scholarly journals Anastomotic Ulcers After Ileocolic Resection for Crohn’s Disease Are Common and Predict Recurrence

2019 ◽  
Vol 26 (7) ◽  
pp. 1050-1058 ◽  
Author(s):  
Robert P Hirten ◽  
Ryan C Ungaro ◽  
Daniel Castaneda ◽  
Sarah Lopatin ◽  
Bruce E Sands ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Multivariable Analysis ◽  
Disease Recurrence ◽  
Ileocolic Resection ◽  
Anastomotic Ulcer ◽  
Endoscopic Recurrence ◽  
Academic Center ◽  
Endoscopic Remission ◽  
The Impact

Abstract Background Crohn’s disease recurrence after ileocolic resection is common and graded with the Rutgeerts score. There is controversy whether anastomotic ulcers represent disease recurrence and should be included in the grading system. The aim of this study was to determine the impact of anastomotic ulcers on Crohn’s disease recurrence in patients with prior ileocolic resections. Secondary aims included defining the prevalence of anastomotic ulcers, risk factors for development, and their natural history. Methods We conducted a retrospective cohort study of patients undergoing an ileocolic resection between 2008 and 2017 at a large academic center, with a postoperative colonoscopy assessing the neoterminal ileum and ileocolic anastomosis. The primary outcome was disease recurrence defined as endoscopic recurrence (>5 ulcers in the neoterminal ileum) or need for another ileocolic resection among patients with or without an anastomotic ulcer in endoscopic remission. Results One hundred eighty-two subjects with Crohn’s disease and an ileocolic resection were included. Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development. One hundred eleven patients were in endoscopic remission on the first postoperative colonoscopy. On multivariable analysis, anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64; 95% CI, 1.21–10.95; P = 0.02). Sixty-six subjects with anastomotic ulcers underwent a second colonoscopy, with 31 patients (79.5%) having persistent ulcers independent of medication escalation. Conclusion Anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection. No factors are associated with their development. They are associated with Crohn’s disease recurrence and are persistent.

scholarly journals P274 The clinical significance of anastomotic ulcers after ileocolic resection to predict postoperative recurrence of Crohn’s disease

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S288-S288
Author(s):  
J Y Kim ◽  
S H Park ◽  
Y J Kim ◽  
J C Park ◽  
S Noh ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Clinical Significance ◽  
Multivariable Analysis ◽  
Postoperative Recurrence ◽  
Ileocolic Resection ◽  
Single Centre ◽  
Endoscopic Recurrence ◽  
Endoscopic Remission

Abstract Background The Rutgeerts score (RS) is used to predict postoperative recurrence in Crohn’s disease (CD) patients after ileocolic resection primarily based on endoscopic finding at the neoterminal ileum. However, assessing anastomotic ulcers (AUs) is still a matter of debate. Our aim was to investigate the clinical significance of AUs on endoscopic recurrence in postoperative CD patients. Methods This was a single-centre retrospective study analysing postoperative CD patients with the RS of i0 to i1 at the first ileocolonoscopy within 1 year after ileocolic resection between 2000 and 2016 and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs predicting endoscopic recurrence (RS ≥ i2b). Results Among 116 patients who were in endoscopic remission at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the 30.0 months (interquartile ranges, 21.3–53.3) of median follow-up periods after the index ileocolonoscopy, 56.1% (55/98) showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs defined as ulcer occupying ≥ 1/4 of the circumference or ≥ 3 ulcers confined to anastomotic ring, or any ulcers extended to ileocolic mucosa showed endoscopic recurrence. On multivariable analysis, the presence of AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87–10.0; p < 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95–6.79; p < 0.001) were associated with endoscopic recurrence, respectively. Conclusion AUs are associated with a significantly higher risk of endoscopic recurrence in postoperative CD patient who are in endoscopic remission.

Outcomes of Passable and Non-passable Strictures in Clinical Trials of Crohn’s Disease: A Post-hoc Analysis

2021 ◽  
Author(s):  
Neeraj Narula ◽  
Emily C L Wong ◽  
Parambir S Dulai ◽  
John K Marshall ◽  
Jean-Frederic Colombel ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Activity Index ◽  
Disease Activity Index ◽  
Symptom Improvement ◽  
Logistic Regression Models ◽  
Post Hoc Analysis ◽  
Endoscopic Remission ◽  
Post Hoc ◽  
The Impact

Abstract Background and Aims There is paucity of evidence on the reversibility of Crohn’s disease [CD]-related strictures treated with therapies. We aimed to describe the clinical and endoscopic outcomes of CD patients with non-passable strictures. Methods This was a post-hoc analysis of three large CD clinical trial programmes examining outcomes with infliximab, ustekinumab, and azathioprine, which included data on 576 patients including 105 with non-passable strictures and 45 with passable strictures, as measured using the Simple Endoscopic Score for Crohn’s Disease [SES-CD]. The impact of non-passable strictures on achieving clinical remission [CR] and endoscopic remission [ER] was assessed using multivariate logistic regression models. CR was defined as a Crohn’s Disease Activity Index [CDAI] <150, clinical response as a CDAI reduction of ≥100 points, and ER as SES-CD score <3. Results After 1 year of treatment, patients with non-passable strictures demonstrated the ability to achieve passable or no strictures in 62.5% of cases, with 52.4% and 37.5% attaining CR and ER, respectively. However, patients with non-passable strictures at baseline were less likely to demonstrate symptom improvement compared with those with passable or no strictures, with reduced odds of 1-year CR (adjusted odds ratio [aOR] 0.17, 95% CI 0.03–0.99, p = 0.048). No significant differences were observed between patients with non-passable strictures at baseline and those with passable or no strictures in rates of ER [aOR 0.82, 95% CI 0.23–2.85, p = 0.751] at 1 year. Conclusions Patients with non-passable strictures can achieve symptomatic and endoscopic remission when receiving therapies used to treat CD, although they are less likely to obtain CR compared with patients without non-passable strictures. These findings support the importance of balancing the presence of non-passable strictures in trial arms.

The Correlation between Vitamin D Levels and the Risk of Postoperative Recurrence in Crohn’s Disease

Digestion ◽  
2021 ◽  
pp. 1-9
Author(s):  
Akihiro Yamada ◽  
Yuga Komaki ◽  
Fukiko Komaki ◽  
Haider Haider ◽  
Dejan Micic ◽  
...  
Keyword(s):  
Vitamin D ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Postoperative Recurrence ◽  
Recurrence Rates ◽  
Reactive Protein ◽  
Endoscopic Recurrence ◽  
Vitamin D Levels ◽  
Endoscopic Remission ◽  
The University

<b><i>Background and Aims:</i></b> Vitamin D deficiency has been associated with disease activity in Crohn’s disease (CD). We assessed whether there is a correlation between vitamin D levels and the risk of postoperative recurrence in CD. <b><i>Methods:</i></b> CD patients who underwent surgery were identified from a prospectively maintained database at the University of Chicago. The primary endpoint was the correlation of serum 25-hydroxy vitamin D levels measured at 6–12 months after surgery and the proportion of patients in endoscopic remission, defined as a simple endoscopic score for CD of 0. Clinical, biological (C-reactive protein), and histologic recurrences were also studied. <b><i>Results:</i></b> Among a total of 89 patients, 17, 46, and 26 patients had vitamin D levels of &#x3c;15, 15–30, and &#x3e;30 ng/mL, respectively. Patients with higher vitamin D levels were significantly more likely to be in endoscopic remission compared to those with lower levels (23, 42, and 67% in ascending tertile order; <i>p</i> = 0.028). On multivariate analysis, vitamin D &#x3e;30 ng/mL (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.07–0.66, <i>p</i> = 0.006) and anti-tumor necrosis factor agent treatment (OR 0.25, 95% CI 0.08–0.83, <i>p</i> = 0.01) were associated with reduced risk of endoscopic recurrence. Rates of clinical, biological, and histologic remission trended to be higher in patients with higher vitamin D levels (<i>p</i> = 0.17, 0.55, 0.062, respectively). <b><i>Conclusion:</i></b> In the present study, higher vitamin D level was associated with lower risk of postoperative endoscopic CD recurrence. Further, studies are warranted to assess the role of vitamin D in postoperative CD recurrence.

Postoperative Management of Crohn’s Disease: What Can We Do to Prevent Recurrence?

2016 ◽  
Vol 2 (11) ◽  
Author(s):  
Adriana Georgiana Olariu ◽  
Liliana Bordeianou
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Disease Recurrence ◽  
Postoperative Recurrence ◽  
Postoperative Management ◽  
Chronic Inflammatory Bowel Disease ◽  
Ileocecal Resection ◽  
Endoscopic Recurrence ◽  
Relapsing Remitting ◽  
Patients Experience

<p>Crohn’s disease (CD) is a chronic inflammatory bowel disease with a relapsing, remitting course.  Approximately one in four CD patients requires surgery within five years of diagnosis. Unfortunately, surgery is rarely curative and up to 70% of CD patients experience endoscopic recurrence and 40% have clinical disease recurrence within 18 months after surgery.</p><p> </p><p>This review is aimed at providing internists and gastroenterologists a foundation for the management of patients who underwent ileocecal resection for CD. We provide an overview of the current definitions of postoperative recurrence and prognostic factors for postoperative CD recurrence. As recent studies raised concerns about the value of these factors, we examine the evidence behind the current risk stratification algorithm and pharmacologic treatment recommendations. Lastly, we discuss future directions for research.</p>

scholarly journals P190 Ileo-caecal Crohn’s Disease; medical or surgical management. Cost and outcomes

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S258-S259
Author(s):  
M Charan ◽  
L Maclaren ◽  
C Bryant ◽  
K Wade ◽  
H Johnson ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Medical Treatment ◽  
Terminal Ileum ◽  
Disease Recurrence ◽  
Outcome Data ◽  
Point Of View ◽  
Endoscopic Recurrence ◽  
Primary Surgery

Abstract Background An ileo-caecectomy is known to be an effective treatment for Crohn’s disease limited to the terminal ileum that can lead to a long term remission. ECCO guidelines recommend that patients with active inflammation should be treated medically. However the LIR!C trial suggested there are QOL benefits and reduced costs to performing primary surgery. Methods We aimed to compare the outcomes of patients treated with primary medical treatment to primary surgery for patients with Crohn’s disease limited to the terminal ileum. We reviewed our database to identify all these patients and analysed outcome data. Results 49 patients were identified: Mean age was 50 yrs (range 22 - 93). 23 were male. Mean length of follow-up was 96 months (range 3 - 404). 1st line treatment was: medical; 33 (67.3%), surgery; 16 (32.6%). Outcomes after medical treatment: 27 of 33 patients failed primary medical treatment, they required surgery at a mean of 38 months (range 1–900) after initiating medical treatment. Colonoscopy after surgery to assess for disease recurrence: Colonoscopic assessment or calprotectin post was undertaken ileo-caecectomy in 4 of 16 patients at a mean of 6.2 months (range 1–10) who underwent primary surgery; and in 25 of 27 patients who underwent surgery following failure of medical treatment. Outcomes after surgery: 4 of 16 patients who had primary surgical treatment had endoscopic recurrence, requiring medical treatment after a mean of 4.4 months (range 0–10). 8 of 27 patients who had surgery post-failure of medical treatment developed disease recurrence, requiring medical treatment after a mean of 40 months (range 7–136) Bile acid malabsorption (BAM): BAM occurred after surgery in 10 of 43 patients. No medically managed patient developed BAM. Conclusion These data suggest that in our population the vast majority of patients with ileo-caecal Crohn’s disease will fail medical treatment and require surgery. 25% of those who undergo surgery will develop BAM (requiring medication), and 40% of those treated surgically will require immunosuppressant treatment in the medium term. These outcomes should be discussed with patients so that they appreciate that ileo-caecectomy is unlikely to lead to long term drug free treatment, and medical treatment is unlikely to lead to the avoidance of surgery. From a health-economics point of view it could be argued there is little point in offering primary medical therapy and ileo-caecectomy should be the initial treatment of choice for patients with limited ileo-caecal Crohn’s disease. Unfortunately endoscopic/calprotectin assessment following primary surgery was often not performed in the majority of patients, and changes in our local practice need to be undertaken to correct this.

scholarly journals DOP36 Non-invasive assessment of postoperative disease recurrence in Crohn’s Disease: A multicenter, prospective cohort study

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S074-S075
Author(s):  
F Furfaro ◽  
A Zilli ◽  
V Craviotto ◽  
A Aratari ◽  
C Bezzio ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Bowel Wall ◽  
Color Doppler ◽  
Disease Recurrence ◽  
Postoperative Recurrence ◽  
Fecal Calprotectin ◽  
Non Invasive ◽  
Endoscopic Recurrence ◽  
Sensitivity Specificity

Abstract Background Prevention of postoperative recurrence is a critical goal in Crohn’s disease (CD) management. Currently, postsurgical CD management and treatment are based on endoscopic monitoring performed within the first year after surgery. However, colonoscopy (CS) is an invasive and expensive procedure, unpleasant to patients. A non-invasive and patient friendly approach is required. Methods Consecutive CD patients who underwent ileo-cecal resection from July 2017 to January 2020 were prospectively enrolled in three Italian Centers and performed CS and bowel ultrasound (US) after six months from the surgery, in a blinded fashion. The patients also underwent complete clinical assessment and blood and stool samples were obtained for C-reactive protein (CRP), and fecal calprotectin (FC) measurements. The disease was considered clinically active if the Harvey–Bradshaw Index (HBI) was higher than 4. Uni- and multivariable analyses were used to assess the correlation between non-invasive parameters, including bowel US findings and FC values and endoscopic recurrence, defined by a Rutgeerts’s score (RS) &gt; 2. Sensitivity, specificity, accuracy, PPV and NPV of bowel US parameters alone and in combination with FC in assessing endoscopic recurrence were calculated. Results Seventy patients were enrolled, 45 patients (64%) had an endoscopic recurrence (RS &gt; 2) at 6 months. Thirteen out of 45 (29%) were symptomatic (HBI &gt; 4). Bowel wall thickness (BWT), bowel wall flow (BWF, presence of vascular signals at color Doppler), the presence of mesenteric hypertrophy, the presence of limph-nodes and FC values significantly correlated with the endoscopic recurrence (p &lt; 0.005). Independent predictors for endoscopic recurrence were BWT (for 1-mm increase: OR 2.63; 95% CI 1.136.12; p= 0.024), presence of lymph-nodes (OR 23.24; 95% CI 1.85291.15; p= 0.014) and FC &gt; 50 µg/g (OR 11.86; 95% CI 2.60–54.09; p= 0.001). Sensitivity, specificity, accuracy, PPV and NPV of bowel US and/or FC are showed in Table 1. Table 1: Diagnostic accuracy of Bowel US and/or FC compared to CS in assessing endoscopic activity (CI 95%): per-patient analysis Conclusion Combined use of bowel US and FC is accurate in assessing endoscopic recurrence at 6 months in CD patients and represent a valid alternative to endoscopic assessment after surgery

scholarly journals Real-World Experience with AGA Guidelines in the Management of Crohn’s Disease following Ileocolonic Resection: A Retrospective Cohort Study

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
Shasha Tang ◽  
Wei Liu ◽  
Weilin Qi ◽  
Tunan Yu ◽  
Qian Cao ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
High Risk ◽  
Crohn's Disease ◽  
Guideline Adherence ◽  
Real Life ◽  
Educational Background ◽  
Endoscopic Recurrence ◽  
Ileocolonic Resection ◽  
One Year ◽  
The Impact

Background. Postoperative endoscopic recurrence (PER) is common in patients with Crohn’s disease (CD) after surgery. The impact of the American Gastroenterological Association (AGA) guideline adherence on PER in real life remains unclear. Methods. The postoperative management of CD patients undergoing ileocolonic resection with anastomosis from 2017 to 2018 was conducted based on the AGA guidelines. Colonoscopies were performed within one year after surgery. Clinical data and risk factors for endoscopic recurrence were analyzed focusing on postoperative pharmacological prophylaxis. Results. All patients were at a high risk of postoperative recurrence according to the AGA guidelines. PER occurred in 29 (28.7%) of these patients. The overall PER rate was 39.2% at one year. The PER rate in patients treated with nitroimidazole, thiopurines, infliximab, or a combination of thiopurines and infliximab for postoperative prophylaxis was 88.1%, 34.1%, 20.5%, and 0%, respectively. Cox regression showed that smoking at the time of surgery and AGA guideline adherence were independent factors associated with PER (HR: 3.75, 95% CI: 1.36-10.33, P=0.01; HR: 0.36, 95% CI: 0.15-0.86, P=0.02). In addition, further investigation revealed that educational background was the main factor related to patients’ nonadherence to AGA guidelines. Conclusions. The majority of CD patients who undergo surgery in clinical practice may be at a high risk of disease recurrence. Thiopurines and infliximab are effective in preventing endoscopic recurrence. Guideline nonadherence is associated with PER at one year, thus indicating that there is room for improvement in adherence to the AGA guidelines.

P015 ILEOCOLIC RESECTION FOR CROHN’S DISEASE: CURRENT TRENDS FROM ANALYSIS OF 2 YEARS OF NSQIP IBD COLLABORATIVE DATA

2020 ◽  
Vol 26 (Supplement_1) ◽  
pp. S51-S52
Author(s):  
William Luo ◽  
Stefan Holubar ◽  
Liliana Bordeianou ◽  
Lynne Crawford ◽  
Bruce Hall ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Anastomotic Leak ◽  
Severe Disease ◽  
Multivariable Analysis ◽  
Ileocolic Resection ◽  
Improvement Program ◽  
Stoma Formation ◽  
Increased Risk ◽  
Secondary Outcomes

Abstract Background Ileocolic resection (ICR) is performed for Crohn’s disease (CD) patients with terminal ileitis requiring surgery. Current National Surgical Quality Improvement Program (NSQIP) data is lacking specificity around IBD surgery, including stoma formation and biologic therapies. The NSQIP IBD Collaborative (NSQIP-IBD) is a multicenter working group formed to better collect and analyze perioperative data unique to IBD patients under the auspices of NSQIP. We present retrospective analysis of a multicenter cohort of ICR for CD to describe the current practice of ICR for CD across our collaborative and explore factors associated with rates of postoperative complications on behalf of NSQIP-IBD. Methods Review of NSQIP data from 10 participating sites was performed to select ICR cases for CD from March 2017 to March 2019. In addition to standard data from NSQIP, IBD-specific data regarding stoma formation, immunosuppressant use (biologics, steroids, and immune modulators), and dysplasia is included. Primary outcome was anastomotic leak measured in a 30-day postoperative window in undiverted patients. Secondary outcomes were total non-leak complications and total postoperative infections. Multivariable analysis was performed to adjust for confounding pre- and intraoperative confounders. Backward selection of covariates and factors was performed using a cutoff of p&lt;0.2 for main effects. Results 506 ICR cases for CD were identified. 78 patients had stomas per our unique ileostomy NSQIP-IBD variable, compared to 38 found by querying generally available NSQIP data (48.7% of total stomas). ICR patients receiving stoma were more likely to have more severe ASA class and weight loss and had significantly lower albumin and hematocrit. Age, BMI, and sex were similar in either group. Intraoperatively, stoma patients were more likely have worse wound class, be emergent, and longer operative time. 421 cases had complete baseline and intraoperative data for multivariable analysis of leak rates. 422 were available for secondary outcomes analysis. Multivariable analysis of leak rates showed significant association with infections prior to operation (PATOS; OR=6.6, 95% CI 1.1–40, p=0.041). Significant predictors of total postoperative complication rate and infection rate are shown in Tables 1 and 2, respectively. Conclusions NSQIP-IBD data provides clearer, more detailed data than the NSQIP colectomy module alone in IBD patients. We show that CD ICR patients receiving stomas were more emergent, had intraoperative infection, or had more severe disease. This is consistent with most contemporary surgical practices. Total infections PATOS are associated with increased risk of postoperative anastomotic leak, non-leak complications, and infections. NSQIP-IBD data improves on existing NSQIP data to allow a more robust analysis of factors and outcomes unique to IBD cases. We anticipate with more time and greater numbers we will be able to obtain even more granular data.

Factors influencing disease recurrence after ileocolic resection in adult and pediatric onset Crohn's disease

2014 ◽  
Vol 208 (4) ◽  
pp. 591-596 ◽  
Author(s):  
Iuliana D. Bobanga ◽  
Shiyu Bai ◽  
Marco A. Swanson ◽  
Bradley J. Champagne ◽  
Harry J. Reynolds ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Disease Recurrence ◽  
Ileocolic Resection ◽  
Factors Influencing ◽  
Pediatric Onset
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