Temporary Faecal Diversion for Refractory Perianal and/or Distal Colonic Crohn's Disease in the Biologic Era: An Updated Systematic Review with Meta-analysis

BACKGROUND AND AIMS

We evaluated short- and long-term outcomes of temporary faecal diversion [FD] for management of refractory Crohn's disease [CD], focusing on outcomes in the biologic era.

METHODS

Through a systematic literature review until March 15, 2023, we identified 33 studies [19 conducted in the biologic era] that evaluated 1578 patients with perianal and/or distal colonic CD who underwent temporary FD [with intent of restoring bowel continuity] and reported long-term outcomes [primary outcome: successful restoration of bowel continuity, defined as remaining ostomy-free after reconnection at a minimum of 6 months after diversion or at the end of follow-up]. We calculated pooled rates (with 95% confidence interval [CI]) using random effects meta-analysis, and examined factors associated with successful restoration of bowel continuity.

RESULTS

Overall, 61% patients [95% CI, 52-68%; 50% in biologic era] experienced clinical improvement after FD. Stoma takedown was attempted in 34% patients [28-41%; 37% in biologic era], 6-18 months after diversion. Among patients where bowel restoration was attempted, 63% patients [54-71%] had successful restoration of bowel continuity, and 26% [20-34%] required re-diversion. Overall, 21% patients [17-27%; 24% in biologic era] who underwent FD were successfully restored; 34% patients [30-39%; 31% in biologic era] required proctectomy with permanent ostomy. On meta-regression, post-diversion biologic use and absence of proctitis was associated with successful bowel restoration after temporary FD in contemporary studies.

CONCLUSION

In the biologic era, temporary FD for refractory perianal and/or distal colonic CD improves symptoms in half the patients, and bowel continuity can be successfully restored in a quarter of patients.

A76 PHYSICIANS PERCEIVED VALUE OF COMPUTED TOMOGRAPHY SCANS FOR INFLAMMATORY BOWEL DISEASE PATIENTS IN THE EMERGENCY DEPARTMENT: A SURVEY OF CANADIAN PHYSICIANS

Background

Despite concerns regarding the risks of ionizing radiation from computed tomography (CT) imaging, the rates of abdominal pelvic CT (APCT) utilization in the emergency department (ED) continues to increase for patients with inflammatory bowel disease (IBD).

Purpose

To determine the factors that drive decisions on when to perform APCT imaging in the ED for patients with IBD and to determine if differences exist between physician specialties.

Method

We performed a quantitative, web-based survey between November 2021 and August 2022. Structured questions for Crohn’s disease (CD) and ulcerative colitis (UC) were developed with input from stakeholders in gastroenterology, surgery, and emergency medicine. Surveys were disseminated to Canadian physicians in each of the three specialities through personal emails, and by newsletter from national specialty organizations. Between specialty comparisons were performed by Chi-squared and Fisher exact tests where appropriate.

Result(s)

A total of 208 participants responded to our survey: median age 44 years (IQR 37-50), 132 (63%) male, and 141 (68%) in an academic practice. Survey participants included 81 (39%) gastroenterologists, 35 (17%) surgeons and 92 (44%) emergency physicians.

There were significant differences between specialties in the perceived rates of positive findings from APCT imaging. In UC, gastroenterologists felt inflammation alone was more common than emergency physicians and bowel obstruction and septic complications less common than surgeons and emergency physicians. In CD, surgeons felt bowel obstructions, septic complications and bowel perforations were more common compared with gastroenterologists and emergency physicians.

There were significant differences between specialties in the types of clinical presentations that drove decisions to arrange APCT imaging (Figure 1a&b). In UC, gastroenterologists were less likely to order APCT imaging for diarrhea with rectal bleeding, abdominal pain without peritoneal findings and fever than surgeons and emergency physicians. In CD, there were similar practice patterns between specialities except gastroenterologists were less likely to order APCT imaging for diarrhea with rectal bleeding than surgeons.

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Conclusion(s)

Our survey identified key differences between physician specialties in the perceived rates of positive findings from APCT imaging and practice patterns of CT utilization. These findings will help to guide the development of future multidisciplinary consensus guidelines for the appropriateness of CT imaging in the ED for patients with IBD.

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Disclosure of Interest

None Declared

A212 THE IMPACT OF COMBINED MEDICAL AND SURGICAL TREATMENT FOR PERIANAL CROHN’S DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Multidisciplinary care involving surgical drainage via examinations under anesthesia (EUA) and anti-tumor necrosis factor (TNF) therapy is recommended for perianal Crohn’s disease (PCD). However, the impact of this combined modality approach is not well-established.

Purpose

To determine the impact of combined modality (surgical and anti-TNF) vs. single modality (either surgical or anti-TNF) therapy on fistula healing in perianal Crohn’s disease.

Method

MEDLINE, EMBASE, and Cochrane databases were searched systematically from inception through September 15, 2022 independently in duplicate. We included studies that reported on fistula outcomes after treatment with combined modality vs. single modality therapy for PCD. Surgery was defined as EUA ± seton or closure procedure. Weighted summary estimates with 95% CI were estimated by random effects models. Study quality was determined using an adapted version of the Newcastle-Ottawa scale.

Result(s)

Thirteen studies met inclusion criteria. The total population included 1279 patients: 685 patients treated with single modality therapy with either surgical or anti-TNF therapy and 594 patients treated with combined modality therapy. Patients treated with combined modality therapy were more likely to achieve fistula healing compared to single modality therapy (65.4% vs. 57.7%; OR 1.68; 95% CI 1.03-2.73, p = 0.04) (Figure 1a). In a subgroup analysis, the rates of fistula healing were higher with combined modality therapy than with surgical therapy alone (OR 2.34; 95% CI 0.85-6.46, p = 0.10) but not anti-TNF therapy alone (OR 1.19; 95% CI 0.78-1.81, p = 0.43), although neither comparison was statistically significant (Figures 1b and c). The majority of studies were rated low-quality due to risk of bias from uncontrolled confounding variables.

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Conclusion(s)

Limited high-quality evidence suggests that fistula healing occurs more frequently in patients treated with combined modality therapy. However, the benefit of a combined modality approach appears to be driven mainly by anti-TNF therapy. Further prospective randomized trials are needed to confirm these findings.

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Disclosure of Interest

None Declared

A177 RISK OF VENOUS THROMBOEMBOLISM IN COVID-19 PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED MATCHED COHORT STUDY

Background

Venous thromboembolism (VTE), is associated with significant morbidity and mortality. Inflammation increases the risk of VTE, and it is a well-recognised complication of both inflammatory bowel disease (IBD) and COVID-19.

Purpose

To compare the risk of VTE among individuals with and without IBD following a positive COVID-19 test.

Method

Using health administrative data from Ontario, Canada we conducted a retrospective matched cohort study.All Ontario residents with a positive SARS-CoV-2 PCR test between January 1,2020 and December 30,2021 who had been diagnosed with IBD prior to their COVID-19 infection (identified using a validated algorithm) were matched to 5 individuals without IBD based on year of birth, sex, mean neighbourhood income quintile, date of positive COVID-19 test, and rural/urban residence. Individuals with a cancer diagnosis in the 5 years prior to their first COVID-19 positive test were excluded. Individuals were followed from positive COVID-19 PCR test until VTE event, death, migration out of Ontario or March 31, 2022.VTEs were identified from emergency department or hospitalization data using ICD-10 codes. Incidence rate of VTEs among individuals with IBD were assessed at 1, 6 and 12 months. Proportional cause-specific hazards models compared the risk of VTEs in people with and without IBD, treating death as a competing risk and controlling for vaccination status (2^nd dose ≥14 days prior to positive COVID-19 test) and a history of VTE (VTE in the 5 years prior to infection).

Result(s)

There were 4293 people with IBD (44% Crohn’s disease, mean age ±SD 46.1±17.2 y) matched to 20,207 with out IBD (mean age 45.3±16.8 y) with a positive SARS-CoV-2 PCR test. Within 1 month of a positive COVID-19 test, the crude incidence rate of VTE in individuals with IBD was 4.77(95%CI, 4.75-4.80) per 100,000 person-days compared to 8.25(95%CI, 8.20-8.30) per 100,000 among people without IBD.Within 6 months, these rates were 1.86(95%CI, 1.86-1.87) and 2.12(95%CI, 2.11-2.12) per 100,000 person-days among people with and without IBD, respectivley. Within 12 months, these rates were 1.59(95% CI, 1.58-1.59) and 1.42(95% CI, 1.42-1.42) per 100,000 person-days among people with and without IBD, respectively.After adjusting for vaccination status and history of VTE there was no difference in the risk of VTE for people with and without IBD (HR 1.08, 95%CI, 0.64 to 1.83).

Conclusion(s)

IBD patients with COVID-19 were not more likely to experience a VTE infection compared with the general popluation. The risk of VTE was highest soon after COVID-19 and declined thereafter.

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Disclosure of Interest

None Declared

A166 RISK STRATIFICATION OF EARLY RE-HOSPITALIZATION IN PERSONS WITH INFLAMMATORY BOWEL DISEASES USING MULTIVARIABLE MODELS

Background

Hospitalization for persons with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a significant contributor to morbidity and health care costs in Canada. Recognition of individuals at high risk of re-hospitalization could help inform targeted outpatient interventions that mitigate this risk.

Purpose

The aim of our study is to derive prediction models of risk of early (90-day) re-hospitalization among persons with IBD.

Method

We conducted a retrospective cohort study of all adult persons with IBD admitted to The Ottawa Hospital, Canada, for an acute IBD-related indication between April 2009 - March 2016. Demographic, clinical, and health services variables were obtained through chart review. Persons were linked to population-based health administrative datasets to identify historical and future IBD-related hospitalizations across the greater Ottawa region. Multivariable logistic regression models of 90-day re-hospitalization in persons with CD and UC were derived, and candidate predictors that demonstrated an independent association with the outcome at a p-value of 0.1 were retained. Bootstrap internal validation (200 iterations) was performed on the final models. Model performance and calibration were evaluated using the optimism-corrected c-statistic value and Hosmer-Lemeshow goodness of fit test, respectively. Adjusted odds ratios are reported with 95% confidence intervals (CI). Optimal probability cut points for re-hospitalization were selected to optimize sensitivity, specificity, and the J (Youden’s) index.

Result(s)

There were 524 CD and 248 UC hospitalizations during the study period. Of these, 57 (10.9%) CD and 27 (10.9%) UC hospitalizations were associated with re-hospitalization within 90 days of discharge. Forty-two candidate predictors were tested among CD hospitalizations, and 35 were tested among UC hospitalizations. Four variables were retained in each of the final models. Model performance and calibration for each variable are described in Table 1. The optimal range of probability cut points allowed for a sensitivity/positive predictive value (PPV)/false positive rate (FPR) of 0.72/0.23/0.29 (maximum J-index of 0.43) in the model for CD, and 0.78/0.33/0.19 (maximum J-index of 0.59) in the model for UC, respectively.

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Conclusion(s)

Demographic, clinical, and health services variables at the time of discharge have the potential to help identify persons with IBD at risk of early re-hospitalization, thereby permitting targeted outpatient intervention. Application of the models to our reference cohorts would earmark 1/3 or less of patients for early post-discharge intervention, with the potential to benefit more than 70% of patients destined for early re-hospitalization. Although the PPVs of our models were low, the models incorrectly predicted early re-hospitalization in less than 30% of patients. We are in process of externally validating these models in other jurisdictions across Ontario to test their generalizability.

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None

Disclosure of Interest

None Declared

Patient-Centered Access to IBD Care: A Qualitative Study

Background

Canada has the highest global age-adjusted incidence and prevalence rates of inflammatory bowel disease (IBD). Due to IBD patient volumes and limited resources, challenges to timely access to specialty care have emerged. To address this gap, the aim of this paper was to understand the experiences and perspectives of persons living with IBD with a focus on accessing health care.

Methods

Using a qualitative descriptive approach, patients diagnosed with IBD (≥18 years of age) were purposively sampled from rural and urban gastroenterology clinics and communities across Canada. Co-facilitated by a researcher and patient research partner, 14 focus groups were recorded, transcribed, and coded for themes. Thematic analysis was used to ascertain the congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 individuals participated in the study. The majority of participants were female (41/63, 65%) and from urban/suburban regions (33/63, 52%), with a mean age of 48.39 (range 16-77 years). The analysis generated three main themes: (1) need for patient to be partner, (2) adapting IBD care access to individual context, and (3) patient-defined care priorities should guide access to IBD care.

Conclusions

The complexity of specialty care access for IBD patients cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the impact of these factors on accessing care. Using a patient-centered exploration of barriers and facilitators, IBD specialty care access in Canada can be better understood and improved on provincial and national levels.

The Effectiveness and Safety of Hyperbaric Oxygen Therapy in Various Phenotypes of Inflammatory Bowel Disease: Systematic Review With Meta-analysis

BACKGROUND

Accumulating evidence suggests that hyperbaric oxygen therapy (HBOT) may be effective for inflammatory bowel disease (IBD). Our systematic review aimed to quantify the effectiveness and safety of HBOT in various IBD phenotypes.

METHODS

We performed a proportional meta-analysis. Multiple databases were systematically searched from inception through November 2020 without language restriction. We included studies that reported effectiveness and/or safety of HBOT in IBD. Weighted summary estimates with 95% confidence intervals (Cis) were calculated for clinical outcomes for each IBD phenotype using random-effects models. Study quality was assessed using the Cochrane evaluation handbook and National Institute of Health criteria.

RESULTS

Nineteen studies with 809 patients total were eligible: 3 randomized controlled trials and 16 case series. Rates of clinical remission included 87% (95% CI, 10-100) for ulcerative colitis (n = 42), 88% (95% CI, 46-98) for luminal Crohn's disease (CD, n = 8), 60% (95% CI, 40-76) for perianal CD (n = 102), 31% (95% CI, 16-50) for pouch disorders (n = 60), 92% (95% CI, 38-100) for pyoderma gangrenosum (n = 5), and 65% (95% CI, 10-97) for perianal sinus/metastatic CD (n = 7). Of the 12 studies that reported on safety, 15% of patients (n = 30) had minor adverse events. Study quality was low in the majority of studies due to an absence of comparator arms, inadequate description of concomitant interventions, and/or lack of objective outcomes.

CONCLUSIONS

Limited high-quality evidence suggests that HBOT is safe and associated with substantial rates of clinical remission for multiple IBD phenotypes. Well-designed randomized controlled trials are warranted to confirm the benefit of HBOT in IBD.

A151 RISK FACTORS FOR VENOUS THROMBOEMBOLISM AFTER HOSPITAL DISCHARGE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which is independently associated with venous thromboembolism (VTE). Although the absolute risk of VTE is greatest during hospitalization, the risk remains elevated in the early post-discharge period. The risk factors for VTE during this vulnerable period remain unknown.

Aims

We performed a systematic review and meta-analysis to determine risk factors for VTE in the post discharge period among adult patients with IBD.

Methods

We performed a systematic search of Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials from inception through April 29, 2021 for publications that reported risk factors for VTE during the post-discharge period among patients with IBD. Study eligibility was assessed independently in duplicate without age or language restriction. We defined the post-discharge period as within 6 months of discharge. Pooled summary estimates of adjusted hazard/odds ratios, when available, were calculated for individual risk factors using random effects model with 95% confidence intervals. The analysis was performed when a minimum of three studies were available for a given risk factor. Heterogeneity was assessed using I² statistic. Study quality was assessed using an adapted version of the National Institute of Health criteria.

Results

We identified 10 studies from a total of 4339 abstracts that met our inclusion criteria: 8 population-based studies, 1 multicenter observational study and 1 single center observational study. Risk factors for post-discharge VTE were assessed at 6 weeks in 1 study, 1 month in 5 studies, 3 months in 2 studies, and 6 months in 2 studies. The variables assessed in our meta-analysis are reported in Table 1. Exposure to corticosteroid (odds ratio [OR], 1.77; 95% CI, 1.53–2.06) but not biologics (OR, 1.21; 95% CI 0.80–1.82) was associated with an increased risk of VTE. Furthermore, greater length of stay (OR 1.49; 95% CI, 1.01–2.20), ulcerative colitis (OR 1.41; 95% CI, 1.19–1.66), history of malignancy (OR 1.35; 95% CI, 1.12–1.62), and surgery during admission (OR 1.26; 95% CI, 1.12–1.42) but not female sex (OR 0.98; 95% CI, 0.88–1.10) or surgery type (OR 1.09; 95% CI, 0.75–1.57) were associated with increased risk of VTE after discharge. Overall, the study quality was rated as fair.

Conclusions

In our meta-analysis, which consisted of moderate quality of evidence, we identified multiple risk factors associated with VTE in the post-discharge period. This work will help inform which factors should be considered for developing point of care clinical predictive models to help guide when extended VTE prophylaxis is required.

Funding Agencies

None

A168 UTILITY OF FOLLOW-UP PANCOLONIC DYE SPRAY CHROMOENDOSCOPY FOR THE DETECTION AND TREATMENT OF DYSPLASTIC LESIONS IDENTIFIED DURING HIGH-DEFINITION WHITE-LIGHT ENDOSCOPY IN PATIENTS WITH COLONIC INFLAMMATORY BOWEL DISEASE

Background

Patients with inflammatory bowel disease (IBD) involving the colorectum are at higher risk for the development of flat and poorly delineated dysplastic lesions. Pancolonic dye spray chromoendoscopy (DCE) can represent an adjunct to white light endoscopy (WLE) that enhances detection and delineation of such lesions.

Aims

We evaluated the utility of follow-up DCE for lesion detection and treatment in patients with IBD who had visible (polypoid or flat lesions) or invisible (identified in non-targeted biopsies) dysplasia detected during high-definition (HD)-WLE.

Methods

We retrospectively studied patients with colonic IBD from The Ottawa Hospital who underwent DCE by a trained endoscopist, as follow-up for dysplasia detected during HD-WLE, over a 7-year time period (2013–2020). We collected demographic and disease-specific variables.

Results

Twenty-four patients were included (mean age 56.7±13.8 years, 50.0% male, 70.8% ulcerative colitis, mean disease duration 18.0±11.0 years, 70.8% moderate or severe disease activity historically, and 41.7% remote history of dysplasia). Seventeen (70.8%) patients were referred following detection of invisible dysplasia; the remainder (29.2%) were referred for surveillance of poorly defined visible dysplastic lesions. For those referred following detection of invisible dysplasia, DCE identified visible dysplasia at the same site in 8/17 (47.1%) patients, at a different site in 6/17 (35.3%) patients, and no dysplasia in 3/17 (17.6%) patients. DCE identified 1.39±1.50 new visible dysplastic lesions per patient that were not identified on index HD-WLE. DCE upgraded the highest grade of dysplasia and diagnosed colorectal cancer in 2/24 (8.3%) patients, which was missed on index HD-WLE. Endoscopic resection was successful in 23/34 (76.7%) dysplastic lesions identified on DCE. However, DCE was unable to facilitate lesion resection in three patients due to advanced lesion characteristics. Follow-up data was available for 17/24 (70.8%) patients (mean 0.88±0.58 years). Of these patients, 7/17 (41.2%) developed subsequent dysplasia, including 4/17 (23.5%) at a site of prior invisible dysplasia, 2/17 (11.8%) at sites of prior visible dysplasia, and 1/17 (5.88%) at a different site. One of these patients developed high-grade dysplasia requiring resection.

Conclusions

In this study, DCE is a valuable tool for dysplasia detection and treatment in persons with colonic IBD who have ill-defined dysplasia identified during HD-WLE. Given some patients developed dysplasia following DCE in our cohort, it is important to maintain close follow-up and obtain biopsies around sites of prior invisible and visible dysplasia. Further studies are required to validate our findings.

Funding Agencies

None

A153 STRATEGIES TO DISTINGUISH PERIANAL FISTULAS RELATED TO CROHN’S DISEASE FROM CRYPTOGLANDULAR DISEASE: SYSTEMATIC REVIEW WITH META-ANALYSIS

Background

Differentiating between perianal fistulas related to cryptoglandular disease (CGD) and Crohn’s disease (CD) is essential to guide disease specific management.

Aims

We aimed to assess the ability of diagnostic strategies to differentiate between CD from CGD in patients with perianal fistulas.

Methods

We performed a diagnostic accuracy systematic review and meta-analysis. Electronic databases (MEDLINE, Embase, Web of Science, CENTRAL) were systematically searched from inception through February 2021 for studies that assessed a diagnostic test’s ability to distinguish fistula types. We calculated weighted summary estimates with 95% confidence intervals for sensitivity and specificity by bivariate analysis, using fixed effects models when data was available from two or more studies. The QUADAS tool was used to assess study quality.

Results

Twenty-one studies were identified and included: clinical symptoms (2 studies; n = 154 patients), MRI characteristics (3 studies; n = 296 patients), ultrasound characteristics (7 studies; n = 1003 patients), video capsule endoscopy (2 studies; n = 44 patients), fecal calprotectin (1 study; n = 56 patients) and various biomarkers (8 studies; n = 440 patients). MRI and ultrasound characteristics had the most robust data. Rectal inflammation, multiple-branched fistula tracts and abscesses on pelvic MRI, and the Crohn’s Ultrasound Fistula Sign, fistula debris and bifurcated fistulas on pelvic ultrasonography had high specificity (range, 80–95% vs. 89–96%) but poor sensitivity (range, 17–37% vs. 31–63%), respectively. Fourteen of twenty-one studies had risk of bias on at least one of the QUADAS domains.

Conclusions

Limited high-quality evidence suggest that imaging characteristics may help discriminate CD from CGD in patients with perianal fistulas. Larger, prospective studies are needed to confirm these findings and to evaluate if combining multiple diagnostic tests can improve diagnostic sensitivity.

Funding Agencies

None

A152 NATURAL HISTORY OF SMALL BOWEL STRICTURES IN CROHN’S DISEASE

Background

Crohn’s disease (CD) is a progressive inflammatory disease that often results in intestinal complications such as small bowel (SB) strictures. SB strictures are frequently associated with substantial morbidity and may require surgery. The natural history of SB strictures in the era of biologic treatments has not been well characterized.

Aims

To determine the proportion of patients with SB strictures who develop complicated stricturing disease and to identify clinical factors associated with this outcome.

Methods

We performed a retrospective observational study between January 1, 2009, and May 31, 2019. Adults (>17 years) with CD who underwent an abdominal CT scan or MRI were identified from our institutional data warehouse using the ICD-10 code K50* and local imaging codes. Reports were reviewed to determine the imaging protocol and the presence of SB strictures. We included CT or MR enterography studies that reported SB strictures and excluded encounters with incomplete records, diverting ostomies, ileal J-pouches, and patients evaluated for pre-surgical planning. Each imaging study was included as a separate encounter in our analysis. Our primary endpoint was the development of complicated stricturing disease defined as stricture-related hospitalization or surgery. Time to event was estimated using Kaplan–Meier analysis and associated factors were assessed by multivariable Cox proportional hazard models adjusted for age, sex, exposure to biologics and corticosteroids.

Results

A total of 6583 unique imaging studies were identified: 926 (14%) studies reported SB strictures without penetrating complications, and 568 (9%) studies reported penetrating complications. A total of 503 (8%) studies, performed on 330 patients, met our inclusion criteria: mean age 42 (SD, 15.1) years and 166 (50%) males. Overall, 144 (44%) patients developed complicated stricturing disease: 106 (32%) patients required surgery and 132 (40%) patients were hospitalized for stricture related complications. Of the patients who underwent surgery, the mean time to surgery was 13 months (SD, 18.3) and among patients who required hospitalization, mean time to hospitalization was 15 months (SD, 17.8) (Figure 1). On multivariable analysis, exposure to corticosteroids (aHR 2.11; 95% CI, 1.54–2.90; p<0.001) but not biologics (aHR 1.1; 95% CI, 0.84–1.43; p<0.48) at the time of the imaging study was independently associated with the development of complicated stricturing disease.

Conclusions

In our single center study, complicated stricturing disease occurred in 44% of patients with CD who had a SB stricture and was associated with corticosteroids but not biologics.These findings, along with additional clinical and radiologic factors may help in the development of clinical support tools to identify patients at highest risk of developing complicated stricturing disease.

Funding Agencies

None

A148 IMPACT OF EXAMINATION UNDER ANESTHESIA PRIOR TO ANTI-TUMOR NECROSIS FACTOR THERAPY ON FISTULA HEALING FOR PERIANAL CROHN’S DISEASE PATIENTS: A COMPARATIVE COHORT STUDY

Background

Current guidelines recommend a combined approach consisting of an examination under anesthesia (EUA) and anti-TNF therapy for perianal Crohn’s Disease (PCD). However, the impact of this approach on fistula healing and long-term outcomes is unknown.

Aims

To assess the effect of EUA on fistula healing and long term outcomes in patients with perianal Crohn’s disese who are treated with anti-TNF therapy.

Methods

We performed a retrospective, single-center, comparative cohort study between 2009 and 2019. We compared patients with PCD who received EUA prior to anti-TNF therapy (combined therapy) to anti-TNF therapy alone. Our primary outcome was fistula closure by clinical assessment. Secondary outcomes included subsequent local surgery and fecal diversion. Logistic regression and multivariable cox-proportional hazard models adjusted for abscesses, concomitant immunomodulators, and time to anti-TNF initiation were performed.

Results

A total of 155 patients underwent 188 distinct anti-TNF starts: 66 (35%) after an EUA. Patients who underwent an EUA prior to anti-TNF therapy were more likely to have an abscess (50% vs. 15%; p < 0.001) and concomitant immunomodulator usage (64% vs. 50%; p = 0.07). Otherwise, there were no differences between cohorts in age, smoking status, disease duration, and location of luminal disease. There were no significant differences in fistula closure at 3, 6, or 12 months between cohorts overall (Table 1). The results remained consistent in sensitivity analyses that excluded patients with abscesses and prior biologic treatment failure. The results were also similar when defining the combined therapy group as those with setons. After a median follow-up of 4.6 years (IQR, 5.95) patients who underwent an EUA prior to anti-TNF therapy were more likely to require a subsequent EUA (aHR 2.2; 95% CI, 1.3–3.6) (Figure 1) but not fecal diversion (aHR 1.3; 95% CI, 0.45–3.9).

Conclusions

In this single center study, combined therapy (EUA prior to anti-TNF therapy) was not associated with improved clinical outcomes compared with anti-TNF therapy alone. These findings suggest that EUA may not be necessary in every patient with PCD prior to initiation of anti-TNF therapy. Future prospective studies that control for fistula complexity are warranted.

Table 1: Unadjusted rates of fistula closure after anti-TNF therapy comparing patients with and without an exam under anesthesia

Funding Agencies

University of Ottawa Department of Medicine

THE INFLUENCE OF THYROIDECTOMY ON ALIMENTARY GLYCOSURIA

1. Removal of the thyroid glands causes a rise in the assimilation limit for dextrose. 2. If the parathyroids are left, this result is permanent. 3. The thyroids probably inhibit normally the direct combustion of the sugar in the muscles.

Stereologic estimation of nucleolar volume in ocular melanoma: a comparative study of size estimators with prognostic impact

The aim of this study was to investigate the relationships between one-, two-, and three-dimensional histomorphometric estimators of nucleolar size in ordinary histologic sections of uveal melanomas from 144 patients. In addition, the prognostic value of the various size parameters was studied. The following estimates were obtained: the mean diameter of the 10 largest nucleoli, the mean nucleolar profile area and associated standard deviation of the nucleolar profile area, the volume-weighted mean nucleolar volume (nucleolar vv), and the macroscopic, largest tumor dimension. All histomorphometric parameters were highly intercorrelated (r > .75). The correlation between the largest tumor dimension and the nucleolar vv was rather poor (r = .35). The efficiency of the sampling scheme for estimation of the nucleolar vv was very high; more than 95% of the totally observed variation was contributed by biologic differences between tumors. Single-term Cox analyses demonstrated a highly significant prognostic value of all five investigated, quantitative variables. Evaluation in a multivariate Cox model showed, however, that only the nucleolar vv and the largest tumor dimension were independent prognostic covariates at the chosen level of significance (5%). Unbiased, shape-independent estimates of the nucleolar vv offered superior prediction of clinical outcome, as compared with lower-dimensional, shape-dependent histomorphometric estimators of nucleolar size.

Prognostic value of nucleolar size and size pleomorphism in choroidal melanomas

Morphometric estimates of nucleolar size have been shown to possess a high prognostic value in patients with uveal melanomas. The authors investigated various quantitative estimators of the mean size and pleomorphism of nucleoli in choroidal melanomas from a consecutive series of 95 Danish patients treated solely by enucleation of the melanoma-bearing eye in the period from 1977 to 1979. The independent prognostic value of the quantitative histopathological variables was evaluated using multivariate Cox analysis. Apart from patient data and information about tumor extent, histological type of melanoma, and largest macroscopic tumor dimension (LTD), the following histomorphometric estimates were obtained: mean diameter of the 10 largest nucleoli (MLN), point-sampled mean nucleolar profile area (nucleolar ao) and the associated standard deviation of nucleolar ao, the volume-weighted mean nucleolar volume (nucleolar vv), and associated variance and relative variance of nucleolar volume (nucleolar Varv(v) and nucleolar CVv(v), respectively). The intra-observer reproducibility of estimates of nucleolar vv was tested in 20 cases and found acceptable (r = 0.84, 2p = 3.6.10(-6)). Correlation analysis indicated that estimates of nucleolar vv and nucleolar Varv(v) are identical in choroidal melanomas, except for a scaling factor. There were no differences of the grouped means of histomorphometric estimates in choroidal melanomas that showed intra- or extra-ocular extension (2p > 0.13). LTD was of the same magnitude in all histological types of melanoma (2p = 0.69). Estimates of nucleolar vv and associated estimates of nucleolar volume pleomorphism were increased in melanomas of the mixed and epitheloid cell type (2p < 0.005). Single factor analyses showed that all quantitative histopathological variables were of prognostic value in the studied patients, in addition to the histological type of tumor. However, using multivariate analysis, only estimates of LTD, MLN, nucleolar vv, and of nucleolar volume pleomorphism had independent prognostic value.

A simple, efficient, and reproducible method for estimating the malignant potential of uveal melanoma from routine H & E slides

The malignant potential of 100 intraocular melanomas was assessed by determining the mean of the ten largest nucleoli (MTLN) using a modification of previously described techniques. For each microslide, a five millimeter path through the central portion of the tumor was traversed on a manually controlled mechanical stage. Selected nucleoli in this area were measured at 2000x power using a digital filar micrometer. In their reproducibility and correlation with malignant potential, these measurements proved comparable to standard deviation of nucleolar area (SDNA), which has been well documented as an objective histologic predictor of mortality from intraocular melanoma. This new method for measuring MTLN requires less than 11 minutes per case, compared to an average of 28 minutes for the original method. The measurements of SDNA required approximately 40 minutes per case and a much more elaborate system than that needed for MTLN.