Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial

Magnetic resonance enterography to predict subsequent disabling Crohn's disease in newly diagnosed patients (METRIC-EF)-multivariable prediction model, multicentre diagnostic inception cohort

OBJECTIVES

Magnetic resonance enterography (MRE) is a first-line investigation to diagnose Crohn's disease (CD), but its role for prognostication is unknown. Accordingly, we assessed the predictive ability of prognostic models including MRE scores (MRE Global Score (MEGS), simplified MR Index of Activity (sMARIA), and Lémann index (LI)) against models using clinical predictors alone for the development of modified Beaugerie disabling CD (MBDD) within 5 years of diagnosis.

METHODS

This was a multicentre, diagnostic inception cohort of patients with newly diagnosed CD across 9 UK hospitals, followed for 4 years or more. We censored development of MBDD ≤ 90 days from diagnosis, and used time-to-event models using Royston-Parmer flexible parametric models.

RESULTS

We included 194 patients, median age 29, IQR 22-44 years, 52% female. Within 5 years of diagnosis, 42% (81/194) developed MBDD. In univariable analysis, initial steroid requirement was associated with increased risk of developing MBDD (HR 2.11 (95% CI 1.36, 3.26). The baseline clinical model had 49% (39, 60) sensitivity and 66% (57, 74) specificity for predicting the top 40% of patients with the greatest risk of developing MBDD, and 86% (77, 92) sensitivity and 35% (27, 45) specificity for predicting the development of MBDD in patients with an absolute risk of ≥ 10%. There was no significant difference in sensitivity when the MEGS, sMARIA, or LI were added to the baseline clinical model.

CONCLUSIONS

Addition of MRE scores at diagnosis to a multivariable model comprising clinical predictors did not improve prediction of MBDD within 5 years of diagnosis.

KEY POINTS

Question Magnetic resonance enterography (MRE) is important for diagnosing and monitoring Crohn's disease (CD), but primary research evaluating its prognostic role is lacking. Findings Adding MRE findings at diagnosis to a multivariable model comprising clinical predictors did not improve the prediction of disabling CD within 5 years of diagnosis. Clinical relevance When tested in a prospective, multicentre trial, current MRE activity and damage scores at diagnosis did not reliably predict whether patients would subsequently develop disabling CD. Notwithstanding this finding, MRE remains an essential tool for diagnosis and monitoring.

Overcoming the challenges of overtreating and undertreating inflammatory bowel disease

Several therapeutic advances have been achieved over the past two decades for inflammatory bowel disease (IBD). The expanding therapeutic armamentarium and the increasingly ambitious treatment targets have led to an increased use of advanced therapies and better outcomes. Nevertheless, many patients remain suboptimally treated and are at risk of disease progression, hospital admission, and surgery, even when advanced therapies are cycled, escalated, or combined. Conversely, IBD can also be characterised by an indolent disease course. Top-down and treat-to-target strategies, although beneficial in a substantial proportion of patients, might not be advantageous in patients with mild disease and might risk overtreatment. Identifying patients with mild activity and a benign disease trajectory in the long-term is important; unnecessary exposure to advanced therapies increases the risk of adverse events and increases financial costs and health-care resource utilisation. This Review details the importance of adopting clinical strategies to avoid the pitfalls of undertreating and overtreating IBD.

Operative Management of Small and Large Bowel Crohn's Disease

The majority of patients with Crohn's disease, despite an ever-increasing number of advanced therapies, require abdominal surgery during their lifetime. In this review article, the authors provide a comprehensive overview of abdominal surgery for Crohn's disease, with an evidence-based focus on surgery for upper gastrointestinal Crohn's disease, bowel-preserving surgery with strictureplasties, selection of ileocolic anastomotic technique for terminal ileal Crohn's disease, extended resections and proctectomy for Crohn's proctocolitis, intentional ileoanal pouch for Crohn's disease, and several "hot topics" including early surgery for ileocolic Crohn's disease, and surgical approaches that target the mesentery including the Kono-S anastomosis and extended mesenteric excision.

Intestinal Ultrasound Findings and Their Prognostic Value in Early Crohn's Disease - a Copenhagen IBD Cohort Study

BACKGROUND & AIMS

We characterize the sonographic features of Crohn's disease at diagnosis and evaluate the prognostic value of intestinal ultrasound during the early stage of disease.

METHODS

A prospective, population-based cohort of patients with newly diagnosed Crohn's disease were followed with intestinal ultrasound in conjunction with symptomatic, biochemical, and endoscopic evaluations.

RESULTS

Between May 2021 and April 2023, 201 patients with adult-onset Crohn's disease were recruited. No associations were found between sonographic inflammation at diagnosis and diagnostic delay. After 3 months, transmural remission was achieved in 38% of patients, with patients with colonic disease achieving transmural remission more often. Transmural remission at 3 months was significantly associated with steroid-free clinical remission at 3 months and all subsequent follow-ups within the first year. Transmural remission was also associated with a lower risk of treatment escalation during follow-up until 12 months (26% vs 53%; P = .003). At 12 months, 41% had achieved transmural remission. Higher baseline body mass index negatively impacted the likelihood of 12-month transmural remission significantly (overweight: odds ratio [OR], 0.34; 95% confidence interval [CI],0.12-0.94; obese: OR, 0.16; 95% CI, 0.04-0.73). The International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) in the terminal ileum at diagnosis was the best predictor of ileocecal resection during the first year, with an optimal threshold of 63 (area under the curve [AUC], 0.92; sensitivity, 100%; specificity, 73%).

CONCLUSIONS

Transmural remission is an achievable outcome target for many patients with newly diagnosed Crohn's disease and is associated with a favorable clinical outcome, including sustained steroid-free clinical remission. Further, intestinal ultrasound findings at diagnosis predict future ileocecal resection.

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Small bowel imaging in Crohn’s disease with a special focus on obesity, pregnancy and postsurgical assessment

Crohn’s disease (CD) is an immune-mediated, multisystem inflammatory disorder characterised by discontinuous transmural, sometimes granulomatous, inflammation of the gastrointestinal tract. Although it can occur anywhere in the gastrointestinal tract, it has a 70% predilection for the terminal ileum. Ileocolonoscopy with biopsy remains the gold standard for initial diagnosis and assessment of CD activity but has several limitations, including invasiveness, risk of complications and cost. With a shifting focus towards treatment targets including transmural healing, non-invasive imaging modalities are being used increasingly to assess the small bowel, particularly the terminal ileum. CT enterography, magnetic resonance enterography and gastrointestinal ultrasound are widely used for small bowel imaging in clinical practice and have relatively good sensitivity and specificity. Obesity is a growing problem for patients with CD and is associated with limitations in medical imaging. Equally, cross-sectional imaging in pregnant and postsurgical patients with CD has its own challenges. In this article, we review small bowel imaging in CD with a special focus on obesity, pregnancy and postsurgical assessment.

The Effect of Colesevelam on the Microbiome in Postoperative Crohn's Disease

BACKGROUND

While surgery plays a pivotal role in the management of ileal Crohn's disease, the risk of endoscopic recurrence following an ileocaecal resection can be greater than 65% within 12 months of surgery. More than 90% of patients with Crohn's disease have a concomitant diagnosis of bile acid diarrhea following an ileal resection. This pilot study aimed to assess whether the use of bile acid sequestrants in patients with Crohn's disease who have undergone a primary terminal ileal resection with concomitant bile acid diarrhea can alter the microbiome and prevent disease recurrence.

METHODS

Patients with Crohn's disease who underwent a primary terminal ileal resection and had symptoms of diarrhea within 1-3 months of surgery underwent 75SeHCAT testing for bile acid diarrhea. If positive (75SeHCAT ≤ 15%), patients were treated with colesevelam and stool samples were collected at 4 weeks, 8 weeks, and 6-12 months posttreatment. If negative (75SeHCAT > 15%), treatment was not given and were reviewed in the clinic as per local guidelines. All patients underwent a 6-12 month postoperative colonoscopy where further stool samples and mucosal biopsies were taken. Disease activity was established using the endoscopic Rutgeert's score, with disease remission defined as Rutgeert's score

RESULTS

A total of 14 patients who completed the study, 10 of whom had a 75SeHCAT positive diagnosis of bile acid diarrhea and were started on treatment with colesevelam. Four patients did not require treatment as 3 were asymptomatic and 1 had a negative 75SeHCAT scan. Three of the fourteen patients had disease recurrence at their 6-12 month postoperative colonoscopy assessment, of which 1 patient was taking colesevelam and 2 patients were not taking colesevelam. A total of 44 fecal samples and 44 mucosal biopsies underwent 16S ribosomal RNA gene analysis to assess α/β-diversity and microbial composition. In the colesevelam treated patients there was no significant difference in α/β-diversity pre- and posttreatment. Pretreatment, the 3 most abundant bacterial classes in all patients were Bacteroidia, Clostridia, and Gammaproteobacteria. Following 6-12 months of treatment, out of the 9 patients on colesevelam, 5/9 (55.6%) had a reduction in Bacteroidia, 9/9 (100%) had an increase in Clostridia, and 7/9 (77.8%) had a reduction in Gammaproteobacteria. Of the 2 patients not given colesevelam, one showed a reduction in Bacteroidia, increase in Clostridia and a reduction in Gammaproteobacteria.

CONCLUSIONS

This small pilot study demonstrated that patients who were given colesevelam, were more likely to be in disease remission at their 6-12 months colonoscopy review compared with those not treated. Furthermore, treatment with colesevelam may have a role in altering the microbiome to help maintain remission states in postoperative Crohn's disease. Larger mechanistic studies are now needed to confirm these findings and demonstrate statistical significance as well as investigate whether this benefit may be present even in those patients with 75SeHCAT negative disease.

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Key Words

• Crohn’s disease
• bile acid diarrhoea
• bile acid sequestrants
• colesevelam
• microbiome
• terminal ileal resection

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MESH Headings

• Humans
• Crohn Disease/surgery
• Crohn Disease/microbiology
• Crohn Disease/drug therapy
• Female
• Male
• Adult
• Pilot Projects
• Gastrointestinal Microbiome/drug effects
• Colesevelam Hydrochloride/therapeutic use
• Middle Aged
• Diarrhea/drug therapy
• Diarrhea/etiology
• Diarrhea/microbiology
• Bile Acids and Salts/metabolism
• Postoperative Complications/drug therapy
• Postoperative Complications/microbiology
• Feces/microbiology
• Colonoscopy
• Ileum/surgery
• Follow-Up Studies
• Recurrence
• Young Adult
• RNA, Ribosomal, 16S/genetics

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Grants

• Bowel and Cancer Research

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Affiliation(s)

Aditi Kumar Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
Mohammed Nabil Quraishi University of Birmingham Microbiome Treatment Centre, Birmingham, UK Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Hafid O Al-Hassi Research Institute in Healthcare Science, University of Wolverhampton, Wolverhampton, UK
Mohammed Elasrag Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham, UK
Jonathan P Segal Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, VIC, Australia Department of Medicine, University of Melbourne, Parkville, VIC, Australia
Manushri Jain Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
Helen Steed Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK School of Medicine and Clinical Practice, Faculty of Sciences and Engineering, University of Wolverhampton, Wolverhampton, UK
Jeffrey Butterworth Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
Adam Farmer Division of Gastroenterology & Hepatology, St Louis University Hospital, St Louis, MO, USA
John Mclaughlin Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK Department of Gastroenterology, Salford Royal Foundation Trust, Stott Lane, UK
Andrew D Beggs University of Birmingham Microbiome Treatment Centre, Birmingham, UK Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
Matthew J Brookes Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK School of Medicine and Clinical Practice, Faculty of Sciences and Engineering, University of Wolverhampton, Wolverhampton, UK

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UNEXPECTED FINDINGS DURING LAPAROTOMY SURGERY AND URGENT SURGICAL INDICATIONS ARE ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN'S DISEASE

BACKGROUND

Patients undergoing Crohn's disease (CD) surgery may develop a higher rate of postoperative complications (POC) than other patients.

AIMS

The aim of this study was to investigate factors determining POC in patients with CD undergoing urgent laparotomy.

METHODS

This is a retrospective cohort study conducted on adult patients undergoing urgent laparotomy for CD. Clinical and surgical variables, medication history, American Society of Anesthesiologists classification, and POC were investigated. Data collection and management were carried out using the REDCap software (REDCap electronic data capture tools) hosted at the hospital institution. For statistical analysis, the χ2 (or Fisher's exact) test, Student's t-test, Mann-Whitney test, and simple and multiple multilevel logistic regression analyses were used.

RESULTS

There was an association regarding the history of adalimumab use (p=0.04, OR 2.8, 95%CI 1.03-7.65), previous use of prednisone (p<0.01, OR 2.03, 95%CI 2.00-2.05), urgent surgery indications (p<0.01, OR=4.32, 95% CI=1.58-11.82), mechanical anastomosis (p=0.02, OR=0.22, 95%CI 0.06-0.80), unexpected intraoperative findings (p=0.02, OR 10.46, 95%CI 1.50-72.99), length of hospital stay greater than 10 days (p<0.01, OR 16.86, 95%CI 2.99-94.96), unplanned intensive care unit (ICU) admission (p=0.01, OR 15.06, 95%CI 1.96-115.70), and planned ICU admission (p<0.01, OR 18.46, 95%CI 3.60-94.51). On multivariate analysis, there was an association between the indication of urgent surgery (or emergency) (p=0.01, OR 4.38, 95%CI 1.43-13.37) and unexpected intraoperative findings (p=0.03, OR 8.11, 95%CI 1.21-54.50).

CONCLUSIONS

Unexpected changes and urgent surgical indications are considered risk factors for POC in patients with CD.

The challenges of implementing earlier surgery for terminal ileal Crohn's disease-A qualitative study of the clinician's perspective

AIM

Evidence suggests that earlier bowel resection may offer more stable remission in localized luminal terminal ileal (TI) Crohn's disease compared with ongoing medical therapy. Surgery is still considered late in the treatment pathway. The aim of this study was to understand the clinician's perspective on 'early' surgery by qualitatively exploring how clinicians make treatment-related decisions.

METHOD

Semistructured interviews with clinicians across the UK with an interest in inflammatory bowel disease (IBD) were undertaken using videoconferencing (February-November 2022). Inductive thematic analysis of interview transcripts was performed; 10% of the data were double-coded. Data saturation was confirmed before stopping recruitment.

RESULTS

Participants included nine consultant surgeons, seven consultant gastroenterologists and seven specialist nurses (n = 23) from secondary care and tertiary referral centres. Five key themes were identified: timing of surgery in practice, barriers to timely surgery, factors influencing decision-making, offering choice and the patient's perspective. A practice of exhausting medical options before considering surgery was commonly described. A lack of IBD specialists (especially surgeons), inadequate opportunities for multidisciplinary teamwork and long waiting lists for surgical clinics and theatre were cited as barriers to timely surgery. According to interviewees, patients prefer medical therapy over surgery; the most dreaded risk is thought to be that of a stoma.

CONCLUSION

This study provides new insights into the barriers to earlier surgery for TI disease. Organizational barriers should be considered when designing local services. Collaborative multidisciplinary teamwork may allow clinicians to consider surgery sooner. A study investigating the patient perspective is warranted.

The Cost of Inflammatory Bowel Disease Care: How to Make it Sustainable

The rising global prevalence of inflammatory bowel diseases (IBDs), such as Crohn's disease and ulcerative colitis, underscores the need to examine current and future IBD care costs. Direct health care expenses, including ambulatory visits, hospitalizations, and medications, are substantial, averaging $9,000 to $12,000 per person annually in high-income regions. However, these estimates do not fully account for factors such as disease severity, accessibility, and variability in health care infrastructure among regions. Indirect costs, predominantly stemming from loss in productivity due to absenteeism, presenteeism, and other intangible costs, further contribute to the financial burden of IBD. Despite efforts to quantify indirect costs, many aspects remain poorly understood, leading to an underestimation of their actual impact. Challenges to achieving cost sustainability include disparities in access, treatment affordability, and the absence of standardized cost-effective care guidelines. Strategies for making IBD care sustainable include early implementation of biologic therapies, focusing on cost-effectiveness in settings with limited resources, and promoting the uptake of biosimilars to reduce direct costs. Multidisciplinary care teams leveraging technology and patient-reported outcomes also hold promise in reducing both direct and indirect costs associated with IBD. Addressing the increasing financial burden of IBD requires a comprehensive approach that tackles disparities, enhances access to cost-effective therapeutics, and promotes collaborative efforts across health care systems. Embracing innovative strategies can pave the way for personalized, cost-effective care accessible to all individuals with IBD, ensuring better outcomes and sustainability.

Understanding the therapeutic toolkit for inflammatory bowel disease

Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, is a group of chronic, immune-mediated disorders of the gastrointestinal tract that present substantial clinical challenges owing to their complex pathophysiology and tendency to relapse. A treat-to-target approach is recommended, involving iterative treatment adjustments to achieve clinical response, reduce inflammatory markers and achieve long-term goals such as mucosal healing. Lifelong medication is often necessary to manage the disease, maintain remission and prevent complications. The therapeutic landscape for IBD has evolved substantially; however, a ceiling on therapeutic efficacy remains and surgery is sometimes required (owing to uncontrolled disease activity or complications). Effective IBD management involves comprehensive care, including medication adherence and a collaborative clinician-patient relationship. This Review discusses current therapeutic options for IBD, detailing mechanisms of action, efficacy, safety profiles and guidelines for use of each drug class. We also explore emerging therapies and the role of surgery. Additionally, the importance of a multidisciplinary team and personalized care in managing IBD is emphasized, advocating for patient empowerment and involvement in treatment decisions. By synthesizing current knowledge and emerging trends, this Review aims to equip healthcare professionals with a thorough understanding of therapeutic options for IBD, enhancing informed, evidence-based decisions in clinical practice.

Durable remission after ileocolic resection for Crohn's disease is achievable in selected patients. Long-term results of a prospective multicentric cohort study of the GETAID Chirurgie

BACKGROUND AND AIMS

Postoperative recurrence requiring medical treatment intensification or redo surgery is common after ileocolic resection (ICR) for Crohn's disease (CD). This study aimed to identify a subgroup of CD patients for whom ICR could achieve durable remission.

METHODS

This retrospective follow-up study analyzed 592 CD patients who underwent ICR (2013-2015) in a nationwide prospective cohort. Patients with >36 months follow-up were included. Primary outcome was durable remission, defined as the absence of endoscopic recurrence and/or medical treatment intensification. Uni- and multivariate analyses identified predictive factors for durable remission.

RESULTS

Among 268 included patients, 59% had B2 phenotype, 70% had a first ICR, and 66% had postoperative medical treatment. After a median follow-up of 85 (36-104) months, 52 patients (19%) experienced durable remission, of whom 24 (46%) didn't require medical treatment and 28 (54%) maintained the same postoperative treatment, including anti-tumor necrosis factor in 15/28 patients (54%). Surgery could stabilize the disease course in 112 patients (41.7%), including 22.4% endoscopic recurrence that didn't require CD treatment initiation or intensification. Durable remission rate was significantly increased in B1 phenotype vs B2/B3 (n = 7/18;39% vs n = 45/250;18%, P = .030) and in first ICR vs redo ICR (n = 43/184;23% vs n = 9/80;11%, P = .023). In multivariate analysis, B1 phenotype was the only independent predictive factor for durable remission (odds ratio = 3.59, IC 95%, 1.13-11.37, P = .030).

CONCLUSIONS

Surgery for CD achieved durable remission in 20%, rising to 40% in those with a B1 phenotype. These results support surgery as a viable alternative to medical treatment, offering treatment-free durable remission and preserving medical treatment options.

Early Surgical Resection in Pediatric Patients with Localized Ileo-Cecal Crohn's Disease: Results of a Retrospective Multicenter Study

Background: Crohn's disease (CD) is an inflammatory bowel disease (IBD) that also affects pediatric patients. It frequently presents as a localized disease, affecting the ileocecal area, ileum, or colon. It requires targeted therapy to achieve a good quality of life and long-term control of disease activity. Despite multiple medical therapies available, several patients benefit from surgical treatment. The aim of our study is to demonstrate how an early surgical approach can bring an improvement in disease activity, evaluating the Simple Endoscopic Score for Crohn's Disease (SES-CD) and the Pediatric Crohn's Disease Activity Index (PCDAI). Methods: A retrospective multicenter study was carried out from 2008 to 2023, including 29 patients, affected by localized CD. These data were analyzed: demographics, SES-CD, and PCDAI, before and after surgery. The differences between groups were analyzed using Student's t-test for continuous variables, and Pearson's Chi-squared test or Fisher's exact test for categorical variables. Results: The SES-CD significantly decreased from 12 (median, range 1-15) to 0 (median, range 0-6) (p < 0.0001) and the PCDAI decreased from 30 (median, range 10-50) to 0 (median, range 0-15) (p < 0.0001). The rate of patients receiving enteral nutrition decreased from 51.7% preoperatively to 0% postoperatively (p = 0.0001). The rate of antibiotic use decreased from 13.8% to 0% (p = 0.0001). The rate of patients receiving ≥2 drugs decreased from 10.3% to 0% (p = 0.0001). Conclusions: The early surgical approach can be considered an excellent therapeutic strategy in patients with localized CD. Both parameters examined, SES-CD and PCDAI, demonstrated a clear improvement in the endoscopic images and in disease activity.

Clusters of Disease Activity and Early Risk Factors of Clinical Course of Pediatric Crohn's Disease

BACKGROUND

This study aimed to define clusters of disease activity and prognostic factors of disease course in a well-characterized cohort of children with Crohn's disease (CD).

METHODS

All patients from the SIGENP IBD (Italian Society of Pediatric Gastroenterology Hepatology and Nutrition Inflammatory Bowel Disease) registry with a 5-year follow-up and 6-monthly evaluation were included. Active disease was defined for each semester as follows: clinical activity (weighted Pediatric Crohn's Disease Activity Index ≥12.5 or Mucosal Inflammation Noninvasive Index ≥8) and active disease on endoscopy (Simple Endoscopic Score for Crohn's Disease >3 or fecal calprotectin >250 µg/g) or imaging. Formula-based clusters were generated based on previously published patterns in adults.

RESULTS

Data from 332 patients were analyzed. A total of 105 (32%) experienced a quiescent disease course; 49 (15%) and 31 (9%) a moderate-to-severe chronically active and chronic intermittent disease, respectively; 104 (31%) and 43 (13%) had active disease in the first 2 years after diagnosis and remission thereafter and vice versa, respectively. Surgery at diagnosis was significantly associated with a quiescent course (odds ratio [OR], 10.05; 95% confidence interval [CI], 3.05-25.22; P=.0005), while growth impairment at the diagnosis and active disease requiring corticosteroids at 6 months were inversely related to the quiescent group (OR, 0.48; 95% CI, 0.27-0.81; P= .007; and OR, 0.35; 95% CI, 0.16-0.71; P= .005, respectively). Perianal involvement at diagnosis and moderate-severe activity at 6 months correlated with disease progression (OR, 3.85; 95% CI, 1.20-12.85; P=.02).

CONCLUSIONS

During the first 5 years of follow-up, one-third of children with CD experience a quiescent course. However, another one-third have a moderate-to-severe disease course. Surgery at the diagnosis is related to a quiescent course, while growth impairment and lack of response to induction therapy correlate with more severe disease activity during follow-up.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interpreting modern randomized controlled trials of medical therapy in inflammatory bowel disease

Treatment options for the medical management of inflammatory bowel disease (IBD) have expanded substantially over the past decade. Multiple classes of advanced therapies, including both monoclonal antibodies and novel oral small molecules, are now available for the treatment of moderately-to-severely active Crohn's disease and ulcerative colitis, highlighted by the approvals of the first IL23p19 antagonists, selective Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators. These advances have been accompanied by the identification of novel targets and the rapid growth in both the number and size of IBD clinical trials. Over a dozen landmark randomized controlled trials (RCTs) have been completed in the past 5 years, including the first head-to-head biologic trials, the first combination biologic studies, and multiple phase III registrational trials of novel compounds with new co-primary and composite end points that will change the treatment landscape for years to come. Importantly, the methodology of RCTs in IBD has evolved substantially, with new trial designs, evaluation of unique patient populations, and different types of efficacy and safety end points being key innovations. In this Review, we provide a comprehensive evaluation of how modern RCTs of IBD medical therapies have evolved and the implications for their appraisal that will help guide the application of these data to clinical practice.

Preventing Recurrence of Crohn's Disease Post-Ileocaecal Surgery in Paediatric Patients: A Therapy Guide Based on Systematic Review of the Evidence

BACKGROUND AND AIMS

Ileocaecal resection (ICR) is frequent in paediatric patients with Crohn's disease (pCD). Despite rates of reoperation being low, the risk of clinical or endoscopic post-operative recurrence (POR) is high; effective medical strategies to prevent POR are thus needed. The aim of this systematic review (SR) was to identify and evaluate the published literature on post-operative medical prevention of POR in pCD to draft a possible therapy guide for pCD patients undergoing ICR.

METHODS

We performed an SR according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards and registered it in the PROSPERO database (ID: CRD42024533855). The population, intervention, control, outcome (PICO) model was focussed on post-surgical medical prevention of POR in pCD with clearly expressed definition of recurrence (endoscopically using a standardized scoring system (e.g. Rutgeerts score) or by laboratory markers, for example, faecal calprotectin (F-CPT), C-reactive protein (CRP) or by histological findings or by clinical activity indexes [e.g. weighted paediatric Crohn's disease activity index - (w)PCDAI]. From inception until 29 February 2024, the following databases were searched: PubMed/MEDLINE, Scopus/Embase, Web of Sciences, Evidence-Based Medicine Reviews (including Cochrane), Cochrane Central Registrar of controlled Trials (CENTRAL), ClinicalTrials.gov and EudraCT. Retrieved articles were evaluated for eligibility and finally selected publications for risk of bias using ROBINS-I tool.

RESULTS

Out of 811 publications identified by the search, only 5 fulfilled inclusion criteria of the SR. None of the studies fully answered our PICO question. The studies were overall of poor quality and the heterogeneity of the data did not allow us to perform meta-analysis, detailed statistical analysis or formal synthesis of data. Adverse events of post-operative medication were not described in any of the included studies. Existing guidelines of European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), European Crohn's and Colitis Organisation (ECCO) and American Gastroenterological Association (AGA) were reviewed and paediatric therapy guide for pCD undergoing ICR was drafted with respect to recent SRs and meta-analyses in adult population and including scarce paediatric data identified by our SR. As pCD patients undergoing ICR are a high-risk population, they should not be left untreated post-operatively. Anti-tumour necrosis factor (anti-TNF) drugs should be considered as first-line therapy in the majority of patients. Non-anti-TNF biologics should be considered in case of anti-TNF failure. Regular endoscopic monitoring starting at 6 months after the surgery and supported by regular F-CPT evaluation should be used to identify early endoscopic recurrence and to escalate the treatment.

CONCLUSION

Our SR revealed that there is wide variability in treatment strategies in children, and high-quality data are generally lacking. At the moment, paediatric prophylaxis of POR should be guided by available adult evidence with respect to the high-risk nature of pCD. Extensive research in pCD should be encouraged.

Early ileal resection in Crohn's disease is not associated with severe long-term outcomes: The ERIC study

BACKGROUND

Early complicated Crohn's disease (CD) may require ileal resection as first-line treatment.

AIM

To evaluate the long-term outcomes of patients who underwent early ileal resection.

METHODS

We conducted a retrospective study in two inflammatory bowel diseases (IBD) referral centres, including patients with ileocaecal resection and segmental ileal resection within 5 years of CD diagnosis. Early resection was defined as within 6 months of diagnosis, intermediate resection between 6 months and 2 years, and late resection between 2 and 5 years. The primary outcome was the cumulative risk of a second ileal surgery. Secondary outcomes included the use of postoperative treatments and morphological recurrence after initial surgery (Rutgeerts score ≥i2, or recurrence on imaging).

RESULTS

Among 393 patients who underwent ileal resection within 5 years of diagnosis, 130, 128 and 135, respectively, had early, intermediate and late resection. The cumulative risk of second surgery at 10 years was not significantly different in the early resection group (25.0% [95% CI 17.4-35.2]), than the intermediate (16.8% [95% CI 10.5-26.2]; p = 0.17) or late resection group (22.7% [95% CI 15.1-33.3]; p = 0.83). The early resection group required fewer postoperative treatments than the late resection group with median survivals without treatments of 3.7 and 0.9 years, respectively (p = 0.002). Patients who had early resection had significantly less morphological recurrence than the late resection group (p = 0.02).

CONCLUSION

Early ileal resection in CD is not associated with a higher risk of a second resection. It may be associated with reduced use of medical treatments and fewer morphological recurrences.

Editorial: Re-Evaluating Early Surgery in Ileocaecal Crohn's Disease. Author's Reply

This article is linked to Grellier et al papers. To view these articles, visit https://doi.org/10.1111/apt.18247 and https://doi.org/10.1111/apt.18290.

Considerations in Paediatric and Adolescent Inflammatory Bowel Disease

The incidence of inflammatory bowel disease [IBD] is rising most rapidly among children and adolescents. Paediatric-onset IBD is associated with a more extensive and severe disease course compared to adult-onset IBD. At a young age, screening for underlying genetic and immunological disorders is important and may impact treatment management. Early and effective treatment is crucial to reach disease remission and prevent complications of ongoing active disease. In children with Crohn's disease, exclusive enteral nutrition is an effective induction therapy. Other promising dietary therapies, such as the Crohn's disease exclusion diet, are emerging. Within paediatric IBD, anti-tumour necrosis factor therapy is the only approved biological thus far and additional treatment options are crucially needed. Other biological therapies, such as vedolizumab and ustekinumab, are currently prescribed off-label in this population. A specific challenge in paediatric IBD is the unacceptable and major delay in approval of drugs for children with IBD. A guided transfer period of paediatric patients to adult care is associated with improved disease outcomes and is required. Major knowledge gaps and challenges within paediatric IBD include the aetiology, diagnostics, and monitoring of disease, tailoring of treatment, and both understanding and coping with the physical and psychological consequences of living with IBD. Challenges and research gaps in paediatrics should be addressed without any delay in comparison with the adult field, in order to ensure a high quality of care for all patients with IBD, irrespective of the age of onset.

Re-resection Rates and Disease Recurrence in Crohn's Disease: A Population-based Study Using Individual-level Patient Data

BACKGROUND AND AIMS

Despite advances in the medical treatment of Crohn's disease [CD], many patients will still need bowel resections and face the subsequent risk of recurrence and re-resection. We describe contemporary re-resection rates and identify disease-modifying factors and risk factors for re-resection.

METHODS

We conducted a retrospective, population-based, individual patient-level data cohort study covering 47.4% of the Danish population, including all CD patients who underwent a primary resection between 2010 and 2020.

RESULTS

Among 631 primary resected patients, 24.5% underwent a second resection, and 5.3% a third. Re-resection rates after 1, 5, and 10 years were 12.6%, 22.4%, and 32.2%, respectively. Reasons for additional resections were mainly disease activity [57%] and stoma reversal [40%]. Disease activity-driven re-resection rates after 1, 5, and 10 years were 3.6%, 10.1%, and 14.1%, respectively. Most stoma reversals occurred within 1 year [80%]. The median time to recurrence was 11.0 months. Biologics started within 1 year of the first resection revealed protective effect against re-resection for stenotic and penetrating phenotypes. Prophylactic biologic therapy at primary ileocaecal resection reduced disease recurrence and re-resection risk (hazard ratio [HR] 0.58, 95% confidence interval [CI] [0.34-0.99], p = 0.047). Risk factors for re-resection were location of resected bowel segments at the primary resection, disease location, disease behaviour, smoking, and perianal disease.

CONCLUSION

Re-resection rates, categorised by disease activity, are lower than those reported in other studies and are closely associated with disease phenotype and localisation. Biologic therapy may be disease-modifying for certain subgroups when initiated within 1 year of resection.

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO Guidelines.

Appearance of the Bowel and Mesentery During Surgery Is Not Predictive of Postoperative Recurrence After Ileocecal Resection for Crohn's Disease: A Prospective Monocentric Study

BACKGROUND

Very few risk factors for postoperative recurrence (POR) of Crohn's Disease (CD) after ileocecal resection have been identified. The aim of the present study was to verify the association between an a priori defined list of intraoperative macroscopic findings and POR.

METHODS

This was a prospective observational study including patients undergoing primary ileocecal resection for CD. Four intraoperative factors were independently evaluated by 2 surgeons: length of resected ileum, mesentery thickness, presence of areas of serosal fat infiltration, or abnormal serosal vasodilation on normal bowel proximal to the resected bowel. The primary end point was early endoscopic POR at month 6 and defined as modified Rutgeerts score ≥i2b. Secondary end points were clinical and surgical recurrence.

RESULTS

Between September 2020 and November 2022, 83 consecutive patients were included. Early endoscopic recurrence occurred in 45 of 76 patients (59.2%). Clinical and biochemical recurrence occurred in 17.3% (95% confidence interval, [CI], 10.4%-28.0%) and 14.6% of the patients after 12 months. The risk of developing endoscopic and clinical recurrence was 1.127 (95% CI, 0.448;2.834, P = .799) and 0.896 (95% CI, 0.324-2.478, P = .832) when serosal fat infiltration was observed, and 1.388 (95% CI, 0.554-3.476, P = .484), and 1.153 (95% CI, 0.417;3.187, P = .783) when abnormal serosal vasodilation was observed. Similarly, length of the resected bowel and mesentery thickness showed no association with POR. A subgroup analysis on patients who received no postoperative medical prophylaxis did not identify any risk factor for endoscopic POR.

CONCLUSIONS

The macroscopic appearance of the bowel and associated mesentery during surgery does not seem to be predictive of POR after ileocecal resection for CD.

How comparative studies can inform treatment decisions for Crohn's disease

INTRODUCTION

As new therapies for the treatment of Crohn's disease (CD) are approved, there is an increasing need for evidence that clarifies their positioning and sequencing.

AREAS COVERED

Comparative effectiveness research (CER) aims to inform physicians' decisions when they choose which intervention (drug or treatment strategy) to administer to their patients. Pragmatic head-to-head trials represent the best tools for CER, but only a few have been published in the IBD field. Network meta-analyses can point toward the superiority of one drug over another, but they do not reflect everyday clinical practice. Finally, real-world evidence complements that coming from head-to-head trials and network meta-analyses, assessing the real-life effectiveness of therapeutic interventions.

EXPERT OPINION

There is insufficient evidence to create a definitive therapeutic algorithm for CD, but some general considerations can be made. Anti-TNF-α agents seemingly represent the most 'sustainable' first-line choice, considering benefit-harm ratio and costs; vedolizumab, ustekinumab, and risankizumab may be considered as first-line choice when safety issues become prominent. In the event of pharmacodynamic failure, out-of-class swap is to be preferred - possibly with anti-IL23p19 as the best option, with unclear data regarding upadacitinib positioning; a second anti-TNF-α could be considered, as a second choice, after pharmacokinetic failure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Common Mistakes in Managing Patients with Inflammatory Bowel Disease

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.

A global consensus on the definitions, diagnosis and management of fibrostenosing small bowel Crohn's disease in clinical practice

Fibrostenosis of the small bowel is common in patients with Crohn's disease. No consensus recommendations on definition, diagnosis and management in clinical practice are currently available. In this Consensus Statement, we present a clinical practice RAND/UCLA appropriateness study on the definition, diagnosis and clinical management of fibrostenosing Crohn's disease. It was conducted by a panel of 28 global experts and one patient representative. Following a systematic literature review, 526 candidate items grouped into 136 questions were generated and subsequently evaluated for appropriateness. Strictures are best defined as wall thickening, luminal narrowing and prestenotic dilation. Cross-sectional imaging is required for accurate diagnosis of fibrostenosing Crohn's disease, and it is recommended before making treatment decisions. It should also assess the degree of inflammation in the bowel wall. Multiple options for medical anti-inflammatory, endoscopic and surgical therapies were suggested, including follow-up strategies following therapy. This Consensus Statement supports clinical practice through providing guidance on definitions, diagnosis and therapeutic management of patients with fibrostenosing small bowel Crohn's disease.

Systematic review: Patient-related, microbial, surgical, and histopathological risk factors for endoscopic post-operative recurrence in patients with Crohn's disease

BACKGROUND

Risk stratification for endoscopic post-operative recurrence (ePOR) in Crohn's disease (CD) is required to identify patients who would benefit most from initiation of prophylactic medication and intensive monitoring of recurrence.

AIMS

To assess the current evidence on patient-related, microbial, surgical and histopathological risk factors for ePOR in patients with CD after ileocolic (re-)resection.

METHODS

Multiple online databases (Embase, MEDLINE, Web of Science and Cochrane Library) were searched up to March 2024. Studies with reported associations of patient-related, microbial, surgical and/or histopathological factors for ePOR (i.e., Rutgeerts' score ≥i2 or modified Rutgeerts' score ≥i2a) were included. The risk of bias was assessed with the Newcastle-Ottawa Scale for observational cohort studies and case-control studies.

RESULTS

In total, 47 studies were included (four RCTs, 29 cohort studies, 12 case-control studies, one cross-sectional study and one individual participant data meta-analysis) including 6006 patients (median sample size 87 patients [interquartile range 46-170]). Risk of bias assessment revealed a poor quality in 41% of the studies. An association was reported in multiple studies of ePOR with active smoking at and post-surgery, male sex and prior bowel resection. A heterogeneous association with ePOR was reported for other risk factors included in the current guidelines (penetrating disease, perianal disease, younger age, extensive small bowel disease and presence of granulomas in the resection specimen or myenteric plexitis in the resection margin), and other patient-related, microbial, surgical and histopathological factors.

CONCLUSION

Risk factors for ePOR in international guidelines are not consistently reported as risk factors in current literature except for active smoking and prior bowel resection. To develop evidence-based, personalised strategies, large prospective studies are warranted to identify risk factors for ePOR. Validation studies of promising (bio)markers are also required.

Personalised therapy in inflammatory bowel disease

Inflammatory bowel diseases (IBD), with ulcerative colitis and Crohn's disease being their most common presentations, comprise a spectrum of diverse disease phenotypes, exhibiting variable behaviors ranging from an indolent course to aggressive phenotypes that impact quality of life of these patients. The last two decades have been marked by the development of new medications (biological therapy and novel small molecules) with diverse mechanisms of action, which have revolutionized the management of IBD, thereby enhancing the quality of life for these patients. This landscape of multiple therapeutic options underscores the need to define which medication will benefit each patient the most and at what speed it should be started. The objective of this review is to present personalized approaches for patients with IBD, thus contributing to therapeutic management.

Relationship between Ustekinumab trough concentrations and clinical, biochemical and endoscopic outcomes in Crohn's disease: A multi-center nationwide retrospective study (TARGET STUDY)

Ustekinumab has been shown to be effective in inducing and maintain clinical and endoscopic remission in Crohn disease (CD). We aim to assess whether ustekinumab trough levels are associated with improved outcomes in CD in real-life. We recruited patients with CD who were treated with ustekinumab for at least 6 months from January 2017 to June 2023. Patients received ustekinumab 6 mg/kg intravenous induction followed by 90 mg every 4-, 8-, or 12-weeks during maintenance were included. We assessed clinical, biochemical, and endoscopic outcomes. Trough concentrations of ustekinumab that were taken from week 42 to week 52 were measured. Primary outcome was to evaluate the relationship between ustekinumab trough concentrations and clinical remission, biochemical normalization, and endoscopic remission. Logistic regression was conducted to assess outcomes. A total of 137 patients with CD, median age of 32 years and 83 (60.6%) males. The median serum levels of ustekinumab measured was 7.2 mcg/mL (interquartile range [IQR] 3.1-9.6). Using Spearman correlation analysis, a strong negative correlation was observed between ustekinumab drug levels and simple endoscopic score (SES-CD) (r = -0.464, P < .001). Additionally, ustekinumab drug levels demonstrated substantial negative correlations with disease severity measured by Harvey-Bradshaw index (HBI) score (r = -0.582, P < .001), C-Reactive Protein (CRP) levels (r = -0.598, P < .001) and fecal calprotectin (FC) levels (r = -0.529, P < .001). A multivariable analysis adjusted for age, sex and body mass index (BMI) showed a significant association between ustekinumab serum drug levels and predefined outcomes. Ustekinumab serum drug level above 4.5 mcg/mL was associated with 24% increase in the likelihood of having an SES-CD score <3 (OR 1.24, confidence interval [CI] 1.12-1.37, P value < .001), 44% more likely to achieve HBI score <5 (OR 1.44, CI 1.26-1.65, P value < .001), 52% higher likelihood of CRP more than 10 (OR 1.52, CI 1.31-1.77, P < .001), and 42% increased likelihood of FC more than 250 (OR 1.42, CI 1.24-1.62, P < .001). Ustekinumab trough concentrations above 4.5 mcg/mL were associated with clinical, biochemical and endoscopic remission in CD. Prospective data is warranted to confirm these findings.

Impact of Kono-S anastomosis on quality of life after ileocolic resection in Crohn's disease: an analysis from the SuPREMe-CD trial

AIM

Crohn's disease has debilitating effects on patients' quality of life. Currently, there are limited data on the effect of anastomotic configuration on health-related quality of life after ileocaecal resection for Crohn's disease. This study aimed to assess the impact of Kono-S anastomosis on quality of life after ileocolic resection, compared to the conventional side-to-side anastomosis.

METHOD

Patients with primary or recurrent Crohn's disease participating in the ongoing SuPREMe-CD trial were interviewed about quality of life using the Inflammatory Bowel Disease Questionnaire (IBDQ). The primary endpoint was disease-specific quality of life, assessed with IBDQ. Secondary outcomes were quality of life related to bowel symptoms, systemic symptoms, social function and emotional function.

RESULTS

Of the 94 patients included, 51 (54%) received the conventional side-to-side anastomosis and 43 (46%) the Kono-S anastomosis. Demographics were comparable between the two groups. The IBDQ was assessed at a mean follow-up of 54.0 ± 18.7 months from surgical intervention. The mean total IBDQ score was 155.1 ± 28.07 in the conventional group and 163.8 ± 25.23 in the Kono-S group (P = 0.11). When considering bowel symptoms and social function, mean scores were 50.7 and 23.5 in the conventional group, and 56.3 and 26.5 in the Kono-S group (P = 0.002 and P = 0.02, respectively). Kono-S anastomosis was independently associated with improved quality of life regarding bowel symptoms (P = 0.006) and social function (P = 0.03) after correcting for other confounding factors on linear regression analysis.

CONCLUSION

Compared to conventional side-to-side anastomosis, patients with Kono-S anastomosis presented significantly better bowel symptoms and social function scores at 54 months after surgery.

Interventional inflammatory bowel disease: current and future practice

PURPOSE OF REVIEW

Inflammatory bowel diseases (IBD) are associated with several well described neoplastic and structural complications. Increasing disease prevalence, healthcare barriers, and medication refractory phenotypes contribute to ongoing complications despite significant strides in medical management. Enhancements in endoscopic technology and techniques have allowed a minimally invasive approach for what has historically required surgery. In this article, we review the current and future landscape of endoscopic IBD intervention.

RECENT FINDINGS

Endoscopic resection is the first line for managing conventional and complex colitis-associated dysplasia. Evidence supporting endoscopic submucosal dissection is mounting, yet there is a paucity of studies evaluating modified endoscopic mucosal resection techniques or hybrid endoscopic submucosal dissection. We also have more clarity in how best to approach fibrostenotic disease, as we learn how to position endoscopic stricturotomy and stenting, relative to balloon dilation. Finally, applications in managing penetrating and postsurgical complications have been described, but still require further study.

SUMMARY

While important knowledge gaps still exist, the application of endoscopic therapies in IBD is more refined, especially within the management of colitis-associated dysplasia and strictures. The indications for endoscopy in perianal disease and other penetrating manifestations of Crohn's disease presents exciting opportunities for growth.

Outcomes and Endpoints of Postoperative Recurrence in Crohn's Disease: Systematic Review and Consensus Conference

BACKGROUND

Outcomes after ileocolonic resection in Crohn's disease [CD] are heterogeneous, and a clear definition of postoperative recurrence remains to be determined. Our Endpoints Working Group of the International Organization for the study of Inflammatory Bowel Disease [IOIBD] aimed to standardise postoperative outcomes, to discuss which endpoints should be used for postoperative clinical trials, and to define those which could be used in trials or registries.

METHODS

Based on a systematic review of the literature, recommendations and statements were drafted and sent to all IOIBD members for a first round of voting. Recommendations and statements were revised based on the voters' comments during a consensus hybrid conference open to all IOIBD members. If no agreement was reached after two rounds of voting, the statement was excluded.

RESULTS

In the systematic review, 3071 manuscripts were screened of which 434 were included. Sixteen recommendations were identified, of which 11 were endorsed. Recommendations and statements include that endoscopy remains the gold standard and should be used as a short-term primary endpoint in both observational cohorts and randomised controlled trials. Clinical symptoms classically used in clinical trials for luminal CD are not reliable in this specific situation. For that reason, longer-term endpoints should be based on the evidence of macroscopic inflammation assessed by imaging techniques, endoscopy, or as reflected by the presence of complications.

CONCLUSIONS

Agencies recommend the use of clinical evaluations, as in the case of luminal CD, and do not recognise primary endpoints based solely on endoscopy. This consensus has led to agreement on the need to define postoperative endoscopy-based and/or imaging-based endpoints.

Surgical treatment of inflammatory bowel disease: From the gastroenterologist's stand-point

Treatment of ulcerative colitis (UC) and Crohn's disease (CD) represents, in the majority of cases, a real challenge to the gastroenterologist's abilities and skills as well as a clinical test concerning his/her levels of medical knowledge and experience. During the last two decades, our pharmaceutical arsenal was significantly strengthened, especially after the introduction of the so-called biological agents, drugs which to a large extent not only improved the results of conservative treatment but also changed the natural history of the disease. However, colectomy is still necessary for some patients with severe UC although smaller compared to the past, precisely because of the improvements achieved in the available conservative treatment. Nevertheless, surgeries to treat colon dysplasia and cancer are increasing to some extent. At the same time, satisfactory improvements in surgical techniques, the pre-and post-operative care of patients, as well as the selection of the appropriate time for performing the surgery have been noticed. Regarding patients with CD, the improvement of conservative treatment did not significantly change the need for surgical treatment since two-thirds of patients need to undergo surgery at some point in the course of their disease. On the other hand, the outcome of the operation has improved through good preoperative care as well as the wide application of more conservative surgical techniques aimed at keeping as much of the bowel in situ as possible. This article discusses the indications for surgical management of UC patients from the gastroenterologist's point of view, the results of the emerging new techniques such as transanal surgery and robotics, as well as alternative operations to the classic ileo-anal-pouch anastomosis. The author also discusses the basic principles of surgical management of patients with CD based on the results of the relevant literature. The self-evident is emphasized, that is, to achieve an excellent therapeutic result in patients with severe inflammatory bowel disease in today's era; the close cooperation of gastroenterologists with surgeons, pathologists, imaging, and nutritionists is of paramount importance.

Challenges in IBD Research 2024: Pragmatic Clinical Research

Pragmatic clinical research is 1 of the 5 focus areas of the Challenges in IBD Research 2024, a multidisciplinary effort by scientists, clinicians, patients, and funders to identify priorities for patient-centric research. This summary provides a comprehensive overview of current gaps in inflammatory bowel disease (IBD) clinical research and actionable approaches to address them. This review is focused on identifying research that is needed to achieve the best outcomes for patients in clinical practice. Research gaps include understanding the needs of understudied patient groups and addressing barriers to care so all patients receive optimal care, validating and using biomarkers to enable early diagnosis and result in better outcomes for adults and children with IBD, and determining the optimal sequencing of treatments (medical, surgical, adjunct) in children and adults. Inclusive pragmatic research is needed to address these gaps and lead to improvements in patient care and outcomes for all populations of patients with IBD.

Impact of antitumour necrosis factor therapy on surgery in inflammatory bowel disease: a population-based study

OBJECTIVE

It is unclear whether widespread use of biologics is reducing inflammatory bowel disease (IBD) surgical resection rates. We designed a population-based study evaluating the impact of early antitumour necrosis factor (TNF) on surgical resection rates up to 5 years from diagnosis.

DESIGN

We evaluated all patients with IBD diagnosed in Cardiff, Wales 2005-2016. The primary measure was the impact of early (within 1 year of diagnosis) sustained (at least 3 months) anti-TNF compared with no therapy on surgical resection rates. Baseline factors were used to balance groups by propensity scores, with inverse probability of treatment weighting (IPTW) methodology and removing immortal time bias. Crohn's disease (CD) and ulcerative colitis (UC) with IBD unclassified (IBD-U) (excluding those with proctitis) were analysed.

RESULTS

1250 patients were studied. For CD, early sustained anti-TNF therapy was associated with a reduced likelihood of resection compared with no treatment (IPTW HR 0.29 (95% CI 0.13 to 0.65), p=0.003). In UC including IBD-U (excluding proctitis), there was an increase in the risk of colectomy for the early sustained anti-TNF group compared with no treatment (IPTW HR 4.6 (95% CI 1.9 to 10), p=0.001).

CONCLUSIONS

Early sustained use of anti-TNF therapy is associated with reduced surgical resection rates in CD, but not in UC where there was a paradoxical increased surgery rate. This was because baseline clinical factors were less predictive of colectomy than anti-TNF usage. These data support the use of early introduction of anti-TNF therapy in CD whereas benefit in UC cannot be assessed by this methodology.

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

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

Comparison of Post-Operative Outcomes of Right Colectomy between Crohn's Disease and Adenocarcinoma of the Right Colon: A Retrospective Cohort Study

(1) Background: Crohn's disease (CD) and right-sided colorectal-carcinoma (CRC) are two common indications for right colectomies. Many studies have tried to identify risk factors associated with post-operative complications for both CD and CRC. However, data directly comparing the outcomes of the two are sparse. This study aims to compare the 30-day post-operative outcome after a right colectomy for CD versus CRC. Its secondary aim is to identify the factors associated with these outcomes for each group. (2) Methods: A retrospective cohort study of 123 patients who underwent a right colectomy for CD or CRC in a single institution between March 2011 and March 2016. (3) Results: There were no significant differences between the groups when comparing the overall complication rate, the median Clavien-Dindo score, reoperation rates and the length of hospitalization. The leak rate was higher in the Crohn's group (13.95% (6/43) vs. 3.75% (3/80)), p = 0.049), although the stoma rate was the same (4/43 9.5%; 7/80 9.9%). (4) Conclusions: This study has shown that post-operative complication rate is similar for right colectomy in CD and CRC. However, Crohn's disease patients did have a higher leak rate.

Biologics, small molecule therapies and surgery in small bowel Crohn's disease

PURPOSE OF REVIEW

The terminal ileum and small bowel (SB) are involved in 30-45% of patients with Crohn's disease, while 20% have both small and large bowel involvement. Ileal Crohn's is associated with higher risk of progression to stricturing and penetrating disease 1 , hence it's imperative to utilize effective therapies to induce and maintain clinical and endoscopic remission and prevent intestinal complications. We review the available data of biologics and upadacitinib in small bowel disease, and the emerging data on the role of surgery as first line therapy for isolated Crohn's ileitis.

RECENT FINDINGS

Most trials assessing drug efficacy do not report efficacy by disease location, and robust data on efficacy of therapies in isolated small bowel Crohn's is sparse. Several studies indicate that small bowel disease is generally less responsive to biologics, and could require higher drug trough levels to achieve endoscopic healing.

SUMMARY

Current therapies for induction and maintenance of remission in moderate to severe Crohn's disease include several classes of monoclonal antibodies and a Janus Kinase inhibitor, upadacitinib. While small bowel Crohn's disease is generally less responsive to treatment, anti-TNFs are still preferred as first line therapy, and the option of early ileocecal resection in early limited ileal disease is gaining interest.

Innate Immunity Activation in Newly Diagnosed Ileocolonic Crohn's Disease: A Cohort Study

BACKGROUND

Recent studies showed that early surgery for Crohn's disease leads to a lower recurrence rate. However, the underlying mechanism is unknown.

OBJECTIVE

The study aims to analyze the innate immunity microenvironment in ileal mucosa according to the duration of Crohn's disease.

DESIGN

A prospective cohort study.

SETTINGS

Tertiary referral center for IBD surgery.

PATIENTS

A total of 88 consecutive patients with Crohn's disease undergoing ileocolonic resection were prospectively enrolled. Mucosal samples were obtained from both healthy and inflamed ileum. Data from a public data set were analyzed as an external validation cohort.

MAIN OUTCOME MEASURES

Neutrophil infiltration was evaluated by histological asessment and macrophage subpopulation was assessed by immunohistochemistry. Expressions of TLR2 , TLR4 , TLR5 , DEFB1 , DEFB4A , DEFB103 , DEFA5 , and DEFA6 were quantified by real-time quantitative polymerase chain reaction. Concentrations of BDNF, CCL-11, ICAM-1, IL-1A, IL-1β, IL-1RN, IL-12p40, IL-12p70, IL-15, IL-17A, IL-23A, MMP-3, CCL-3, KITLG, and VEGFA were determined with an immunometric assay.

RESULTS

Neutrophil infiltration is inversely correlated with disease duration. DEFB4A mRNA expression tended to be higher in late-stage Crohn's disease ( p = 0.07). A higher number of macrophages expressed CD163 at low intensity in late-stage Crohn's disease ( p = 0.04). The concentration of IL-15 ( p = 0.02) and IL-23A ( p = 0.05) was higher in healthy ileal mucosa of early-stage patients. In the external cohort, expressions of DEFB1 ( p = 0.03), DEFB4A ( p = 0.01), IL-2 ( p = 0.04), and IL-3 ( p = 0.03) increased in patients with late-stage Crohn's disease.

LIMITATIONS

A relatively small number of patients, especially in the newly diagnosed group.

CONCLUSIONS

In newly diagnosed Crohn's disease, high levels of IL-15 and IL-23 in healthy mucosa suggest that innate immunity is the starter of acute inflammation. Moreover, M2 macrophages increase in the healthy mucosa of patients with late-stage Crohn's disease, suggesting that reparative and profibrotic processes are predominant in the long term, and in this phase, anti-inflammatory therapy may be less efficient. See Video Abstract .

ACTIVACIN DE LA INMUNIDAD INNATA EN LA RECIENTEMENTE DIAGNOSTICADA ENFERMEDAD DE CROHN ILEOCLICA UN ESTUDIO DE COHORTE

ANTECEDENTES:Estudios recientes demostraron que la cirugía temprana para la enfermedad de Crohn (EC) conduce a una menor tasa de recurrencia. Sin embargo, se desconoce el mecanismo subyacente.OBJETIVO:El estudio tiene como objetivo analizar el microambiente de la inmunidad innata en la mucosa ileal según la duración de la EC.DISEÑO:Un estudio de cohorte prospectivo.AJUSTES:Centro terciario de referencia para cirugía de EII.PACIENTES:Fueron registrados de manera prospectiva y consecutiva 88 pacientes con EC sometidos a resección ileocolónica. Se obtuvieron muestras de mucosa ileal, tanto del íleon sano como del íleon inflamado. Los datos se analizaron como una cohorte de validación externa.PRINCIPALES MEDIDAS DE RESULTADO:Fueron evaluados la infiltración de neutrófilos por histología y la subpoblación de macrófagos por inmunohistoquímica. La expresión de TLR2, TLR4, TLR5, DEFB1, DEFB4A, DEFB103, DEFA5 y DEFA6 fueron cuantificados mediante qPCR en tiempo real. Las concentraciones de BDNF, CCL-11, ICAM-1, IL-1A, IL-1B, IL-1RN, IL-12 p40, IL-12 p70, IL-15, IL-17A, IL-23A, MMP-3, CCL-3, KITLG, VEGFA se determinaron con ensayo inmunométrico.RESULTADOS:La infiltración de neutrófilos se correlaciona inversamente con la duración de la enfermedad. La expresión del ARNm de DEFB4A mostro una tendencia a ser mayor en la EC en etapa tardía ( p = 0,07). Un mayor número de macrófagos expresaron CD163 a baja intensidad en la etapa tardía ( p = 0,04). La concentración de IL15 ( p = 0,02) e IL23A ( p = 0,05) fue mayor en la mucosa ileal sana de pacientes en estadio temprano. En la cohorte externa, la expresión de DEFB1 ( p = 0,03) y DEFB4A ( p = 0,01), IL2 ( p = 0,04) e IL3 ( p = 0,03) aumentó en pacientes en etapa tardía.LIMITACIONES:Un número relativamente pequeño de pacientes, especialmente en el grupo recién diagnosticado.CONCLUSIONES:En la EC recién diagnosticada, los altos niveles de IL-15 e IL-23 en la mucosa sana sugieren que la inmunidad innata es el promotor de la inflamación aguda. Además, los macrófagos M2 aumentan en la mucosa sana de pacientes con EC en etapa tardía, lo que sugiere que los procesos reparadores y profibróticos son predominantes a largo plazo y en esta fase, la terapia antiinflamatoria puede ser menos eficiente. (Traducción-Dr. Osvaldo Gauto ).

The Reduction of Anastomosis-Related Morbidity Using the Kono-S Anastomosis in Patients with Crohn's Disease: A Meta-Analysis

(1) Background: we conducted this study to evaluate the effect of Kono-S anastomosis on postoperative morbidity after bowel resection for Crohn's disease. (2) Methods: This study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint was the overall complications rate. Secondary outcomes included specific complications analyses, disease recurrence and efficiency endpoints. A systematic literature screening was performed in major electronic scholar databases (Medline, Scopus, Web of Science), from inception to 17 January 2024. Both Random (RE) and Fixed Effects (FE) models were estimated; the reported analysis was based on the Cochran Q test results. (3) Results: Overall, eight studies and 913 patients were included in this meta-analysis. Pooled analyses confirmed that Kono-S was not superior in terms of overall morbidity (OR: 0.69 [0.42, 1.15], p = 0.16). Kono-S displayed a reduced risk for anastomotic leakage (OR: 0.34 [0.16, 0.71], p = 0.004) and reoperation (OR: 0.12 [0.05, 0.27], p < 0.001), and a shortened length of hospital stay (WMD: -0.54 [-0.73, -0.34], p < 0.001). On the contrary, Kono-S results in higher rates of postoperative SSIs (OR: 1.85 [1.02, 3.35], p = 0.04). (4) Conclusions: This study confirms a comparable morbidity, but a lower risk of anastomotic leak and reoperation of Kono-S over conventional anastomoses. Further high quality studies are required to validate these findings.

Risk Factors for Complications and Disease Recurrence after Ileocecal Resection for Crohn's Disease in Children and Adults

This study reports the complication and disease recurrence rates for ileocecal resection for pediatric and adult Crohn's disease (CD) and identifies perioperative risk factors for these adverse outcomes in the two groups. Patients who underwent ileocecal resection for CD in a tertiary hospital in Italy (2010-2021) were included. Risk factors for postoperative complications and clinical and surgical disease recurrences were investigated with multivariate models. A total of 96 patients were included (children, 25%). There were no intraoperative complications. Thirty-one (32.3%) patients experienced 35 (36.5%) postoperative complications, and five (5.2%) were severe (Clavien-Dindo III-IV-V), with no intergroup difference for either overall postoperative complication rate (p = 0.257) or severe postoperative complication rate (p = 0.097). Most of these (77.1%) occurred within 30 days after surgery, especially in adults (p = 0.013). The multivariate analysis did not show risk factors for postoperative complications. Clinical and surgical recurrence rates after 5 years were 46.8% and 14.6%, respectively, with no intergroup rate differences. Clinical disease recurrence was positively correlated with previous abdominal surgery (p = 0.047) and negatively correlated with preoperative Hb levels (p = 0.046). A positive correlation was found between perianal disease and both clinical (p = 0.045) and surgical disease recurrences (p = 0.045). Urgent surgery was positively associated with surgical disease recurrence (p = 0.045). Notably, no children underwent urgent surgery in this study. In conclusion, the risk of postoperative complications among CD patients receiving ileocecal resection remains high, but most of them are nonserious. Some factors, such as urgent surgery, may increase the risk of disease recurrences.