Ileocolic Disease Research Articles

Bowel Resection Margins in Crohn's Disease: Do They Matter?

AbstractMany patients with Crohn's disease (CD) will ultimately require surgical intervention for refractory disease despite recognizing that surgery does not cure CD. The initial operation, primarily for ileocolic disease, is focused on resecting the offending pathology and ideally providing a reduced likelihood for subsequent operations and additional bowel loss through surgical techniques. The appropriate margin, macro- vs. microscopic, lays in balance to provide an adequate resection that minimizes bowel loss, compared to an extensive resection which ensures a thorough resection but inherently includes the loss of normal bowel in attempts to reduce recurrent symptomatic disease. Ensuring the appropriately timed operation, performed in optimal conditions, with apt mesenteric resections and an ideal anastomotic configuration are all only part of the equation, as bowel margins play an important role in limiting surgical recurrence and maintaining bowel length. A grossly normal margin assessed by the lack of serositis and the mesenteric “pinch test” can result in an appropriate margin without sacrificing normal bowel in this group of patients who are at risk of further bowel loss from CD recurrence.

Recurrent Crohn's disease

Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.

Clinical factors associated with severity in patients with inflammatory bowel disease in Brazil based on 2-year national registry data from GEDIIB

The Brazilian Organization for Crohn's Disease and Colitis (GEDIIB) established a national registry of inflammatory bowel disease (IBD). The aim of the study was to identify clinical factors associated with disease severity in IBD patients in Brazil. A population-based risk model aimed at stratifying the severity of IBD based on previous hospitalization, use of biologics, and need for surgery for ulcerative colitis (UC) and Crohn’s Disease (CD) and on previous complications for CD. A total of 1179 patients (34.4 ± 14.7y; females 59%) were included: 46.6% with UC, 44.2% with CD, and 0.9% with unclassified IBD (IBD-U). The time from the beginning of the symptoms to diagnosis was 3.85y. In CD, 41.2% of patients presented with ileocolic disease, 32% inflammatory behavior, and 15.5% perianal disease. In UC, 46.3% presented with extensive colitis. Regarding treatment, 68.1%, 67%, and 47.6% received biological therapy, salicylates and immunosuppressors, respectively. Severe disease was associated with the presence of extensive colitis, EIM, male, comorbidities, and familial history of colorectal cancer in patients with UC. The presence of Montreal B2 and B3 behaviors, colonic location, and EIM were associated with CD severity. In conclusion, disease severity was associated with younger age, greater disease extent, and the presence of rheumatic EIM.

P190 Identification of clinical risk factors for postoperative endoscopic recurrence in Crohn’s disease: a prospective, multicenter cohort study

Abstract Background Further refinement of clinical risk stratification for postoperative endoscopic recurrence in patients with Crohn’s disease is required to identify patients who will benefit from prophylactic therapy. Therefore, we aimed to assess risk factors for endoscopic recurrence in a large prospective, multicenter cohort study. Methods CD patients (≥16 years) scheduled for ileocolic (re-)resection (ICR) and those who underwent an ileocolonoscopy at 6 months following ICR were included. Primary outcome of the study was endoscopic recurrence (modified Rutgeerts’ score ≥ i2b at 6 months). Multivariable logistic regression was performed to identify clinical risk factors. The model included a random effect for the study center to correct for potential correlation between treating center and the outcome. Results In total, 298 patients underwent ICR (79.2% primary ICR, 20.8% re-resection) after a median disease duration of 5.3 years (IQR 1.0 – 12.4). 60.4% of patients were female with a median age at surgery of 34.1 years (IQR 25.7 – 50.5). 67.8% of the patients were exposed to ≥1 biological prior to surgery. Postoperative prophylactic medication (<12 weeks to ICR) was initiated in 85/298 (28.5%) patients; 24.7% immunomodulator, 29.4% anti-TNF, 27.1% combination therapy [immunomodulator with anti-TNF agent], 4.7% vedolizumab, 14.1% ustekinumab. Mean time to postoperative ileocolonoscopy was 6.2 months (SD 1.3). Endoscopic recurrence was diagnosed in 37.9% of the patients. Multivariable logistic regression identified active smoking (adjusted OR [aOR] 3.12; 95% CI 1.63 – 5.98) and penetrating disease behaviour (aOR 1.92; 95% CI 1.04 – 3.57) as risk factors for endoscopic recurrence, whilst ileocolic disease (versus ileal disease; aOR 0.27; 95% CI 0.15 – 0.49) and postoperative prophylactic medication (aOR 0.24; 95% CI 0.12 – 0.47) were identified as protective factors for endoscopic recurrence (Table 1). Conclusion Active smoking and penetrating disease behaviour at time of surgery were identified as risk factors for early postoperative recurrence in Crohn’s disease. Reversely, ileocolic disease at time of surgery and initiation of postoperative prophylactic medication were identified as protective factors for early endoscopic recurrence. Young age at surgery, perianal disease and a prior intestinal resection, included as risk factors in the current international guidelines, were not associated with early endoscopic postoperative recurrence in this large prospective cohort study.

Short and medium term results of the surgical management of ileocecal Crohn's disease

The treatment of Crohn's disease (CD) is based on medical therapy and surgery is reserved for failure of medical management or complications. To evaluate endoscopic, clinical, and surgical recurrence of CD after surgery. In a prospectively maintained database, consecutive patients older than 15 years subjected to an ileocecal resection for ileocolic disease from January 2011 to April 2021, were identified. The diagnosis of CD was confirmed with the pathologic report. Patients with less than one year of follow-up were excluded. Information was obtained retrospectively from the database and clinical records. Fourteen patients were identified. The mean age at the time of surgery was 38 years. Surgery was performed at a median of 41.5 months (0-300) after the diagnosis of CD, nine elective and five emergency procedures. In five patients there were four major and two minor postoperative complications, with no anastomotic leakage. Six patients had endoscopic recurrence and seven had clinical recurrence (50%) at a mean of 15 months, one of whom required a second operation. There was no mortality. After the surgical treatment of CD, the clinical and endoscopic recurrence rate continues to be high.

The Prevalence of Concomitant Skip Small Bowel Lesions in Crohn’s Disease and Their Effects on Reoperation in Patients Undergoing Ileocolic Resection

AimsConcomitant lesions in the small intestine are common in Crohn’s disease (CD). This study aimed to detect the incidence of small bowel (SB) lesions in patients undergoing surgical resection for symptomatic ileocolic disease and whether concomitant SB lesions are associated with reoperation due to recurrent CD. MethodsIn this observational, historical cohort study, consecutive patients with CD undergoing primary ileocolic resection (ICR) from 2007 to 2019 were included. Clinical variables and intraoperative findings were extracted from a prospectively maintained database and analyzed by Cox proportional hazards regression models for identifying risk factors of reoperation. ResultsOf the 404 patients included, there were 202 (50%) patients having concomitant SB lesions, and 108 of them underwent concurrent surgical intervention for SB lesions whereas 94 did not. The presence of concomitant SB lesions was a risk factor for reoperation (p = 0.041). Subgroup analysis indicated that patients with concomitant uncomplicated SB lesions left in situ had a comparable rate of reoperation (p = 0.605) whereas patients having concomitant complicated SB lesions undergoing simultaneous surgical intervention showed a higher reoperation rate (P = 0.006) when compared with those without concomitant SB lesions. Interestingly, the adverse effects of concomitant SB lesions can be reversed in the setting of postoperative anti-TNF agents [HR 0.2; 95% CI (0.04–0.9); P=0.040]. ConclusionsConcomitant SB lesion(s), especially those complicated lesions, could be a risk factor for postoperative surgical recurrence in patients undergoing ICR. Active postoperative management strategies such as anti-TNF agents should be provided for these patients.

Surgical Management of Small Bowel Crohn's Disease.

Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.

Three novel variants in SOX10 gene: Waardenburg and PCWH syndromes

BackgroundWaardenburg syndrome (WS) is a rare genetic disorder characterized by musculoskeletal abnormalities, deafness and hypopigmentation of hair and skin. This article’s aim is to investigate clinical and genetic characteristics of WS in three unrelated Caucasian individuals.Case presentationThe first patient was a 25-year-old female with congenital bilateral hearing loss, bright-blue-eyes, hypopigmentation of hair and skin, megacolon, language retardation, tenosynovitis and neuromas. The second case was an infant symptomatic from birth, with dysphagia, Hirschsprung disease and neurological abnormalities. The third patient was a 14-year-old boy with congenital bilateral hearing loss and ileocolic Hirschsprung disease. In order to identify variants in potentially causal genes of the patients’ phenotype, genetical testing was conducted: targeted clinical exome, targeted exome and trio exome, respectively. We identified three novel variants spread throughout the coding sequence of SOX10. The c.395C>G variant identified de novo in patient 1 was a single nucleotide substitution in exon 2. The c.850G>T variant identified as heterozygous in patient 2 was a loss-of-function variant that generated a premature stop codon. The c.966dupT variant identified in patient 3 was a duplication that generated a premature stop codon. It had been identified in his father, arising a possible germinal mosaicism. According to in silico predictors the variant identified in patient 1 was considered as pathogenic, whereas the other two were classified as likely pathogenic.ConclusionsAn exact description of the mutations responsible for WS provides useful information to explain clinical features of WS and contributes to better genetic counselling of WS patients.

State-of-the-art surgery for Crohn's disease: Part I-small intestine/ileal disease.

The management of Crohn's disease has evolved significantly over the past 20years. The arrival of biologic therapies has altered not only the management and outcomes but also rates for refractory disease requiring surgery. New surgical techniques have paralleled these medical advances, and this article will provide an overview of these new modalities as well as their outcomes. This is the first of a three-part series and will focus on terminal ileal and ileocolic disease.

Complicated Crohn’s Disease is Associated with Adverse Outcomes in Patients Hospitalized for Acute Abdominal Pain

Background: To determine long-term outcome in Crohn’s disease patients hospitalized for acute abdominal pain. Methods: Retrospective chart review of consecutive Crohn’s disease patients hospitalized for acute abdominal pain at the tertiary referral centre. Results: Between 2015 and 2020, 65 patients (35M, 30F, mean 42 years) were hospitalized because of acute abdominal pain. 83% of patients had ileocolic disease and 39% of patients presented with complicated (stricturing or penetrating) disease. 32 patients (49%) had been hospitalized previously and 14% had undergone intestinal resections in the past. Acute clinical signs other than abdominal pain were: vomiting (35%), fever (45%), abdominal distension (38%), diarrhoea (52%). Leukocytosis was noted in 52% of patients, elevated C-reactive protein level in 83% of patients and severe anemia in 18% of patients. Mean follow-up time was 43 months. During the follow-up period, 14 patients (21%) underwent surgery – 6 during the same hospitalization and 8 later. The hospital readmission rate was 40%. Two patients died. Complicated disease was associated both with hospital readmission (Hazard ratio 3.9, p=0.05) and need for surgery (HR 10.3, p=0.002). Also, history of previous hospitalizations was associated with an increased readmission rate (HR 6.8, p=0.012). Conclusion: Ileocolic disease is the main cause of hospitalization for acute abdominal pain. Complicated (structuring or penetrating) disease should be diagnosed early and surveilled closely.

P212 Assessment of Crohn’s disease activity using global MaRIA score in patients with ileal and ileocolonic disease

Abstract Background Magnetic resonance index of activity (MaRIA) is composed of features independently associated with endoscopic disease activity and is surrogate marker of disease activity. The aim of this study was to evaluate correlation of global MaRIA (gMaRIA) with clinical and biochemical disease activity indices and diagnostic accuracy for active disease in patients with terminal ileum disease and ileocolonic disease. Methods This is a cross-sectional study which included 251 patients with diagnosed CD. Global MaRIA (gMaRIA) index was calculated on 6 bowel segments (the distal ileum, ascending, transverse, descending, sigmoid colon and rectum) using following parameters: bowel wall thickness, ulcers, edema and relative contrast enhancement. Disease activity was defined as combination of clinical and biochemical disease activity (CRP>5 or HBI≥5). Disease extension was classified using Montreal classification (L1 ileum, L2 colon, L3 ileum and colon). Results This study included 251 CD patients [age 35 (25–47), 55.3% males, BMI 21.8 (18–25) kg/m2, median disease duration 7 (2–15) years]. Ileal disease (L1) was present in 84 (33.5%) and ileocolonic disease (L3) in 151 (60.1%) patients. Correlation of gMARIA with biochemical indices of disease activity (CRP) was r=0.48, p<0.001 and with HBI r=0.33, p<0.001. Diagnostic accuracy of gMARIA in defining active disease in patients with L1 disease was considerably high [AUC 0.83 (95%CI 0.72–0.91)]. On the other hand, diagnostic accuracy in defining active disease in patients with L3 disease was good [AUC 0.71 (95%CI 0.62–0.79)], which is lower compared to L1 disease. In surgically naïve patients diagnostic accuracy of L1 disease was [AUC 0.88 (95%CI 0.72–0.96)], and for L3 disease [AUC 0.78 (95%CI 0.64–0.89)]. Conclusion Global MaRIA index showed higher diagnostic accuracy in detecting clinically and biochemically active disease in terminal ileum compared to ileocolic disease. These results emphasize the important role of magnetic resonance enterography in monitoring disease activity in patients with isolated ileal disease. Global MaRIA score correlates better with biochemical disease activity compared to clinical disease activity, which points out to the significance of biochemical remission.

Crohn Disease

The role of surgery in the management of Crohn disease has undergone a dramatic evolution over the past 50 years. Currently, surgical treatment of Crohn disease is seldom performed in the emergency setting; it is nearly always performed after failed medical therapy. The general indications for surgical treatment are described and include specific attention to complications of the disease, including obstruction, symptomatic fistulas, abscess formation, cancer or dysplasia, and failure to grow. The special considerations of surgical therapy are also described, including pregnancy, the marking of stoma sites, and the choice of incision, which may involve laparoscopy. Surgical management of Crohn disease is evaluated in terms of therapy at specific sites, including esophageal, gastric, and duodenal disease; jejunoileal disease; ileocolic disease; colonic disease; and anal disease. Chemoprophylaxis is also described, as is surveillance and behavioral modification. Tables outline the Vienna Classification System, Crohn Disease Activity Index, Harvey-Bradshaw Index, extraintestinal manifestations, and the medical treatment of Crohn disease. Figures show endoscopic images of Crohn disease, computed tomographic enterography, a capsule endoscopy showing large Crohn structures, surgery rates over time, caput medusa, an example of stenotic ileocolic Crohn disease, an enterocutaneous fistula, Heineke-Mikulicz strictureplasty, Finney strictureplasty, a fibrotic stricture, an example of a large ulcer, pyoderma gangrenosum, a sigmoid colon stricture, toxic megacolon, and vessel loops for drainage of abscesses. This review contains 15 figures, 5 tables, and 76 references.

P384 Lower infliximab trough levels are associated with higher bowel wall thickness in Crohn’s disease

Abstract Background Therapeutic drug monitoring (TDM) is currently used to optimise anti-TNFα therapy in Crohn’s disease, as higher infliximab trough levels (ITL) are associated with better rates of clinical remission and mucosal healing. Transmural healing is emerging as a potential target in Crohn′s disease, but whether there is any relation with ITL remains unclear. Here, we investigated the relation between ITL with bowel wall thickness (BWT) in patients with CD in maintenance therapy with IFX. Methods A retrospective cohort study of CD patients treated with IFX in mono or combination therapy. Patients were included if they had an available ITL during maintenance therapy and available entero-magnetic resonance or computerised tomography performed ±4 months. Transmural inflammation was defined as BWT ≥ 4 mm. Median BWT was measured in the most affected segment. An ROC curve was plotted to determine the best cut-off point of ITL to predict transmural inflammation. Mann–Whitney U-test, logistic regression and Spearman correlation were performed to assess the ITL relation with BWT. Results Twenty-nine patients were included (males 55.2%; mean age 39.6 ± 18 years; combo therapy 48.2%). According to the Montreal Classification, most patients were A2 (75.2%), with ileal (L1: 34.5%) or ileocolic disease (L3: 51.7%), and behaviour was: B1 41.4%, B2 24.1%, and B3 34.5%, with concomitant perianal disease in 37.9%. 82.2% were in clinical remission. The median IFX TL was 3.2 μg/ml (IQR 1.15–5.15) and median bowel wall thickness was 7 mm (IQR 4–9). 75.9% of patients had BWT > 4 mm. A BWT > 4 mm was associated with lower clinical remission rates (75% vs. 100%, p = 0.27) and higher C-reactive protein (0.31 vs. 0.14, p = 0.09), albeit not significantly. The area under the curve of ITL for bowel wall thickness was 0.70 (best cut-off value 1.8). Having ITL < 1.8 μg/ml was associated with higher median BWT (8.7 vs. 5.9 mm, p = 0.02) and was a predictive factor for transmural inflammation (OR 1.57, 95% CI [1.08–2.30], p = 0.02). BWT showed a fair correlation with ITL (r = −0.43, p = 0.02). Conclusion In our cohort of CD patients treated with infliximab (mono or combo therapy), lower infliximab trough levels were associated with higher bowel wall thickness, reflecting worse transmural inflammation. Proactive TDM could offer a possibility to improve BWT and reduce transmural inflammation.

Clinical course in Crohn’s disease: factors associated with behaviour change and surgery

Background: Crohn’s disease (CD) is a chronic and progressive disease that changes its behaviour over time. Transmural inflammation in CD leads to stricturing and/or penetrating complications.Aim: To evaluate the frequency of long-term progression of CD phenotypes, the need of abdominal surgery, and the main factors associated with these outcomes.Methods: A retrospective study was conducted with a prospective follow-up. Montreal classification was assessed at the moment of the diagnosis and at the end of the follow-up period.Results: Two hundred and ninety patients were included, with mean follow-up duration of nine years. A change in behaviour was observed in 46 patients (15.9%). Ileocolic location (60.9% vs. 45.1%; p = .049), age at diagnosis <16 years (8.7% vs. 2.0%; p = .017), the use of steroids at diagnosis (43.2% vs. 27.0%; p = .031) and shorter exposure time to biological therapy (15.9 months vs 41.3 months; p < .001) were identified as risk factors for phenotype change. Regarding surgery, 70 patients (24.1%) were submitted to abdominal surgery. Smoking habits (41.3% vs. 26.9%; p = .048), stricturing behaviour (50% vs. 18.4%; p < .001), penetrating behaviour 34.8% vs. 7.8%; p < .001), hospitalisations in the first year of diagnosis (52.3% vs. 12.4%; p < .001), and use of steroids at diagnosis (61.4% vs. 23.6%; p < .001) were more frequently seen in patients subjected to surgery. Patients subjected to surgery were less frequently treated with biological therapy (8.7% vs. 23.4%; p < .025).Conclusions: A behaviour progression was observed in about one-sixth of the patients. Progression to a stricturing pattern was the most frequent change in behaviour. Stricturing and penetrating behaviour, higher number of hospitalisations in the first year of diagnosis, use of steroids at diagnosis, smoking status, age at diagnosis <16 years and ileocolic disease location were associated with an unfavourable clinical evolution.

Clinical Pattern of Surgical Crohn Disease Patients.

Backround/Objective: The aim of investigation was to evaluate if there is a pattern regarding the anatomical location of the disease and type of surgery performed/surgical indication. Also a analysis was performed regarding the complication rate in two subgroups deriving from urban and rural environments. Methods: Data was obtained from the medical records of patients with CD and centralized. Tests of statistical analysis included the CHY-SQUARE test and the results were presented as a retrospective, longitudinal study. Results: The group was formed of 60 patients. Patients with ileocolic disease were frequently diagnosed with obstruction and benefited from an enterectomy with anastomosis. Patients with colonic disease were frequently diagnosed with perforation and benefited from colectomy and stomy. Patients from rural areas had a milder evolution when compared with patients from urban enviroments. Conclusions: Although most patients with CD eventually require surgery, the indication could be anticipated by recognition of the concept of clinical patterns, and type of surgery required could be predicted if the clinical aspect of the patient/disease were identified.

Association of granulomas in mesenteric lymph nodes in Crohn's disease with younger age and transmural inflammation.

Mesenteric lymph nodes were usually removed during bowel resection surgery for Crohn's disease (CD). Mesenteric lymph node (MLN) granuloma predicted postoperative disease recurrence in patients with CD after ileocolic resection (ICR). This study was aimed to identify factors associated with MLN granulomas in a cohort of CD patients who underwent ICR. The study group consisted of 18 patients with CD who underwent the index ICR between 2004 and 2012 and had MLN granulomas. The control group included 32 cases negative for MLN granulomas, which were randomly selected from the same period. Clinicodemographic and histological features were compared in these two groups. The presence of MLN granuloma was associated with younger age, perianal disease, and ileocolic disease. Gender, body mass index, smoking status, disease duration, extraintestinal manifestation, length of bowel resected, total number of nodes examined, medical treatment, and indications for surgery were not significantly different between the groups. The presence of MLN granuloma was associated with mural granuloma, transmural inflammation, mural abscess, hypertrophy of the muscularis propria, fibrosis of the muscularis propria, and serosal fibrosis in the small bowel. The multivariable analysis confirms that MLN granuloma was associated with age and transmural inflammation. In CD patients who underwent the index ICR, the presence of MLN granuloma was associated with younger age and transmural inflammation. Our current results suggest that the detection of MLN granulomas may be enhanced in patients at higher risk, that is, younger patients or those with transmural inflammation on imaging or histopathology.

Clinical and inflammatory response to first ileocolic resection for Crohn’s disease

The intention of the first ileocolic resection in Crohn’s disease is to remove local disease, which relieves symptoms of intestinal obstruction, but should also relieve clinically significant systemic inflammation and allow discontinuation of corticosteroids. By means of five clinically relevant criteria for continued specific treatment, we evaluated the response of 117 patients to their first ileocolic resection for Crohn’s disease, which was undertaken at Karolinska University Hospital, Stockholm, Sweden, between 2000 and 2010. The five criteria were the persistence of systemic inflammation and continued or resumed corticosteroid therapy, high defecation frequency or presence of a stoma, and the need for new bowel surgery within 1 year. The presence of systemic inflammation and use of anti-inflammatory drugs were assessed 1 month preoperatively and 6–12 months after surgery. Other events of interest were assessed within 12 months. The median age was 31 years and 51 patients (44 %) were women. In all, 54 patients (46 %) were operated on within the first year of diagnosis and episodes of bowel obstruction were the prime surgical indication in 80 (68 %) patients. Of the patients, 100 (85 %) had an ileocolic resection and 17 (15 %) had terminal ileal surgery. As anticipated, C‑reactive protein (CRP), albumin, and hemoglobin concentrations all normalized significantly after surgery but 15 (13 %) patients still had CRP values of ≥ 30 mg/l and one fourth (29/117, 25 %) still used corticosteroids. Seventeen patients (15 %) had six or more defecations per day or a temporary stoma and four (3 %) patients had new surgery for symptomatic Crohn’s disease. Altogether, 46 (39 %) patients met one or more of the criteria for continued or renewed treatment within 1 year with a higher risk in patients with ileocolic disease as compared with ileal disease when adjusted for age and reoperation (p = 0.030). The curable intention of the first ileocolic resection for Crohn’s disease often fails, as the need for continued or renewed medical or surgical treatment in the first year is high.

PTH-198 Preoperative parenteral nutrition in crohn’s disease patients requiring abdominal surgery

Introduction The benefits of parenteral nutrition (PN) in Crohn’s Disease (CD) prior to abdominal surgery remains debatable, with two recent studies suggesting preoperative PN given to patients with moderate to severe CD minimises the risk of early postoperative complications. Method Retrospective cohort study of consecutive CD patients who received PN prior to abdominal surgery, from January 2013 to January 2015. Total days of PN received prior to surgery, changes in weight and BMI, and changes to CRP and albumin in all patients receiving PN were analysed. Adverse events related to PN, including line-related complications, and post-operative complications were also recorded. Results Of 62 operations performed for CD over the study period, 6 patients (4 male) received pre-operative PN. PN was administered via a PICC line with a dedicated lumen in all patients. All patients continued PO liquid intake and existing CD medications. 5 patients had stricturing and penetrating disease (3 with ileocaecal disease, and 2 with colonic disease). 2 of these patients had phlegmons, 2 had complex peri-anal fistulising disease, and 1 had a high output entero-cutaneous fistula. A further patient had isolated ileocolic stricturing disease. 4 patients required ileocaecal resection, 1 required panproctocolectomy and 1 sub-total colectomy. Pre-operative PN was administered for a mean of 41 days. Weight and BMI increased in all 6 patients (mean weight increased from 51.2 kg to 57.7 kg, mean BMI from 17.5 kg/m2to 19.8 kg/m2). The weight gained was maintained at routine follow-up after surgery. Mean CRP improved from 35.5 to 18.3, and albumin from 35.5 g/L to 38.3 g/L. Mean post-operative stay was 12 days, and diversion stoma was not required in 80% (4 patients). Line complications (catheter related infection/thrombosis) were not seen. One patient (16.7%) required PN withdrawal 2 days before planned surgery for suspected line sepsis not confirmed on blood cultures. No serious post-operative complications occurred, and only a single patient required antibiotics post-operatively for a small collection (not requiring surgical or radiological intervention). Conclusion In this small group of complex CD patients who received pre-operative PN, sustained weight gain and improvement in inflammatory markers was observed. Two recent studies suggest favourable postoperative outcomes, and our findings are in keeping with this. The role of optimisation with PN warrants further investigation and randomised controlled studies are required. Disclosure of interest None Declared.

A Single Nucleotide Polymorphism in the STAT5 Gene Favors Colonic as Opposed to Small-Bowel Inflammation in Crohn’s Disease

Crohn's disease is a chronic inflammatory ailment that can affect the colon and/or small intestine. A genetic basis for disease distribution is being sought, although the available data are seminal. The STAT5 gene is known to influence colonic permeability, mucosal regeneration, and interleukin 2 production, although its role in the distribution of Crohn's disease is unclear. The aim of this study was identification of single nucleotide polymorphisms associated with Crohn's distribution, with the goal of distinguishing disease subcategories and differing pathophysiologies. This was a retrospective cohort study. The study was conducted in a single tertiary referral center. A total of 173 patients with Crohn's disease who were identified from our biobank were segregated by disease distribution (colitis, n = 28; ileocolic disease, n = 116; enteritis, n = 29) and were genotyped for 258 Crohn's-associated single nucleotide polymorphisms. Patients with ulcerative colitis (n = 119) were also genotyped to confirm the association of identified single nucleotide polymorphisms with small-bowel sparing, colonic pathology. We investigated an association between single nucleotide polymorphisms and Crohn's disease distribution. Single nucleotide polymorphism rs16967637 in the STAT5 gene was associated with small-bowel sparing Crohn's disease when the enteritis group was compared with either a combined colitis/ileocolic group (p = 0.025) or those with only ileocolic disease (p = 0.04). Homozygosity for the at-risk allele (C) was present in 59% of patients with sparing of the small bowel. The association of this single nucleotide polymorphism with small-bowel sparing disease persisted when patients with ulcerative colitis were compared with the group with Crohn's enteritis (p = 0.036), as well as after combining patients with ulcerative colitis with both the Crohn's colitis group (p = 0.009) and the Crohn's ileocolitis/colitis group (p = 0.00008). This study was limited by the small numbers of study subjects with isolated enteritis or colitis. Single nucleotide polymorphism rs16967637 in the STAT5 gene was the only single nucleotide polymorphism associated with Crohn's disease without enteritis. Homozygosity for the at-risk allele demonstrated the strongest association with this phenotype. These results suggest a role for this single nucleotide polymorphism in the development of inflammatory bowel disease of the large intestine.

Crohn’s Disease in Caucasians and African Americans, as Defined by Clinical Predictors and Single Nucleotide Polymorphisms

To compare three aspects of Crohn's disease (CD) between African Americans and Caucasians: (1) demographic data and environmental factors affecting CD susceptibility, (2) disease presentation and clinical course, and (3) genetic susceptibility via the use of single nucleotide polymorphism (SNP) data for inflammatory bowel disease (IBD) susceptibility loci. Clinical data and peripheral blood were obtained from 1032 patients (554 CD patients and 478 controls) derived from a clinically well-defined university-based medical and surgical digestive disease practice and included those who were diagnosed with IBD. Genomic DNA was extracted and polymerase chain reaction (PCR) amplification and genotyping were performed for 11 SNPs, including the NOD2, IL-23r, OCTN 1, and the IGR gene variants. A total of 554 patients with CD were included in this study: 53 African Americans (10%), 485 Caucasians (87%), and 15 of other races (3%). The strongest demographic predictor of CD in African American patients was a family history of IBD. Ileocolic disease (L3) was the most common site involved in both African Americans and Caucasians, while the penetrating phenotype (B3) was the most common CD disease behavior in both races. Genotype association analysis showed a significant association between 2 IL23r gene SNPs and CD susceptibility in African Americans (p = .016 and .028, respectively). We believe this study is the first to report on genotype-phenotype associations in African American CD patients and compare findings to Caucasian CD patients within the same geographic area. We found no association between NOD2 gene SNPs and CD susceptibility in African Americans patients (p > .05).