Complex Crohn's Disease Research Articles

Closing the internal opening with a rectal advancement flap increases the efficacy of mesenchymal stem cell injection for complex Crohn's disease anal fistulas.

The efficacy of injections of mesenchymal stem cells (MSC) for anal fistula treatment may be impaired by the persistence of stools passing into the fistula, causing bacterial contamination and a local inflammatory reaction. We aimed to compare remission rates between patients treated by MSC injection with simple sutures and those treated with a rectal advancement flap. This single-center prospective study compared the first patients who underwent internal opening closure with sutures with the subsequent patients treated with a flap. Complete clinical remission was defined as complete closure of the external opening(s) without pain or discharge, and complete radiological remission was defined as a Magnifi-CD score of 0. We compared the first 42 patients who had sutures with the 20 subsequent patients who had an advancement flap. The median follow-up was 15.5 [8.8-24.9]months. The cumulative incidence of complete clinical response at M12 was 53.8% [38.1-69.6%] in the suture group versus 93.3% [77.4-100.0] in the flap group (p < 0.001). The Magnifi-CD score was 0 for 41.7% [25.5-59.2%]) of patients treated with sutures versus 72.7% [39.0-63.9%]) of patients treated with a flap (p=0.093). Anal incontinence score did not differ between the two groups. Practicing an advancement flap was the only significant factor associated with complete clinical remission over time (adjusted HR [95% CI] of 2.6 [1.4-4.9], p = 0.003). Complete clinical remission rates following MSC injection are significantly higher after closure of the internal opening with a rectal flap than after closure with sutures, without consequences on anal continence.

P933 Closing the internal opening with a rectal advancement flap increases the effectiveness of mesenchymal stem cell (MSC) injection in the treatment of complex Crohn's disease anal fistulas

Abstract Background The injection of MSCs into complex anoperineal fistulas of Crohn's disease gives a combined clinical and radiological remission of between 35 and 50% at 12 months. In our department, surgical closure is now done by rectal advancement flap (and no longer with simple stitches) in order to minimize the passage of stools and contamination of the fistula tract. The aim of this study was to compare the remission rate and the quality of life between patients treated with MSC injection using simple stitches versus a rectal flap to close the internal opening. Methods This single-center prospective study included all our consecutive patients who had a MSC injection. The first patients of the series who had closure of the internal opening(s) with stitches (2020- 2022) were compared with those who had a flap (2022-2023). Complete clinical remission was defined by complete closure of the external opening(s) without pain or discharge, and complete radiological remission by a Magnifi-CD score equal to 0 (Hindryckx P, et al. Gastroenterology 2019). Quality of Life was assessed by the Crohn's Anal Fistula Quality of Life scale (CAF-QoL) (Adegbola SO, et al. Gut 2021). Results We included 68 patients (50% women, mean age: 38 ± 13.8 years). The first 42 had stitches and the following 20 had an advancement flap (6 patients had no procedure due to an anal stenosis). The median follow-up was 12 months [6-24]. The overall complete clinical remission was 66.7% at M12: 51.1% [35.5-66.8] in the "stitches" group versus 87.5% [69.7-100.0] in the "flap" group (p = 0.005) (Figure). The difference was noticed early from M1. The mean overall Magnifi-CD MRI score decreased from 15.5 ± 4.7 to 6.5 ± 7.1 at M12 (p &amp;lt; 0.001) with no difference between the 2 groups. However, more patients in the flap group had a Magnifi-CD score of 0: 62.5% versus 38.2%. The CAF-QoL quality of life score improved from 51.3 ± 24.7 to 21.2 ± 20.8 at M12 (p &amp;lt; 0.001) with no significant difference between the 2 groups. The duration of the procedure was longer on average by 19 ± 7 minutes in the "flap" group. There was no difference in the anal incontinence score between the 2 groups. In logistic regression, the advancement flap was significantly associated with complete clinical remission (p = 0.007, HR (95% CI): 2.3 [1.3-4.3]). Conclusion Closing the internal opening with a rectal advancement flap improves the effectiveness of MSC injections with a complete clinical and radiological remission rate of 87.5% and 62.5% respectively, without consequences on anal continence.

Visceral adiposity and inflammatory bowel disease.

Visceral adiposity and inflammatory bowel disease.

Real-world effectiveness and safety of ustekinumab for the treatment of Crohn's disease: the Scottish ustekinumab cohort.

Ustekinumab is a monoclonal antibody that targets interleukin-12/23. In Scotland, it was approved for the treatment of moderate to severe Crohn's disease in 2017. The objective of this study was to establish the real-world effectiveness and safety of ustekinumab in the treatment of Crohn's disease. We conducted a retrospective study of patients receiving ustekinumab across eight Scottish National Health Service health boards between 2017 and 2019. Inclusion criteria included a diagnosis of Crohn's disease with symptoms attributed to active disease plus objective signs of inflammation at baseline (C-reactive protein≥5mg/L or fecal calprotectin≥250μg/g or inflammation on endoscopy/magnetic resonance imaging) and completion of induction plus at least one clinical follow-up at 8weeks. Kaplan-Meier survival analysis was used to establish 12-month cumulative rates of clinical remission, mucosal healing, deep remission, and perianal fistula response. Rates of serious adverse events were described quantitatively. Our cohort consisted of 216 patients (female sex, 37.9%; median age, 39.0years, interquartile range [IQR] 28.8-51.8years; disease duration, 9.9years, IQR 6.0-16.5years; prior biologic, 98.6%) with a median follow-up of 35.0weeks (IQR 17.4-52.0weeks). Twelve-month cumulative rates of clinical remission, mucosal healing, and deep remission (clinical remission plus mucosal healing) were 32.0%, 32.7%, and 19.3%, respectively. In patients with active perianal disease (n=37), the 12-month cumulative perianal response rate was 53.1%. The serious adverse event rate was 13.6 per 100 patient-years of follow-up. Ustekinumab is a safe and effective treatment for the treatment of complex Crohn's disease.

Laparoscopic Surgery for Complex Crohn's Disease: A Meta-Analysis.

Aim: There is still no consensus on whether laparoscopic surgery can be routinely recommended as a safe approach for complex Crohn's disease (CD). Methods: PubMed, Embase, and Cochrane library databases were searched (up to February 2019). Comparative studies reporting laparoscopic surgery for complex CD (LC group) comparing with simple CD (LS group) were included. The outcomes were blood loss, operative time, conversion rate, length of hospital stay, postoperative complications, and reoperation rate within 30 days after surgery. Results: Thirteen retrospective studies with 1120 participants were included. The LC group has significantly more blood loss (weighted mean difference [WMD] 43.64 mL; 95% confidence interval (CI) 8.37-78.91; P = .020), longer operative time (WMD 17.59 minutes; 95% CI 6.38-28.81; P = .002), higher conversion rate (WMD 2.04%; 95% CI 1.43-2.91; P < .001), and longer length of hospital stay (WMD 0.86 day; 95% CI 0.53-1.19; P < .001). Overall postoperative complication rates (WMD 0.98; 95% CI 0.71-1.34; P = .90) did not differ significantly between the 2 groups. Conclusions: LC is safe and feasible with comparable postoperative complications, although there is a more blood loss, longer operative time, higher conversion rate, and longer length of hospital stay.

Reoperative Surgery in Complex Crohn's Disease.

This article provides a structured approach to the technical aspects of reoperative surgery for Crohn's disease. Specific indications for surgery including repeat ileocolic resection, Crohn's complications of ileal pouch anal anastomosis and continent ileostomy, completion proctectomy, and the role of small bowel transplant will be discussed.

Role of Fecal Diversion in Complex Crohn's Disease.

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.

Minimally Invasive Surgery in Complex Crohn's Disease.

Minimally invasive approaches are safe, feasible, and often recommended as the initial choice in the surgical management of Crohn's disease. However, a consensus has not been reached as the ideal approach in the surgical treatment of complex and recurrent Crohn's disease. Laparoscopy may provide advantages such as shorter length of stay and decreased postoperative pain and result in less adhesion formation in patients with complex disease. Robotic techniques may be beneficial in selected patients for completion proctectomy, providing better visualization in the narrow pelvis and increased dexterity. Decision of surgical technique should be made on a case-by-case basis.

Strictureplasty in Complex Crohn's Disease: Beyond the Basics.

The strictureplasty operation was originally adopted for use in selected patients with Crohn's disease to allow for bowel conservation. The procedure and its usage have evolved over time as experience and confidence with the technique has grown. The short- and long-term outcomes of strictureplasty compared with resection attest to its safety and durable efficacy.

Ileocolic Resection for Complex Crohn's Disease

Ileocolic Resection for Complex Crohn's Disease

Stepwise Training in Laparoscopic Surgery for Complex Ileocolonic Crohn's Disease: Analysis of 127 Training Episodes

The inflammation encountered in Crohn's disease makes a minimally invasive approach challenging due to a thickened mesentery, fistulas, abscesses, and large phlegmons with high reported rates of conversion and septic complications. Aim of this study was to evaluate the feasibility of a stepwise approach to training in laparoscopic surgery for complex Crohn's disease. Every surgical procedure was divided in 4 different training tasks: access and exposure, bowel mobilization, division of the mesentery, anastomosis. Extensive adhesiolysis and division and repair of fistulae were considered as additional tasks when present. The laparoscopic competence assessment tool was used to evaluate the safety and proficiency of the surgical performance. The primary outcome was the rate of training tasks successfully completed by surgical trainees. One hundred and twenty seven training episodes were included and 86 were performed by trainees (67.7%). Fistula division was the less commonly performed training task (25%), while mobilisation and anastomosis were performed by the supervised trainee in 90% and 85% of the cases. Safety and proficiency scores were significantly higher for senior trainees compared to junior trainees. Laparoscopic surgery for complex Crohn's disease can be safely performed in a supervised setting with acceptable operating time, postoperative length of hospital stay, and 30 day morbidity.

A Novel Ileocolonic Crohn's Staging Tool: The Development and Validation of an Evidence-Based, End-User Informed Radiological Decision-Aid

Background: Consensus guidelines emphasise the importance of multidisciplinary team driven care for patients with complex Crohn's disease. There are, however, no clear definitions of complexity beyond the presence or absence of pre-operative intra-abdominal sepsis. This study aims to develop a staging instrument (The St Mark's - Amsterdam tool) for complex ileocolonic Crohn's disease based upon best evidence and end-user expert opinion. The secondary aim is to investigate validation and reliability evidence for this staging tool. Methods: Items for the staging tool were developed using a literature review and semi-structured interviews. Validity was tested using pre-operative, peri-operative and post-operative outcome measures which were reviewed against intra-operative and histopathologically and radiologically assigned stages. Reliability was tested against intra-operative and histopathologically assigned stages using magnetic resonance enterography (MRE) and computer tomographic enterography (CTE), which were used to provide an objective pre-operative stage for patients who have undergone ileocolonic resection. Findings: A 4-stage tool was derived including items detailing ileocolonic radiological disease: 1) predominantly inflammatory stricture; 2) predominantly fibrotic stricture; 3) fistulating; and 4) intra-abdominal abscess/collection. Validity testing demonstrated a greater proportions of pre-operative anaemia, concomitant sigmoidectomy and pre-emptive stoma formation, and/or post-operative intra-abdominal septic complications and/or Clavien-Dindo≥3, with increasing intra-operative and histopathologically and pre-operative radiological stage (p<0.05). Good reliability was demonstrated between pre-operative radiological stages and intra-operative and histopathologically assigned stages (R=0.8; p<0.001). Interpretation:This novel staging tool has been validated to show greater morbidity with increasing stage severity. It can reliably be used to pre-operatively stage patients, and inform surgical decision-making and estimate morbidity. It also allows for appropriate case mix adjustment from a research and outcomes reporting. Further multi-center prospective validation of this tool is required for both clinical and research purposes. Funding Statement: Morar, Sevdalis, Edwards and Faiz were funding by the Health Service Award, Crohn’s And Colitis UK (IBDHS/13/1). Nick Sevdalis’ research is funded by the NIHR via the ‘Collaboration for Leadership in Applied Health Research and Care South London’ (CLAHRC South London) at King's College Hospital NHS Foundation Trust, London, UK. Sevdalis is also part of King's Improvement Science, which is part of the NIHR CLAHRC South London and comprises a specialist team of improvement scientists and senior researchers based at King’s College London. King's Improvement Science is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’ Charity, the Maudsley Charity and the Health Foundation. Nick Sevdalis is also funded by the South London and Maudsley NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Edwards was funded by the South Devon Healthcare Charitable Fund (1052232). Declaration of Interests: NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organization globally. Ethics Approval Statement: Institutional approval from the local NHS hospital research and development committee was obtained (11/2014) prior to data collection. Data were obtained by cross-referencing two prospectively maintained databases within our institution from over a 10-year period [January 1, 2005 to January 1, 2015].

Single Port Laparoscopic Surgery for Complex Crohn's Disease Is Safe with a Lower Conversion Rate.

Single port laparoscopic surgery (SPLS) is a technique which is increasing in popularity. The benefit of SPLS in complex Crohn's disease (CD), which includes a significant cohort of young patients sometimes needing multiple operations, has not been comprehensively assessed. This study analyses our early experience with this technique. Patients who underwent SPLS for CD were included. Data were collected prospectively from January 2013 to December 2015. Ileocolic resections, right hemicolectomy, small bowel stricturoplasties, and resections were included in the complex CD cohort. Primary and redo operations were analyzed separately. Forty-five patients were included in the study (39 ileocolic resections and 6 small bowel stricturoplasty/resections). Of the total, 27 were primary resections and 18 were redo resections. The median age was 41 years (range 14-72 years), and the median hospital stay was 8 days (range 3-28 days). The total complication rate was 35.5% most of which were Clavien-Dindo type 1 and 2. There was no difference in operating time, average blood loss, conversion rates, complication rate, and hospital stay, between those who had primary or redo surgery. SPLS can be performed safely in patients with complex CD even in redo surgery. There may be some technical advantages to the procedure in this group of patients.

Feasibility of laparoscopic surgery for complex Crohn's disease of the small intestine.

The laparoscopic approach for complex Crohn's disease (CD), which involves abscess formation, fistula formation, and recurrent CD, is controversial. The aim of this study was to investigate the feasibility and safety of the laparoscopic approach for complex CD. Fifty-six patients who had undergone surgery for CD of the small bowel from January 2007 to August 2014 were divided into two groups: the laparoscopic approach for complex CD group (LC group, n = 31) and the laparoscopic approach for simple CD group (LS group, n = 25). The preoperative data and surgical outcomes of the LC group were compared with those of the LS groups. There were no significant differences in preoperative data and operating time between the two groups. Blood loss was not significantly different between the LC and LS groups. The incision length was longer in the LC group than the LS group (P = 0.004). The incidence of severe postoperative complications in the LC group was higher than in the LS group (P = 0.026). The length of postoperative stay was similar in the LC and LS groups. The laparoscopic approach for complex CD is feasible and provides good cosmesis that is comparable to that offered by simple CD.

Su1181 Does Magnetic Resonance Enterography Influence Management Strategies in Complex Crohn's Disease?

Su1181 Does Magnetic Resonance Enterography Influence Management Strategies in Complex Crohn's Disease?

Laparoscopic surgery for complex Crohn's disease

In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex CD involving localized abscess, fistula or recurrent disease. The aim of this systematic literature review was to assess the feasibility and safety of laparoscopic surgery for complex or recurrent CD. In the current literature, there are nine non-randomized cohort studies, two of which were case-matched. The mean rate of conversion to open laparotomy reported in these series ranged from 7% to 42%. Morbidity rate and hospital stay following laparoscopic resection for complex CD were similar to those for initial resection or for non-complex CD. In summary, even though strong evidence is lacking and more contributions with larger size are needed, the limited experiences available from the literature confirm that the laparoscopic approach for complex CD is both feasible and safe in the hands of experienced IBD surgeons with extensive expertise in laparoscopic surgery. Further studies are required to confirm these results and determine precisely patient selection criteria.

P338 The safety of laparoscopy in complex Crohn's disease

UC, we retrospectively compared the therapeutic effect of IFX and Tac and also evaluated the therapeutic effect of switching between IFX and Tac. Methods: A total of 80 UC patients treated with either IFX or Tac between July, 2009 and June, 2012 in our institute were retrospectively analyzed. We assessed disease activity at 3 months after starting treatment using Lichtiger index. A score of Lichtiger index less than or equal to 4 was defined as clinical remission. Colonoscopy was conducted at 3 6 months after starting treatment. Results: IFX and Tac were administered as a first-line therapy to 38 and 42 steroid-refractory patients, respectively. The average Lichtiger index score of 42 patients who received Tac was 11.6, and that of 38 patients who received IFX was 8.3, showing that Tac was used for more severe cases than IFX in our institute. Nineteen cases (45.2%) out of the 42 Tac treated cases achieved clinical remission at 3 months, while 19 cases (50.0%) out of 38 IFX treated cases achieved clinical remission. Thus, there was no significant difference on the clinical efficacy of IFX and Tac as a first-line treatment. We next analyzed 10 cases who received Tac after IFX had failed (IFX-Tac) and 17 cases who received IFX after Tac had failed (Tac-IFX). Only 2 case (20.0%) out of the 10 cases in the IFX-Tac group achieved clinical remission. Five cases (29.4%) out of the 17 cases in the TacIFX group achieved clinical remission. These findings suggest that the clinical efficacy of IFX and Tac is inferior when used as salvage therapy compared with these drugs used as the firstline treatment. Conclusions: IFX and Tac are effective therapy in treating steroid-refractory UC. There was no difference on the clinical efficacy between the two agents, although Tac was used for more severe cases than IFX in our institute. Cases who did not respond to the first-line therapy responded less to the secondline treatment. Switching therapy must be considered carefully, because it does not have a satisfactory efficacy and may cause serious adverse events.

Enfermedad de CROHN metastásica: respuesta a intensificación de tratamiento con adalimumab

Inflammatory bowel disease is accompanied by extraintestinal manifestations in a high percentage of patients. Cutaneous lesions are the second most prevalent of these manifestations, and within these, metastatic Crohn's disease is one of the least common, being the least frequent specific cutaneous manifestation of Crohn's disease. This entity includes cutaneous and subcutaneous lesions with a non-caseating granulomatous appearance on histological analysis identical to that of Crohn's disease. These lesions are not found adjacent to the digestive tract. Due to the low prevalence of these manifestations, conclusive trials on the treatment of choice have not been performed and there is no well-defined therapeutic strategy. Distinct therapies with varying results have been reported.We report the case of a female patient with longstanding and complex Crohn's disease who developed metastatic cutaneous manifestations while receiving adalimumab. The cutaneous manifestations responded well to dose intensification of this drug. A review of the literature is provided.

Impact of Complex Crohn's Disease on the Outcome of Laparoscopic Ileocecal Resection

This prospective study assessed the feasibility of laparoscopic ileocolonic resection for complex Crohn's disease, i.e., recurrence or complication from abscess and/or fistula, and compared postoperative outcomes in patients with and without complex Crohn's disease. Between November 1998 and August 2007, 124 laparoscopic ileocolonic resections were attempted for Crohn's disease: 54 patients with complex Crohn's disease (group I) and 70 patients without complex Crohn's disease (group II). Postoperative mortality and morbidity were compared between group I and group II. Indications for surgery in group I included fistula (43 percent), abscess (30 percent), and recurrent disease after ileocolonic resection (27 percent). Complex Crohn's disease was significantly associated with increased mean (standard deviations) operative time [214 (13) vs. 191(53) minutes, P < 0.05), increased conversion rate to open procedure (37 percent vs. 14 percent, P < 0.01), and increased use of temporary stoma (39 percent vs. 9 percent, P < 0.001). No patients died. Overall postoperative morbidity was similar between both groups [17 percent vs. 17 percent, P = not significant (NS)], including major surgical postoperative complications (7 percent vs. 6 percent, P = NS). Mean (SD) hospital stay was not statistically different between both groups [8 (3) vs. 7 (3) days, P = NS]. This large comparative study suggested that laparoscopic ileocolonic resection for complex Crohn's disease was feasible and safe with good postoperative outcomes. In our experience, complex Crohn's disease does not appear as a contraindication to a laparoscopic approach.

Bowel associated dermatosis – arthritis syndrome: a case report

We report a rare case of Bowel Associated Dermatosis – Arthritis Syndrome in a young patient with complex Crohn's disease who presented with fever, arthritis, rash and worsening of diarrhea with abdominal pain, who promptly responded to a short course of steroids.