We Cannot Say Biologic Therapy Is Not Useful in Patients With Short-Bowel Syndrome From Resections Related to Crohn’s Disease, nor Can We Conclude They Are of Value

Abstract

Limketkai et al1Limketkai B.N. et al.Clin Gastroenterol Hepatol. 2017; 15: 1908-1914Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar provided a glimpse into an infrequently studied group of patients, those with short-bowel syndrome and Crohn’s disease. Because of their decreased absorptive surface and resultant diarrhea, they are excluded from studies of investigational agents—usually biologics. These patients generally have the worst disease as well, or they would not have had so much bowel resected! It is therefore an important question to ask as to whether biologic therapy is useful in these patients and does it lead to a reduction in subsequent intestinal resections? However, I believe that neither the National Inpatient Database nor the International Classification of Diseases, 9th revision, code 579.3 is a good data source to examine this clinical problem. Until the International Classification of Diseases, 11th revision, is adopted, there is no specific code for short-bowel syndrome, no less the subset of those patients with intestinal failure. The diagnosis code 579.3 does not capture all patients with short-bowel syndrome, includes patients that do not even have short-bowel syndrome (eg, postsurgical malnutrition), and fails to differentiate between short-bowel syndrome with and without intestinal failure. The authors assumed that all postoperative malabsorption is equivalent to intestinal failure. It is well established that not all patients with postsurgical malabsorption have intestinal failure,2O’Keefe S.J. et al.Clin Gastroenterol. 2006; 4: 6-10Abstract Full Text Full Text PDF Scopus (382) Google Scholar and unless the authors combed through the medical records for each subject to determine whether the patients required home parenteral nutrition postoperatively, it is difficult to determine if intestinal failure was present. By definition, patients with intestinal failure are those who cannot maintain nutritional autonomy and therefore are dependent on intravenous fluid and/or nutrition because their malabsorption is severe enough wherein net fluid and/or energy losses exceed that absorbed.2O’Keefe S.J. et al.Clin Gastroenterol. 2006; 4: 6-10Abstract Full Text Full Text PDF Scopus (382) Google Scholar, 3Pironi L. et al.Clin Nutr. 2015; 34: 171-180Abstract Full Text Full Text PDF PubMed Scopus (376) Google Scholar They may develop multiple medical complications and have multiple hospital admissions each year.4Pironi L. Best Pract Res Clin Gastroenterol. 2016; 30: 173-185Crossref PubMed Scopus (126) Google Scholar, 5Howard L. et al.JPEN J Parenter Enteral Nutr. 1991; 15: 384-393Crossref PubMed Scopus (217) Google Scholar Such patients are not infrequently admitted for catheter-related issues and other problems related to short-bowel syndrome—each of which would be counted as a hospital discharge, and may falsely increase the denominator used to determine the relative number of resections. Furthermore, these patients may require a small resection in the process, or re-anastomosis of small bowel to colon, or for a bowel obstruction unrelated to active Crohn’s disease. Therefore, although I admire the effort put forth, the data presented by Limketkai et al1Limketkai B.N. et al.Clin Gastroenterol Hepatol. 2017; 15: 1908-1914Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar cannot be used to draw firm conclusions about the effectiveness (or lack thereof) of biologics in patients with Crohn’s disease and short-bowel syndrome. Treatment With Biologic Agents Has Not Reduced Surgeries Among Patients With Crohn’s Disease With Short Bowel SyndromeClinical Gastroenterology and HepatologyVol. 15Issue 12PreviewLittle is known about the effects of biologic agents used to treat Crohn’s disease (CD) on its long-term complications, such as short bowel syndrome and intestinal failure (SBS-IF). We evaluated trends in small bowel resections and health care utilization among patients with CD with and without SBS-IF. Full-Text PDF ReplyClinical Gastroenterology and HepatologyVol. 16Issue 5PreviewWe appreciate Dr Buchman’s thoughtful commentary on our study of the changing trends of bowel resections in patients with Crohn’s disease with and without short-bowel syndrome and/or intestinal failure (SBS-IF).1 We agree that there are notable limitations inherent in the use of administrative databases, such as the National Inpatient Sample, and in the use of the International Classification of Diseases (ICD) codes for analyses that require significant precision. We similarly acknowledge that the ICD, 9th revision, code 579.3 may not be the ideal identifier of SBS-IF because of its modest specificity. Full-Text PDF