IBD Surgery Research Articles

Risk Prediction for Complications in Inflammatory Bowel Disease Surgery: External Validation of the American College of Surgeons' National Surgical Quality Improvement Program Surgical Risk Calculator.

Many patients with inflammatory bowel disease [IBD] require surgery during their disease course. Having individual risk predictions available prior to surgery could aid in better informed decision making for personalised treatment trajectories in IBD surgery. The American College of Surgeons National Surgical Quality Improvement Program [ACS NSQIP] has developed a surgical risk calculator that calculates risks for postoperative outcomes using 20 patient and surgical predictors. We aimed to validate the calculator for IBD surgery to determine its accuracy in this patient cohort. Predicted risks were calculated for patients operated for IBD between December 2017 and January 2022 at two tertiary centres and compared with actual outcomes within 30 postoperative days. Predictive performance was assessed for several postoperative complications, using metrics for discrimination and calibration. Risks were calculated for 508 patient trajectories undergoing surgery for IBD. Incidence of any complication, serious complications, reoperation, and readmission were 32.1%, 21.1%, 15.2%, and 18.3%, respectively. Of 212 patients with an anastomosis, 19 experienced leakage [9.0%]. Discriminative performance and calibration were modest. Risk prediction for any complication, serious complication, reoperation, readmission, and anastomotic leakage had a c statistic of 0.605 (95% confidence interval [CI] 0.534-0.640), 0.623 [95% CI 0.558-0.688], 0.590 [95% CI 0.513-0.668], 0.621 [95% CI 0.557-0.685], and 0.574 [95% CI 0.396-0.751], respectively, and a Brier score of 0.240, 0.166, 0.138, 0.152, and 0.113, respectively. The accuracy of risks calculated by the ACS NSQIP Surgical Risk Calculator was deemed insufficient for patients undergoing surgery for IBD, generally underestimating postoperative risks. Recalibration or additional variables could be necessary to predict risks in this cohort.

TU2.6 Pre-Operative Optimisation of Elective IBD Patients: Are we meeting the standard?

Abstract Aim Inflammatory bowel disease represents a significant healthcare burden. Management requires a multi-disciplinary approach and a combination of both surgical and medical considerations. The aim of this study was to compare current practice within our colorectal unit for pre-operative optimisation of IBD patients with ACPGBI recommendations, with the view of introducing a proforma for these patients to ensure pre-operative optimisation standards are met. Methods This was a retrospective study identifying patients undergoing elective surgery for IBD in our unit between January 2019-October 2020. Data was collected on pre-operative management and compared to the broad principles of optimisation outlined by ACPGBI in their 2018 guidelines. Clavien-Dindo classification was used to define post-operative complications. Results 94 patients were identified, 67 in 2019 and 27 patients in 2020. 4.3% had active intra-abdominal sepsis. No patients had a clearly documented comprehensive nutritional assessment. 15.6% patients were on oral steroids pre-operatively (Dose ≤30mg). 43.8% were on biologic therapy. Mean length of stay was 11.3days. 39.7% of patients experienced post-operative complications. However, only 12.8% of patients had a Clavien-Dindo score of ≥3. There was no mortality. Conclusion ACPGBI guidelines highlight key areas for adequate pre-operative optimisation. Our study highlighted that our morbidity following IBD surgery was comparable to those in literature. However, key areas of improvement were identified including comprehensive nutritional assessment. Current work involves creating a pre-operative proforma to encompass this and will be followed by a re-audit.

Declining Corticosteroid Use for Inflammatory Bowel Disease Across Alberta: A Population-Based Cohort Study.

Corticosteroid-free remission is a primary treatment goal in IBD which may be achieved with greater use of anti-TNF therapy. We defined temporal trends of corticosteroid use, anti-TNF use, hospitalization and surgery in a prevalent IBD cohort within the province of Alberta, Canada. Health administrative data were used to identify medication dispensing, hospitalizations and surgery in individuals with IBD from 2010 to 2015. Temporal trends were calculated using log-binomial regression for medications and log-linear models for hospitalizations and surgery rates. Analyses were stratified based on geographic location. Of 28890 individuals with IBD, 50.3% had Crohn's disease. One in six individuals (15.45%) were dispensed a corticosteroid. Corticosteroid use decreased in both metropolitan areas (AAPC -20.08%, 95% CI: -21.78 to -18.04) and non-metropolitan areas (AAPC -18.14%, 95% CI: -20.78 to -18.04) with a similar pattern for corticosteroid dependence. Corticosteroid dependence was more prevalent in UC vs. CD (P < 0.05), and in the pediatric IBD cohort (13.45) compared to the adult (8.89) and elderly (7.54) cohorts (per 100 prevalent population, P < 0.001). The proportion of individuals dispensed an anti-TNF increased over the study period (AAPC 12.58%, 95% CI: 11.56 to 13.61). Significantly more non-metropolitan versus metropolitan residing individuals were hospitalized for any reason, for an IBD-related, or IBD-specific indication (all P < 0.001) though the proportion requiring IBD surgery was similar between groups. An increase in anti-TNF use corresponded to a decline in corticosteroid use and dependence in those with IBD. Inequities in IBD care still exist based on location and age.

Perfusion Visualization during Ileal J-Pouch Formation—A Proposal for the Standardization of Intraoperative Imaging with Indocyanine Green Near-Infrared Fluorescence and a Postoperative Follow-Up in IBD Surgery

Background: An anastomotic leak (AL) after a restorative proctocolectomy and an ileal J-pouch increases morbidity and the risk of pouch failure. Thus, a perfusion assessment during J-pouch formation is crucial. While indocyanine green near-infrared fluorescence (ICG-NIRF) has shown potential to reduce ALs, its suitability in a restorative proctocolectomy remains unclear. We aimed to develop a standardized approach for investigating ICG-NIRF and ALs in pouch surgery. Methods: Patients undergoing a restorative proctocolectomy with an ileal J-pouch for ulcerative colitis at an IBD-referral-center were included in a prospective study in which an AL within 30 postoperative days was the primary outcome. Intraoperatively, standardized perfusion visualization with ICG-NIRF was performed and video recorded for postoperative analysis at three time points. Quantitative clinical and technical variables (secondary outcome) were correlated with the primary outcome by descriptive analysis and logistic regression. A novel definition and grading of AL of the J-pouch was applied. A postoperative pouchoscopy was routinely performed to screen for AL. Results: Intraoperative ICG-NIRF-visualization and its postoperative visual analysis in 25 patients did not indicate an AL. The anastomotic site after pouch formation appeared completely fluorescent with a strong fluorescence signal (category 2) in all cases of ALs (4 of 25). Anastomotic site was not changed. ICG-NIRF visualization was reproducible and standardized. Logistic regression identified a two-stage approach vs. a three-stage approach (Odds ratio (OR) = 20.00, 95% confidence interval [CI] = 1.37–580.18, p = 0.029) as a risk factor for ALs. Conclusion: We present a standardized, comparable approach of ICG-NIRF visualization in pouch surgery. Our data indicate that the visual interpretation of ICG-NIRF alone may not detect ALs of the pouch in all cases—quantifiable, objective methods of interpretation may be required in the future.

Simple Clinical Screening Underestimates Malnutrition in Surgical Patients with Inflammatory Bowel Disease-An ACS NSQIP Analysis.

The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m2 in patients <70 years OR BMI < 22 kg/m2 in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment.

ENHANCED RECOVERY PROGRAMS: HOW ARE WE BENEFITTING PATIENTS WITH IBD?

Abstract BACKGROUND Enhanced Recovery Programs (ERPs) improve postoperative outcomes in colorectal surgery. Patients with IBD have been shown to benefit from use of ERP, but are immunosuppressed and chronically ill. We aimed to determine how patient outcomes under an ERP are affected by IBD. METHODS Patients undergoing colorectal surgery for IBD under an ERP from Oct 2015-May 2021 at a single institution were abstracted using ACS-NSQIP data, which was cross referenced with an internal health literacy database (BRIEF, 4-20). Adherence was defined as the sum of adherence to six components: pre-admission counseling, pre-op VTE prophylaxis, clear liquid diet pre-op, regional anesthesia, anti-emetic prophylaxis, and multi-modal pain management. Chi-square and two-sample t-test were used to compare patients with and without IBD. Multivariable linear and logistic regression were used to determine factors associated with IBD, SSI, and 30-day readmission. RESULTS Overall, patients (n=2,221) were 54% female, 76% White, 26% privately insured, 78% ASA Class 3, with mean age 57 yr, BMI 28.8 (SD=7.4). BRIEF scores were available for 644 patients, with a mean of 18.1. There were 308 patients (13.9%) undergoing surgery for IBD. Surgeries were 99.5% inpatient, 81.6% elective and 60% were laparoscopic. Procedure types included partial colectomy (69%), proctectomy (21%), total colectomy (6%), and total colectomy with proctectomy (4%). Overall ERP adherence was 59% (3.52 out of 6 components). Mean pLOS was 6.9 days (SD=7.7), SSI rate was 12.6%, readmission rate was 13.2% On univariate analysis, patients with IBD were younger (41 vs 60 yr, p&amp;lt;0.001), healthier at the time of surgery (ASA2: 23% vs 12%, ASA3: 73% vs 79%, p&amp;lt;0.001), and more male (53% vs 45%, p=0.02), White (82% vs 75%, p=0.004), and privately insured (42% vs 23%, p&amp;lt;0.001). IBD patients had lower BMI (27.4 vs 29, p&amp;lt;0.001) and more frequently underwent total colectomy (16% vs 5%) and total colectomy with proctectomy (14% vs 2%, p&amp;lt;0.001), as well as laparoscopic surgery (65% vs 59%, p=0.04). Despite similar ERP adherence (60% vs 59%, p=0.6), patients with IBD had higher rates of SSI (17% vs 12%, p=0.008) and readmission (20.6% vs 12%, p&amp;lt;0.001). On multivariable analysis, patients who were older (OR 0.92), Black (OR 0.25) or publicly insured (Medicaid OR 0.28, Medicare OR 0.53) we’re less like to have IBD. Those with IBD had greater health literacy scores (OR 1.11). Controlling for patient- and provider-level factors, patients with IBD were more likely to have post-operative SSI (OR 2.7) and readmission (OR 1.8). CONCLUSION Within an ERP, IBD is independently associated with greater rates of SSI and readmission despite factors associated with improved post-operative outcomes: younger age, private insurance, and greater health literacy. Additional research is needed to better adapt ERPs to the needs of patients with IBD.

CURRENT VENOUS THROMBOEMBOLISM CHEMOPROPHYLAXIS PRACTICES AFTER SURGERY FOR IBD: SAVES-IBD TRIAL INITIAL REPORT

Abstract BACKGROUND Despite standard of care chemoprophylaxis, postoperative VTEs occur in ∼4% of IBD patients, and little data on current practices in IBD has been reported. We cultivated a baseline cohort to inform power calculations for a forthcoming prospective, multicenter trial of VTE prophylaxis comparing the efficacy &amp; safety of standard of care vs. aspirin (SAVES-IBD Trial). In this initial report we describe the current standard of care VTE prophylaxis practice patterns in our collaborative. METHODS The National Surgical Quality Improvement Program (NSQIP) IBD Collaborative designed and implemented 6 VTE specific-variables including 1) Inpatient VTE chemoprophylaxis, 2) extended (post-discharge) prophylaxis, 3) length of time on primary prophylaxis, 4) VTE location, and 30-days bleeding requiring 5) transfusion or 6) reoperation. Data was collected prospectively from Sept 2020 – Mar 2021. Patients age &amp;gt;18 undergoing elective or emergent colectomy or proctectomy with a post-op IBD diagnosis were included. Patients with VTE present at admission (n=10, 2.3%) were excluded. RESULTS Over 6-months, 434 patients from 13 centers were accrued; median 22 cases, IQR 18.5 – 28. Demographics: median age 41.5 years, 50% female, median BMI 24.7 kg/m2. Diagnoses: 263 (60.9%) Crohn’s vs. 169 (39%) UC/IBDu, while 359 (82.7%) and 75 (17.3%) patients underwent colectomy and proctectomy, respectively including 69 (15.9%) IPAAs and 256 (59.0%) ileostomies, and 21 (4.8%) emergency cases. IBD Medications: 237 (54.6%) biologics, 233 (53.7%) steroids, 51 (11.8%) immunomodulators. A total of 395 (91.4%) received inpatient chemoprophylaxis including LMWH in 236 (59.7%), UFH in 158 (40.0%), DOAC in 1 (0.3%), and aspirin (none), and no chemoprophylaxis in 37 (8.5%). Extended chemoprophylaxis was utilized in 209 (48.7%) and included LMWH in 179 (85.6%), DOAC in 18 (8.6%), aspirin in 7 (3.3%), and UFH in 5 (2.4%). Overall, bleeding complications occurred in 38 (8.8%) patients with 34 (8.4%) requiring transfusion and 9 (2.1%) needing reoperation. Postoperatively, VTEs were diagnosed in 19 (4.4%) patients. VTE locations: portomesenteric vein thrombosis 8 (42%), upper extremity 3 (15.8%) or lower extremity 3 (15.8%) DVT, pulmonary embolism 2 (10.5%), and other 3 (15.8%). Univariate analysis of risk factors is shown in Table 1. Patients with 0-2 risk factors had a VTE rate of 2.9%, while in those with &amp;gt;2 risk factors, 31.8% developed VTE (p&amp;lt;0.0001). CONCLUSION In this cohort of surgical IBD patients from IBD specialty centers, we observed a 2.3% rate of pre-operative, and a 4.4% rate of post-operative, VTE. These rates have informed the SAVES-IBD power calculations. We also observed that almost half of IBD surgery patients in these centers were prescribed extended chemoprophylaxis, most commonly with enoxaparin, rarely with aspirin. Validation of the prophylaxis variables is in-progress.

P396 COVID-19 pandemic-related endoscopy delays did not translate to deleterious outcomes for patients with Inflammatory Bowel Disease: A retrospective cohort study

BackgroundInflammatory Bowel Disease (IBD) patients require frequent endoscopies for disease assessment and confirmation of remission, making it a crucial component in their management. It is unknown if measures put in place to reduce the spread of the virus SARS-CoV-2, including the delay of non-urgent IBD patient endoscopy, resulted in more deleterious outcomes for patients with IBD. Therefore, we aimed to determine if delays in endoscopy during the COVID-19 pandemic were associated with an increased risk of adverse IBD outcomes (emergency room, ER presentation, hospitalization, surgery or escalation of drug therapy).MethodsA retrospective cohort study was performed in IBD patients receiving outpatient endoscopies between March and August, 2019 (pre-COVID-19 pandemic) and, 2020 (during the COVID-19 pandemic) at two tertiary care centers affiliated with Western University, London, Canada. Data pertaining to endoscopy timing, IBD drug prescription, ER attendance, hospitalization, and surgery were collected.ResultsA total of, 1160 endoscopies (2019, n=718;, 2020, n=442) occurred across, 1083 patients (2019, n=669;, 2020, n=414). More endoscopies were delayed in, 2020 than, 2019 (26.7% vs., 9.7% respectively, p<0.0001) and for longer, 56 days (IQR=63) in, 2020 vs., 30 days (IQR=42) in, 2019. No differences were seen in the baseline demographic characteristics based on cohort year or occurrence of endoscopy delay. Also, rurality, sex, IBD type, and age were not associated with a delay in endoscopy. It was found that endoscopy delay was not associated with an increased risk of an adverse IBD outcome (composite outcome of emergency room presentation, ER presentation, hospitalization, surgery or escalation of drug therapy) (RR, 1.23, p=0.20).ConclusionA greater proportion of delays in endoscopy were observed during the COVID-19 pandemic; however, delays in general were not associated with more adverse IBD outcomes, and were found to be associated with less deleterious IBD outcomes. This may reflect the accurate and preferential triage of more severe IBD patients to endoscopic assessments.

P487 Surgery due to inflammatory bowel disease during pregnancy: mothers and offspring outcomes (SCAR Study)

Abstract Background Data on the outcomes of surgery due to IBD in pregnant patients is scarce, and primarily dates back more than 3 decades ago. Primary aim: to evaluate the evolution of pregnancies and offspring after surgery due to IBD. Secondary aims: to describe the indications for surgery, the surgical techniques used, and the frequency of caesarean section concomitant to surgery for IBD Methods SCAR is a retrospective, multicenter study approved by ECCO COllaborative Network For Exceptionally Rare Case Reports (CONFER). Patients operated on due to IBD during pregnancy after 1998 (first biologic agent approved) were included. Data on patients’ demographics, IBD characteristics, medical treatments, IBD activity, pregnancy outcomes, surgery, delivery, foetal and maternal outcomes, were recorded Results 44 IBD patients were included (figure 1), all singleton pregnancies. Seven patients (16%) were diagnosed with IBD during pregnancy, 75% had Crohn’s disease (51% fistulizing behavior), and 23% had ulcerative colitis. 34% had previously undergone surgery due to IBD. Several complementary examinations were performed during pregnancy without complications (figure 2) Patients were being administered the following medications: corticosteroids (61%), biologicals (57%), thiopurines (23%) with 20% being on biologics and thiopurines. 93% of surgeries were performed in University hospitals, (2nd Trimester: 55%; 3rd trimester: 27%) with 77% of them being urgent surgeries (figure 3) One patient had hemoperitoneum during surgery, and 27% had postsurgical complications. No woman died. 62.5% of deliveries were induced (figure 4), 70% of them by C-section, with 51% of mothers having a prolonged hospitalization. There were 40 newborns alive and 4 miscarriages/stillbirths (1 in the 1st, 2 in the 2nd, and 1 in the 3rd trimester): 2 occurred during surgery and 2 occurred 2 weeks after surgery. 14% of the surgeries during the 2nd trimester and 64% of those in the 3rd trimester ended up with a simultaneous C-section or delivery. Of the 40 newborns alive, there were 9 healthy (24%), 61% premature, and 47% with low birth weight. A total of 42% of newborns needed hospitalization (25% in the intensive care unit, mainly due to respiratory distress) Conclusion The need for surgery for IBD during pregnancy remains an extremely serious situation. Maternal and foetal mortality are lower than previously described, most likely due to better supporting care. However, even in the current years, 30% of the mothers and 80% of newborns have complications, and 25% of the offspring need admission to the intensive care unit. Therefore, surgical management should be performed by a multidisciplinary team, involving gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists.

P231 Emergency Colectomy for IBD Is Not Associated with Increased Risk of Postoperative Infection, Reoperation or Readmission

Abstract Background The current literature suggests that IBD patients have worse outcomes after emergency surgery when compared to elective surgery. We hypothesized that this association will be lost after matching cohorts of emergency and elective patients. We aimed to confirm the current emergency IBD surgery literature in a large cohort of unmatched IBD patients. We then aimed to determine if postoperative outcomes are worse in matched patients undergoing elective vs emergency colectomy. Methods We utilized the NSQIP PUF IBD Cohort 2005–2019 to assess 30-day outcomes in adult IBD patients undergoing emergency vs elective colectomy. Our primary outcome was any complication. Our secondary endpoints were readmission, reoperation, and mortality. Univariable and multivariable logistic regression models were used to examine the association between emergency surgery and complications in the unmatched cohort. Propensity-score matching was performed to match emergency patients to non-emergency patients on a 1:1 basis. A logistic regression model was used to assign a propensity score to each patient using emergency surgery as the outcome. All preoperative and perioperative characteristics were included in the model except those with &amp;gt; 20% missing data. The probability of emergency surgery based on these factors was used as the propensity score. A greedy matching algorithm was used to find the best controls matches for each case. A Love plot was used to show the covariate balance. Conditional logistic regression were used to evaluate the association between outcomes and emergency surgery on the matched sample. Results A total of 16,790 patients (15,849 elective, 941 emergency) were included in the unmatched cohort analysis. 30-day outcomes in 21 categories including length of stay, surgical site infection, sepsis, death and cardiovascular, renal and thrombotic complications were worse in the emergency cohort (Table 1). After matching, 632 sets were constructed. The majority of adverse outcomes demonstrated in the unmatched cohort lost significance. Only unplanned intubation (OR 2.6, p=.006), &amp;gt;48 hours on a ventilator (OR 2.8, p&amp;lt;.001), septic shock (OR 3.6, p&amp;lt;.001) and any complication (OR 1.3, p=.03) retained significance (Table 2). Conclusion In concordance with the current literature, we demonstrated increased rates of postoperative infection, cardiovascular and renal complications, reoperation and length of stay in unmatched groups of IBD patients undergoing emergency vs elective surgery. However, the majority of these complications were not significantly different after propensity matching. This suggests that emergency surgery is not associated with poorer outcomes in terms of length of stay, mortality and most morbidities as previously thought.

CURRENT VENOUS THROMBOEMBOLISM CHEMOPROPHYLAXIS PRACTICES AFTER SURGERY FOR IBD: SAVES-IBD TRIAL INITIAL REPORT

Despite standard of care chemoprophylaxis, postoperative VTEs occur in ∼4% of IBD patients, and little data on current practices in IBD has been reported. We cultivated a baseline cohort to inform power calculations for a forthcoming prospective, multicenter trial of VTE prophylaxis comparing the efficacy & safety of standard of care vs. aspirin (SAVES-IBD Trial). In this initial report we describe the current standard of care VTE prophylaxis practice patterns in our collaborative. The National Surgical Quality Improvement Program (NSQIP) IBD Collaborative designed and implemented 6 VTE specific-variables including 1) Inpatient VTE chemoprophylaxis, 2) extended (post-discharge) prophylaxis, 3) length of time on primary prophylaxis, 4) VTE location, and 30-days bleeding requiring 5) transfusion or 6) reoperation. Data was collected prospectively from Sept 2020 – Mar 2021. Patients age >18 undergoing elective or emergent colectomy or proctectomy with a post-op IBD diagnosis were included. Patients with VTE present at admission (n=10, 2.3%) were excluded. Over 6-months, 434 patients from 13 centers were accrued; median 22 cases, IQR 18.5 – 28. Demographics: median age 41.5 years, 50% female, median BMI 24.7 kg/m2. Diagnoses: 263 (60.9%) Crohn’s vs. 169 (39%) UC/IBDu, while 359 (82.7%) and 75 (17.3%) patients underwent colectomy and proctectomy, respectively including 69 (15.9%) IPAAs and 256 (59.0%) ileostomies, and 21 (4.8%) emergency cases. IBD Medications: 237 (54.6%) biologics, 233 (53.7%) steroids, 51 (11.8%) immunomodulators. A total of 395 (91.4%) received inpatient chemoprophylaxis including LMWH in 236 (59.7%), UFH in 158 (40.0%), DOAC in 1 (0.3%), and aspirin (none), and no chemoprophylaxis in 37 (8.5%). Extended chemoprophylaxis was utilized in 209 (48.7%) and included LMWH in 179 (85.6%), DOAC in 18 (8.6%), aspirin in 7 (3.3%), and UFH in 5 (2.4%). Overall, bleeding complications occurred in 38 (8.8%) patients with 34 (8.4%) requiring transfusion and 9 (2.1%) needing reoperation. Postoperatively, VTEs were diagnosed in 19 (4.4%) patients. VTE locations: portomesenteric vein thrombosis 8 (42%), upper extremity 3 (15.8%) or lower extremity 3 (15.8%) DVT, pulmonary embolism 2 (10.5%), and other 3 (15.8%). Univariate analysis of risk factors is shown in Table 1. Patients with 0-2 risk factors had a VTE rate of 2.9%, while in those with >2 risk factors, 31.8% developed VTE (p<0.0001). In this cohort of surgical IBD patients from IBD specialty centers, we observed a 2.3% rate of pre-operative, and a 4.4% rate of post-operative, VTE. These rates have informed the SAVES-IBD power calculations. We also observed that almost half of IBD surgery patients in these centers were prescribed extended chemoprophylaxis, most commonly with enoxaparin, rarely with aspirin. Validation of the prophylaxis variables is in-progress.

P667 Characterization of a large Hispanic cohort with Inflammatory Bowel Disease across a 25-year span

Abstract Background Inflammatory Bowel Disease (IBD) in Hispanics has increased, but characterization of this population is limited. We describe the demographic and clinical characteristics of a large Hispanic population with IBD and compare it among two periods, 1995- 2009 and 2010–2019. Methods The Registry of IBD has been recruiting patients with IBD continuously since 1995. Data is obtained from the subject and the medical record. This study includes 1365 Hispanics recruited between 1995 and 2019. Variables include age, gender, age at onset and diagnosis, IBD type, family history, smoking, extraintestinal manifestations (EIM), medications, and surgery for IBD. Descriptive statistics included frequency, median, mean, and standard deviation. SPSS software was used for comparison analysis utilizing Chi square and Fisher′s test. The protocol is approved by the IRB. Results 712 were males and 653 females. Crohn’s disease (CD) was more prevalent in males (479/836, 57.3%) and ulcerative colitis (UC) in females (288/517, 55.7%). The mean age at diagnosis was 34.1 + 15.4 for UC and 24.4 + 12 for CD (p&amp;lt;.001). History of smoking was infrequent (24.3%). Interval between onset of symptoms and diagnosis was 1.8 + 4.7 yrs. for UC and 2.5 + 5.3 yrs. for CD (p=.012). At recruitment, duration of disease was 7.4 + 8.4 yrs. for UC and 5.6 + 7.3 yrs. for CD (p&amp;lt;.001). Family history of IBD was present in 23% of CD and UC participants. The most frequent EIM was arthropathy in 37.9% and 25.9 % of UC and CD (p=.670), followed by skin manifestations in 13.2% and 18.9% respectively (p=.070). Aminosalicylates (94.9%) and corticosteroids (81.6%) were more frequent in UC, and immunomodulators (23%) and anti-TNF drugs (aTNF) (46.2%) in CD (p&amp;lt;.001). At the time of recruitment, 54.5% of CD and 23.7% of UC patients had previous surgery for IBD. Stratification of subjects into two groups by date of recruitment,1995–2009 and 2010–2019, showed similar ages at onset and diagnosis, but the time to diagnosis decreased for UC (2 vs 1.55 yrs.) and increased for CD (2.2 vs 2.6 yrs.) in the later interval. Medications varied between decades, with aTNF increasing markedly in CD and UC (p&amp;lt;.001) and aminosalicylates decreasing in CD (p&amp;lt;.001) in the later years. Surgery for UC decreased from 25.2% to 20.7%, whereas surgery for CD remained the same (52.2% vs 52.5%). Conclusion We describe a large cohort of Hispanics with IBD studied over two decades. Differences over time may reflect changes in disease phenotypes, environmental influences and the impact of physician awareness and new management guidelines and therapies. Further studies are needed to better characterize this population and explore outcomes.

P603 Patient characteristics and adverse effects in biologic treatment of Crohn’s Disease and Ulcerative Colitis: A nationwide Danish cohort study years 2015–2018

Abstract Background Biological therapies have demonstrated effectiveness in the treatment of Crohn’s Disease (CD) and Ulcerative Colitis (UC), but comparative analyses of the various treatments remain limited. Methods Using Danish national registries, we performed a nationwide cohort study including all bio-naïve individuals diagnosed with UC or CD initiating treatment with infliximab (IFX), adalimumab (ADA), vedolizumab (VDZ), golimumab (GOL), or ustekinumab (UST) during 2015–2018. The hazard ratios (HR) of hospitalization, surgery, and start of corticosteroid therapy were explored using Cox regression adjusted for health-related and socio-economic parameters at treatment initiation. Results More than 90% of 1,836 CD and 1,886 UC patients had IFX as first-line treatment. Patients with ADA, VDZ, UST or GOL as first-line treatment were older at diagnosis and start of biologic treatment. A larger proportion were women, had higher education, and had previously had IBD surgery. We observed a higher risk of all-cause hospitalization (HR: 1.56 (95% CI: 1.16; 2.10)) among CD patients with ADA as first-line treatment compared to IFX. No risk difference was observed of IBD hospitalization, IBD related surgery, or use of corticosteroids between ADA- and IFX-treated CD patients. We observed no risk difference between ADA- and IFX-treated UC patients for any outcomes. For both CD and UC patients, analyses of VDZ were based on very low number of cases and the results were inconclusive. Analyses of GOL and UST were not possible because of low numbers. Second-line treatment with VDZ compared to ADA among CD patients previously treated with IFX showed no risk difference of all-cause hospitalization (1.32 (0.91; 1.92)), IBD hospitalization (1.27 (0.68; 2.35)), IBD related surgery (1.41 (0.69; 2.85)), or use of corticosteroids (0.70 (0.27; 1.82)). Among UC patients, second-line VDZ was associated with an increased risk of IBD related surgery (1.94 (1.01; 3.71)), but not of all-cause hospitalization (0.77 (0.48; 1.24)), IBD hospitalization (0.75 (0.38; 1.46)), or corticosteroid use (0.92 (0.37; 2.28)) compared to ADA. Conclusion We observed increased risk of hospitalization among CD patients treated with ADA compared to IFX, and increased risk of IBD-related surgery in UC patients receiving VDZ as second line treatment compared to ADA. The differences in key baseline characteristics patients initiating biologic treatment with ADA, VDZ, UST or GOL compared to IFX might reflect differences in disease state, that justify deviations from treatment guideline. It should be further investigated if the associations are an effect of differences in treatment efficacy and safety or confounding by differences in disease state at treatment start.

P321 Cessation of Anti-Tumour Necrosis Factor Therapy in Patients with Perianal Fistulizing Crohn’s Disease: Individual Patient Data Meta-Analysis of 323 patients from 12 studies

Abstract Background The risk of relapse after anti-tumour necrosis factor [TNF] therapy cessation in Crohn’s disease [CD] patients with perianal fistulas is unclear. We aimed to assess the risk of relapse after anti-TNF cessation in a large cohort and to identify risk factors. Methods A systemic literature search was conducted to identify cohort studies reporting on the incidence of relapse after cessation of anti-TNF therapy in CD patients. Individual patient data [IPD] were requested from the original study cohorts. Inclusion criteria for IPD-meta-analysis (IPD-MA) included age ³ 18 years, perianal fistulizing CD as indication for start of anti-TNF therapy, minimal treatment duration ³3 doses, and remission of luminal and perianal CD at cessation of anti-TNF therapy. Primary outcome was CD relapse [either perianal or luminal]. Perianal fistula relapse was defined as recurrence of draining perianal fistula related to previous or new fistula tracks, or abscess. Luminal relapse was defined as a clinical, biochemical, endoscopic, or radiological relapse requiring treatment or dose optimization of IBD medication or surgery. In a secondary analysis, risk factors associated with relapse were assessed using multivariate logistic regression analysis. Results A total of 307 patients from 12 studies in 9 countries were included in this IPD-MA. The median duration of anti-TNF treatment prior to therapy cessation was 14 months [IQR 6.1 – 29.9]. In 272/307 patients [89%] anti-TNF therapy was started for active perianal fistula and in 34 [11%] for both active perianal fistula and luminal CD. 169 patients [55%] developed a relapse [either perianal or luminal] after a median follow-up after cessation of 25 months [IQR 12 – 54]. Overall cumulative incidence of relapse was 31% and 43% at 1 and 2 years after anti-TNF cessation. Risk factor for CD relapse include upper GI involvement (L4) [HR 1.9], whereas older age [A3 vs A1, HR 0.48] and continuation of concomitant immunomodulators [HR 0.62] were protective factors. For a subgroup of patients with active perianal fistula and in luminal remission at start of anti-TNF, the cumulative incidence relapse rates were 25% and 43% at 1 and 2 years. No considerable differences in risk factors were found within this subgroup regarding risk of recurrence. Of the 179 patients who relapsed, 104 were retreated with anti-TNF with a response rate of 85%. Conclusion According to this IPD-MA, approximately two-thirds of CD patients with perianal fistula remain in remission with regard to fistulizing and luminal disease during 2 years after cessation of anti-TNF therapy. Further risk stratification based on perianal fistula characteristics is required.

DOP10 Persistent sonographic Inflammation as a predictor of clinical complications in patients with Crohn’s Disease

Abstract Background Transmural healing has emerged as a new treatment target and can be assessed non-invasively with intestinal ultrasound (IUS). We investigated whether the presence of persistent sonographic changes were associated with clinical complications including medication escalation, corticosteroid use, hospitalisation and surgery in Crohn’s disease (CD) patients in clinical remission at baseline. Methods A retrospective study on 212 patients (50% male) with CD who had IUS between August 2017- June 2020 was performed at a tertiary centre. Our analysis included patients in clinical remission at baseline IUS (HBI≤2 or CDAI&amp;lt;150). Patients were excluded if they had disease confined to the rectum, stoma in situ, suboptimal IUS assessment or &amp;lt; 6 months of follow up available. We compared time of medical escalation, corticosteroid use, IBD related hospitalisation or related surgery in patients with and without sonographic inflammation defined as bowel wall thickness (BWT) &amp;gt;3mm and/or hyperaemia on colour doppler imaging, followed for a median of 19 months. We identified factors associated with survival using Kaplan Meier analysis and Cox proportional hazard model. Results At baseline IUS, 61% of patients had sonographic inflammation. During the follow-up period medical escalation occurred in 51% of patients, corticosteroid use in 23%, hospitalisation in 20% and IBD related surgery in 13% of patients. The presence of sonographic inflammation at baseline was associated with increased risk of medical escalation (p=0.0057), corticosteroid use (p=0.037), hospitalisation (P=0.0085) and surgery (P=0.0062) (Figure 1 A-D). On multivariable analysis only maximal BWT significantly predicted medical escalation (HR 1.22 (1.02–1.46), P=0.0268). The presence of hyperaemia at baseline IUS was significantly associated with corticosteroid use (HR 2.20 (1.13–4.28), P= 0.02). No sonographic parameter predicted the need for IBD related hospitalisation or surgery. Baseline immunomodulator use and stricturing (B3) phenotype was significantly associated with surgery (HR 3.59 (1.22–10.54), P=0.02, HR 4.01 (1.14–14.03), P=0.03, respectively). Figure 1: Kaplan-Meier analysis of the effect of sonographic healing vs sonographic inflammation. A) Medication escalation-free survival. B) Corticosteroid-free survival. C) Hospitalisation-free survival. D) Surgery-free survival. Conclusion In CD patients in clinical remission, persistent sonographic inflammation can be used as a non-invasive marker of increased risk for clinical complications.

Rectal Cancer Incidence is Low Following Rectal Diversion or Subtotal Colectomy for IBD: Results of a Population-based Study.

Following subtotal colectomy or diversion for medically refractory inflammatory bowel disease [IBD], completion proctectomy has been recommended to reduce the risk of rectal cancer. However, this recommendation is based on low-quality evidence. Our objectives were to estimate the cumulative incidence of rectal cancer and evaluate if surveillance endoscopy reduces the risk of rectal cancer. We performed a population-based retrospective cohort study in Ontario, Canada, of all patients undergoing either subtotal colectomy or diversion for medically refractory IBD over 1991-2015. We excluded patients with a previous history of colorectal cancer or previous rectal resection, and those with <1 year of observation. We calculated the rate of incident rectal cancer using a competing risks model, and evaluated the effect of surveillance endoscopy on the rate of rectal cancer. In all, 3700 patients were included with a median follow-up of 4.3 years. Of this cohort, 47% underwent rectal resection or restoration of gastrointestinal [GI] continuity during the observation period; 40 patients were diagnosed with rectal cancer, with a cumulative incidence of rectal cancer of 0.81% (95% confidence interval [CI] 0.53%, 1.20%) and 1.86% [95% CI 1.29%, 2.61%] at 10 and 20 years, respectively. Surveillance endoscopy was associated with a lower rate of rectal cancer (subhazard ratio [sHR] 0.37, 95% CI 0.16, 0.82, p = 0.014]. Among patients with a retained rectum following surgery for IBD, the risk of rectal cancer is low and appears to be lower when surveillance endoscopy is performed. Expectant management with surveillance endoscopy may be a reasonable alternative to completion proctectomy in selected patients.

Old, New, and Out of the Box in IBD Surgery: Proceedings of the European Crohn's and Colitis Organisation 2020 Congress From a Surgical Perspective.

Old, New, and Out of the Box in IBD Surgery: Proceedings of the European Crohn's and Colitis Organisation 2020 Congress From a Surgical Perspective.

CLINICAL SIGNIFICANCE OF PSOAS MUSCLE COMPOSITION IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract Background Total psoas muscle cross sectional area, as identified with computed tomography (CT), has been associated with clinical outcomes in various disease states. Unfortunately, total psoas CSA does not differentiate muscle density nor fat, both of which may be abnormal in obesity. Using a novel CT method to partition psoas muscle into low and high density muscle, recent studies have demonstrated low and high attenuating psoas muscle may be superior to total psoas CSA in identifying sarcopenic obesity. The impact of varying muscle composition in patients with inflammatory bowel disease is unknown. Methods We conducted a retrospective cohort study of IBD patients from a tertiary care center. Psoas muscle composition was determined using a novel and validated CT method. High and low attenuating bilateral psoas muscle was measured at the level of the 3rd lumbar vertebra. Clinical remission, surgery, hospitalization, and corticosteroid use were stratified by low and high density muscle and evaluated 6 weeks from the index CT. Results We identified 115 consecutive patients with a routine CT scan. Majority of patients had a greater quantity of low-density muscle (LDM), 95% had CD and 71% were not in clinical remission at the time of baseline CT. Of those with a greater quantity of LDM, 68% had history of IBD surgery and 60% were current/former smokers. The mean pre-CT body mass index (BMI) for the greater quantity LDM was significantly higher (p=0.002) than the mean pre-CTE BMI for those with low LDMC. Seventy percent with greater quantity of low-density muscle were either overweight or obese and 20% had a normal range BMI. Six months after the baseline CT, 53% in the lower quantity LDM had clinical remission, whereas 33.3% had remission in the high LDMC (p=0.05). Patients with greater quantity LDM were more likely to require corticosteroids in the 6 months after index CT, as compared to those with lower quantity LDM (p=0.02). Conclusion This observational study showed an association between greater quantity of LDM and obesity and worse IBD-related outcomes. This is the first study to evaluate the impact of muscle composition on IBD outcomes and our results offer a novel tool to risk stratify patients with IBD. Our study is limited by the retrospective nature, limited sample size, and narrow longitudinal follow-up. Larger prospective studies with greater longitudinal follow-up are needed to confirm our retrospective findings.

Patient and clinician national registry synergy to enhance quality improvement in United Kingdom IBD surgery – is there appetite?

Patient and clinician national registry synergy to enhance quality improvement in United Kingdom IBD surgery – is there appetite?

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BackgroundRacial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients. MethodsThis is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005–2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes. ResultsOf 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1–1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1–2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4–1.9), and sepsis (OR: 1.7; 95% CI 1.4–2.02) compared to White patients. ConclusionsRacial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.