Granuloma Presence at Initial Surgery Predicts Need for Repeat Surgery Independent of Rutgeerts Score in Crohn's Disease

BACKGROUND

Approximately half of Crohn's disease (CD) patients experience recurrence and need for repeat resections, highlighting need for prognostic biomarkers. Presence of epithelioid granuloma on surgical tissue and high Rutgeerts endoscopic score are associated with postoperative CD clinical recurrence. We sought to evaluate presence of epithelioid granuloma at first surgery and Rutgeerts score as a combined risk assessment for CD surgical recurrence.

METHODS

Our study included consented CD patients who underwent initial ileocecal resection and were prospectively followed postoperatively. From 2009 to 2019, 418 CD patients underwent initial ileocecal resection with >4 years of follow-up, including postoperative endoscopic assessment (Rutgeerts score).

RESULTS

Postoperative CD patients were grouped based on granuloma presence (30.6%; n = 128) or absence (69.4%; n = 290). Endoscopic recurrence (defined as Rutgeerts score ≥i2) was similar between the granuloma (26%) and no granuloma (25%) groups, respectively (P = .82). Patients with granuloma and CD endoscopic recurrence at first postoperative endoscopy had higher number of bowel surgeries compared with all other groups (no granuloma or CD endoscopic recurrence, P = .007; no granuloma but CD endoscopic recurrence present, P = .04; granuloma present and no CD endoscopic recurrence, P = .04). Epithelioid granuloma presence was associated with 1.65 times higher risk of subsequent surgery independently from first postoperative endoscopic recurrence Rutgeerts score.

CONCLUSIONS

Granuloma presence on initial surgical histology is immediately available and identifies high-risk CD patients who may benefit from early postoperative treatment, and these precision intervention trials are warranted.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A nomogram incorporating ileal and anastomotic lesions separately to predict the long-term outcome of Crohn's disease after ileocolonic resection

Background

The Rutgeerts score (RS) is widely used to predict postoperative recurrence after ileocolonic resection for Crohn's disease (CD) based on the severity of lesions at the neoterminal ileum and anastomosis (RS i0-i4). However, the value of anastomotic ulcers remains controversial.

Objectives

Our aim was to establish a nomogram model incorporating ileal and anastomotic lesions separately to predict the long-term outcomes of CD after ileal or ileocolonic resection.

Design

A total of 136 patients with CD were included in this retrospective cohort study.

Methods

Consecutive CD patients who underwent ileal or ileocolonic resections with postoperative ileocolonoscopy evaluation within 1 year after the surgery were included. The primary endpoint was postoperative clinical relapse (CR). An endoscopic classification separating ileal and anastomotic lesions was applied (Ix for neoterminal ileum lesions; Ax for anastomotic lesions). A nomogram was constructed to predict CR. The performance of the model was evaluated by the receiver-operating characteristic (ROC) curve and decision curve analysis (DCA).

Results

CR was observed in 47.1% (n = 64) of patients within a median follow-up of 26.9 (interquartile range, 11.4-55.2) months. The risk of CR was significantly higher in patients with an RS ⩾ i2 assessed by the first postoperative endoscopy compared with patients with an RS ⩽ i1 (p < 0.001). Moreover, the cumulative rate of CR was significantly higher in patients with ileal lesions (I1-4) compared with patients without (I0) (p < 0.001). Besides, patients with anastomotic lesions (A1-3) had significantly higher rates of CR than patients without (A0) (p = 0.002). A nomogram, incorporating scores of postoperative ileal or anastomotic lesions, sex, L2-subtype and perianal disease, was established. The DCA analysis indicated that the nomogram had a higher benefit for CR, especially at the timeframe of 24-60 months after index endoscopy, compared to the traditional RS score.

Conclusion

A nomogram incorporating postoperative ileal and anastomotic lesions separately was developed to predict CR in CD patients, which may serve as a practical tool to identify high-risk patients who need timely postoperative intervention.

The Performance of the Rutgeerts Score, SES-CD, and MM-SES-CD for Prediction of Postoperative Clinical Recurrence in Crohn's Disease

BACKGROUND

We compared the Simple Endoscopic Score for Crohn's Disease (SES-CD) and Modified Multiplied SES-CD (MM-SES-CD) scores with the Rutgeerts score for predicting clinical recurrence (CR) of postoperative Crohn's disease (CD).

METHODS

This post hoc analysis of the prospective, multicenter, randomized, double-blind, placebo-controlled trial comparing remicade and placebo in the prevention of recurrence in Crohn's disease patients undergoing surgical resection who are at an increased risk of recurrence (PREVENT) study used receiver operating characteristic curve analyses to compare the Rutgeerts, SES-CD, and MM-SES-CD scores at week 76 for subsequent CR by week 104 in 208 participants. Multivariate logistic regression models evaluated cutoffs for the odds of experiencing CR by week 104, after adjustment for confounders. CR was defined as Crohn's Disease Activity Index score ≥200 and ≥70-point increase from baseline (or development of fistulas, abscesses, or treatment failure) and endoscopic recurrence by week 104, defined as Rutgeerts score ≥i2.

RESULTS

The week 76 Rutgeerts score predicted CR by week 104 with fair accuracy (area under the receiver-operating characteristic curve [AUC], 0.74; 95% confidence interval [CI], 0.65-0.83), which was similar to the SES-CD ileum score (AUC, 0.72; 95% CI, 0.64-0.80) and the MM-SES-CD ileum score (AUC, 0.72; 95% CI, 0.63-0.80). Compared with cutoffs by the other scores, the MM-SES-CD total score ≥26 at week 76 had the highest odds ratio to predict CR by week 104. Patients with a week 76 MM-SES-CD total score ≥26 were 4.41 times (95% CI, 2.06-9.43, P < .001) more likely to have CR by week 104 compared with those with an MM-SES-CD total score <26.

CONCLUSIONS

The SES-CD and MM-SES-CD perform similarly to the Rutgeerts score for predicting subsequent CR of postoperative CD. The MM-SES-CD threshold of ≥26 was predictive of postoperative CR. Clinicians and trialists could consider using the SES-CD or MM-SES-CD to assess postoperative CD given their ability to capture colonic disease recurrence and predict CR.

Rate and risk factors of postoperative endoscopic recurrence of moderate- to high-risk Crohn's disease patients - A real-world experience from a Middle Eastern cohort

BACKGROUND

Crohn's disease (CD) frequently recurs after intestinal resection. Azathioprine (AZA) and biological therapies have shown efficacy in preventing postoperative recurrence (POR). Data on POR from Middle Eastern populations is lacking. This study aimed to evaluate the rate of endoscopic POR in a cohort of CD patients who underwent ileocecal resection (ICR), and to assess the effectiveness of AZA and biological therapies in reducing the risk of disease recurrence.

METHODS

We performed a retrospective cohort study on 105 CD patients followed at our center, who underwent ileal resection and were at moderate to high risk for POR. Clinical and laboratory data were collected; the primary endpoint was post ICR endoscopic recurrence at 24 months defined by Rutgeerts' score of i2 or more despite treatment.

RESULTS

In total, 105 patients with Crohn's disease met our inclusion criteria; 76.2% were in remission and did not have endoscopic POR at 24 months. Further, 41.9% were on biological therapy, and 34.3% were mainly on AZA. Out of the 28.2% who had POR, approximately 15% were on biological therapies. Penetrating phenotype was the only predictive factor for decreasing POR (OR = 0.19, 95% CI: 0.04-0.98, P = 0.04) as identified in multiple logistic regression analysis.

CONCLUSIONS

The use of biological therapies post-surgery was not superior than AZA in reducing the endoscopic POR for mod- high risk CD patients. Only penetrating behavior of the CD was associated with significantly lower risk of endoscopic recurrence. This finding is worth further investigation in more robust study designs and among larger samples of patients.

A Role for CXCR3 Ligands as Biomarkers of Post-Operative Crohn's Disease Recurrence

BACKGROUND AND AIMS

Crohn's disease [CD] recurrence following ileocolic resection [ICR] is common. We sought to identify blood-based biomarkers associated with CD recurrence.

METHODS

CD patients undergoing ICR were recruited across six centres. Serum samples were obtained at post-operative colonoscopy. A multiplex immunoassay was used to analyse 92 inflammation-related proteins [Olink Proteomics]. Bayesian analysis was used to identify proteins associated with increasing Rutgeerts score. Identified proteins were used in receiver operating characteristic [ROC] analysis to examine the ability to identify CD recurrence [Rutgeerts score ≥i2]. Existing single cell data were interrogated to further elucidate the role of the identified proteins.

RESULTS

Data from 276 colonoscopies in 213 patients were available. Median time from surgery to first and second colonoscopy was 7 (interquartile range [IQR] 6-9) and 19 [IQR 16-23] months, respectively. Disease recurrence was evident at 60 [30%] first and 36 [49%] second colonoscopies. Of 14 proteins significantly associated with Rutgeerts score, the strongest signal was seen for CXCL9 and MMP1. Among patients on anti-tumour necrosis factor drugs, CXCL9 and CXCL11 were most strongly associated with Rutgeerts score. Both are CXCR3 ligands. Incorporation of identified proteins into ROC analysis improved the ability to identify disease recurrence as compared to C-reactive protein alone: area under the curve [AUC] 0.75 (95% confidence interval [CI]: 0.66-0.82] vs 0.64 [95% CI 0.56-0.72], p = 0.012. Single cell transcriptomic data provide evidence that innate immune cells are the primary source of the identified proteins.

CONCLUSIONS

CXCR3 ligands are associated with CD recurrence following ICR. Incorporation of novel blood-based candidate biomarkers may aid in identification of CD recurrence.

Endoscopic scoring systems for the evaluation and monitoring of disease activity in Crohn's disease

Crohn's disease is a chronic relapsing idiopathic condition that can affect any part of the gastrointestinal tract. It has been shown that mucosal healing is associated with improved clinical outcomes such as reduced risk of surgery, hospitalization and complications. Nowadays mucosal healing is considered the optimal target of medical therapy. To evaluate the mucosa in an objective and standardized manner, it is important to rely on accurate and validated endoscopic scores. The Crohn's disease endoscopic index of severity, the simple endoscopic score for Crohn's disease as well as the Rutgeerts score will be reviewed. Their clinical implications and limitations will be discussed.

Endoscopic Surveillance in Inflammatory Bowel Disease

Introduction

Endoscopy is a key technique for the surveillance of patients with inflammatory bowel diseases (Crohn's disease (CD) and ulcerative colitis). Indication to perform endoscopy for surveillance includes assessment of response to therapy, postoperative surveillance, and surveillance for intraepithelial neoplasia.

Methods

In addition to personal experience, a literature search was performed and the guidelines were consulted.

Results and Conclusion

Endoscopy is the gold standard in the long-term assessment of mucosal healing and in the short-term control of response to intensified therapy. For postoperative surveillance in CD, mucosal changes (as graded by the Rutgeerts score) are predictive of clinical recurrence. For neoplasia surveillance, virtual chromoendoscopy has not (yet) replaced conventional chromoendoscopy. Surveillance can be optimized by the use of high-definition endoscopes as well as (pan-)chromoendoscopy and requires time to scrutinize the mucosa. This approach seems to be superior to random biopsies.

Disagreement Among Gastroenterologists Using the Mayo and Rutgeerts Endoscopic Scores

BACKGROUND

Endoscopy is routinely performed in patients with inflammatory bowel disease to evaluate disease severity and guide important clinical decisions. However, variability in the interpretation of endoscopic findings can significantly impact patient management.

METHODS

Fifty-eight gastroenterologists were invited to participate in an online survey including pictures and video recordings of colonoscopies performed in patients with ulcerative colitis (UC) and Crohn's disease (CD). Participants were asked to rate the colorectal mucosa in patients with UC using the Mayo endoscopic subscore (MES), and the neo-terminal ileum and anastomosis in operated patients with CD using the Rutgeerts score (RS). Overall interrater agreement (IRA) and for several key end points was assessed using Krippendorff's alpha test.

RESULTS

The IRAs for the MES and RS were 0.47 (95% confidence interval [CI], 0.41-0.54) and 0.33 (95% CI, 0.28-0.38). The IRAs for UC mucosal healing (MES ≤ 1) and complete mucosal healing (MES = 0) were 0.57 (95% CI, 0.40-0.72) and 0.89 (95% CI, 0.73-1) and for CD postoperative recurrence (RS ≥ i2), and IRAs for severe postoperative recurrence (RS ≥ 3) were 0.44 (95% CI, 0.24-0.62) and 0.54 (95% CI, 0.36-0.71), respectively. Unexpectedly, although clinical information significantly influenced the IRA, participant expertise and consultation of scores did not produce significant changes in the IRA.

CONCLUSIONS

A high rate of disagreement in endoscopic scoring was found in this study, even among experienced physicians. The variability in the assessment of mucosal healing and postoperative recurrence may translate into relevant differences in patient management.

Training Programs on Endoscopic Scoring Systems for Inflammatory Bowel Disease Lead to a Significant Increase in Interobserver Agreement Among Community Gastroenterologists

BACKGROUND AND AIMS

Endoscopic outcomes are increasingly used in clinical trials and in routine practice for inflammatory bowel disease [IBD] in order to reach more objective patient evaluations than possible using only clinical features. However, reproducibility of endoscopic scoring systems used to categorize endoscopic activity has been reported to be suboptimal. The aim of this study was to analyse the inter-rated agreement of non-dedicated gastroenterologists on IBD endoscopic scoring systems, and to explore the effects of a dedicated training programme on agreement.

METHODS

A total of 237 physicians attended training courses on IBD endoscopic scoring systems, and they independently scored a set of IBD endoscopic videos for ulcerative colitis [with Mayo endoscopic subscore], post-operative Crohn's disease [with Rutgeerts score] and luminal Crohn's disease (with the Simple Endoscopic Score for Crohn's Disease [SESCD] and Crohn's Endoscopic Index of Severity [CDEIS]). A second round of scoring was collected after discussion about determinants of discrepancy. Interobserver agreement was measured by means of the Fleiss' kappa [kappa] or intraclass correlation coefficient [ICC] as appropriate.

RESULTS

The inter-rater agreement increased from kappa 0.51 (95% confidence interval [95% CI] 0.48-0.55) to 0.76 [95% CI 0.72-0.79] for the Mayo endoscopic subscore, and from 0.45 [95% CI 0.40-0.50] to 0.79 [0.74-0.83] for the Rutgeerts score before and after the training programme, respectively, and both differences were significant [P < 0.0001]. The ICC was 0.77 [95% CI 0.56-0.96] for SESCD and 0.76 [0.54- 0.96] for CDEIS, respectively, with only one measurement.

DISCUSSION

The basal inter-rater agreement of inexperienced gastroenterologists focused on IBD management is moderate; however, a dedicated training programme can significantly impact on inter-rater agreement, increasing it to levels expected among expert central reviewers.

Correlation of the Rutgeerts score and recurrence of Crohn's disease in patients with end ileostomy

Background

Recurrence of Crohn’s disease (CD) can occur after surgery, including end ileostomy (EI). The Rutgeerts score (RS) was developed to predict postsurgical CD recurrence via ileocolonoscopy in patients having ileocolonic resection. The role of ileoscopic evaluation via stoma for assessing recurrence of CD has not been investigated. The aim of this study was to evaluate the role of ileoscopy for predicting disease recurrence in CD patients after EI with the use of RS.

Methods

A total of 73 eligible CD patients with at least two ileoscopies in our institution following EI were included. Mucosal inflammation of the neo-terminal ileum was graded based on the RS. The primary outcomes were the need for endoscopic stricture dilation and subsequent surgery due to recurrence of disease. The secondary outcomes were CD-related hospitalization and the need to escalate CD-associated medications.

Results

The median duration of CD until EI was 9 years (interquartile range: 4-13 years), and the median duration from EI to the first ileoscopy was 28 months (interquartile range: 11-93 months). The RSs in the neo-terminal ileum close to EI were calculated, and subjects were divided into two groups: the normal RS group with the score being zero (n = 25) and the abnormal RS group with the RS score being ≥1 (n = 48). Patients in the abnormal RS group were more likely to have recurrence of CD (92% vs 27%) and need endoscopic dilation of stricture (40% vs 10%), subsequent bowel surgery (68% vs 15%), disease-related hospitalizations (80% vs 23%) and escalation of CD medications (64% vs 25%) than those in the normal RS group. Time-to-event analysis showed that patients in the abnormal RS group were at a higher risk of endoscopic dilation (odds ratio (OR) = 1.5; 95% CI: 1.09–1.9), need of second bowel surgery (OR = 1.5; 95%CI: 1.2–1.8) and disease-related hospitalizations (OR = 1.3; 95%CI: 1.1–1.6) after adjusting for factors such as duration from surgery to sensor, duration of disease and the patient’s sex (all P < 0.001). Further multivariable analysis showed that patients in the abnormal RS group were more likely to need escalation of CD-related medications after adjusting for duration from surgery and age (OR = 5.3; 95% CI: 1.7–16.5; P = 0.004).

Conclusion

RS can be used to predict the recurrence of CD in patients with EI. A high RS score based on ileoscopy appeared to be associated with poor outcomes. This may be considered a useful decision-making tool for monitoring disease after ileostomy surgery.

Ileal or Anastomotic Location of Lesions Does Not Impact Rate of Postoperative Recurrence in Crohn's Disease Patients Classified i2 on the Rutgeerts Score

BACKGROUND

The Rutgeerts score with 5 grades of severity (i0-i4) is a suitable endoscopic model to predict clinical recurrence following ileocolonic resection in Crohn's disease (CD). Definition of grade i2 includes lesions confined to the ileocolonic anastomosis (i2a) or moderate lesions on the neo-terminal ileum (i2b). The aim of the present study was to evaluate the probability of clinical recurrence in i2a and i2b patients.

METHODS

This multicenter retrospective study included all CD patients classified i2 at the first postoperative ileocolonoscopy. The primary outcome was to evaluate the probability of clinical recurrence in patients classified i2a and i2b. The secondary outcome was to compare the rate of global recurrence of CD.

RESULTS

Fifty patients were included: 23 were classified i2a and 27 were classified i2b. The median duration of follow-up was 40 (18.0-80.4) months in the i2a group and 53.5 (25.0-69.0) months in the i2b group (p = 0.9). The probability of clinical recurrence was not significantly different between patients classified i2a and i2b (p = 0.64). Median time to clinical recurrence after the first ileocolonoscopy and probability of global CD recurrence were not different between the two groups (p ≥ 0.19).

CONCLUSIONS

The rate of clinical postoperative recurrence is not different in i2a and i2b patients. These results suggest that the same therapeutic strategy should be used in all patients classified i2 on the Rutgeerts score whatever the location of postoperative CD recurrence.

Interobserver Variation Study of the Rutgeerts Score to Assess Endoscopic Recurrence after Surgery for Crohn's Disease

BACKGROUND

After resection surgery for Crohn's disease, recurrence of endoscopic lesions at the site of the anastomosis or in the neoterminal ileum is graded according to the Rutgeerts score (RS). The goal of this study was to test the interobserver variability for RS.

METHODS

Thirteen trained endoscopists evaluated the RS on 39 videotapes of patients who had undergone resection for Crohn's disease with an ileocolonic anastomosis 6 months earlier. Videotapes were randomly assigned to endoscopists through a balanced incomplete block design. Each videotape was scored independently by four endoscopists, and each endoscopist evaluated 12 videotapes, making a total of 156 videotape assessments. Reproducibility levels of the RS were assessed through unweighted kappa estimates among multiple raters. The proportion of inappropriate therapeutic initiation was estimated by randomly selecting one endoscopist for each videorecording, assuming that the majority of endoscopists correctly classified endoscopic recurrence.

RESULTS

The kappa estimates were 0.43 (95% confidence interval: 0.33-0.52) for the RS on a 5-grade scale, 0.47 (0.28-0.66) for RS < i2 vs. ≥ i2, and 0.64 (0.42-0.85) for RS ≤ i2 vs. > i2. The percentages of inappropriate therapeutic initiation were 12.8% (3.8-21.9) when initiation was triggered by a RS ≥ i2 and 8.3% (1.1-15.6) when initiation was triggered by a RS > i2 (p = 0.41).

CONCLUSION

The reproducibility of the RS was moderate, especially when differentiating <i2 from ≥i2, which may lead to incorrect therapeutic decisions in >10% of patients.