Previous Intestinal Resection Research Articles

Review article: Measuring disease severity in inflammatory bowel disease - Beyond treat to target.

Inflammatory bowel disease (IBD) follows a heterogenous disease course and predicting a patient's prognosis is challenging. There is a wide burden of illness in IBD and existing tools measure disease activity at a snapshot in time. Comprehensive assessment of IBD severity should incorporate disease activity, prognosis, and the impacts of disease on a patient. This review investigates the concept of disease severity in adults with IBD to highlight key components contributing to this. To perform this narrative review, a Medline search was conducted for full-text articles available at 1st March 2024 using search terms which encompassed disease activity assessment, disease severity, prognosis, natural history of Crohn's disease (CD) and ulcerative colitis (UC), and the burden of IBD. Current methods of disease assessment in IBD have evolved from a focus on the burden of symptoms to one that includes inflammatory targets, genetic, serological, and proteomic profiles, and assessments of quality-of-life (QoL), disability, and psychosocial health. Longitudinal studies of IBD suggest that the burden of illness is driven by disease phenotype, clinical markers of complicated disease course (previous intestinal resection, corticosteroid use, perianal disease in CD, recent hospitalisations in UC), gut inflammation, and the impact of IBD on the patient. Disease severity in IBD can be difficult to conceptualise due to the multitude of factors that contribute to IBD outcomes. Measurement of IBD severity may better encapsulate the full burden of illness rather than gut inflammation alone at a single timepoint and may be associated with longitudinal outcomes.

Long-term Outcome of Risankizumab in Crohn’s Disease: a Real-world GETAID Study

IntroductionThe aim of this study was to assess the long-term effectiveness and safety of risankizumab maintenance treatment in a large real-world cohort of patients with CD. Patients and MethodsFrom May 2021 to August 2023, all consecutive CD patients treated with risankizumab in 25 GETAID centers have been retrospectively included. The primary endpoint was steroid-free clinical remission (Harvey Bradshaw Index (HBI) <5) at 52 weeks. ResultsOf the 174 patients included, 99%, 93%, and 96% had been previously exposed to anti-TNF, vedolizumab, and ustekinumab, respectively. All patients had received ≥3 biologics and 108 (62%) had previous intestinal resection. Median follow-up was 13.7 (10.0-18.1) months. The rates of steroid-free clinical remission and clinical remission at week 26 were 47% (72/152) and 52% (79/152), and 46% (58/125), and 48% (60/125) at week 52, respectively. Risankizumab persistence rates were 94%, 89%, and 79% at weeks 12, 26, and 52, respectively. At the end of follow-up, 45 (45/174, 26%) patients had discontinued risankizumab (loss of response, 42%; primary failure, 37%; intolerance, 13%). Thirty-six patients (36/174, 20.9%) were hospitalized and 22 (22/174, 12.6%) required intestinal resection. Fifty-one (29%) patients had an adverse event including 26 (15%) serious adverse events (CD flare, n=17). One death (myocardial infarction) and one cancer (papillary thyroid carcinoma) were observed. ConclusionThis is the first real-life study to report long-term outcomes in patients with refractory CD treated with risankizumab. Half of the patients achieved steroid-free clinical remission after one year, and the safety profile was consistent with the literature.

DIETARY INTERVENTION AS A NOVEL TOOL TO IMPROVE DIAGNOSTIC ACCURACY OF PATENCY CAPSULE IN CROHN'S DISEASE PATIENTS

Abstract INTRODUCTION AND AIM Patency capsule (PC) is a recommended procedure to confirm that the gastrointestinal tract is patent before ingestion of video capsule endoscopy (VCE). However, in some patients non-expelled PC may be due to slow transit time and not due to small bowel stricture. We examined if a nutritional intervention during the PC test which we introduced into routine clinical practice could improve passed PC rate and reduce false positive results. METHODS A retrospective study of patients who were subjected to standard protocol of PC procedure or to a nutrition-modified protocol of PC. Nutritional-modification comprised individualized dietary advice on the consumption of personally-convicted laxative foods after PC ingestion. Imaging study at 30 hours post-ingestion was performed to ascertain passage of PC in patients who did not visually see a passed PC in stool. RESULTS A total of 49 Crohn's patients who ingested PC were included (median age 33.7, 28.6% with previous intestinal resection). 26 patients followed the nutrition-modified personalized protocol and 23 did not (15 for technical reasons, eight for non-compliance). In total, 38 PC passed and 11 failed. Patients on dietary modification had significantly reduced rate of a failed PC compared to patients receiving standard protocol (7.7% versus 39.13%, respectively, odds ratio 0.13, 95% [CI] 0.0244-0.687, P value = 0.016). All patients with a passed PC subsequently ingested a VCE without complications. CONCLUSION Personalized nutritional intervention to promote colonic transit time may serve as a novel practical easy-to-follow dietary tool, in order to improve the diagnostic accuracy of patency capsule. Prospective controlled trials are warranted to corroborate these findings. Study flowchart. CD, Crohn’s disease; CT: Computed tomography; PC: Patency capsule. Percentage (%) of patients with failed PC with nutrition protocol or with standard protocol.

P613 Dietary intervention as a novel tool to improve diagnostic accuracy of patency capsule in Crohn’s Disease patients

Abstract Background Patency capsule (PC) is recommended to confirm the patency of the small bowel before ingestion of video capsule endoscopy (VCE). However, in some patients non-expelled PC could be due to slow transit time and not due to small bowel stricture. We examined if dietary intervention during the PC could improve passed PC rate and reduce false positive results. Methods A retrospective study of patients who received diet-modified protocol of PC test, introduced into routine clinical practice on February 2023, compared with standard protocol. Dietary-modification comprised individualized dietary advice on the consumption of personally-conceived laxative foods after PC ingestion. Abdominal X-ray at 30 hours post-ingestion was performed to ascertain passage of PC in patients who did not see an intact PC in stool, followed by low-dose limited computed tomography (CT) in patients with evident PC on X-ray to assure passage to colon. Results A total of 52 Crohn's patients who ingested PC were included (median age 32.4, 28.8% with previous intestinal resection). 26 of the patients followed the dietary-modified personalized protocol and 26 followed the standard protocol. In total, 38/52 PC passed and 14/52 (26.9%) failed. Patients on dietary modification had significantly reduced rate of a failed PC compared to patients receiving standard protocol (7.7% versus 46.1%, respectively, odds ratio 0.1, 95% confidence interval 0.02-0.49, P=0.005). 12/14 patients with a failed PC underwent low-dose CT, which showed PC was in the colon (false positive PC) in 11/12 patients (92%, 9/11 in standard group, 2/11 in dietary group). All 11 patients with a passed PC in colon subsequently ingested a VCE without complications. Conclusion Majority of failed PC are falsely positive, stemming from slow-transit of PC in the colon. Personalized dietary intervention to promote colonic transit may serve as a novel practical tool to reduce false positive tests and improve the diagnostic accuracy of patency capsule.

P478 Fatigue, physical fitness, and physical activity in patients with inflammatory bowel disease

Abstract Background Fatigue is a common and debilitating symptom in patients with Inflammatory Bowel Disease (IBD) with a great impact on quality of life and work productivity. A better comprehension of the contributing factors to fatigue could potentially pave the way for more targeted and effective strategies for managing fatigue in IBD. Fatigue may be associated with lower levels of physical activity and reduced physical fitness. Yet, the interaction between these factors in IBD, measured with validated tests, is not fully understood. Therefore, this study aimed to investigate the association between fatigue and physical fitness and physical activity in patients with IBD. Methods Adult patients with IBD in remission or with mild-to-moderate clinical disease activity with an ASA Physical Status &amp;lt;III were eligible for inclusion. Fatigue was defined as a Checklist Individual Strength-fatigue subscale score ≥35. Patient and clinical characteristics were collected, including age, sex, body mass index, comorbidities, disease duration, disease location and behavior, clinical and biochemical disease activity, smoking status, previous intestinal resection, and medication use. Cardiorespiratory fitness was measured using cardiopulmonary exercise testing to assess the oxygen uptake at peak exercise (VO2peak). Muscular strength (peak torque at 60°/s) and endurance (fatigue rate as percentage decline in peak torque over 30 repetitions at 180°/s) of the knee extensor and flexor muscles were assessed using an isokinetic dynamometer. Objective physical activity data were collected continuously for seven consecutive days utilizing the MOX accelerometer, with activities categorized into sedentary, standing, light (LPA), moderate (MPA), and vigorous physical activity (VPA) levels. Results In total, 50 patients were included, with 17 being classified as fatigued. Fatigued patients had significantly higher BMIs, a higher frequency of clinical disease activity, and a higher prevalence of smoking (Table 1). They also exhibited significantly lower VO2peak (mean [±SD] 28.1 [±7.9] vs. 36.0 [±9.8] mL·kg-1·min-1, p=0.007) and higher knee extensor fatigue rate (mean [±SD] 39.0% [±8.8] vs. 31.1% [±10.4], p=0.010) compared to non-fatigued patients. There was no statistical significant difference in physical activity between fatigued and non-fatigued patients. Conclusion Although physical activity did not differ between patients with and without fatigue, fatigued patients exhibited lower cardiorespiratory fitness and knee extensor muscular endurance. A larger population is needed to further investigate the influence of patient and disease characteristics on this relationship to work towards more targeted and effective strategies for managing fatigue in patients with IBD.

P963 The comparative effectiveness and safety of different biologics in young (&amp;lt;60 years) versus elderly (≥60 years) patients with IBD: results from a real-world experience at a Belgian tertiary centre

Abstract Background The therapeutic armamentarium for inflammatory bowel disease (IBD) is rapidly expanding as well as the number of elderly patients with IBD. Given the frailty of this subpopulation, it is of increasing importance to have data on the efficacy and safety of different therapies in this cohort. Aim: To assess the efficacy and severe adverse event (SAE) rate of different biologics in young (&amp;lt;60 years (yr)) versus elderly patients with IBD (≥60 yr) in a real-world tertiary cohort. Methods A retrospective monocentric study was performed at the Ghent University Hospital. Patients starting anti-TNF, ustekinumab (UST) or vedolizumab (VDZ) from 01/2018 to 06/2021 with follow-up until 12/2022 were included. Co-primary endpoints after induction and after 1 yr of therapy were: clinical response (CRp) and remission (CRm), biochemical response (BRp) and remission (BRm) and endoscopic response (ERp) and remission (ERm). The secondary endpoint was treatment survival. Severe adverse events (SAE) were defined as intestinal resection (IR), IBD-inflammation related hospitalization (IBD-hosp), IBD-treatment related hospitalization (e.g. infections) (treat-hosp), malignancy and death. Multivariate logistic regression (MLR) and Cox regression model (CRM) were applied to assess potential risk factors (RF). Results A total of 267 patients were included (33 patients ≥60 yr). Significantly different baseline characteristics are shown in Table 1A. After induction, no differences in CRp, CRm, BRp, ERp or ERm were found between both groups (Table 1B). Only BRm was numerically higher in younger patients, but not statistically significant after MLR (Table 1C). After one year of therapy, no difference was seen for CRp, CRm, BRp, BRm, ERp or ERm (Table 1B). There was no difference regarding treatment survival for both groups (aHR 0.701, [0.346-1.420], P=0.324) (figure 1), as well as for reason to stop biologic (P=0.336). Regarding SAEs, a higher rate was seen for elderly patients (26.9% vs. 45.5%, P=0.028), also after CRM (aHR 1.86, [1.01-3.44], P=0.047), adjusting for type of biologic, use of systemic corticosteroids or immunomodulators, previous IR, disease duration and number of previous biologics used. Regarding different subtypes of SAE, no difference for IR (P=0.503), IBD-hosp (P=0.714), specific IBD related SAE (P=0.480), malignancy (P=0.162) and death (P=1.000) were found. Treat-hosp was higher in elderly patients (5.1% vs. 24.2%, P=0.001), which was confirmed in the CRM (aHR 5.01, [1.92-13.04], P&amp;lt;0.001). Conclusion No difference was seen regarding efficacy of different biologics in younger versus elderly patients with IBD. SAE rate was higher in elderly patients.

DOP89 Impact of biologics on the risk of early postoperative complications in Crohn’s disease: a French nationwide study

Abstract Background While the effect of anti-TNFs on postoperative outcomes in patients with Crohn’s disease (CD) has been widely studied, the impact of vedolizumab and ustekinumab on the risk of postoperative complications remains poorly known. Methods All consecutive patients who underwent intestinal resection for CD between July 2014 and April 2022 within 22 French centers were included in a retrospective cohort. The risk of early post-operative complications (≤30days) in patients exposed to biologics was compared to patients not exposed by logistic regression and propensity score-matched analysis adjusted for age, previous intestinal resection, corticosteroids or immunosuppressants exposure, disease activity, presence of abscess, urgent surgery and initial stoma (preoperative contra-indication to anastomosis). Results Among the 1201 patients included, respectively 491 (41%), 76 (6.3%) and 57 (4.7%) were exposed to anti-TNFs, ustekinumab, or vedolizumab within six months before surgery. A total of 317 (26.4%) patients had at least one complication of which 123 (38%) were considered as severe (DINDO III/IV). New surgery was necessary in 69 (5.7%) patients and secondary stoma in 23 (1.9%). Three deaths were observed (0.25%). The rates of overall complications in patients not exposed to biologics, exposed to anti-TNFs, ustekinumab or vedolizumab were respectively 26.1%, 25.1%, 34.7% and 29.8%. The risks of intra-abdominal infectious complications in these four groups were respectively 13.5%, 11.1%, 13.3% and 8.8%. In multivariate analysis, age [OR, 1.02 (1.01-1.04); p=0.004], disease activity [OR, 8.36 (1.79 – 149); p=0.037], the presence of an abscess [OR, 2.01 (1.25-3.20); p=0.004] and initial stoma [OR, 1.70 (1.10 –2.61); p=0.016] were significantly associated with intra-abdominal infectious complications. Conversely, preoperative enteral nutrition [OR, 0.12 (0.01 -0.59); p=0.040] was associated with a reduction in this risk. Exposure to anti-TNFs [OR, 0.80 (0.51-1.24); p=0.31], ustekinumab [OR, 1.17 (0.39-3.51); p=0.78] and vedolizumab [OR, 1.28 (0.32-5.17); p=0.72] within the 3 months before surgery were not associated with the risk of intra-abdominal infectious complications. Similar results were observed in patients exposed to these treatments in the month before surgery. Conclusion In this large cohort, a quarter of patients operated on for CD presented an early postoperative complication and 10% a severe complication. Preoperative exposure to anti-TNFs, vedolizumab or ustekinumab was not associated with an increased risk of early postoperative complications. Preoperative enteral nutrition was associated with a reduced risk of intra-abdominal infectious complication.

P638 Effectiveness and safety of risankizumab induction therapy for 100 patients with Crohn’s disease: a GETAID multicentre cohort study

Abstract Background Phase III trials have demonstrated the efficacy of risankizumab in moderate-to-severe Crohn’s disease (CD), but no real-world data are currently available. We aimed to assess the short-term effectiveness and safety of risankizumab in patients with CD. Methods From May 2021 to May 2022, all patients with refractory luminal CD treated with risankizumab in 22 French GETAID centers were retrospectively included. The primary endpoint was steroid-free clinical remission at week 12 (Harvey-Bradshaw (HB) score &amp;lt; 5). Secondary endpoints included clinical response (≥ 3-point decrease of HB score and/or (HB) score &amp;lt; 5), biological remission (CRP ≤ 5 mg/L), need for CD-related surgery, and adverse events. Results Among the 100 patients included, all have been previously exposed to anti-TNF agents, 94 to vedolizumab, 98 to ustekinumab (all exposed to at least three biologics) and 61 had previous intestinal resection. All but three (97%) received a 600 mg risankizumab intravenous induction at weeks 0-4-8. At week 12, steroid-free clinical remission was observed in 45.8% of patients, clinical remission in 58% and clinical response in 78.5%. Absence/mild abdominal pain with normal stool frequency was noted in 50% of patients at week 12. Biological remission was observed in 50% of patients. Six patients discontinued risankizumab before the week 12 visit due to lack of efficacy. CD-related hospitalization was needed in six patients, and three underwent intestinal resection. In multivariable analysis, only a history of ustekinumab loss of response (vs primary failure) (Odds Ratio (OR), 2.80 ; 95%CI, 1.07 – 7.82; p=0.041) was significantly associated with clinical remission at week 12. Twenty adverse events (AE) occurred in 20 patients including 7 serious AE corresponding to 6 CD exacerbation and one severe hypertension. Conclusion In a cohort of highly refractory patients with luminal CD and multiple prior drug failures including ustekinumab, risankizumab induction provided clinical response in about 3 out of 4 patients and steroid-free clinical remission in about half of patients.

P660 Body composition and health-related quality of life in adult Crohn’s Disease during clinical remission: The INTICO2 cohort study

Abstract Background A reduction in the absolute or relative mass of lean tissue or muscle mass in the context of disease and/or malnutrition are well-described features associated with poor prognosis. Conversely, excessive adiposity may lead to metabolic disease, increased inflammation and has been linked to adverse CD outcomes. Bioelectrical impedance analysis (BIA) allows estimation of fat-mass index (FMi kg/m2) and fat-free mass index (FFMi kg/m2) which can be expressed standardised as Z scores using device-specific age and gender reference ranges. Here we report the body composition and relationship between BMI, elevated FMi and reduced FFMi Z scores and patient reported outcome measures in an adult cohort in CD clinical remission. Methods 194 adult CD outpatients in clinical and biochemical remission were recruited from a single tertiary IBD service (Harvey Bradshaw Index &amp;lt;5 and calprotectin &amp;lt;250µg) as part of the INTICO2 observational study. 55 had undergone previous intestinal resection, 81 were on biological therapy, 67 immunomodulator and 33 both. Subjects needed to be in intestinal continuity and not currently receiving either exclusive or partial EN or IV nutrition. Body composition was assessed using BIA (seca mBCA 515) and expressed as FMi and FFMi Z scores. Health and disease-related quality of life was assessed using Short Form 36 (SF36) and the fatigue-specific PROM FACIT-F. Results The Median BMI of the cohort was 26.1 (18.0-48.9) Kg/m2. One subject was underweight (≤18.5) by BMI, 37% of patients (71/194) were overweight (BMI ≥25), of which 47 (24% of cohort) were obese (BMI≥30). 16/97 of men and 11/97 of women were below the 5th centile (SDS score &amp;lt;-2) for age and sex matched values for FFMi, respectively. Of the 27 individuals with reduced lean mass, 20 had a normal BMI (20-25), 2 were overweight (25-30). 14/97 and 21/97 of women were above the 95th centile for FMI Z-scores (SDS score &amp;gt;2), all had BMI over 30. Excessive fatigue was present among the population affecting 25% (49/194). FMiz was correlated to excessive fatigue among women (r- 0.236 p&amp;lt;0.05), but there was no relationship to FFMiZ among either sex. Conclusion While weight loss is a recognised presentation of CD, this characterisation of a large outpatient adult cohort in remission found the commonest BMI-defined malnutritional states to be overweight or obese. In the population of individuals with predominantly normal or elevated BMI, sarcopenia was common, masked by excessive adiposity and may not have been appreciated without BIA assessment of body composition. Body composition analysis estimates of excessive age and sex matched adiposity was correlated to excessive fatigue, which was common in the population.

P455 Comparison of two strategies for the management of post-operative recurrence in Crohn’s disease patients with one clinical risk factor: a multicentre IG-IBD study

Abstract Background Prevention of postoperative recurrence (POR) in Crohn’s disease (CD) after ileo-colonic (IC) resection is still a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in presence of at least one clinical risk factor (RF). Due to drug-related adverse events and the relative high cost of biologics, we aimed to determine whether prevention of POR can be postponed and guided by endoscopy in CD patients with only one RF. Methods A multicentre retrospective study was conducted in 12 IG-IBD Italian centres. CD patients with only one RF for POR, including previous intestinal resection, extensive small intestine resection (&amp;gt;50 cm), fistulising phenotype, history of perianal disease, or active smoking were considered. Patients who performed a colonoscopy between 6 to 12 months after curative IC resection were included. Two groups were formed based on whether immunosuppressive therapy was started immediately after surgery (prophylaxis group) or guided by endoscopy (observation group). Primary endpoints were the rates of any endoscopic recurrence (Rutgeerts ≥i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence (HBI≥5) rates at 6, 12 and 24 months after surgery. Results A total of 195 patients were enrolled. Out of all, 61 (31.3%) received immunoprophylaxis at a median time of 32 days [IQR 26-55] after surgery (n=14 infliximab, n=37 adalimumab, n=7 azathioprine, n=3 ustekinumab). Baseline patient characteristics are detailed in Table 1. Particularly, risk factors for POR were homogeneously distributed between the 2 groups. Colonoscopy was performed after a median time of 8 months [IQR 6-11]. No differences between immunoprophylaxis and endoscopy-driven approach was found regarding any endoscopic recurrence (36.1% in prophylaxis group vs 45.5% in observation group, p=0.10) and severe endoscopic recurrence (9.8% in prophylaxis group vs 15.7% in observation group, p=0.15). In 32 patients with a second colonoscopy at a median time of 30.5 months [IQR 22-43.75] after surgery, any recurrence and severe recurrence rates were also similar (p=0.55 and p=0.43, respectively). Early clinical recurrence at 6 months was reported in 23.4% of patients on immunoprophylaxis vs 31.5% who were not (p=0.43). Clinical recurrence rates between prophylaxis and observation group were also similar at 12 months (17.9% vs 34.8%, respectively, p=0.09) and at 24 months (17.9% vs 24.1%, respectively, p=0.63). Conclusion In CD patients with only one RF for POR, immediate immunoprophylaxis after curative IC resection does not decrease the rate of early clinical and endoscopic recurrence. Prospective and larger studies are needed to confirm our results.

ILEOSCOPY: WHEN ILEAL EVALUATION IS NOT MANDATORY DURING COLONOSCOPY.

Ileitis is defined as ileal inflammation, with several etiologies, including inflammatory bowel disease (IBD), and can be evaluated during the colonoscopy exam, but its mandatory evaluation is discussed, because of few diagnosis and procedure time. This study aims to evaluate the correlation of colonoscopic ileitis with the clinical presentation, in order to identify the cases where ileal examination is mandatory. A retrospective, cross-sectional study was conducted between 2013 and 2017. The examination report, indications for colonoscopy, and medical records were evaluated in order to identify whether the colonoscopic findings were clinically significant. Patients over 18 years of age who had undergone ileoscopy were included, whereas patients below 18 years of age, those with previous intestinal resections, and repeated examinations of the same patient in the study period were excluded. The estimated association measure was the odds ratio with 95% confidence intervals. P-values <0.05 indicated statistical significance. A total of 3382 cases were included. Among these participants, 64.5% were females and the average age was 56.9±13.1 years (18-89 years). Ileal alterations were observed in 5.3% of the patients, with 2.69% being clinically significant between all patients, and 0.96% excluding those with IBD. There was a positive correlation between the ileitis findings and IBD control examinations and a negative correlation in screening and change in bowel habit indications. Among the indications with ileitis clinically significant, IBD control still had a positive correlation, 'diarrhea' and 'others' did not show a statistical significance, and all other indications presented a negative correlation for ileal assessment. Ileal evaluation in only mandatory in IBD control. When the main colonoscopy objective is detecting colonic neoplasms, ileoscopy is unnecessary.

ILEITIS - DO ENDOSCOPIST AND PATHOLOGIST SPEAK THE SAME LANGUAGE?

Ileitis is defined as an inflammation of the ileum, which is evaluated during colonoscopy. Biopsies should be performed on altered ileus, aiding to the diagnosis. Evaluate the correlation of anatomopathological findings on ileitis between pathologists and endoscopists. A retrospective, cross-sectional study, between 2013 and 2017. Examination report, indications for colonoscopy, and medical records were evaluated to identify whether the colonoscopic findings were clinically significant. Anatomopathological samples were reviewed by a pathologist expert in gastrointestinal tract. Patients over 18 years of age who had undergone ileoscopy were included, whereas patients below 18 years of age and those with previous intestinal resections were excluded. The correlation was assessed using the kappa coefficient index. A total of 5833 colonoscopies were conducted in the study period and 3880 cases were included. Ileal alterations were observed in 206 cases, with 2.94% being clinically significant. A hundred and sixty three biopsies were evaluated using the kappa index, resulting in agreement among pathologists of 0.067 and among pathologist and endoscopist of 0.141. It was observed that despite the low concordance between pathologists and endoscopists, there was no change in patient outcomes. This study confirms the importance of knowledge of the main anatomopathological changes related to ileitis by pathologists and endoscopists, making the best diagnosis and follow-up.

P598 Previous Intestinal Resection Is Associated with Postoperative Complications in Crohn’s Disease: A Cohort Study

Abstract Background To assess the influence of a previous intestinal resection on postoperative complications for Crohn’s disease (CD). Methods Data on patients with CD undergoing surgery in our department from January 2016 through December 2019 were retrospectively reviewed. Information collected included demographic details, surgical data, and postoperative outcome. A cross- sectional study design was employed. Associations between postoperative complications and preoperative clinical indicators were further analyzed. Results Of the 129 patients with CD studied, 62 patients (48.06%) underwent previous resection. These patients were more likely to be older (P=0:031), have longer disease duration (P=0:025), use less 5-aminosalicylic acid/sulfasalazine preoperatively (P = 0:013), have lower body mass index (P = 0:003), and have a higher American Society of Anesthesiologists (ASA) Physical Status Classification System score (P = 0:043). Patients who had previous surgery had a longer duration of operation (P = 0:003), greater estimated blood loss (P = 0:001), and longer hospital stay (P &amp;lt; 0:001) and were more inclined to develop postoperative complications (P=0:047), particularly anastomotic leak (P=0:021) and severe (Clavien– Dindo grade III/IV) complications (P = 0:038). After multivariate analysis, previous intestinal resection (P = 0:019), preoperative use of steroids (P = 0:026), and ASA score of more than II (P &amp;lt; 0:001) were determined to be the independent prognostic risk factors for postoperative complications. During the 30-day follow-up period, there was no postoperative mortality or readmission. Conclusion Previous intestinal resection in patients with CD is an independent predictor of overall postoperative complications.

P549 Changing Lanes: Switching Therapies in Inflammatory Bowel Disease, An Observational Study

Abstract Background Switching between therapies in inflammatory bowel disease (IBD) is common and a paucity of data exists regarding the optimal switching strategy. A number of new drug therapies have recently emerged for the treatment of IBD. Failure of biologic and small molecule therapies occur regularly, prompting the need for a treatment switch. Our aim is to review trends amongst our patients who switched biologic/small molecule therapy to identify high risk characteristics and to look for predictor variables which may reduce the need to switch in the future. Methods This is a 4 year retrospective observational study of IBD patients who underwent a therapy switch. Patients were identified from a prospectively maintained IBD database of 141 patients. Patient demographics, treatment history, disease history, biomarkers (within 3 months of switch) and endoscopy results were reviewed. Minitab17 was used for statistical analysis. Results Switching of biologic therapy was observed in 39 patients (28%); 21 (54%) were male; mean age was 42.8Y. Of these, 21 (53.9%) had Crohn’s disease (CD), 17 (44%) had ulcerative colitis (UC) and 1 patient had indeterminate colitis. Mean disease duration at time of switch was 78 months. 82% (n=14/17) of UC patients had pancolitis. 43% (n=9/21) of CD patients had a previous intestinal resection. The most common initial therapy was Adalimumab 46% (n=18) (Fig1) with the most common switch to IFX 36% (n=14) (Fig2). Primary LOR occurred in 28% (n=11) and secondary LOR in 44% (n=17), the remainder switched due to infusion reaction/adverse effects (n=10) and clinical remission (n=1). Mean CRP was 13.68 (95% CI: 7.28, 20.09), mean FCP was 874 (95% CI: 418, 1329), mean mayo score was 1.88 (95% CI: 1.37, 2.39), mean SES CD score was 5.79 (95% CI: 3.24, 8.33). Median IFX level was 0.8ug/ml (IQR 0.4, 9.7), 37.5% (n=6/16) of the patients on IFX developed ADAs to IFX. Median Adalimumab level was 5.2ug/ml (IQR 1.4, 13.5) and 11% (n=2/18) developed ADAs to Adalimumab. A significant negative correlation was found between FCP and IFX level using Spearman rank correlation -0.822, p = 0.01. 39% (n=15) were on an immunomodulator, no significant association was found between immunomodulator therapy and primary/secondary LOR, p= 0.67 and p= 0.63. 28% (n=11) were admitted with an IBD flare in the 1st year post switch and 13% (n=5) underwent intestinal resection. 8 (21%) subsequently switched to a 3rd biologic agent. Conclusion The most common therapy switch was within Anti-TNF drug class, mean CRP and FCP were raised at the time of switch and a significant number of patients were admitted in the year post switch with an IBD flare. Pancolitis in UC and previous intestinal surgery in CD were common characteristics of those who switched.

Previous Intestinal Resection Is Associated with Postoperative Complications in Crohn's Disease: A Cohort Study.

Background To assess the influence of a previous intestinal resection on postoperative complications for Crohn's disease (CD). Methods Data on patients with CD undergoing surgery in our department from January 2016 through December 2019 were retrospectively reviewed. Information collected included demographic details, surgical data, and postoperative outcome. A cross-sectional study design was employed. Associations between postoperative complications and preoperative clinical indicators were further analyzed. Results Of the 129 patients with CD studied, 62 patients (48.06%) underwent previous resection. These patients were more likely to be older (P = 0.031), have longer disease duration (P = 0.025), use less 5-aminosalicylic acid/sulfasalazine preoperatively (P = 0.013), have lower body mass index (P = 0.003), and have a higher American Society of Anesthesiologists (ASA) Physical Status Classification System score (P = 0.043). Patients who had previous surgery had a longer duration of operation (P = 0.003), greater estimated blood loss (P = 0.001), and longer hospital stay (P < 0.001) and were more inclined to develop postoperative complications (P = 0.047), particularly anastomotic leak (P = 0.021) and severe (Clavien–Dindo grade III/IV) complications (P = 0.038). After multivariate analysis, previous intestinal resection (P = 0.019), preoperative use of steroids (P = 0.026), and ASA score of more than II (P < 0.001) were determined to be the independent prognostic risk factors for postoperative complications. During the 30-day follow-up period, there was no postoperative mortality or readmission. Conclusions Previous intestinal resection in patients with CD is an independent predictor of overall postoperative complications.

Tu1085 POST-OPERATIVE CROHN'S DISEASE PATIENTS UNDERGOING COLONOSCOPY REQUIRE SIGNIFICANTLY MORE ANALGESIA & SEDATION COMPARED TO A NON-IBD POST-OPERATIVE POPULATION

Rates of surgical intervention in Crohn’s disease have declined. However, a significant proportion of patients still require surgical resection and have been shown to have higher post-op pain scores and analgesia requirements. The aim of this study was to assess sedation requirements and comfort scores of post-operative Crohn’s disease patients at endoscopy. Patients with a previous intestinal resection undergoing colonoscopy 2014-2017 were identified via an electronic reporting system. Data regarding patient & disease characteristics, sedation requirements, Gloucester comfort scores and endoscopy reports were collected.Crohn’s disease patients with prior intestinal resection were compared to a non-IBD population post-intestinal resection. 212 patients were included. n=66 Crohn’s disease, n=2 UC and n=144 non-IBD patients underwent colonoscopy. Patient characteristics described in Table 1. 10.8% of patients had a documented history of chronic pain, hysterectomy or other relevant conditions that may affect comfort scores. 53% of patients with Crohn’s disease were on active treatment for IBD at the time of endoscopy. The median dose of midazolam administered was 3mg (IQR 2.12-4mg); median fentanyl dose was 50mcg. (IQR 50-75mcg).Significantly more midazolam was used in 2014 compared to procedures performed in 2016-17. (median 4mg vs 3mg; p=0.014). The median dose of Midazolam given was significantly higher in patients with Crohn’s disease (3mg IQR 3-5mg vs 3mg IQR 2-4; p=0.009).The median dose of fentanyl required was significantly higher in post-operative Crohn’s disease patients. (75mcg IQR 50-100mcg vs 50mcg ; p=0.001). The median comfort score in the Crohn’s disease patients was higher (indicating more discomfort) when compared to the non-IBD cohort. (median score 2 & 1 respectively) There was no significant difference in the proportion of patients with chronic pain etc or with multiple intestinal resections. (p=0.5 and p=0.41). There was a statistically significant difference in comfort scores with only n=25 Crohn’s disease patients (37.9%) having comfort score 1 when compared to n=79 non-IBD patients (55%) (p=0.04). Post-op Crohn’s disease patients with significant active endoscopic disease required significantly higher doses of midazolam compared to those patients with quiescent disease.(4mg IQR 3-5mg vs 3mg IQR 2.5-4mg;p=0.038) There was a trend towards significance in fentanyl dose. (75mcg IQR 50-100mcg vs 50mcg IQR 50-100mcg;p=0.06) Patients with Crohn’s disease undergoing colonoscopy in the post-operative setting have significantly higher analgesia requirements. Comfort scores are significantly worse when compared to non-IBD patients who have had similar intestinal resections. Endoscopists should use techniques e.g. CO2 insufflation, in addition to medication to ensure comfort amongst patients with Crohn’s disease.

Bowel damage and disability in Crohn's disease: a prospective study in a tertiary referral centre of the Lémann Index and Inflammatory Bowel Disease Disability Index.

The notion of Crohn's disease (CD) as a chronic, progressive and disabling condition has led to the development of new indexes: the Lémann Index measuring cumulative bowel damage and the Inflammatory Bowel Disease (IBD) Disability Index, assessing functional disability. To measure the Lémann Index and the IBD Disability Index in a large prospective cohort of CD patients and to assessthe correlation between these two indexes. We performed a prospective study in a tertiary referral centre including all consecutive CD outpatients. We assessed the Lémann Index and the IBD Disability Index questionnaire in all patients. One hundred and thirty CD patients were consecutively included. The mean Lémann Index (±SD) was 11.9±14.1 and ranged from 0 to 72.5 points. Factors associated with a high bowel damage score were: disease duration, anal location, previous intestinal resection, clinical and biological disease activity, exposure to immunosuppressants, and exposure to anti-TNF (P<0.005). Among patients exposed to anti-TNF, the Lémann Index was lower in those who were exposed in the first 2years of their disease (P=0.015). The mean IBD Disability Index was 28.8±6.3 and ranged from 0 to 71 points. The factors associated with high disability score were: female gender, anal location, extra digestive manifestations, clinical and biological disease activity and exposure to anti-TNF (P<0.005). No correlation was observed between the Lémann Index and IBD Disability Index (P=0.15). This is the first study to prospectively evaluate the Lémann Index and the IBD Disability Index in a large cohort of CD patients in a tertiary centre. Early introduction of anti-TNF treatment was associated with lower bowel damage scores, and no correlation was observed between the Lémann Index and the IBD Disability Index. Further dedicated prospective studies are necessary to confirm these results.

P646 Utilisation of indocyanine green fluorescence imaging for Crohn’s disease following intestinal resection

Abstract Background Growing evidences have shown that there are important advantages related to the utilisation of indocyanine green fluorescence imaging (ICG-FI) to reduce the risk of postoperative anastomotic leakage (AL) in colorectal surgery. However, the impact of ICG-FI on postoperative AL of Crohn’s disease (CD) following intestinal resection has not been investigated. Methods This is a retrospective study of consecutive CD patients who were treated with intestinal resection and anastomosis at a single institution between January 2017 and August 2019. The cohort was divided into 2 groups, those with ICG-FI compared with those without ICG-FI for intestinal resection. ICG was administered intravenously with a bolus of 5 mg, and the intestinal perfusion was evaluated by a SPY Elite system. Their baseline characteristics and perioperative outcomes were further analysed. Results No adverse reactions were recorded. Of the 88 CD patients who underwent intestinal resection, 36 patients underwent ICG-FI during intestinal resection, while 52 CD patients who underwent routine intestinal resection were from a prospectively maintained database. The 2 groups were similar in terms of patient demographics, immunosuppressive medication use, and the procedural factors. In patients with ICG-FI, poor perfusion of the bowel judged by ICG-FI led to additional intestinal resection in 25% (9/36). ICG-FI reduces the AL rate from 13.5% (7 leaks) of non-ICF-FI group to 8.3% (3 leaks) in ICG-FI group (p = 0.456). Forty-four (50%) patients had previous intestinal resection. Overall, 10 anastomotic leaks were identified (11.4% leak rate). There were 2 leaks (4.5%) detected in patients with no previous intestinal resection, compared with 8 leaks (18.2%) identified in patients with a history of previous intestinal resection (p = 0.044). The number of previous resections correlated with increasing risk for AL (correlation coefficient = 0.998). In univariate analysis, steroid use, CRP level and preoperative weight loss &amp;gt;10% in 6 months were independently associated with AL. Conclusion ICG-FI is applicable to intestinal resection for CD and may play a role in perfusion-related AL. A large prospective randomised trial should be warranted.

P618 Post-operative Crohn’s disease patients undergoing colonoscopy require significantly more analgesia and sedation compared with a non-IBD population

Abstract Background Rates of surgical intervention in Crohn’s disease have declined. However, a significant proportion of patients still require surgical resection and have been shown to have higher post-op pain scores and analgesia requirements. The aim of this study was to assess sedation requirements and comfort scores of post-operative Crohn’s disease patients at endoscopy. Methods Patients with a previous intestinal resection undergoing colonoscopy in 2017 were identified using an electronic reporting system. Data regarding patient demographics, disease characteristics, sedation requirements, comfort scores and endoscopy reports were collected. Patients with Crohn’s disease were compared with a non-IBD post-op population. Results n = 153 patients were included. n = 56 Crohn’s disease, n = 2 UC and n = 95 non-IBD patients underwent colonoscopy. Patient characteristics in Table 1. 13.6% of patients had a documented history of chronic pain or other relevant conditions that may affect comfort scores. 68.3% of patients with Crohn’s disease were on therapy at the time of endoscopy. The median dose of midazolam administered was 3 mg (IQR 2–4 mg); median fentanyl dose was 50 μg. (IQR 50–75 μg). The median dose of Midazolam was significantly higher in patients with Crohn’s disease (3 mg IQR 3–4 mg vs. 3 mg IQR 2–3; p = 0.006). The median dose of fentanyl required was also significantly higher in post-operative Crohn’s patients (50 μg IQR 50–100 μg vs. 50 μg; p = 0.001). The median comfort score in Crohn’s disease patients was higher (indicating more discomfort) when compared with the non-IBD cohort. (median score 2 and 1 respectively) There was no significant difference in the proportion of patients with chronic pain or multiple intestinal resections (p = 0.84 and p = 0.142). There was a statistically significant difference in comfort scores;n = 19 Crohn’s disease patients (39.6%) had comfort score 1, compared with n = 70 non-IBD patients (71.4%) (p = 0.04). There was no significant difference in the median doses of midazolam or fentanyl when comparing Crohn’s disease patients with and without active endoscopic disease. (p = 0.07 and p = 0.10 respectively). Conclusion Patients with Crohn’s disease undergoing colonoscopy in the post-operative setting have significantly higher analgesia requirements. Comfort scores are significantly worse when compared with non-IBD patients who have had similar intestinal resections. Endoscopists should use techniques, e.g. CO2 insufflation in addition to medication to ensure comfort amongst patients with Crohn’s disease.

Risk factors for postoperative complications after elective ileocolic resection for Crohn's disease: a retrospective study.

BackgroundThe incidence of postoperative complications (POC) in patients with Crohn’s disease (CD) who undergo intestinal resection is high. The literature provides conflicting data about the risk factors for POC, especially regarding preoperative immunosuppressive medications. The purpose of this study was to evaluate the impact of anti-tumor necrosis factor (TNF) agents on the postoperative course and identify other predictors for POC after ileocolic resection (ICR).MethodsThis was a single-center retrospective study that included 153 CD patients who underwent elective ICR in a Greek tertiary center between January 2010 and December 2018. Risk factors for overall POC and intra-abdominal septic complications (IASC) were assessed with univariate and multivariate analyses.ResultsOverall POC and IASC occurred in 35 (22.9%) and 19 (12.4%) patients, respectively. In multivariate analysis, anti-TNF agents (n=61), as either monotherapy or combination treatment, were not associated with an increased risk for overall POC (21.3% vs. 23.9%, P=0.71) or IASC (13.1% vs. 12.0%, P=0.83). Similarly, no combined immunosuppressive regimen significantly correlated with POC. Patients with perianal disease, disease duration >10 years, or previous intestinal resections had significantly higher rates of both overall POC and IASC. In multivariate analysis, previous resection was the only independent risk factor for overall POC (odds ratio [OR] 3.90, 95% confidence interval [CI] 1.38-11.06; P=0.010) and IASC (OR 4.56, 95%CI 1.51-13.77; P=0.007).ConclusionsPreoperative administration of anti-TNF agents or other immunosuppressive regimens was not a risk factor for total POC or IASC. A history of previous resection independently correlated with both overall POC and IASC.