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

Comparative Efficacy of Novel Biologics, Anti-tumor Necrosis Factor Agents, and Immunomodulators to Prevent Postoperative Recurrence in Crohn's Disease: A Systematic Review and Network Meta-analysis

BACKGROUND AND AIMS

Our objective was to compare the efficacy of novel biologics (such as vedolizumab and ustekinumab), anti-tumor necrosis factor (anti-TNF) agents, and immunomodulators (IMMs) in preventing postoperative recurrence (POR) of Crohn's disease (CD).

METHODS

We searched the PubMed, Embase, and the Cochrane Library databases up to December 2023 to identify placebo-controlled, no-treatment comparison, or positive-controlled studies for the prevention of POR in CD. Endoscopic recurrence and clinical recurrence were the primary and secondary endpoints for the efficacy assessment. We conducted traditional direct and Bayesian network meta-analyses to evaluate the preventive effects of selected drugs. Additionally, we ranked interventions based on their scores under the Surface Under the Cumulative Ranking curve (SUCRA).

RESULTS

A total of 17 studies involving 2786 patients were included. In the direct meta-analysis, anti-TNFs, vedolizumab, and IMMs showed greater efficacy in preventing endoscopic POR, compared with controls (placebo or no treatment). In preventing clinical POR, anti-TNFs and IMMs outperformed the controls. The network meta-analysis revealed that the risk of endoscopic POR was considerably lower in patients receiving anti-TNFs, vedolizumab, and ustekinumab compared with controls. Regarding the reduction of clinical POR, only anti-TNFs showed significant efficacy compared with controls. Vedolizumab and anti-TNFs were ranked as the most effective strategies in preventing endoscopic and clinical recurrence, respectively.

CONCLUSIONS

According to direct and network meta-analysis, in CD patients after surgical resection, novel biologics, especially vedolizumab, were quite effective in decreasing the risk of endoscopic POR, whereas anti-TNFs appeared to perform best in reducing the risk of clinical POR.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Small bowel Crohn's disease neglected by gastroenterologists and anorectal surgeons with a 7-year delay in diagnosis: A case report

RATIONAL

Small bowel Crohn's disease (SBCD) is a common site of Crohn's disease (CD). However, owing to the anatomical characteristics of the small bowel and the limitations of traditional examination methods, the detection and diagnosis of SBCD remain difficult. Gastroenterologists and anorectal surgeons should pay more attention to improving the early diagnosis rate, so as to improve the prognosis of patients and reduce the probability of surgery due to complications.

PATIENT CONCERNS

Here, we presented a case of a young male with severe localized pain in the right kidney area and fever but no weight loss or diarrhea, who had a history of perianal abscess surgery 7 years ago and an elevated platelet count reviewing his previous medical examination report.

DIAGNOSES

SBCD was not diagnosed until complications of intestinal fistula developed 7 years after perianal abscess surgery.

INTERVENTIONS

Anti-infection treatment was administered due to elevated inflammatory markers and evidence of infection on computed tomography scan, and exclusive enteral nutrition (EEN) was then performed because of the diagnosis of SBCD. Although the infection was absorbed by the treatment with EEN, a laparoscopic modified partial enterectomy was finally performed due to the complication of intestinal fistula.

OUTCOMES

The patient was discharged on the seventh postoperative day without postoperative complications and started biologic therapy 2 weeks after surgery because he had high-risk factors for postoperative recurrence. The pathological report revealed the involvement of the ileum in CD, and confirmed the existence of the intestinal fistula.

LESSONS

Gastroenterologists and anorectal surgeons should be aware that perianal abscess could be the first manifestation of SBCD; even if typical CD manifestations are absent, proper further examinations are necessary based on the comprehensive analysis of clinical data of patients. In addition, the platelet count deserves attention in patients with potentially possible CD. More importantly, it is important to emphasize the importance of EEN in adult CD patients.

Recent advances in intestinal fibrosis

Despite many progresses have been made in the treatment of inflammatory bowel disease, especially due to the increasing number of effective therapies, the development of tissue fibrosis is a very common occurrence along the natural history of this condition. To a certain extent, fibrogenesis is a physiological and necessary process in all those conditions characterised by chronic inflammation. However, the excessive deposition of extracellular matrix within the bowel wall will end up in the formation of strictures, with the consequent need for surgery. A number of mechanisms have been described in this process, but some of them are not yet clear. For sure, the main trigger is the presence of a persistent inflammatory status within the mucosa, which in turn favours the occurrence of a pro-fibrogenic environment. Among the main key players, myofibroblasts, fibroblasts, immune cells, growth factors and cytokines must be mentioned. Although there are no available therapies able to target fibrosis, the only way to prevent it is by controlling inflammation. In this review, we summarize the state of art of the mechanisms involved in gut fibrogenesis, how to diagnose it, and which potential targets could be druggable to tackle fibrosis.