1
|
Shah RS, Bachour S, Joseph A, Xiao H, Lyu R, Syed H, Li T, Pothula S, Vinaithirthan V, Ali AH, Contreras S, Hu JH, Barnes EL, Axelrad JE, Holubar SD, Regueiro M, Cohen BL, Click BH. Real-World Surgical and Endoscopic Recurrence Based on Risk Profiles and Prophylaxis Utilization in Postoperative Crohn's Disease. Clin Gastroenterol Hepatol 2024; 22:847-857.e12. [PMID: 37879523 DOI: 10.1016/j.cgh.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 09/30/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND & AIMS Preoperative risk stratification may help guide prophylactic biologic utilization for the prevention of postoperative Crohn's disease (CD) recurrence; however, there are limited data exploring and validating proposed clinical risk factors. We aimed to explore the preoperative clinical risk profiles, quantify individual risk factors, and assess the impact of biologic prophylaxis on postoperative recurrence risk in a real-world cohort. METHODS In this multicenter retrospective analysis, patients with CD who underwent ileocolonic resection (ICR) from 2009 to 2020 were identified. High-risk (active smoking, ≥2 prior surgeries, penetrating disease, and/or perianal disease) and low-risk (nonsmokers and age >50 y) features were used to stratify patients. We assessed the risk of endoscopic (Rutgeert score, ≥i2b) and surgical recurrence by risk strata and biologic prophylaxis (≤90 days postoperatively) with logistic and time-to-event analyses. RESULTS A total of 1404 adult CD patients who underwent ICR were included. Of the high-risk factors, 2 or more ICRs (odds ratio [OR], 1.71; 95% CI, 1.13-2.57), active smoking (OR, 1.73; 95% CI, 1.17-2.53), penetrating disease (OR, 1.41; 95% CI, 1.02-1.94), and history of perianal disease alone (OR, 1.99; 95% CI, 1.42-2.79) were associated with surgical but not endoscopic recurrence. Surgical recurrence was lower in high-risk patients receiving prophylaxis vs not (10.2% vs 16.7%; P = .02), and endoscopic recurrence was lower in those receiving prophylaxis irrespective of risk strata (high-risk, 28.1% vs 37.4%; P = .03; and low-risk, 21.1% vs 38.3%; P = .002). CONCLUSIONS Clinical risk factors accurately illustrate patients at risk for surgical recurrence, but have limited utility in predicting endoscopic recurrence. Biologic prophylaxis may be of benefit irrespective of risk stratification and future studies should assess this.
Collapse
Affiliation(s)
- Ravi S Shah
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Salam Bachour
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Huijun Xiao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Terry Li
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Shravya Pothula
- Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Adel Hajj Ali
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sussel Contreras
- Department of Gastroenterology and Hepatology, New York University, New York, New York
| | - Jessica H Hu
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Jordan E Axelrad
- Department of Gastroenterology and Hepatology, New York University, New York, New York
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin H Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| |
Collapse
|
2
|
Bachour SP, Click BH. Clinical Update on the Prevention and Management of Postoperative Crohn's Disease Recurrence. Curr Gastroenterol Rep 2024; 26:41-52. [PMID: 38227128 DOI: 10.1007/s11894-023-00911-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE OF REVIEW Despite advances in therapeutics, a significant portion of patients with Crohn's disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn's disease recurrence. RECENT FINDINGS Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and "-omic" risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy. Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn's disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.
Collapse
Affiliation(s)
- Salam P Bachour
- Brigham and Women's Hospital, Department of Medicine, Boston, MA, 02115, USA
| | - Benjamin H Click
- University of Colorado Anschutz Medical Campus, Division of Gastroenterology and Hepatology, 13001 E 17th Pl, Aurora, CO, 80045, USA.
| |
Collapse
|
3
|
Powers JC, Cohen BL, Rieder F, Click BH, Lyu R, Westbrook K, Hull T, Holubar S, Regueiro MD, Qazi T. Preoperative Use of Multiple Advanced Therapies Is Not Associated With Endoscopic Inflammatory Pouch Diseases. Inflamm Bowel Dis 2024; 30:203-212. [PMID: 37061838 DOI: 10.1093/ibd/izad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Indexed: 04/17/2023]
Abstract
BACKGROUND Patients with an ileal pouch-anal anastomosis (IPAA) can experience pouch inflammation postoperatively. The use of antitumor necrosis factor (anti-TNF) biologics may be associated with pouch inflammation, but limited data exist on the impact of multiple advanced therapies on development of subsequent pouch inflammation. The aim of this study was to assess for an association between preoperative use of multiple advanced therapies and risk of endoscopically detected inflammatory pouch diseases (EIPDs). METHODS We performed a retrospective analysis of ulcerative colitis (UC) and indeterminate colitis (IBDU) patients who underwent an IPAA at a quaternary care center from January 2015 to December 2019. Patients were grouped based on number and type of preoperative drug exposures. The primary outcome was EIPD within 5 years of IPAA. RESULTS Two hundred ninety-eight patients were included in this analysis. Most of these patients had UC (95.0%) and demonstrated pancolonic disease distribution (86.1%). The majority of patients were male (57.4%) and underwent surgery for medically refractory disease (79.2%). The overall median age at surgery was 38.6 years. Preoperatively, 68 patients were biologic/small molecule-naïve, 125 received anti-TNF agents only, and 105 received non-anti-TNF agents only or multiple classes. Ninety-one patients developed EIPD. There was no significant association between type (P = .38) or number (P = .58) of exposures and EIPD, but older individuals had a lower risk of EIPD (P = .001; hazard ratio, 0.972; 95% confidence interval, 0.956-0.989). CONCLUSION Development of EIPD was not associated with number or type of preoperative advanced therapies.
Collapse
Affiliation(s)
- Joseph Carter Powers
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, USA
| | - Katherine Westbrook
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel D Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
4
|
Bachour SP, Khan MZ, Shah RS, Joseph A, Syed H, Ali AH, Rieder F, Holubar SD, Barnes EL, Axelrad J, Regueiro M, Cohen BL, Click BH. Anastomotic Configuration and Temporary Diverting Ileostomy Do Not Increase Risk of Anastomotic Stricture in Postoperative Crohn's Disease. Am J Gastroenterol 2023; 118:2212-2219. [PMID: 37410924 PMCID: PMC10921865 DOI: 10.14309/ajg.0000000000002393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated. METHODS A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection. RESULTS A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection. DISCUSSION AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.
Collapse
Affiliation(s)
- Salam P. Bachour
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Muhammad Z. Khan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ravi S. Shah
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adel Hajj Ali
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - Stefan D. Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jordan Axelrad
- Department of Gastroenterology and Hepatology, New York University, New York, NY, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin L. Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H. Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
5
|
Bachour SP, Shah RS, Joseph A, Syed H, Ali AH, Rieder F, Barnes EL, Axelrad J, Holubar SD, Regueiro M, Cohen BL, Click BH. Change in Biologic Class Promotes Endoscopic Remission Following Endoscopic Postoperative Crohn's Disease Recurrence. J Clin Gastroenterol 2023:00004836-990000000-00238. [PMID: 38019054 DOI: 10.1097/mcg.0000000000001943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/19/2023] [Indexed: 11/30/2023]
Abstract
GOALS Assess the outcomes of various therapeutic regimens to treat initial endoscopic postoperative recurrence despite biologic prophylaxis. BACKGROUND Postoperative biologic prophylaxis reduces postoperative Crohn's disease (CD) recurrence rates. Optimal treatment strategies for endoscopic recurrence have not been elucidated. STUDY Retrospective cohort study of adult CD patients who underwent ileocolonic resection between 2009 and 2020. Patients with endoscopic postoperative recurrence despite prophylactic biologic therapy and ≥1 subsequent colonoscopy were included. Treatment changes after recurrence were categorized as (1) therapy optimization or continuation or (2) new biologic class. The primary outcome was composite endoscopic or surgical recurrence at the time of or prior to subsequent follow-up colonoscopy. RESULTS Eighty-one CD patients with endoscopic recurrence (54.3% i2b, 22.2% i3, and 23.5% i4) despite biologic prophylaxis (86.4% anti-tumor necrosis factor, 8.6% vedolizumab, 4.9% ustekinumab) were included. Most patients received therapy optimization or continuation (76.3%, n=61) following recurrence compared to being started on a new biologic class. Sixty patients (N=48 therapy optimization; N=12 new biologic class) experienced composite recurrence (78.3% endoscopic, 21.7% surgical). On multivariable modeling, initiation of a new biologic class was associated with reduced risk for composite recurrence compared to therapy optimization or continuation (aOR: 0.26; P=0.04). Additionally, initiation of a new biologic class was associated with endoscopic improvement when adjusting for endoscopic severity at the time of recurrence (aOR: 3.4; P=0.05). On sensitivity analysis, a new biologic class was associated or trended with improved rates of endoscopic healing and composite recurrence when directly compared to therapy optimization or continuation. CONCLUSION In patients with CD who experience endoscopic recurrence despite biologic prophylaxis, changing the mechanism of biologic action may promote endoscopic improvement.
Collapse
Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ravi S Shah
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic
| | - Adel Hajj Ali
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
- Department of Colorectal Surgery, Cleveland Clinic
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, NC
| | - Jordan Axelrad
- Department of Gastroenterology and Hepatology, New York University, New York, NY
| | - Stefan D Holubar
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
| | - Benjamin H Click
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO
| |
Collapse
|
6
|
Bachour SP, Shah RS, Lyu R, Rieder F, Qazi T, Lashner B, Achkar JP, Philpott J, Barnes EL, Axelrad J, Holubar SD, Lightner AL, Regueiro M, Cohen BL, Click BH. Mild neoterminal ileal post-operative recurrence of Crohn's disease conveys higher risk for severe endoscopic disease progression than isolated anastomotic lesions. Aliment Pharmacol Ther 2022; 55:1139-1150. [PMID: 35285534 PMCID: PMC9677520 DOI: 10.1111/apt.16804] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 12/15/2022]
Abstract
There are conflicting data assessing the impact of isolated post-operative anastomotic inflammation on future disease progression. The aim of this study was to determine the relative risk of severe disease progression in post-operative Crohn's disease (CD) patients with isolated anastomotic disease. METHODS Retrospective cohort study of adult CD patients undergoing ileocolonic resection between 2009 and 2020. Patients with a post-operative ileocolonoscopy ≤18 months from surgery and ≥1 subsequent ileocolonoscopy were included. Disease activity was assessed using the modified Rutgeerts' score (RS). Primary outcome was severe endoscopic progression, defined as i3 or i4 disease, on immediate subsequent ileocolonoscopy and during entire post-operative follow-up. Secondary outcome was surgical recurrence. RESULTS One hundred and ninety-nine CD patients had an ileocolonoscopy ≤18 months from surgery, index RS of i0-i2b and ≥1 subsequent ileocolonoscopy. At index ileocolonoscopy, 34.7% had i0 disease, 16.1% i1, 24.6% i2a and 24.6% i2b. On multivariable logistic regression, i2b disease was associated with severe endoscopic progression compared to i0 or i1 (aOR 5.53; P < 0.001) and i2a disease patients (aOR 2.63; P = 0.03). However, i2a disease did not confer increased risk compared to i0 or i1 disease (P = 0.09). Furthermore, i2b patients experienced severe endoscopic progression significantly earlier than i0 or i1 disease (aHR 4.68; P < 0.001), whereas i2a disease did not differ from i0 or i1 disease (P = 0.25). Surgical recurrence was not associated with index RS i0-i2b (P = 0.86). CONCLUSION Post-operative ileal disease recurrence, not isolated anastomotic inflammation, confers increased risk for severe endoscopic disease progression. Location of CD recurrence may impact optimal management strategies.
Collapse
Affiliation(s)
- Salam P. Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Ravi S. Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Ruishen Lyu
- Cleveland Clinic Department of Quantitative Health Sciences
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition,Department of Inflammation and Immunity, Lerner Research Institute
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Edward L. Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology
| | | | | | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin L. Cohen
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin H. Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| |
Collapse
|
7
|
Holubar SD, Gunter RL, Click BH, Achkar JP, Lightner AL, Lipman JM, Hull TL, Regueiro M, Rieder F, Steele SR. Mesenteric Excision and Exclusion for Ileocolic Crohn's Disease: Feasibility and Safety of an Innovative, Combined Surgical Approach With Extended Mesenteric Excision and Kono-S Anastomosis. Dis Colon Rectum 2022; 65:e5-e13. [PMID: 34882636 PMCID: PMC9148419 DOI: 10.1097/dcr.0000000000002287] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Ileocolic resection for Crohn's disease traditionally does not include a high ligation of the ileocolic pedicle, and most commonly is performed with a stapled side-to-side ileocolic anastomosis. The mesentery has recently been implicated in the pathophysiology of Crohn's disease. Two techniques have been developed and are associated with reduced postoperative recurrence: the Kono-S anastomosis that excludes diseased mesentery and extended mesenteric excision that resects diseased mesentery. We aimed to assess the technical feasibility and safety of a novel combination of techniques: mesenteric excision and exclusion. TECHNIQUES This initial report is a single-center descriptive study of consecutive adults who underwent mesenteric excision and exclusion for primary or recurrent ileocolic Crohn's disease from September 2020 to June 2021. Medication exposure and endoscopic balloon dilation before surgery were recorded. Phenotype was classified using the Montreal Classification. Thirty-day outcomes were reported. A video of the mesenteric excision and exclusion including the Kono-S anastomosis is presented. RESULTS Twenty-two patients with ileocolic Crohn's disease underwent mesenteric excision and exclusion: 100% had strictures, 59% had fistulas, 81% were on biologics, and 27% had previous ileocolic resection(s). Seventy-two percent underwent laparoscopic procedures, a mesenteric defect was closed in 86%, omental flaps were fashioned in 77%, and 3 patients were diverted. Median operative time was 175 minutes. Median postoperative stay was 4 days. At 30 days, there were 2 readmissions for reintervention: 1 seton placement and 1 percutaneous drainage of a sterile collection. There were no cases of intra-abdominal sepsis or anastomotic leak. CONCLUSIONS Mesenteric excision and exclusion represents an innovative, progressive, and promising approach that appears to be highly feasible and safe. Further study is warranted to determine if mesenteric excision and exclusion is associated with reduced postoperative recurrence of ileocolic Crohn's disease.
Collapse
Affiliation(s)
- Stefan D. Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Rebecca L. Gunter
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin H. Click
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Amy L. Lightner
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy M. Lipman
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Tracy L. Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Scott R. Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
8
|
Abstract
Postoperative recurrence of Crohn's disease is common and requires a multidisciplinary approach between surgeons and gastroenterologists in the perioperative and postoperative period to improve outcomes in this patient population. Endoscopic recurrence precedes clinical and surgical recurrence and endoscopic monitoring is crucial to guide postoperative management. Risk stratification of patients is recommended to guide early prophylactic management, and follow-up endoscopic monitoring can guide intensification of therapy. This review summarizes evidence behind postoperative recurrence rates, disease monitoring techniques, nonbiologic and biologic therapies available to prevent and treat postoperative recurrence, risk factors associated with recurrence, and postoperative management strategies guided by endoscopic monitoring.
Collapse
Affiliation(s)
- Ravi S. Shah
- Cleveland Clinic - Internal Medicine, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Benjamin H. Click
- Cleveland Clinic - Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| |
Collapse
|
9
|
Shah RS, Bachour S, Jia X, Holubar SD, Hull TL, Achkar JP, Philpott J, Qazi T, Rieder F, Cohen BL, Regueiro MD, Lightner AL, Click BH. Hypoalbuminaemia, Not Biologic Exposure, Is Associated with Postoperative Complications in Crohn's Disease Patients Undergoing Ileocolic Resection. J Crohns Colitis 2021; 15:1142-1151. [PMID: 33388775 PMCID: PMC8427722 DOI: 10.1093/ecco-jcc/jjaa268] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on the postoperative outcomes in Crohn's disease patients exposed to preoperative ustekinumab or vedolizumab. We hypothesised that preoperative biologic use in Crohn's disease is not associated with postoperative complications after ileocolic resection. METHODS Crohn's disease patients who underwent ileocolic resection over 2009-2019 were identified at a large regional health system. Preoperative biologic use within 12 weeks of surgery was categorised as no biologic, anti-tumour necrosis factor, vedolizumab, or ustekinumab. The primary endpoint was 90-day intra-abdominal septic complication. Risk factors included preoperative medical therapies, demographics, disease characteristics, laboratory values, and surgical approach. Regression models assessed the association of biologic use with intra-abdominal septic complication. RESULTS A total of 815 Crohn's disease patients who underwent an ileocolic resection were included [62% no biologic, 31.4% anti-tumour necrosis factor, 3.9% vedolizumab, 2.6% ustekinumab]. Primary anastomosis was performed in 85.9% of patients [side-to-side 48.8%, end-to-side 26%, end-to-end 25%] in primarily a stapled [77.2%] manner. Minimally invasive approach was used in 41.4%. The 90-day postoperative intra-abdominal sepsis rate of 810 patients was 12%, abscess rate was 9.6%, and anastomotic leak rate was 3.2%. Multivariable regression modelling controlling for confounding variables demonstrated that preoperative biologic use with anti-tumour necrosis factor [p = 0.21], vedolizumab [p = 0.17], or ustekinumab [p = 0.52] was not significantly associated with intra-abdominal septic complication. Preoperative albumin < 3.5 g/dl was independently associated with intra-abdominal septic complication (odds ratio [OR] 1.76 [1.03, 3.01]). CONCLUSIONS In Crohn's disease patients undergoing ileocolic resection, preoperative biologics are not associated with 90-day postoperative intra-abdominal septic complication. Preoperative biologic exposure should not delay necessary surgery.
Collapse
Affiliation(s)
- Ravi S Shah
- Department of Internal Medicine, Cleveland Clinic, OH, USA,Corresponding author: Benjamin H. Click, MD, 9500 Euclid Avenue, A-30, Cleveland, OH 44195, USA. Tel: 216-444-1711; fax: 216-445-3889;
| | - Salam Bachour
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Xue Jia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica Philpott
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel D Regueiro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW To examine the quantifiable economic impact of inflammatory bowel disease (IBD), key cost drivers and determinants, and the impact of value-based care in IBD. Finally, we prognosticate on future directions and opportunities on healthcare economics in IBD. RECENT FINDINGS New value-based initiatives, technologically driven interventions, and quality improvement programs have demonstrated reductions in healthcare utilization and enhanced patient outcomes, and several have realized cost of care reductions. IBD is a costly, chronic illness with unbalanced spending by a small proportion of individuals. Pharmaceutical costs are overtaking inpatient expenses as the primary cost driver. Value-based care initiatives including the IBD medical home, remote monitoring platforms such as myIBDcoach and Project Sonar, and learning healthcare networks exemplified by ImproveCareNow have all demonstrated successes in improving care quality, patient outcomes, and reduced healthcare spending in some populations. The future of value-based care in IBD is bright, with ample opportunities for model refinement, collaboration, and growth.
Collapse
Affiliation(s)
- Jonathan A Beard
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Diana L Franco
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
11
|
Click BH, Greer JB, Regueiro MD, Hartman DJ, Davis PL, Siegel CA, Herfarth HH, Rosh JR, Shah SA, Koltun WA, Binion DG, Baidoo L, Szigethy E. IBD LIVE Series-Case 7: The Brain-Gut Connection and the Importance of Integrated Care in IBD. Inflamm Bowel Dis 2017; 23:681-694. [PMID: 28426450 DOI: 10.1097/mib.0000000000001101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Benjamin H Click
- 1Gastroenterology Fellow II, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 2Assistant Professor of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 3Professor of Medicine, Associate Chief for Education, Co-Director, Inflammatory Bowel Disease Center, Head, IBD Clinical Program, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4Associate Professor of Pathology, Associate Director of Pathology Informatics, Department of Pathology, Division of Anatomic Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 5Clinical Associate Professor of Radiology, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 6Associate Professor of Medicine and of The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; 7Director of the Inflammatory Bowel Disease Center at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire; 8Professor of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina; 9Director, Division of Gastroenterology and Nutrition, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey; 10Professor of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York; 11Chief of Gastroenterology, The Miriam Hospital, Providence, Rhode Island; 12Clinical Professor of Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; 13Chief, Division of Colon and Rectal Surgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania; 14Director, Hershey Penn State IBD Center, Professor of Surgery, Peter and Marshia Carlino Chair in IBD, Penn State College of Medicine, Hershey, Pennsylvania; 15Professor of Medicine, Clinical and Translational Science, Co-Director of the IBD Center, Director of Translational IBD Research, Director, Nutrition Support Service, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 16Associate Professor of Medicine, Director, Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and 17Associate Professor of Psychiatry, Pediatrics, and Medicine, University of Pittsburgh School of Medicine, Director, Visceral Inflammation and Pain Center, Co-Director Total Care-IBD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|