1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Villejuif, France.,MAP5 laboratory (UMR CNRS 8145), Université Paris Descartes, Université de Paris, Paris, France
| | - Franck Carbonnel
- Hôpital de Bicêtre, Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France.,Inserm U1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Villejuif, France
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45
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1209] [Impact Index Per Article: 241.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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46
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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47
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Straughan DM, McLoughlin KC, Mullinax JE, Marciano BE, Freeman AF, Anderson VL, Uzel G, Azoury SC, Sorber R, Quadri HS, Malech HL, DeRavin SS, Kamal N, Koh C, Zerbe CS, Kuhns DB, Gallin JI, Heller T, Holland SM, Rudloff U. The Changing Paradigm of Management of Liver Abscesses in Chronic Granulomatous Disease. Clin Infect Dis 2019; 66:1427-1434. [PMID: 29145578 DOI: 10.1093/cid/cix1012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Chronic granulomatous disease (CGD) is a rare genetic disorder causing recurrent infections. More than one-quarter of patients develop hepatic abscesses and liver dysfunction. Recent reports suggest that disease-modifying treatment with corticosteroids is effective for these abscesses. Comparison of corticosteroid therapy to traditional invasive treatments has not been performed. Methods Records of 268 patients with CGD treated at the National Institutes of Health from 1980 to 2014 were reviewed. Patients with liver involvement and complete records were included. We recorded residual reactive oxygen intermediate (ROI) production by neutrophils, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase germline mutation status, laboratory values, imaging characteristics, time to repeat hepatic interventions, and overall survival among 3 treatment cohorts: open liver surgery (OS), percutaneous liver-directed interventional radiology therapy (IR), and high-dose corticosteroid management (CM). Results Eighty-eight of 268 patients with CGD suffered liver involvement. Twenty-six patients with a median follow-up of 15.5 years (8.5-32.9 years of follow-up) had complete records and underwent 100 standard interventions (42 IR and 58 OS). Eight patients received a treatment with high-dose corticosteroids only. There were no differences in NADPH genotype, size, or number of abscesses between patients treated with OS, IR, or CM. Time to repeat intervention was extended in OS compared with IR (18.8 vs 9.5 months, P = .04) and further increased in CM alone (median time to recurrence not met). Impaired macrophage and neutrophil function measured by ROI production correlated with shorter time to repeat intervention (r = 0.6, P = .0019). Conclusions Treatment of CGD-associated liver abscesses with corticosteroids was associated with fewer subsequent hepatic interventions and improved outcome compared to invasive treatments.
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Affiliation(s)
- David M Straughan
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryl
| | - Kaitlin C McLoughlin
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryl
| | - John E Mullinax
- Department of Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Beatriz E Marciano
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Alexandra F Freeman
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Victoria L Anderson
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Said C Azoury
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryl.,Department of Surgery, The Johns Hopkins Hospital, Baltimore
| | - Rebecca Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore
| | - Humair S Quadri
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryl
| | - Harry L Malech
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Suk See DeRavin
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Natasha Kamal
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda
| | - Christa S Zerbe
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | | | - John I Gallin
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda
| | - Udo Rudloff
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryl
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48
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Abstract
Introduction: Despite the introduction of novel therapies and treatment strategies for ulcerative colitis (UC), many patients develop acute, severe episodes, warranting prompt care and aggressive management. There is a significant unmet need to improve outcomes in these patients. Clinicians must be able to identify those that will have worse prognosis and plan an aggressive therapy with an early/proactive adjustments in management if needed.Areas covered: The aim of this review is to evaluate the most recent evidence on the assessment and management of patients with acute severe ulcerative colitis. We searched the mainstream literature search engines for the most recent evidence on diagnosis and management of acute UC.Expert Opinion: The approach to patients with severe UC includes clinical and endoscopic assessment of disease severity and ruling out over-infections. While intravenous corticosteroids remain the first line therapy for acute severe colitis, many patients do not respond and require escalation to calcineurin inhibitors or infliximab, and may ultimately require colectomy. Even though several novel therapies are available or in development, their role in acute severe episodes of colitis is unknown.
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Affiliation(s)
- Rocío Sedano
- Division of Gastroenterology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Rodrigo Quera
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Clínica Las Condes, Santiago, Chile
| | - Daniela Simian
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Clínica Las Condes, Santiago, Chile
| | - Andres J Yarur
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Emergent colectomy rates decreased while elective ileal pouch rates were stable over time: a nationwide inpatient sample study. Int J Colorectal Dis 2019; 34:1771-1779. [PMID: 31512019 PMCID: PMC7060938 DOI: 10.1007/s00384-019-03375-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Despite advances in biologic therapy, approximately 10-15% of ulcerative colitis (UC) patients require surgery. We aimed to (1) examine the rates of emergent colectomy and elective ileal pouch anal anastomosis (IPAA) over time among UC patients in the USA and (2) investigate disparities in surgery rates by patient demographics. METHODS Data from the Nationwide Inpatient Sample (NIS) from 2000 to 2014 were analyzed. Inclusion criteria were admissions with a primary UC ICD-9-CM diagnosis code and age > 18. Emergent cases were defined as those admitted through the emergency room with an outcome ICD-9-CM code for subtotal colectomy. Elective IPAA cases were defined with an outcome ICD-9-CM code for IPAA, used as a surrogate measure of colectomy. Patient and hospital-level demographics were analyzed. Temporal trends of colectomy were analyzed utilizing joinpoint-regression analysis with calculation of annual percentage change (APC). RESULTS A total of 470,708 admissions were included over the 14-year period. Emergent colectomy rate significantly declined (APC - 7.35%, p = 0.0002), while the rate of elective IPAA remained stable (APC - 0.21%, p = 0.8). Emergent colectomy rates declined similarly across all demographics, though not as marked among patients age 50 and older and Medicare patients. Elective IPAA rates were significantly lower among blacks and patients with public insurance. CONCLUSIONS There has been a significant decline in emergent UC colectomy rates in the USA; however, the overall need for surgery appears unchanged given stable IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.
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50
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Abstract
OBJECTIVE To investigate differences in surgical approach and postoperative outcomes for patients with ulcerative colitis (UC) before and after the introduction of biologic therapy. BACKGROUND Biologic use has dramatically increased since Food and Drug Administration approval of infliximab. Studies conflict as to the effect of these agents on surgical outcomes with some demonstrating worse surgical outcomes whereas others have found no difference. METHODS We used an administrative, all-payer, all-age group database located in New York State. Patients were included if they had a diagnosis of UC and underwent surgery for their disease from 1995 to 2013. Outcomes were compared for the index admission, at 90-day, and 1-year follow up. RESULTS A total of 7070 patients were included for analysis; 54% patients underwent surgery between 1995 and 2005 and the remaining 46% patients underwent surgery between 2005 and 2013. There was a significant increase in the proportion of patients who underwent at least 3 procedures after 2005(14% vs 9%, P < 0.01). On adjusted analysis, patients undergoing surgery after 2005 had higher likelihood of major events (odd s ratio, OR = 1.42; 95% confidence interval, CI = 1.13-1.78), procedural complications (OR = 1.42; 95% CI = 1.20-1.68), and nonroutine discharge (OR = 3.17; 95% CI = 2.79-3.60) during the index admission. Similar trends for worse adjusted outcomes in patients initially undergoing surgery after 2005 were seen at 90-day and 1-year follow up. CONCLUSIONS Since the introduction of biologic agents in 2005, surgery for patients with UC is more likely to require multiple procedures. Despite robust adjustments, patients having surgery recently have worse postoperative morbidity during the index hospitalization, at 90-day and 1-year follow up. More work is necessary to improve outcomes in these higher risk patients that undergo surgery.
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