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Mañosa M, Rivière P, de Greef I, Oller B, Roig C, Calafat M, Garcia-Planella E, Laharie D, Ferrante M, Domènech E. Long-term risk of delayed postoperative Crohn's disease recurrence in patients with no or mild endoscopic recurrence at first assessment. Eur J Clin Invest 2024:e14219. [PMID: 38647188 DOI: 10.1111/eci.14219] [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: 02/20/2024] [Revised: 03/25/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Early endoscopic evaluation is recommended for assessment of postoperative recurrence (POR) of Crohn's disease (CD) but no further monitoring recommendations are available. AIM To evaluate the long-term outcome of patients without endoscopic POR at first endoscopic assessment. METHODS Retrospective four-centre study including consecutive CD patients with ileocolonic resection (ICR) without endoscopic POR (Rutgeerts score i0-i1) at first endoscopic assessment performed within 18 months from ICR. All patients had a clinical follow-up ≥24 months and at least one further endoscopic assessment. Main outcomes were endoscopic, clinical and surgical POR, need for rescue therapy and "delayed POR" (any need for rescue therapy or clinical or surgical POR) during follow-up. RESULTS Overall, 183 patients were included (79% with risk factors for POR, 44% without postoperative prophylaxis). Endoscopic POR was observed in 42% of patients. Clinical POR-free survival was 89.4% and 81.5% at 3 and 5 years, and delayed POR-free survival was 76.9% and 63.4% at 5 and 10 years, respectively. In multivariate analysis, postoperative prophylaxis (HR .55; 95% CI .325-.942) and active smoking (HR 1.72; 95%CI 1.003-2.962) were independent risk factors for clinical POR, whereas presence of mild endoscopic lesions at index ileocolonoscopy (i1) was the only risk factor for delayed POR (HR 1.824; 95% CI 1.108-3.002). CONCLUSIONS Long-term risk of POR among patients with no or mild endoscopic lesions at first ileocolonoscopy after surgery is steadily low, being higher among smokers, in the absence of postoperative prophylaxis and when mild endoscopic lesions are observed in the first endoscopic assessment.
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Affiliation(s)
- Míriam Mañosa
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Pauline Rivière
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, CHU de Bordeaux, Bordeaux, France
- INSERM CIC 1401, Bordeaux, France
| | - Ine de Greef
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Blanca Oller
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Cristina Roig
- Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Margalida Calafat
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - David Laharie
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, CHU de Bordeaux, Bordeaux, France
- INSERM CIC 1401, Bordeaux, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Eugeni Domènech
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
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Fasulo E, D’Amico F, Osorio L, Allocca M, Fiorino G, Zilli A, Parigi TL, Danese S, Furfaro F. The Management of Postoperative Recurrence in Crohn's Disease. J Clin Med 2023; 13:119. [PMID: 38202126 PMCID: PMC10779955 DOI: 10.3390/jcm13010119] [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: 11/13/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease with different phenotypes of presentation, inflammatory, penetrating, or stricturing disease, that significantly impacts patient well-being and quality of life. Despite advances in medical therapy, surgery sometimes represents the only treatment to address complications, such as strictures, fistulas, or abscesses. Minimizing postoperative recurrence (POR) remains a major challenge for both clinicians and patients; consequently, various therapeutic strategies have been developed to prevent or delay POR. The current review outlines an updated overview of POR management. We focused on diagnostic assessment, which included endoscopic examination, biochemical analyses, and cross-sectional imaging techniques, all crucial tools used to accurately diagnose this condition. Additionally, we delved into the associated risk factors contributing to POR development. Furthermore, we examined recent advances in the prophylaxis and treatment of POR in CD.
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Affiliation(s)
- Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Ferdinando D’Amico
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20089 Milan, Italy
| | - Laura Osorio
- Gastroenterologist Hospital Pablo Tobon Uribe, Medellín 050010, Colombia;
| | - Mariangela Allocca
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Gionata Fiorino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Alessandra Zilli
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Tommaso Lorenzo Parigi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Federica Furfaro
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
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Ferrante M, Pouillon L, Mañosa M, Savarino E, Allez M, Kapizioni C, Arebi N, Carvello M, Myrelid P, De Vries AC, Rivière P, Panis Y, Domènech E. Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis 2023; 17:1707-1722. [PMID: 37070324 DOI: 10.1093/ecco-jcc/jjad053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Despite the introduction of biological therapies, an ileocolonic resection is often required in patients with Crohn's disease [CD]. Unfortunately, surgery is not curative, as many patients will develop postoperative recurrence [POR], eventually leading to further bowel damage and a decreased quality of life. The 8th Scientific Workshop of ECCO reviewed the available scientific data on both prevention and treatment of POR in patients with CD undergoing an ileocolonic resection, dealing with conventional and biological therapies, as well as non-medical interventions, including endoscopic and surgical approaches in case of POR. Based on the available data, an algorithm for the postoperative management in daily clinical practice was developed.
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Affiliation(s)
- Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Lieven Pouillon
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Míriam Mañosa
- Department of Gastroenterology and Hepatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Matthieu Allez
- Gastroenterology Department, Hôpital Saint-Louis - APHP, Université Paris Cité, INSERM U1160, Paris, France
| | - Christina Kapizioni
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Naila Arebi
- Department of Inflammatory Bowel Disease, St Mark's Hospital, Harrow, London, UK
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Annemarie C De Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise-Paré Hartmann, Neuily/Seine, France
| | - Eugeni Domènech
- Department of Gastroenterology and Hepatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Arkenbosch JHC, Beelen EMJ, Dijkstra G, Romberg-Camps M, Duijvestein M, Hoentjen F, van der Marel S, Maljaars PWJ, Jansen S, de Boer NKH, West RL, Horjus CS, Stassen LPS, van Schaik FDM, van Ruler O, Jharap BJH, Visschedijk M, Janssen A, Erler NS, Doukas M, Ooms AHAG, Kats-Ugurlu G, van der Woude CJ, de Vries AC. Prophylactic Medication for the Prevention of Endoscopic Recurrence in Crohn's Disease: a Prospective Study Based on Clinical Risk Stratification. J Crohns Colitis 2023; 17:221-230. [PMID: 36094558 PMCID: PMC10024543 DOI: 10.1093/ecco-jcc/jjac128] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND To prevent recurrence after ileocolonic resection [ICR] in Crohn's disease [CD], postoperative prophylaxis based on risk stratification is recommended in international guidelines. This study aimed to evaluate postoperative CD recurrence after implementation of a clinical management algorithm and to determine the predictive value of clinical and histological risk factors [RFs]. METHODS In this multicentre, prospective cohort study, CD patients [≥16 years] scheduled for ICR were included. The algorithm advised no postoperative medication for low-risk patients, and treatment with prophylaxis [immunosuppressant/biological] for high-risk patients [≥1 RF: active smoking, penetrating disease, prior ICR]. Clinical and histological RFs [active inflammation, granulomas, plexitis in resection margins] for endoscopic recurrence [Rutgeerts' score ≥i2b at 6 months] were assessed using logistic regression and ROC curves based on predicted probabilities. RESULTS In total, 213 CD patients after ICR were included [age 34.5 years; 65% women] (93 [44%] low-risk; 120 [56%] high-risk: 45 [38%] smoking; 51 [43%] penetrating disease; 51 [43%] prior ICR). Adherence to the algorithm was 82% in low-risk [no prophylaxis] and 51% in high-risk patients [prophylaxis]. Endoscopic recurrence was higher in patients treated without prophylaxis than with prophylaxis in both low [45% vs 16%, p = 0.012] and high-risk patients [49% vs 26%, p = 0.019]. Clinical risk stratification including the prescription of prophylaxis corresponded to an area under the curve [AUC] of 0.70 (95% confidence interval [CI] 0.61-0.79). Clinical RFs combined with histological RFs increased the AUC to 0.73 [95% CI 0.64-0.81]. CONCLUSION Adherence to this management algorithm is 65%. Prophylactic medication after ICR prevents endoscopic recurrence in low- and high-risk patients. Clinical risk stratification has an acceptable predictive value, but further refinement is needed.
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Affiliation(s)
- Jeanine H C Arkenbosch
- Corresponding author: A. C. De Vries, MD, PhD, Department of Gastroenterology and Hepatology Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, the Netherlands. Tel: 0031 107 030 792;
| | | | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology and Hepatology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, AGEM Research Institute, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sander van der Marel
- Department of Gastroenterology and Hepatology, Haaglanden Medical Center, The Hague, the Netherlands
| | - P W Jeroen Maljaars
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sita Jansen
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, the Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, the Netherlands
| | - Rachel L West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Carmen S Horjus
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Fiona D M van Schaik
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Bindia J H Jharap
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Marijn Visschedijk
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
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5
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Joustra V, van Sabben J, van der Does de Willebois E, Duijvestein M, de Boer N, Jansen J, van der Bilt J, Lameris W, Bemelman W, Buskens C, D'Haens G. Benefit of risk-stratified prophylactic treatment on clinical outcome in post-operative Crohn's disease. J Crohns Colitis 2022; 17:318-328. [PMID: 36124739 PMCID: PMC10069621 DOI: 10.1093/ecco-jcc/jjac139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS While immediate post-operative treatment has shown effectiveness in reducing endoscopic post-operative recurrence (POR), evidence regarding the clinical benefit is limited. We compared rates of clinical POR in Crohn's disease (CD) patients receiving immediate prophylactic treatment with patients receiving endoscopy-driven treatment. METHODS We retrospectively collected data from 376 consecutive CD patients that underwent an ileocecal resection with anastomosis between 2007 and 2018 with at least 3 years of follow-up at 3 sites. Subsequently, high- and low-risk patients categorized by established guidelines who underwent endoscopy within 12 months postoperatively were grouped according to a prophylactic- or endoscopy-driven approach and compared for incidence and time till endoscopic- and clinical POR. RESULTS Prophylactic treatment reduced rates of- and time till endoscopic POR within 1 year in high-risk (HR 0.48, 95% CI 0.27-0.86, p=0.04, NNT=5) but not low-risk (HR 0.90, 95%CI 0.32-2.56, p=0.85) patients. Conversely, no significant differences in clinical POR within 3 years between prophylactic- and endoscopy-driven low-risk (HR 1.17, 95%CI 0.41-3.29, p=0.75) and high-risk patients were observed (HR 1.06, 95%CI 0.63-1.79, p=0.82, NNT=22). However, a large numerical albeit not statistical significant difference in 3 year clinical POR (28.6% vs. 62.5%, p=0.11) in a subset of high-risk patients with ≥3 or more ECCO-defined risk factors was observed, indicating a cumulative effect of having multiple risk factors. CONCLUSION Our observations favor step-up treatment guided by early endoscopic evaluation with prophylactic treatment reserved for carefully selected high-risk patients in order to avoid potential overtreatment of a significant number of patients.
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Affiliation(s)
- Vincent Joustra
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Joris van Sabben
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nanne de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Jarmila van der Bilt
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Wytze Lameris
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Willem Bemelman
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Christianne Buskens
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
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Schaefer M, Laurent V, Grandmougin A, Vuitton L, Bourreille A, Luc A, Clerc-Urmes I, Orry X, Frampas E, De Billy M, Pouillon L, Le Berre C, Gay C, Meyer J, Baumann C, Peyrin-Biroulet L. A Magnetic Resonance Imaging Index to Predict Crohn's Disease Postoperative Recurrence: The MONITOR Index. Clin Gastroenterol Hepatol 2022; 20:e1040-e1049. [PMID: 34216820 DOI: 10.1016/j.cgh.2021.06.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/01/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS We developed and validated a magnetic resonance imaging-based index to predict Crohn's disease (CD) postoperative recurrence (POR). METHODS Patients with CD who underwent a postoperative evaluation for recurrence (with colonoscopy and MRI no longer than 105 days apart) were included between 2006 and 2016 in University Hospital of Nancy, France. MRI items with good levels of intra-rater and inter-rater agreement (Gwet's coefficient ≥0.5) were selected. The MRI in Crohn's Disease to Predict Postoperative Recurrence (MONITOR) index's performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and accuracy, by considering the Rutgeerts score as the gold standard. The MONITOR index was validated with a bootstrap method and an independent cohort. RESULTS Seventy-three MRI datasets were interpreted by 2 radiologists. Seven items (bowel wall thickness, contrast enhancement, T2 signal increase, diffusion-weighted signal increase, edema, ulcers, and the length of the diseased segment) had a Gwet's coefficient ≥0.5 and were significantly associated with the Rutgeerts score, leading to their inclusion in the MONITOR index. All the items had a weighting of 1, except the "ulcers" item weighting 2.5, reflecting the higher adjusted odds ratio. The AUROC [95% confidence interval] for the prediction of endoscopic POR (Rutgeerts score >i1) was 0.80 [0.70-0.90]. The optimal threshold was a MONITOR index ≥1, giving a sensitivity of 79%, a specificity of 55%, a predictive positive value of 68%, and a predictive negative value of 68%. The bootstrap validation gave an AUROC of 0.85 [0.73-0.97]. In the validation cohort, a MONITOR index ≥1 gave a sensitivity of 87%, a specificity of 75%, a predictive positive value of 84.6%, and a predictive negative value of 75%. CONCLUSIONS The MONITOR index is an efficient, reliable, easy-to-apply tool that can be used in clinical practice to predict the POR of CD.
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Affiliation(s)
- Marion Schaefer
- Department of Hepatogastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Valérie Laurent
- Central Department of Radiology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Aurélie Grandmougin
- Central Department of Radiology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Lucine Vuitton
- Department of Gastroenterology, Besançon University Hospital, Besancon
| | | | - Amandine Luc
- Unit of Methodology, Data Management and Statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Isabelle Clerc-Urmes
- Unit of Methodology, Data Management and Statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Xavier Orry
- Central Department of Radiology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Eric Frampas
- Department of Radiology, Nantes University Hospital, Nantes
| | | | - Lieven Pouillon
- Department of Hepatogastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | | | - Claire Gay
- Department of Gastroenterology, Besançon University Hospital, Besancon
| | - Jeremy Meyer
- Department of Radiology, Nantes University Hospital, Nantes
| | - Cédric Baumann
- Unit of Methodology, Data Management and Statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy
| | - Laurent Peyrin-Biroulet
- Department of Hepatogastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy; INSERM U1256, Nutrition-Génétique et Exposition aux Risques Environnementaux, Faculté de Médecine, Université de Lorraine, Vandoeuvre-les-Nancy, France.
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7
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Guo Z, Zhu Y, Xu Y, Cao L, Li Y, Gong J, Wang Z, Zhu W. Endoscopic Evaluation at 1 Month After Ileocolic Resection for Crohn's Disease Predicts Future Postoperative Recurrence and Is Safe. Dis Colon Rectum 2022; 65:382-389. [PMID: 34759245 DOI: 10.1097/dcr.0000000000002012] [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: 02/08/2023]
Abstract
BACKGROUND Endoscopy remains the gold standard for evaluating postoperative recurrence in Crohn's disease. Timely therapy adjustment according to endoscopic findings can improve long-term outcomes. OBJECTIVE We aimed to determine the characteristics, clinical values, and safety of the endoscopic evaluation at 1 month after surgery. DESIGN This was a prospective observational study. SETTINGS This study was conducted in a tertiary referral hospital. PATIENTS Patients with Crohn's disease undergoing ileocolic resection between January 2016 and November 2018 were included. INTERVENTIONS The first postoperative ileocolonoscopy was performed at 4-5 weeks after surgery. MAIN OUTCOME MEASURES The primary outcome was postoperative recurrence within 12 months after surgery. Univariate and multivariate analyses were performed to identify risk factors. RESULTS Among 84 ileocolonoscopies at 4-5 weeks, no endoscopic complication occurred. The main endoscopic findings at the first evaluation were anastomotic circumferential ulcers (10, 11.9%), anastomotic scattered ulcers (35, 41.7%), ulcers in the neoterminal ileum (16, 19.0%), edema in anastomosis (50, 59.5%), mild narrowing in anastomosis (7, 8.3%), and mild narrowing in neoterminal ileum (3, 3.6%). Anastomotic scattered ulcers were associated with future postoperative recurrence (OR, 2.532 (95% CI, 1.02-6.32), p = 0.046). Fecal calprotectin >150 ug/g on postoperative day 14 could predict anastomotic scattered ulcers (OR' 2.91 (95% CI, 1.31-7.47), p = 0.027). The modified Rutgeerts score was used to define endoscopic findings: i0, 37 (44.0%); i1, 4 (4.8%); i2a, 29 (34.5%); i2b, 11 (13.1%); i3, 0; i4, 3 (3.6%). Score ≥i2a were associated with future postoperative recurrence (OR, 3.17 (95% CI, 1.22-8.27), p = 0.018). No factor was associated with a Rutgeerts score of ≥i2a at the first endoscopic evaluation. LIMITATIONS This was a single-center study with a small cohort of patients. CONCLUSIONS Endoscopic evaluation at 1 month after surgery in CD was safe. Anastomotic scattered ulcers occurred in nearly half of patients and were associated with future postoperative recurrence. See Video Abstract at http://links.lww.com/DCR/B760.LA EVALUACIÓN ENDOSCÓPICA A UN MES DESPUÉS DE LA RESECCIÓN ILEOCÓLICA PARA LA ENFERMEDAD DE CROHN, PREDICE FUTURA RECURRENCIA POSOPERATORIA Y ES SEGURAANTECEDENTES:La endoscopia sigue siendo el estándar de oro para evaluar la recurrencia posoperatoria en la enfermedad de Crohn (EC). El ajuste oportuno en la terapia de acuerdo con los hallazgos endoscópicos, puede mejorar los resultados a largo plazo.OBJETIVO:Determinar las características, valores clínicos y seguridad de la evaluación endoscópica, al mes de la cirugía.DISEÑO:Estudio observacional prospectivo.ENTORNO CLINICO:El estudio se llevó a cabo en un hospital de referencia terciario.PACIENTES:Se incluyeron pacientes con EC sometidos a resección ileocólica entre enero de 2016 y noviembre de 2018.INTERVENCIONES:La primera ileocolonoscopia posoperatoria se realizó a las 4-5 semanas posteriores a la cirugía.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia posoperatoria dentro de los 12 meses posteriores a la cirugía. Se realizaron análisis univariados y multivariados para identificar factores de riesgo.RESULTADOS:Entre 84 ileocolonoscopias a las 4-5 semanas, no ocurrió ninguna complicación endoscópica. Los principales hallazgos endoscópicos en la primera evaluación, fueron úlceras anastomóticas circunferenciales (10, 11,9%), úlceras anastomóticas dispersas (35, 41,7%), úlceras en el íleon neo-terminal (16, 19,0%), edema en la anastomosis (50, 59,5%), estrechamiento leve en la anastomosis (7, 8,3%) y estrechamiento leve en el íleon neo-terminal (3, 3,6%). Las úlceras anastomóticas dispersas se asociaron con recurrencia posoperatoria futura (OR, 2,532 (95% CI, 1,02-6,32), p = 0,046). La calprotectina fecal en el post d 14 > 150 ug / g podría predecir úlceras anastomóticas dispersas (OR' 2,91 (95% CI, 1,31-7,47), p = 0,027). Se utilizó la puntuación de Rutgeerts modificada para definir los hallazgos endoscópicos: i0, 37 (44,0%); i1, 4 (4,8%); i2a, 29 (34,5%); i2b, 11 (13,1%); i3, 0; i4, 3 (3,6%). La puntuación ≥i2a se asoció con recurrencia posoperatoria futura (OR, 3,17 (95% CI, 1,22-8,27), p = 0,018). Ningún factor se asoció con ≥i2a en la primera endoscopia.LIMITACIONES:Estudio de un solo centro con una pequeña cohorte de pacientes.CONCLUSIONES:La evaluación endoscópica al mes de la cirugía en EC, fue segura. Se produjeron úlceras anastomóticas dispersas en casi la mitad de los pacientes y se asociaron con una futura recurrencia posoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B760. (Traducción - Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Yipeng Zhu
- Nanjing Medical University, Nanjing, P.R. China
| | - Yihan Xu
- Nanjing Medical University, Nanjing, P.R. China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Zhiming Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
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8
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Ble A, Renzulli C, Cenci F, Grimaldi M, Barone M, Sedano R, Chang J, Nguyen TM, Hogan M, Zou G, MacDonald JK, Ma C, Sandborn WJ, Feagan BG, Merlo Pich E, Jairath V. The Relationship Between Endoscopic and Clinical Recurrence in Postoperative Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2021; 16:490-499. [PMID: 34508572 PMCID: PMC8919832 DOI: 10.1093/ecco-jcc/jjab163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND AIMS We aimed to quantify the magnitude of the association between endoscopic recurrence and clinical recurrence [symptom relapse] in patients with postoperative Crohn's disease. METHODS Databases were searched to October 2, 2020, for randomised controlled trials [RCTs] and cohort studies of adult patients with Crohn's disease with ileocolonic resection and anastomosis. Summary effect estimates for the association between clinical recurrence and endoscopic recurrence were quantified by risk ratios [RR] and 95% confidence intervals [95% CI]. Mixed-effects meta-regression evaluated the role of confounders. Spearman correlation coefficients were calculated to assess the relationship between these outcomes as endpoints in RCTs. An exploratory mixed-effects meta-regression model with the logit of the rate of clinical recurrence as the outcome and the rate of endoscopic recurrence as a predictor was also evaluated. RESULTS In all, 37 studies [N = 4053] were included. For eight RCTs with available data, the RR for clinical recurrence for patients who experienced endoscopic recurrence was 10.77 [95% CI 4.08 to 28.40; GRADE moderate certainty evidence]; the corresponding estimate from 11 cohort studies was 21.33 [95% CI 9.55 to 47.66; GRADE low certainty evidence]. A single cohort study showed a linear relationship between Rutgeerts score and clinical recurrence risk. There was a strong correlation between endoscopic recurrence and clinical recurrence treatment effect estimates as trial outcomes [weighted Spearman correlation coefficient 0.51]. CONCLUSIONS The associations between endoscopic recurrence and subsequent clinical recurrence lend support to the choice of endoscopic recurrence to monitor postoperative disease activity and as a primary endpoint in clinical trials of postoperative Crohn's disease.
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Affiliation(s)
| | | | - Fabio Cenci
- Corporate R&D, Alfasigma S.p.A., Bologna, Italy
| | | | | | - Rocio Sedano
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - Joshua Chang
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Tran M Nguyen
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Malcolm Hogan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Guangyong Zou
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John K MacDonald
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - William J Sandborn
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G Feagan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Vipul Jairath
- Corresponding author: Vipul Jairath, MB, ChB, DPhil, Department of Medicine, Western University, 399 Windermere Road, London, ON, Canada N6A 5A5. Tel.: 519-685-8500, ext. 33655;
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9
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Yu J, Hyun HK, Park J, Kang EA, Park SJ, Park JJ, Kim TI, Kim WH, Cheon JH. Continued Postoperative Use of Tumor Necrosis Factor-α Inhibitors for the Prevention of Crohn's Disease Recurrence. Gut Liver 2021; 16:414-422. [PMID: 34420935 PMCID: PMC9099390 DOI: 10.5009/gnl210062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background/Aims Many patients with Crohn’s disease (CD) undergo intestinal resection during the disease course. Despite surgery, postoperative recurrence (POR) commonly occurs. Although postoperative use of tumor necrosis factor α (TNF-α) inhibitors is known to be effective in preventing POR, few studies have evaluated the effectiveness of continuing the same TNF-α inhibitors postoperatively in patients who received TNF-ɑ inhibitors before surgery. Methods This retrospective observational study was performed in a single tertiary medical center. We retrospectively reviewed patients who had undergone the first intestinal resection due to CD and divided them into two groups TNF-α inhibitor users in both the preoperative and postoperative periods, and TNF-α inhibitor users in only the preoperative period. We compared the clinical outcomes between these two groups. Results In total, 45 patients who used TNF-α inhibitors preoperatively were recruited. Among them, TNF-α inhibitors were used postoperatively in 20 patients (44.4%). The baseline characteristics except age at diagnosis were similar in both groups. The rates of surgical and endoscopic recurrence were not different between the two groups, but the cumulative clinical recurrence rate was significantly lower in the postoperative TNF-α inhibitors group (log-rank p=0.003). In multivariate Cox regression analysis, postoperative TNF-α inhibitors use was significantly associated with a decreased risk of clinical recurrence (adjusted hazard ratio, 0.204; 95% confidence interval, 0.060 to 0.691; p=0.011). Conclusions Continuing TNF-α inhibitors postoperatively in patients who were receiving TNF-α inhibitors before surgery significantly reduced the rate of clinical recurrence. For patients with CD who received TNF-α inhibitors preoperatively, continuing their use after surgery could be recommended.
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Affiliation(s)
- Jongwook Yu
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Kyung Hyun
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jihye Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Ae Kang
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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10
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Antitumor Necrosis Factor Agents to Treat Endoscopic Postoperative Recurrence of Crohn's Disease: A Nationwide Study With Propensity-Matched Score Analysis. Clin Transl Gastroenterol 2021; 11:e00218. [PMID: 32955190 PMCID: PMC7431219 DOI: 10.14309/ctg.0000000000000218] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Patients with Crohn's disease experiencing endoscopic postoperative recurrence (POR) may benefit from antitumor necrosis factor (TNF) agents but scarce data on this are available. Our aim was to assess the efficacy of anti-TNF in improving mucosal lesions in patients with endoscopic POR.
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11
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Rates of Postoperative Recurrence of Crohn's Disease and Effects of Immunosuppressive and Biologic Therapies. Clin Gastroenterol Hepatol 2021; 19:713-720.e1. [PMID: 32272248 DOI: 10.1016/j.cgh.2020.03.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 03/02/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The Rutgeerts' scoring system is used to evaluate patients with Crohn's disease (CD) following ileocolic resection, based on endoscopic findings at the anastomosis and in the neoterminal ileum. We investigated rates of clinical and surgical recurrence of CD after surgery and effect of therapy modification based on post-operative endoscopic findings. METHODS We collected data from 365 adults with CD (20% with Rutgeerts' score i0, 10% with score i1, 49% with score i2, 12% with score i3, 9% with score i4) who underwent ileocolonoscopy within 12 months of ileocolic resection with anastomosis from 2000 through 2013 at 2 centers in Belgium and France. Patients were followed for 3 y or more after the ileocolonoscopy. Clinical post-operative recurrence (POR) was defined as occurrence of CD symptoms along with biologic, radiologic, and/or endoscopic features of disease activity; modified surgical POR was defined as either an endoscopic or surgical intervention. RESULTS After a median follow-up time of 88 months, 48% of patients had clinical POR and 26% had modified surgical POR. Rates of survival without clinical POR or a modified surgical POR were lower in patients with Rutgeerts' scores of i2, i3, or i4 compared to patients with scores of i0 or i1 (P < .001 and P = .02). New immunosuppressant or biological therapy was initiated following endoscopy in 129/254 patients (51%) with Rutgeerts' score of i2, i3, or i4 vs 7/111 patients (6%) with scores of i0 or i1 (odds ratio for new therapy, 14.9; 95% CI, 7.1-36.8; P < .001). A modest decrease in risk of clinical POR was observed for patients with Rutgeerts scores of i3 or i4 after initiation of immunosuppressive or biological therapy based on endoscopic findings (Breslow P = .03), but this was not observed for patients with scores of i2 (Breslow P = .46). CONCLUSIONS Use of immunosuppressants and tumor necrosis factor antagonists to treat patients with an asymptomatic endoscopic post-operative recurrence of CD did not reduce long-term risk of clinical recurrence in patients with Rutgeerts' scores of i2, but it had a small effect in patients with scores of i3 or i4.
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12
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Ileocolonic End-to-End Anastomoses in Crohn's Disease Increase the Risk of Early Post-operative Endoscopic Recurrence in Those Undergoing an Emergency Resection. J Gastrointest Surg 2021; 25:241-251. [PMID: 32378095 DOI: 10.1007/s11605-020-04578-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Several risk factors affecting post-operative recurrence in Crohn's disease patients have been studied, and of these, the role of the anastomosis remains contentious. We aimed to compare the risk of developing early post-operative endoscopic recurrence (EPER), in resections that had an end-to-end anastomosis (ETEA) to a side-to-side anastomosis (STSA). METHODS All Crohn's disease patients that underwent an ileocolic or small bowel resection between January 2012 and June 2017 at two tertiary IBD centres were reviewed retrospectively. Included patients had a minimum of 12-month clinical follow-up and a colonoscopy within 12 months of the resection or stoma reversal. Univariate and multivariate binary logistic regression analyses determined the independent risk factors for early post-operative endoscopic recurrence, defined as a Rutgeerts score of ≥ i2b. RESULTS Ninety-two resections associated with an ETEA or a STSA were included for analysis. The ETEA was the most common anastomosis, constructed in 55 patients (59.8%). Forty-nine operations (53.3%) resulted in a ≥ i2b recurrence at the first surveillance colonoscopy. The multivariate analysis showed that there was no difference between the ETEA and STSA in determining the odds ratio (OR) for developing EPER (OR = 2.41 (0.95-6.05), P = 0.06). In those that underwent a resection emergently however, the significant determinants of EPER were as follows: having an ETEA (OR = 38.12 (2.44-595.87), P = 0.01), failing to commence a biologic and/or an immunosuppressant early (OR = 24.21 (1.69, 347.81), P = 0.02), and active smoking (OR = 7.19 (1.12-46.21), P = 0.04). CONCLUSION The ETEA is best avoided in those undergoing an emergency resection. The early commencement of a biologic and/or an immunosuppressant and smoking cessation is imperative this high-risk group of patients.
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13
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Candia R, Bravo-Soto GA, Monrroy H, Hernandez C, Nguyen GC. Colonoscopy-guided therapy for the prevention of post-operative recurrence of Crohn's disease. Cochrane Database Syst Rev 2020; 8:CD012328. [PMID: 32746500 PMCID: PMC8094885 DOI: 10.1002/14651858.cd012328.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND About half of patients with Crohn's disease (CD) require surgery within 10 years of diagnosis. Resection of the affected segment is highly effective, however the majority of patients experience clinical recurrence after surgery. Most of these patients have asymptomatic endoscopic recurrence weeks or months before starting with symptoms. This inflammation can be detected by colonoscopy and is a good predictor of poor prognosis.Therapy guided by colonoscopy could tailor the management and improve the prognosis of postoperative CD. OBJECTIVES To assess the effects of prophylactic therapy guided by colonoscopy in reducing the postoperative recurrence of CD in adults. SEARCH METHODS The following electronic databases were searched up to 17 December 2019: MEDLINE, Embase, CENTRAL, Clinical Trials.gov, WHO Trial Registry and Cochrane IBD specialized register. Reference lists of included articles, as well as conference proceedings were handsearched. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs and cohort studies comparing colonoscopy-guided management versus management non-guided by colonoscopy. DATA COLLECTION AND ANALYSIS Two review authors independently considered studies for eligibility, extracted the data and assessed study quality. Methodological quality was assessed using both the Cochrane 'Risk of bias' tool for RCTs and Newcastle-Ottawa scale (NOS) for cohort studies. The primary outcome was clinical recurrence. Secondary outcomes included: endoscopic, surgical recurrence and adverse events. We calculated the risk ratio (RR) for each dichotomous outcome and extracted the hazard ratio (HR) for time-to-event outcomes. All estimates were reported with their corresponding 95% confidence interval (CI). Data were analysed on an intention-to-treat (ITT) basis. The overall quality of the evidence was evaluated using GRADE criteria. MAIN RESULTS Two RCTs (237 participants) and five cohort studies (794 participants) met the inclusion criteria. Meta-analysis was not conducted as the studies were highly heterogeneous. We included two comparisons. Intensification of prophylactic-therapy guided by colonoscopy versus intensification guided by clinical recurrence One unblinded RCT and four retrospective cohort studies addressed this comparison. All participants received the same prophylactic therapy immediately after surgery. In the colonoscopy-based management group the therapy was intensified in case of endoscopic recurrence; in the control group the therapy was intensified only in case of symptoms. In the RCT, clinical recurrence (defined as Crohn's Disease Activity Index (CDAI) > 150 points) in the colonoscopy-based management group was 37.7% (46/122) compared to 46.1% (21/52) in the control group at 18 months' follow up (RR 0.82, 95% CI: 0.56 to 1.18, 174 participants, low-certainty evidence). There may be a reduction in endoscopic recurrence at 18 months with colonoscopy-based management (RR 0.73, 95% CI 0.56 to 0.95, 1 RCT, 174 participants, low-certainty evidence). The certainty of the evidence for surgical recurrence was very low, due to only four cohort studies with inconsistent results reporting this outcome. Adverse events at 18 months were similar in both groups, with 82% in the intervention group (100/122) and 86.5% in the control group (45/52) (RR 0.95, 95% CI:0.83 to 1.08, 1 RCT, 174 participants, low-certainty of evidence).The most common adverse events reported were alopecia, wound infection, sensory symptoms, systemic lupus, vasculitis and severe injection site reaction. Perforations or haemorrhages secondary to colonoscopy were not reported. Initiation of prophylactic-therapy guided by colonoscopy versus initiation immediately after surgery An unblinded RCT and two retrospective cohort studies addressed this comparison. The control group received prophylactic therapy immediately after surgery, and in the colonoscopy-based management group the therapy was delayed up to detection of endoscopic recurrence. The effects on clinical and endoscopic recurrence are uncertain (clinical recurrence until week 102: RR 1.16, 95% CI 0.73 to 1.84; endoscopic recurrence at week 102: RR 1.16, 95% CI 0.73 to 1.84; 1 RCT, 63 participants, very low-certainty evidence). Results from one cohort study were similarly uncertain (median follow-up 32 months, 199 participants). The effects on surgical recurrence at a median follow-up of 50 to 55 months were also uncertain in one cohort study (RR 0.79, 95% CI 0.38 to 1.62, 133 participants, very low-certainty evidence). There were fewer adverse events with colonoscopy-based management (54.8% (17/31)) compared with the control group (93.8% (30/32)) but the evidence is very uncertain (RR 0.58, 95% CI 0.42 to 0.82; 1 RCT, 63 participants). Common adverse events were infections, gastrointestinal intolerance, leukopenia, pancreatitis and skin lesions. Perforations or haemorrhages secondary to colonoscopy were not reported. AUTHORS' CONCLUSIONS Intensification of prophylactic-therapy guided by colonoscopy may reduce clinical and endoscopic postoperative recurrence of CD compared to intensification guided by symptoms, and there may be little or no difference in adverse effects. We are uncertain whether initiation of therapy guided by colonoscopy impacts postoperative recurrence and adverse events when compared to initiation immediately after surgery, as the certainty of the evidence is very low. Further studies are necessary to improve the certainty of the evidence of this review.
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Affiliation(s)
- Roberto Candia
- Departamento de Gastroenterologia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Hugo Monrroy
- Departamento de Gastroenterologia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristian Hernandez
- Departamento de Gastroenterologia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Geoffrey C Nguyen
- Institute of Health Policy, Management and Evaluation, University of Toronto, and Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, Toronto, Canada
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14
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Optimal strategies to prevent recrudescent Crohn's disease after resection. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Frimor C, Kjeldsen J, Ainsworth M. Treatment to target in patients with inflammatory bowel disease. What is the evidence? Scand J Gastroenterol 2020; 55:528-536. [PMID: 32503364 DOI: 10.1080/00365521.2020.1764091] [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] [Indexed: 02/04/2023]
Abstract
Background: Inflammatory bowel diseases (IBD) are chronic, progressive diseases of the gastrointestinal tract. Current therapy has not been able to change the long-term course of the disease, but treatment to a specific therapeutic target could be a game-changer.Objectives: To assess the evidence of a treat to target (T2T) algorithm being superior to clinical management in the treatment of IBD, a systematic review of the literature is conducted.Search methods: A comprehensive survey of PubMed and Embase covering the period April 2018 to July 2019 including articles referenced in relevant studies.Selection criteria: Both randomized clinical trials (RCT) and observational studies were included. To be eligible for inclusion, the studies had to describe or analyze the effects of T2T on remission and/or recurrence of disease in patients with IBD.Main results: Twenty-two studies were included in this review, seven RCTs, eight comparative and seven non-comparative observational studies. Large heterogeneity between T2T algorithms applied, type of IBD investigated and outcomes evaluated characterized the studies.Authors' conclusions: The comprehensive search identified only 22 heterogeneous studies. Out of these, a total of 14 indicated a positive effect of a T2T algorithm. Out of the seven RCT studies, four indicated a positive effect. Thus, T2T algorithms may be superior to the clinical management of IBD. However, the evidence is sparse and inconsistent.
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Affiliation(s)
- Camilla Frimor
- Department of Medical Gastrointestinal Diseases, Odense University Hospital, Odense, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastrointestinal Diseases, Odense University Hospital, Odense, Denmark.,Medicinsk Gastroenterologi, Syddansk Universitet, Odense, Denmark
| | - Mark Ainsworth
- Department of Medical Gastrointestinal Diseases, Odense University Hospital, Odense, Denmark
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Bolckmans R, Singh S, Ratnatunga K, Wickramasinghe D, Sahnan K, Adegbola S, Kalman D, Jones H, Travis S, Warusavitarne J, Myrelid P, George B. Temporary faecal diversion in ileocolic resection for Crohn's disease: is there an impact on long-term surgical recurrence? Colorectal Dis 2020; 22:430-438. [PMID: 31715062 DOI: 10.1111/codi.14895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022]
Abstract
AIM Temporary faecal diversion after ileocolic resection (ICR) for Crohn's disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. METHOD This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence. RESULTS Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P < 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12). CONCLUSION Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.
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Affiliation(s)
- R Bolckmans
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Singh
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K Ratnatunga
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D Wickramasinghe
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - K Sahnan
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - S Adegbola
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - D Kalman
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - H Jones
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - J Warusavitarne
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - P Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - B George
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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18
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Gjuladin‐Hellon T, Iheozor‐Ejiofor Z, Gordon M, Akobeng AK. Azathioprine and 6-mercaptopurine for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev 2019; 8:CD010233. [PMID: 31425621 PMCID: PMC6699648 DOI: 10.1002/14651858.cd010233.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic relapsing inflammatory condition and maintenance of remission is a major issue as many patients fail to achieve remission with medical management and require surgical interventions. Purine analogues such as azathioprine (AZA) and 6-mercaptopurine (6-MP) have been used to maintain surgically-induced remission in CD, but the effectiveness, tolerability and safety of these agents remains controversial. OBJECTIVES To assess the efficacy and safety of purine analogues (AZA and 6-MP) for maintenance of surgically-induced remission in CD. SEARCH METHODS We searched PubMed, MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to 26 July 2018 (and from inception to 31 July 2019). In addition, we searched reference lists of all included studies and relevant reviews, conference proceedings and trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) with a duration of at least three months that enrolled adults and children with surgically-induced remission of CD and compared AZA or 6-MP to no treatment, placebo or any other active intervention were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility, extracted data, assessed the risk of bias and assessed the certainty of the evidence using GRADE. The primary outcome was clinical relapse. Secondary outcomes included endoscopic relapse, radiologic and surgical relapse, adverse events (AEs), serious adverse events (SAEs), withdrawal due to AEs and health-related quality of life. MAIN RESULTS Ten RCTs with a total of 928 participants were included. Study participants were adults recruited from university clinics and gastroenterology hospitals who received interventions post-surgery for a duration between 12 to 36 months. Most study participants were recruited less than three months after surgery in all except one study where participants were recruited between 6 to 24 months post-surgery. One study was rated as low risk of bias, six studies were rated high risk of bias and three were rated unclear risk of bias.There was moderate certainty evidence that purine analogues are more efficient for preventing clinical relapse than placebo. At 12 to 36 months, 51% (109/215) of AZA/6-MP participants relapsed compared to 64% (124/193) of placebo participants (RR 0.79; 95% CI 0.67 to 0.92; 408 participants; 3 studies; I² = 0%; moderate certainty evidence). The certainty of the evidence regarding the efficacy of AZA or 6-MP for maintaining postoperative clinical remission compared to 5-ASA compounds was low. At 12 to 24 months , 64% (113/177) of purine analogue participants relapsed compared to 59% (101/170) of 5-ASA participants (RR 1.05; 95% CI 0.89 to 1.24; 347 participants; 4 studies; I² = 8%; low certainty evidence). The certainty of evidence that purine analogues are inferior for preventing postsurgical clinical relapse compared to tumour necrosis factor alpha agents (anti-TNF-α) was very low. At 12 to 24 months, 43% (29/67) of AZA participants relapsed compared to 14% (10/72) of anti-TNF-α participants (RR 2.89; 95% CI 1.50 to 5.57; 139 participants; 3 studies; I² = 0%; very low certainty evidence).The effect of purine analogues compounds on AEs compared to placebo or any active treatment was uncertain, as the quality of evidence ranged from very low to low. After 12 to 24 months, 14% (12/87) of purine analogue participants experienced an AE compared to 10% (8/81) of placebo participants (RR 1.36; 95% CI 0.57 to 3.27; 168 participants; 2 studies; I² = 0%; low certainty evidence). The effect of purine analogues on AEs compared to 5-ASA agents was uncertain. After 12 to 24 months, 41% (73/176) of purine analogue participants had an AE compared to 47% (81/171) of 5-ASA participants (RR 0.89; 95% CI 0.74 to 1.07; 346 participants; 4 studies; I² = 15%; low certainty evidence). The effect of purine analogues on AEs in comparison to anti TNF-α agents was uncertain. At 12 to 24 months, 57% (32/56) of AZA participants had an AE compared to 51% (31/61) of anti-TNF-α participants (RR 1.13; 95% CI 0.83 to 1.53; 117 participants; 2 studies; I² = 0%; low certainty evidence). Purine analogue participants were more like than 5-ASA participants to have a SAE (RR 3.39, 95% CI 1.26 to 9.13, 311 participants; 3 studies; I² = 9%; very low certainty evidence), or to withdraw due to an AE (RR 2.21, 95% CI 1.28 to 3.81; 425 participants; 5 studies; I² = 0%; low certainty evidence). Commonly reported AEs across all studies included leucopenia, arthralgia, abdominal pain or severe epigastric intolerance, elevated liver enzymes, nausea and vomiting, pancreatitis, anaemia, nasopharyngitis and flatulence. AUTHORS' CONCLUSIONS Moderate certainty evidence suggests that AZA and 6-MP may be superior to placebo for maintenance of surgically-induced remission in participants with CD. There was no clear difference in the number of clinical relapses when purine analogues were compared with 5-ASA agents, however this is based on low certainty evidence. There was very low certainty evidence that AZA and 6-MP are more likely to result in more serious adverse events (SAEs) and withdrawals due to an AE (low certainty) when compared to 5-ASA agents. Very low certainty evidence suggests that purine analogues may be inferior to anti-TNF-α agents, however, no firm conclusions can be drawn. Further research investigating the efficacy and safety of AZA and 6-MP in comparison to other active medications in surgically-induced remission of CD is warranted.
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Affiliation(s)
| | | | - Morris Gordon
- University of Central LancashireSchool of MedicinePrestonLancashireUKPR1 7BH
- Blackpool Victoria HospitalFamilies DivisionBlackpoolUK
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19
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Rao N, Kumar S, Taylor S, Plumb A. Diagnostic pathways in Crohn's disease. Clin Radiol 2019; 74:578-591. [PMID: 31005268 DOI: 10.1016/j.crad.2019.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/14/2019] [Indexed: 12/17/2022]
Abstract
The management of Crohn's disease (CD) is shifting from a stepwise, incremental approach based on symptom control to more aggressive early combined immunosuppression in an attempt to induce remission more rapidly and avoid long-term bowel damage. Accurately defining disease activity is a major challenge, as there is often a disconnect between symptomatology and underlying disease status. The role of imaging in CD has evolved such that it now plays a central role establishing the initial diagnosis, characterising disease phenotype, activity assessment, disease surveillance, and assessing response to therapy. Furthermore, the "treat-to-target" approach is being investigated in CD, with resolution of transmural inflammation on cross-sectional imaging being the treatment goal. In this review, we summarise the principal imaging techniques available to the radiologist, the key findings, and provide some guidance on the preferred imaging option in the diagnostic pathway. We consider the relative merits and drawbacks of each imaging technique before offering a brief discussion of some current developments and research avenues in CD imaging. We discuss how imaging may be useful in a "treat-to-target" approach. Finally, we highlight some practical considerations around service configuration and delivery to optimise imaging in CD in an accurate, cost-effective manner.
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Affiliation(s)
- N Rao
- Department of Radiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - S Kumar
- Centre for Medical Imaging, University College London, London, UK
| | - S Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - A Plumb
- Centre for Medical Imaging, University College London, London, UK.
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20
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Negreanu L, Voiosu T, State M, Voiosu A, Bengus A, Mateescu BR. Endoscopy in inflammatory bowel disease: from guidelines to real life. Therap Adv Gastroenterol 2019; 12:1756284819865153. [PMID: 31384307 PMCID: PMC6657117 DOI: 10.1177/1756284819865153] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/21/2019] [Indexed: 02/04/2023] Open
Abstract
Endoscopy has a central role in the management of inflammatory bowel disease (IBD), providing crucial data for diagnostic and therapeutic decisions, treating disease-related complications, and assisting in the early detection of dysplasia and prevention of colorectal cancer in the setting of IBD. Treatment targets have significantly shifted in IBD, focusing on achieving mucosal healing, a more meaningful endpoint than clinical remission. With the emergence of novel therapies, we aim to alter the course of the disease and prevent irreversible damage to the bowel. To that end, obtaining reliable and reproducible assessments of endoscopic disease activity has become an issue of great importance. Although several guidelines include recommendations regarding endoscopic surveillance in patients with long-standing IBD, there is an open debate regarding the best examination method and the appropriate follow-up intervals. Another important issue is whether surveillance guidelines are actually implemented in real-life practice and what is the preferred surveillance method among endoscopists. Significant changes have occurred in the endoscopic world with the development of new diagnostic and therapeutic modalities and their incorporation in everyday practice. We aimed to assess the real-life application of guideline recommendations regarding endoscopy in IBD patients and to review newly emerged data which might impact these recommendations in the near future.
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Affiliation(s)
| | - Theodor Voiosu
- Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Monica State
- Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Andrei Voiosu
- Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Andreea Bengus
- Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Bogdan Radu Mateescu
- Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
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21
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Guo Z, Cai X, Liu R, Gong J, Li Y, Cao L, Wang Z, Zhu W. Immediate prophylactic vs endoscopic or symptomatic-driven azathioprine treatment to prevent surgical recurrence after intestinal resection for Crohn's disease. Colorectal Dis 2018; 20:O267-O276. [PMID: 30051962 DOI: 10.1111/codi.14352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/03/2018] [Indexed: 12/13/2022]
Abstract
AIM Azathioprine can prevent postoperative recurrences in Crohn's disease. We compared the efficacy of azathioprine in preventing surgical recurrence to explore whether immediate prophylaxis after surgery is better than azathioprine started after endoscopic or clinical recurrence. METHOD Data of patients with intestinal resection and ileocolic anastomosis for Crohn's disease between 2006 and 2015 were retrieved from a prospectively maintained database. Patients were grouped according to the strategies of postoperative therapy with azathioprine. Univariate and multivariate proportional hazard Cox regression analyses were conducted to identify independent predictive factors for surgical recurrence. RESULTS Only age equal to or less than 16 years at diagnosis was an independent risk factor for surgical recurrence in all 166 patients (P = 0.005). In patients with high risk of recurrence (27 in the symptom-driven group, 39 in the endoscopy-driven group and 69 in the immediate prophylaxis group), both immediate and endoscopy-driven azathioprine delayed and reduced surgical recurrence compared with symptom-driven azathioprine (P = 0.035, 0.019). Their efficacy in reducing surgical recurrence was confirmed by Cox regression analyses (hazard ratio 0.465, P = 0.045; hazard ratio 0.352, P = 0.028). Surgical recurrence was similar between the immediate and endoscopy-driven groups. In addition, age ≤ 16 at diagnosis was still an independent risk factor for surgical recurrence in this subgroup. CONCLUSIONS In patients with high risk of recurrence, both immediate prophylactic azathioprine after surgery and azathioprine started after endoscopic recurrence can delay and reduce surgical recurrence compared with azathioprine started after clinical recurrence. In addition, azathioprine started immediately after surgery was not superior to azathioprine started after discovery of endoscopic recurrence.
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Affiliation(s)
- Z Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - X Cai
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Nanjing Medical University, Nanjing, China
| | - R Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - J Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Y Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - L Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Z Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - W Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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22
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Guo J, Chen BL, Chen ZH, Luo XP, Qiu Y, Zhang SH, Feng R, He Y, Zeng ZR, Song XM, Ben-Horin S, Mao R, Chen MH. Thiopurines prevented surgical recurrence in patients with Crohn's disease after intestinal resection: Strategy based on risk stratification. J Gastroenterol Hepatol 2018; 33:608-614. [PMID: 28804920 DOI: 10.1111/jgh.13922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/02/2017] [Accepted: 08/08/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Thiopurines (TPs) are effective in reducing clinical and endoscopic recurrence in postoperative patients with Crohn's disease (CD). However, whether TPs could prevent surgical recurrence (SR) remains unknown. We aimed to explore whether TPs could prevent SR and identify risk factors associated with SR. METHODS This was a retrospective cohort study of 246 postoperative patients with CD. Cox proportional hazard model was used to identify risk factors for SR. Patients were stratified according to the presence of risk factors. RESULTS A total of 50 (20.3%) patients suffered SR after a mean follow up of 54.3±46.4 months. Multivariable analysis showed independent risk factors for SR were penetrating disease behavior (HR 8.628; 95% CI 1.573-47.341; P = 0.01), ileocolonic disease location (HR 2.597; 95% CI 1.047-6.445; P = 0.04) and isolated upper gastrointestinal disease (UGID) location (HR 5.082; 95% CI 1.496-17.267; P = 0.009). However, use of TPs after surgery significantly reduced the risk of SR (HR 0.120; 95% CI 0.063-0.231; P < 0.001). When stratifying patients according to risk factors, there was no statistical difference of SR between patients treated or not by TPs (P = 0.08) in low-risk group (n = 46). However, in high risk group (n = 200), patients with TPs use had a lower risk of SR than those without TPs (HR 0.093; 95% CI 0.048-0.178; P < 0.001). CONCLUSIONS Penetrating disease behavior and ileocolonic/isolated (UGID) location were associated with SR in CD patients. TPs use was beneficial in decreasing risk for SR in CD patients at high risk.
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Affiliation(s)
- Jing Guo
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bai-Li Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhi-Hui Chen
- Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xia-Peng Luo
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sheng-Hong Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhi-Rong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xin-Ming Song
- Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shomron Ben-Horin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Min-Hu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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23
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Schlussel AT, Cherng NB, Alavi K. Current trends and challenges in the postoperative medical management of Crohn's disease: A systematic review. Am J Surg 2017; 214:931-937. [DOI: 10.1016/j.amjsurg.2017.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/27/2017] [Accepted: 04/29/2017] [Indexed: 12/26/2022]
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López-Sanromán A, Vera-Mendoza I, Domènech E, Taxonera C, Vega Ruiz V, Marín-Jiménez I, Guardiola J, Castro L, Esteve M, Iglesias E, Ceballos D, Martínez-Montiel P, Gisbert JP, Mínguez M, Echarri A, Calvet X, Barrio J, Hinojosa J, Martín-Arranz MD, Márquez-Mosquera L, Bermejo F, Rimola J, Pons V, Nos P. Adalimumab vs Azathioprine in the Prevention of Postoperative Crohn's Disease Recurrence. A GETECCU Randomised Trial. J Crohns Colitis 2017; 11:1293-1301. [PMID: 28402454 DOI: 10.1093/ecco-jcc/jjx051] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/05/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Postoperative recurrence of Crohn's disease [POR-CD] is almost certain if no prophylaxis is administered. Evidence for optimal treatment is lacking. Our aim was to compare the efficacy of adalimumab [ADA] and azathioprine [AZA] in this setting. METHODS We performed a phase 3, 52-week, multicentre, randomised, superiority study [APPRECIA], in which patients with ileocolonic resection were randomised either to ADA 160-80-40 mg subcutaneously [SC] or AZA 2.5 mg/kg/day, both associated with metronidazole. The primary endpoint was endoscopic recurrence at 1 year [Rutgeerts i2b, i3, i4], as evaluated by a blinded central reader. RESULTS We recruited 91 patients [median age 35.0 years, disease duration 6.0 years, 23.8% smokers, 7.1% previous resections]. The study drugs were administered to 84 patients. Treatment was discontinued owing to adverse events in 11 patients [13.1%]. Discontinuation was significantly less frequent in the ADA [4.4%] than in the AZA group [23.2%] (dif.: 18.6% [95% CI 4.1-33.2], p = 0.011). According to the intention-to-treat analysis, therapy failed in 23/39 patients in the AZA group [59%] and 19/45 patients in the ADA group [42.2%] [p = 0.12]. In the per-protocol analysis [61 patients with centrally evaluable images], recurrence was recorded in 8/24 [33.3%] patients in the AZA and 11/37 [29.7%] in the ADA group [p = 0.76]. No statistically significant differences between the groups were found for recurrence in magnetic resonance images, biological markers of activity, surgical procedures, or hospital admissions. CONCLUSIONS ADA has not demonstrated a better efficacy than AZA [both associated with metronidazole] for prophylaxis of POR-CD in an unselected population, although tolerance to ADA is significantly better. ClinicalTrials.gov NCT01564823.
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Affiliation(s)
| | - Isabel Vera-Mendoza
- Gastroenterology-Hepatology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - Eugeni Domènech
- Gastroenterology-Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Taxonera
- Digestive Diseases Unit, Hospital Clínico San Carlos, Instituto Investigación Sanitaria San Carlos [IdISSC], Madrid, Spain
| | - Vicente Vega Ruiz
- General Surgery Unit, Hospital Universitario Puerto Real, Puerto Real, Spain
| | - Ignacio Marín-Jiménez
- Digestive Diseases Unit, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón [IiSGM], Madrid, Spain
| | - Jordi Guardiola
- Gastroenterology-Hepatology Unit, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Luisa Castro
- Digestive Diseases Unit, Hospital Universitario Virgen de Macarena, Sevilla, Spain
| | - María Esteve
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Gastroenterology-Hepatology Unit, Hospital Universitari Mutua Terrassa, Terrassa, Spain
| | - Eva Iglesias
- Digestive Diseases Unit, Hospital Reina Sofía, Córdoba, Spain
| | - Daniel Ceballos
- Gastroenterology-Hepatology Unit, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa [IIS-IP], Madrid, Spain
| | - Miguel Mínguez
- Digestive Diseases Unit, Hospital Clínic de Valencia, University of Valencia, Valencia, Spain
| | - Ana Echarri
- Digestive Diseases Unit, Hospital Arquitecto Marcide, Ferrol, Spain
| | - Xavier Calvet
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Jesús Barrio
- Digestive Diseases Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | | | - Fernando Bermejo
- Digestive Diseases Unit, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Jordi Rimola
- Radiology Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Vicente Pons
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Hospital Universitario y Politécnico de La Fe, Valencia, Spain
| | - Pilar Nos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], Instituto de Salud Carlos III, Madrid, Spain.,Digestive Diseases Unit, Hospital Universitario y Politécnico de La Fe, Valencia, Spain
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Gklavas A, Dellaportas D, Papaconstantinou I. Risk factors for postoperative recurrence of Crohn's disease with emphasis on surgical predictors. Ann Gastroenterol 2017; 30:598-612. [PMID: 29118554 PMCID: PMC5670279 DOI: 10.20524/aog.2017.0195] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/10/2017] [Indexed: 12/12/2022] Open
Abstract
Intestinal resection for Crohn’s disease is not curative and postoperative recurrence rates remain high. Early detection of indices associated with recurrence and risk stratification are fundamental for the postoperative management of patients. Early endoscopy at 6-12 months is the “gold standard” procedure, whereas other modalities such as fecal calprotectin and imaging techniques can contribute to the diagnosis of recurrence. The purpose of this review is to summarize current data regarding risk factors correlated with postoperative relapse. Smoking is a well-established, modifiable risk factor. There are sufficient data that correlate penetrating disease, perianal involvement, extensive resections, prior surgery, histological features (plexitis and granulomas), and improper management after resection with high rates for recurrence. The literature provides conflicting data for other possible predictors, such as age, sex, family history of inflammatory bowel disease, location of disease, strictureplasties, blood transfusions, and postoperative complications, necessitating further evidence. On the other hand, surgical factors such as anastomotic configuration, open or laparoscopic approach, and microscopic disease at specimen margins when macroscopic disease is resected, seem not to be related with an increased risk of recurrence. Further recognition of histological features as well as gene-related factors are promising fields for research.
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Affiliation(s)
- Antonios Gklavas
- 2 Department of Surgery, Aretaieion University Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Dionysios Dellaportas
- 2 Department of Surgery, Aretaieion University Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Papaconstantinou
- 2 Department of Surgery, Aretaieion University Hospital, University of Athens, School of Medicine, Athens, Greece
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Abstract
Approximately 25% to 35% of patients with Crohn's disease (CD) who undergo surgery require repeat surgery. Active smoking, multiple prior surgeries, and penetrating or perianal disease are risk factors for recurrence of CD after surgical resection. Early initiation of prophylactic therapy is effective in decreasing the risk of recurrence. Active colonoscopic surveillance for the early detection of endoscopic recurrence within 6 to 12 months of surgery is recommended. In symptomatic patients without evidence of endoscopic recurrence, noninflammatory causes should be sought.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, 9452 Medical Center Drive, ACTRI 1W501, La Jolla, CA 92093, USA; Division of Biomedical Informatics, University of California San Diego, 9452 Medical Center Drive, ACTRI 1W501, La Jolla, CA 92093, USA.
| | - Geoffrey C Nguyen
- Joseph and Wolf Lebovic Health Complex, Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Mount Sinai Hospital, University of Toronto, Suite 437, 600 University Avenue, Toronto, Ontario M5G 1x5, Canada; Institute for Clinical Evaluative Sciences, 155 College Street, Suite 424, Toronto, Ontario M5T 3M6, Canada.
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Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre la monitorización, prevención y tratamiento de la recurrencia posquirúrgica en la enfermedad de Crohn. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:472-483. [DOI: 10.1016/j.gastrohep.2017.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/13/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022]
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Lemmens B, de Buck van Overstraeten A, Arijs I, Sagaert X, Van Assche G, Vermeire S, Tertychnyy A, Geboes K, Wolthuis A, D'Hoore A, De Hertogh G, Ferrante M. Submucosal Plexitis as a Predictive Factor for Postoperative Endoscopic Recurrence in Patients with Crohn's Disease Undergoing a Resection with Ileocolonic Anastomosis: Results from a Prospective Single-centre Study. J Crohns Colitis 2017; 11:212-220. [PMID: 27466173 DOI: 10.1093/ecco-jcc/jjw135] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 07/09/2016] [Accepted: 07/17/2016] [Indexed: 12/13/2022]
Abstract
AIM Ileocolonoscopy allows early detection of recurrence after surgical resection for Crohn's disease [CD]. Plexitis, defined as presence of inflammatory cells in or around enteric ganglia or nerve bundles, in the proximal surgical margin has been associated with an increased overall recurrence risk. We investigated prospectively whether plexitis can predict endoscopic recurrence [ER] in a consecutive cohort of CD patients undergoing ileocolonic resection. METHODS All CD patients undergoing ileocolonic resection in our institution between October 2009 and December 2012 were eligible for this study. Clinical data were obtained prospectively from the patients' files, and biopsies from the proximal surgical margins were analysed immunohistochemically for inflammation at the myenteric and submucosal plexus [lymphocytes, mast cells, eosinophils]. The degree of plexitis was correlated with the presence of ER at 6 months, defined as a modified Rutgeerts' score of ≥ i2b. Multivariate models were developed and tested to predict posterior probability of ER. RESULTS A total of 74 patients were included. Six months after ileocolonic resection, 50% showed ER. Known risk factors such as penetrating disease, previous resections, and active smoking, showed no relation with ER. On the other hand, submucosal lymphocytic plexitis was associated with ER [p = 0.020]. The predictive value of lymphocytic cell count increased with more extensive biopsy sampling and with application of immunohistochemistry. CONCLUSIONS Submucosal lymphocytic plexitis in the proximal surgical margin was significantly related with a higher risk for ER after ileocolonic resection. These data support development of a postoperative prevention trial with vedolizumab, which may block lymphocytic trafficking in the postoperative bowel.
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Affiliation(s)
- Bart Lemmens
- Translational Cell & Tissue Research, Department of Imaging and Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Anthony de Buck van Overstraeten
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Clinical and Experimental Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Ingrid Arijs
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Clinical and Experimental Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Xavier Sagaert
- Translational Cell & Tissue Research, Department of Imaging and Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gert Van Assche
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Clinical and Experimental Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Clinical and Experimental Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Karel Geboes
- Translational Cell & Tissue Research, Department of Imaging and Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Andre D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gert De Hertogh
- Translational Cell & Tissue Research, Department of Imaging and Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Clinical and Experimental Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium .,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Regueiro M, Velayos F, Greer JB, Bougatsos C, Chou R, Sultan S, Singh S. American Gastroenterological Association Institute Technical Review on the Management of Crohn's Disease After Surgical Resection. Gastroenterology 2017; 152:277-295.e3. [PMID: 27840073 DOI: 10.1053/j.gastro.2016.10.039] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Miguel Regueiro
- Inflammatory Bowel Disease Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Fernando Velayos
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Julia B Greer
- Inflammatory Bowel Disease Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon
| | - Shahnaz Sultan
- Department of Medicine, University of Minnesota and VA Health Care System, Minneapolis, Minnesota
| | - Siddharth Singh
- Divisions of Gastroenterology and Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla, California
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Moran CP, Neary B, Doherty GA. Endoscopic evaluation in diagnosis and management of inflammatory bowel disease. World J Gastrointest Endosc 2016; 8:723-732. [PMID: 28042386 PMCID: PMC5159670 DOI: 10.4253/wjge.v8.i20.723] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/16/2016] [Accepted: 09/22/2016] [Indexed: 02/05/2023] Open
Abstract
Endoscopy is a keystone in the management of patients with inflammatory bowel disease (IBD). It is the fundamental diagnostic tool for IBD, and can help discern between ulcerative colitis and Crohn’s disease. Endoscopic assessment provides an objective end point in clinical trials, and identifies patients in clinical practice who may benefit from treatment escalation and may assist risk stratification in patients seeking to discontinue therapy. Recent advances in endoscopic assessment of patients with IBD include video capsule endoscopy, and chromoendoscopy. Technological advances enable improved visualization and focused biopsy sampling. Endoscopic resection and close surveillance of dysplastic lesions where feasible is recommended instead of prophylactic colectomy.
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Mowat C, Arnott I, Cahill A, Smith M, Ahmad T, Subramanian S, Travis S, Morris J, Hamlin J, Dhar A, Nwokolo C, Edwards C, Creed T, Bloom S, Yousif M, Thomas L, Campbell S, Lewis SJ, Sebastian S, Sen S, Lal S, Hawkey C, Murray C, Cummings F, Goh J, Lindsay JO, Arebi N, Potts L, McKinley AJ, Thomson JM, Todd JA, Collie M, Dunlop MG, Mowat A, Gaya DR, Winter J, Naismith GD, Ennis H, Keerie C, Lewis S, Prescott RJ, Kennedy NA, Satsangi J. Mercaptopurine versus placebo to prevent recurrence of Crohn's disease after surgical resection (TOPPIC): a multicentre, double-blind, randomised controlled trial. Lancet Gastroenterol Hepatol 2016; 1:273-282. [PMID: 28404197 PMCID: PMC6358144 DOI: 10.1016/s2468-1253(16)30078-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Up to 60% of patients with Crohn's disease need intestinal resection within the first 10 years of diagnosis, and postoperative recurrence is common. We investigated whether mercaptopurine can prevent or delay postoperative clinical recurrence of Crohn's disease. METHODS We did a randomised, placebo-controlled, double-blind trial at 29 UK secondary and tertiary hospitals of patients (aged >16 years in Scotland or >18 years in England and Wales) who had a confirmed diagnosis of Crohn's disease and had undergone intestinal resection. Patients were randomly assigned (1:1) by a computer-generated web-based randomisation system to oral daily mercaptopurine at a dose of 1 mg/kg bodyweight rounded to the nearest 25 mg or placebo; patients with low thiopurine methyltransferase activity received half the normal dose. Patients and their carers and physicians were masked to the treatment allocation. Patients were followed up for 3 years. The primary endpoint was clinical recurrence of Crohn's disease (Crohn's Disease Activity Index >150 plus 100-point increase in score) and the need for anti-inflammatory rescue treatment or primary surgical intervention. Primary and safety analyses were by intention to treat. Subgroup analyses by smoking status, previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis were also done. This trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN89489788) and the European Clinical Trials Database (EudraCT number 2006-005800-15). FINDINGS Between June 6, 2008, and April 23, 2012, 240 patients with Crohn's disease were randomly assigned: 128 to mercaptopurine and 112 to placebo. All patients received at least one dose of study drug, and no randomly assigned patients were excluded from the analysis. 16 (13%) of patients in the mercaptopurine group versus 26 (23%) patients in the placebo group had a clinical recurrence of Crohn's disease and needed anti-inflammatory rescue treatment or primary surgical intervention (adjusted hazard ratio [HR] 0·54, 95% CI 0·27-1·06; p=0·07; unadjusted HR 0·53, 95% CI 0·28-0·99; p=0·046). In a subgroup analysis, three (10%) of 29 smokers in the mercaptopurine group and 12 (46%) of 26 in the placebo group had a clinical recurrence that needed treatment (HR 0·13, 95% CI 0·04-0·46), compared with 13 (13%) of 99 non-smokers in the mercaptopurine group and 14 (16%) of 86 in the placebo group (0·90, 0·42-1·94; pinteraction=0·018). The effect of mercaptopurine did not significantly differ from placebo for any of the other planned subgroup analyses (previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis). The incidence and types of adverse events were similar in the mercaptopurine and placebo groups. One patient on placebo died of ischaemic heart disease. Adverse events caused discontinuation of treatment in 39 (30%) of 128 patients in the mercaptopurine group versus 41 (37%) of 112 in the placebo group. INTERPRETATION Mercaptopurine is effective in preventing postoperative clinical recurrence of Crohn's disease, but only in patients who are smokers. Thus, in smokers, thiopurine treatment seems to be justified in the postoperative period, although smoking cessation should be strongly encouraged given that smoking increases the risk of recurrence. FUNDING Medical Research Council.
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Affiliation(s)
- Craig Mowat
- Gastrointestinal Unit, Ninewells Hospital, Dundee, UK
| | - Ian Arnott
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK
| | - Aiden Cahill
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Malcolm Smith
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK; IBD Pharmacogenetics Unit, University of Exeter, Exeter, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - John Morris
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - John Hamlin
- Department of Gastroenterology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, Darlington, UK
| | - Chuka Nwokolo
- Department of Gastroenterology, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Cathryn Edwards
- Department of Gastroenterology, Torbay Hospital, South Devon Healthcare NHS Foundation Trust, Torbay, Devon, UK
| | - Tom Creed
- Department of Gastroenterology, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mohamed Yousif
- Department of Gastroenterology, Rotherham NHS Foundation Trust Hospital, Rotherham, UK
| | - Linzi Thomas
- Department of Gastroenterology, Singleton Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Simon Campbell
- Department of Gastroenterology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Stephen J Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Sandip Sen
- Department of Gastroenterology, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Simon Lal
- Department of Gastroenterology, Salford Royal NHS Foundation Trust Hospital, Salford, UK
| | - Chris Hawkey
- Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Charles Murray
- Department of Gastroenterology, Royal Free London NHS Foundation Trust Hospital, London, UK
| | - Fraser Cummings
- Department of Gastroenterology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jason Goh
- Department of Gastroenterology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James O Lindsay
- Department of Gastroenterology, Barts Health NHS Trust, Barts and the London School of Medicine, London, UK
| | - Naila Arebi
- Inflammatory Bowel Disease Unit, St Mark's Hospital, North West London Hospitals NHS Trust, London, UK
| | - Lindsay Potts
- Gastrointestinal Unit, Raigmore Hospital, Inverness, UK
| | | | - John M Thomson
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - John A Todd
- Gastrointestinal Unit, Ninewells Hospital, Dundee, UK
| | - Mhairi Collie
- Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | | | - Ashley Mowat
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Daniel R Gaya
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Jack Winter
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Holly Ennis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Nicholas A Kennedy
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK; IBD Pharmacogenetics Unit, University of Exeter, Exeter, UK
| | - Jack Satsangi
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK.
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Regueiro MD, Greer JB, Hanauer SB. Established Management Paradigms in IBD: Treatment Targets and Therapeutic Tools. ACTA ACUST UNITED AC 2016. [DOI: 10.1038/ajgsup.2016.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nguyen V, Kanth R, Gazo J, Sorrentino D. Management of post-operative Crohn's disease in 2017: where do we go from here? Expert Rev Gastroenterol Hepatol 2016; 10:1257-1269. [PMID: 27678049 DOI: 10.1080/17474124.2016.1241708] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Postoperative recurrence (POR) of Crohn's disease is common after surgical resection. How to best manage POR remains uncertain. Areas covered: In this review, we will first describe the natural course and the best modalities to diagnose this surgical sequela. We will then focus on the potential risk factors for relapse and highlight the main shortcomings in the current study designs and endoscopic and clinical scoring systems, which may partly explain the unexpected outcomes of recent clinical trials. Finally, we will propose a strategy to address the management of POR. Expert commentary: Anti-tumor necrosis factor (Anti-TNF) agents are the most effective therapy to prevent POR in Crohn's disease. Patient risk stratification and active monitoring with scheduled ileocolonoscopy are cornerstones of optimal POR management. Further studies are needed to address areas of uncertainty including timing and duration of therapy and the role of therapeutic drug monitoring in this setting.
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Affiliation(s)
- Vu Nguyen
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States
| | - Rajan Kanth
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States
| | - Joshua Gazo
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States
| | - Dario Sorrentino
- a Gastroenterology , Virginia Tech - Carilion School of Medicine , Roanoke , VA , United States.,b Clinical and Experimental Medical Sciences , University of Udine Medical School , Udine , Italy
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Campbell JP, Vaughn BP. Optimal delivery of follow-up care after surgery for Crohn's disease: current perspectives. Clin Exp Gastroenterol 2016; 9:237-48. [PMID: 27540307 PMCID: PMC4982489 DOI: 10.2147/ceg.s96078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite improvements in medical therapies for Crohn’s disease (CD), up to 70% of patients require surgery within 10 years of diagnosis. Surgery is not curative, and almost all patients will experience endoscopic recurrence, and many will go on to clinical recurrence. Identifying patients at high-risk of endoscopic recurrence and standardizing postoperative assessments are essential in preventing clinical recurrence of CD. In this review, we discuss the assessment, monitoring, and treatment of postoperative CD patients. We address the various individual risk factors as well as composite risk factors. Medications used for primary CD treatment can be used in the postoperative setting to prevent endoscopic or clinical recurrence with varying efficacy, although the cost-effectiveness of these approaches are not fully understood. Future directions for postoperative CD management include evaluation of newer biologic agents such as anti-integrin therapy and fecal microbiota transplant for prevention of recurrence. Development of a standard preoperative risk assessment tool to clearly stratify those at high-risk of recurrence is necessary to guide empiric therapy. Lastly, the incorporation of noninvasive testing into disease monitoring will likely lead to early detection of endoscopic recurrence that will allow for tailored treatment to prevent clinical recurrence.
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Affiliation(s)
- James P Campbell
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Byron P Vaughn
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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Abstract
Endoscopic scoring systems in Crohn’s disease and ulcerative colitis aim to translate the assessment of mucosal disease activity into a quantified value. This value seeks to provide a clear, objective record of the endoscopic mucosal severity, which can then be used to guide medical management decisions. The primary driver of all endoscopic indices, however, is to define a scale of responsiveness for therapeutic endpoints in clinical trials. Mucosal healing now has widespread acceptance as a therapeutic and clinical endpoint, but despite the development of multiple endoscopic scoring systems, the endoscopic definition has yet to be resolved. This review describes recent advances in endoscopic scoring systems for ulcerative colitis (Mayo Clinic endoscopy subscore, UCEIS, and UCCIS among others) and for Crohn’s disease.
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Post-operative recurrence of Crohn's disease: A prospective study at 5 years. Dig Liver Dis 2016; 48:489-494. [PMID: 26905749 DOI: 10.1016/j.dld.2016.01.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 01/04/2016] [Accepted: 01/16/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND We aimed to prospectively assess whether endoscopic recurrence severity at 1 year in Crohn's disease is predictive of clinical recurrence within 5 years. METHODS Clinical recurrence (Crohn's Disease Activity Index>150) was assessed yearly for 5 years in Crohn's disease patients undergoing ileo-colonic resection. At 1 year, recurrence was assessed by colonoscopy (Rutgeerts' score ≥i1 or ≥2i) and small intestine contrast ultrasonography. RESULTS 40 patients were included (23 males, median age 39 [16-69] years). Clinical recurrence occurred within 5 years in 16 (40%) patients (years 1, 2, 3, 4, 5: 2 [5%]; 10 [25%]; 4 [10%]; 2 [5%]; 4 [10%], respectively). At 1 year, endoscopic recurrence (score≥i1) occurred in 39 (97.5%) patients (score≥i2: 33 [82.5%]). Ultrasound detected lesions compatible with recurrence in 39/40 (97.5%) patients. Endoscopic score at 1 year was correlated with clinical score at 2 years (p=0.007; r=0.41). Endoscopic score at 1 year was higher in patients with (n=10) vs without (n=30) clinical recurrence at 2 years (3 [2-4] vs 2 [0-4]; p=0.003). Higher endoscopic score (>i2) at 1 year was a risk factor for clinical recurrence within 5 years (OR=0.18; 95% CI 0.04-0.71; p=0.008). CONCLUSIONS In Crohn's disease, severity of endoscopic recurrence at 1 year remains a predictive marker of clinical recurrence within 5 years. Small intestine contrast ultrasonography is useful for assessing 1-year recurrence.
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Hernández Ramírez V. Prevention of post-operative recurrence in Crohn´s disease. Are we ready for a treat-to-target strategy? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 107:583-5. [PMID: 26437975 DOI: 10.17235/reed.2015.3990/2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gordon M, Taylor K, Akobeng AK, Thomas AG. Azathioprine and 6-mercaptopurine for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev 2014; 2014:CD010233. [PMID: 25081347 PMCID: PMC6486089 DOI: 10.1002/14651858.cd010233.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic relapsing inflammatory condition. Many patients fail to achieve remission with medical management and require surgical interventions. Purine analogues have been used to maintain surgically-induced remission in CD, but the effectiveness of these agents is unclear. OBJECTIVES The objectives were to evaluate the efficacy and safety of purine analogues for maintenance of surgically-induced remission in CD. SEARCH METHODS We searched the following databases from inception to 30 April 2014: PubMed, MEDLINE, EMBASE, CENTRAL, and the Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register). We also searched the reference lists of all included studies, and contacted personal sources and drug companies to identify additional studies. The searches were not limited by language. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared purine analogues to placebo or another intervention, with treatment durations of at least six months were considered for inclusion. Participants were patients of any age with CD in remission following surgery. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and extracted data. Methodological quality was assessed using the Cochrane risk of bias tool. The primary outcome measures were clinical and endoscopic relapse as defined by the primary studies. Secondary outcomes included adverse events, withdrawal due to adverse events and serious adverse events. Data were analysed on an intention-to-treat basis where patients with missing final outcomes were assumed to have relapsed. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. The Chi(2) and I(2) statistics were used to assess heterogeneity. The overall quality of the evidence supporting the primary outcomes and selected secondary outcomes was assessed using the GRADE criteria. MAIN RESULTS Seven RCTs (n = 584 patients) were included in the review. Three studies compared azathioprine to 5-aminosalicylic acid (5-ASA). One small study compared azathioprine to both 5-ASA and adalimumab. One study compared azathioprine to placebo and another study compared 6-mercaptopurine to 5-ASA and placebo. One small study compared azathioprine to infliximab. Three studies were judged to be at low risk of bias. Four studies were judged to be at high risk of bias due to blinding. The study (n = 22) comparing azathioprine to infliximab found that the effects on the proportion of patients who had a clinical (RR 2.00, 95% CI 0.21 to 18.98) or endoscopic relapse (RR 4.40, 95% CI 0.59 to 3.07) were uncertain. One study (n = 33) found decreased clinical (RR 5.18, 95% CI 1.35 to 19.83) and endoscopic relapse (RR 10.35, 95% CI 1.50 to 71.32) rates favouring adalimumab over azathioprine. A pooled analysis of two studies (n = 168 patients) showed decreased clinical relapse rates at one or two years favouring purine analogues over placebo. Forty-eight per cent of patients in the purine analogue group experienced a clinical relapse compared to 63% of placebo patients (RR 0.74, 95% CI 0.58 to 0.94). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was low due to high risk of bias (one study was single-blind) and sparse data (93 events). One study (87 patients) found a reduction in endoscopic relapse rates favouring 6-mercaptopurine over placebo. Seventeen per cent of 6-mercaptopurine patients had an endoscopic relapse at two years compared to 42% of placebo patients (RR 0.40, 95% CI 0.19 to 0.83). A GRADE analysis indicated that the overall quality of the evidence for this outcome was low due to very sparse data (25 events). A pooled analysis of five studies (n = 425 patients) showed no difference in clinical relapse rates at one or two years between purine analogues and 5-ASA agents. Sixty-three per cent of patients in the purine analogues group experienced a clinical relapse compared to 54% of 5-ASA patients (RR 1.15, 95% CI 0.99 to 1.34). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was very low due to high risk of bias (two open-label studies), sparse data (249 events) and moderate heterogeneity (I(2) = 45%). There was no difference in endoscopic relapse at 12 months between azathioprine and 5-ASA (RR 0.78, 95% CI 0.52 to 1.17; 1 study, 35 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was very low due to high risk of bias (open-label study) and very sparse data (26 events). There was a reduction in endoscopic relapse at 24 months favouring 6-mercaptopurine over 5-ASA patients. Seventeen per cent of 6-mercaptopurine patients had an endoscopic relapse compared to 48% of 5-ASA patients (RR 0.36, 95% CI 0.18 to 0.72; 1 study, 91 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was low due to very sparse data (29 events). Adverse events that required withdrawal were more common in the purine analogue group compared to 5-ASA. Twenty per cent of patients in the purine analogue group withdrew due to adverse events compared to 10% of 5-ASA patients (RR 2.07, 95% CI 1.26 to 3.39; 5 studies, 423 patients).The results for withdrawal due to adverse events between purine analogues and placebo or for other comparisons were uncertain. Commonly reported adverse events across all studies included leucopenia, arthralgia, abdominal pain or severe epigastric intolerance, elevated liver enzymes, nausea and vomiting, pancreatitis, anaemia, exacerbation of Crohn's disease, nasopharyngitis, and flatulence. AUTHORS' CONCLUSIONS Purine analogues may be superior to placebo for maintenance of surgically-induced remission in patients with CD, although this is based on two small studies. The results for efficacy outcomes between purine analogues and 5-ASA agents were uncertain. However, patients taking purine analogues were more likely than 5-ASA patients to discontinue therapy due to adverse events. No firm conclusions can be drawn from the two small studies that compared azathioprine to infliximab or adalimumab. Adalimumab may be superior to azathioprine but further research is needed to confirm these results. Further research investigating the efficacy and safety of azathioprine and 6-mercaptopurine in comparison to other active medications in patients with surgically-induced remission of CD is warranted.
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Affiliation(s)
| | - Kelly Taylor
- North Manchester General HospitalDepartment of PaediatricsCrumpsallUK
| | | | - Adrian G Thomas
- Royal Manchester Children's HospitalOxford RoadManchesterUKM13 9WL
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