Surgery In Crohn's Disease Patients Research Articles

Crohn Disease Prognostication With Semiautomatic Dual-Energy Computed Tomography Enterography-Derived Iodine Density.

The objective of this study was to determine if dual-energy computed tomography enterography (DECTE)-obtained iodine density can predict medical management change or surgery in Crohn disease patients. The most active-appearing bowel segment on DECTE in 21 Crohn disease patients was retrospectively interrogated with prototype software determining the percentage of bowel wall (I) in specified ranges. Patients were categorized into 3 groups after DECTE: (1) no management change, (2) outpatient medication change, and (3) inpatient admission or surgery. Crohn's disease activity index was calculated. Group 3's percentage iodine density of >3 mg/mL and Crohn's disease activity index were compared with group 1/2. Crohn's disease activity index and percentage iodine density of >2 mg/mL were compared for groups 2/3 versus group 1 patients. There were 5 group 1, 6 group 2, and 10 group 3 patients. Group 3 patients had higher frequency of iodine density >3 mg/mL (27%) compared with groups 1/2 patients (12.6%) (P < 0.05). Crohn's disease activity index was similar (P = 0.98). Groups 2/3 patients had 60.5% iodine density of >2 mg/mL, whereas group 1 patients had 31.7% iodine density of >2 mg/mL (P < 0.05). Crohn's disease activity index was similar (P = 0.12). Iodine density from DECTE may predict medical or surgical Crohn disease management.

The Efficacy of Anti-Tumor Necrosis Factor Alpha for Symptomatic Stricturing Small Bowel Crohn's Disease.

IntroductionCrohn’s disease (CD) is a chronic inflammatory disease. Current treatment aims to prevent complications and the need for surgical intervention. In patients with symptomatic complications, such as strictures, the possible benefits of anti-tumor necrosis factor-alpha (anti-TNF-α) therapy are currently the subject of considerable debate. This study aims to determine whether anti-TNF-α therapy could decrease the need for or delay the time until surgery in patients with CD presenting with symptomatic strictures of the small bowel in the King Abdulaziz University Hospital (KAUH), Saudi Arabia.MethodsWe conducted a retrospective, single-center study that assessed the need for surgical treatment in adult patients with symptomatic stricturing CD who were treated conventionally or with TNF-α inhibitors. Simple logistic regression was used to examine the association between surgical resection and biologics therapy and stepwise elimination logistic regression analysis was used to identify predictors of surgical resection.ResultsIn total, 75 patients fulfilled the study criteria with 50 in the anti-TNF-α arm and 25 in the conventional arm. Surgical resection was required for six patients (12.2%) in the anti-TNF-α treatment arm and one patient (4%) in the conventional treatment arm (P=0.26). Endoscopic balloon dilatation was performed in two patients (4%) in the anti-TNF-α arm and one patient (4%) in the conventional arm (P=0.69). No statistically significant association was observed between surgical resection and treatment with biologic therapy (odds ratio [OR]=0.50, 95% CI: 0.16-1.53, P=0.22). Stepwise elimination identified age (OR=4.54, 95% CI: 0.79-25.11, P=0.09) and disease duration (OR=1.01, 95% CI: 1.00-1.02, P=0.004) as significant predictors of surgery.ConclusionsIn this cohort, anti-TNF-α therapy did not provide additional benefits with regards to avoiding or delaying surgery in CD patients with stricturing of the small bowel.

Clinical outcomes of endoscopic balloon dilatation of intestinal strictures in patients with Crohn's disease.

Intestinal strictures are common complications of Crohn's disease (CD). Endoscopic balloon dilatation (EBD) constitutes an alternative therapy to surgery, but associated factors of procedure success are inconclusive. Therefore, we aimed to evaluate the EBD success rate and its associated factors in CD patients.This is a retrospective cohort study of consecutive EBDs that were conducted between 2006 and 2014 among patients with CD with lower gastrointestinal tract strictures. Patients’ and stricture characteristics, short term procedure success and related complications at 1 week follow-up, and long-term clinical endpoints were documented.A total of 138 dilatations were performed on 64 CD patients. The overall dilatation success rate was 84.8%, with no difference between primary or anastomotic strictures, or between first or recurrent dilatation procedures. Long strictures (≥4 cm) were negatively associated with successful EBDs, but not with perforations. A multivariate analysis adjusting for age, sex, smoking, and disease duration revealed that a maximal dilatation diameter of ≥15 mm was positively associated with a successful EBD, while an inflamed stricture was negatively associated with procedure success. Strictures which were both long and inflamed were associated with the lowest EBD success rates compared with other strictures. Only 32.8% of patients required surgery during the follow-up period. Long-term prevention of surgery was negatively associated with stricture length and with a successful EBD.EBD is highly successful in treating intestinal strictures and in prevention of surgery in CD patients. Although EBD of long strictures is safe, it will not prevent surgery in the majority of cases.

Gastric Acid Suppression Is Associated with an Increased Risk of Adverse Outcomes in Inflammatory Bowel Disease

Background: The intestinal microbiota may influence inflammatory bowel disease (IBD) activity. Histamine 2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) can alter the intestinal microbiota. The aim of this study was to assess the relationship between H2RAs, PPIs, and IBD-related outcomes. Methods: We conducted a case-control study of IBD patients using the Veterans Health Affairs databases. Cases were defined by their first instance of an IBD-related hospitalization or surgery and the exposure of interest was H2RA or PPI use 30 days prior to the outcome. Incidence density ratios were calculated using conditional logistic regression. Results: In a cohort of 58,459 patients with IBD, we found 4,887 cases and 9,761 controls with ulcerative colitis (UC) and 4,876 cases and 9,745 controls with Crohn disease (CD). Filled prescriptions for H2RAs were associated with an increased risk of IBD-related hospitalization or surgery in CD patients (adjusted incidence density ratio 1.18; 95% CI 1.03-1.34). A similar association was found for PPIs in UC patients (adjusted incidence density ratio 1.11; 95% CI 1.02-1.21) and CD patients (adjusted incidence density ratio 1.12; 95% CI 1.02-1.22). Conclusions: H2RAs and PPIs were associated with a modestly increased risk of IBD-related hospitalization or surgery.

P583 Trends in endoscopy management after surgery in a national cohort of Spanish Crohn's disease patients. Results from PRACTICROHN study

Background: Recurrence of Crohn disease (CD) after an ileo-colonic resection is predicted by the severity of endoscopic lesions during the first year after resection, hence guidelines recommend every patient to underwent endoscopy during the first year after surgery. The aim of our study was to describe the management and results of endoscopy after surgery in a population of CD patients between 2007 and 2010. Methods: PRACTICROHN was a study that included patients aged ≥18 years-old from 26 Spanish hospitals who underwent CD-related ileocolonic or ileorectal resection with ileocolonic or ileorectal anastomosis between January 2007 and December 2010. Clinical data was retrospectively collected from clinical charts during 5 years follow-up after surgery. Endoscopies were analyzed according to prophylactic treatment prescribed, year of surgery and hospital size. Categorical variables were compared with the χ2 test or Fisher's exact test Kaplan-Meier method was used to assess time to clinical recurrence and a log-ranktest to obtain statistical significance. Results: 314 patients were analyzed (mean age 40 years [SD 13], 48% men). Of these, 52 (16.6%) had suffered more than one resection before the index surgery. In 143 (46.3%) a colonoscopy was performed during the first year after surgery. In 2007, only 24/75 patients (33%) underwent endoscopy in the first year, while in 2010 endoscopy was performed in 47/79 (59.5%) p=0.017 (Fig. 1). Figure 1. Frequency (%) of endoscopies in the first year by year of surgery. During first year after surgery, 22 (7%) patients presented with endoscopic recurrence without symptoms. Along the five years follow-up 222 patients underwent colonoscopy. Rutgeerts score was ≥2 in 122 patients (55%). Rutgeerts score in patients that received prophylactic treatment was significantly lower than in patients without prophylaxis (Table 1). Table 1 The size of the hospital did not influence the percentage of endoscopies performed, being similar in hospitals <500 beds, between 500 and 900 and in hospitals with more than 900 beds. Conclusions: From 2007 to 2010 there was a trend towards performing significantly more endoscopies after surgery in CD patients, as recommended by guidelines. The number of endoscopic recurrence without symptoms in our study reinforces the importance of performing colonoscopies in high risk CD patients.

C-reactive protein as a diagnostic and prognostic factor in inflammatory bowel diseases.

The study aimed to evaluate high-sensitivity CRP (hsCRP) as a diagnostic and predictive marker in patients with inflammatory bowel disease (IBD). Medical history of 106 patients with IBD revealed hsCRP concentrations at diagnosis and during the follow-up period. The study showed that the majority of investigated patients had elevated hsCRP concentrations at diagnosis, although the mean concentration was much higher in the group of patients with Crohn's disease (CD) than the group with ulcerative colitis (UC) (P<0.001). The overall decrease in mean hsCRP concentration observed during the follow-up period was larger in the group of CD patients. The analysis showed a correlation between hsCRP concentrations at diagnosis and risk of surgery in the group of CD patients (r=0.408, P=0.002), but not in the group of UC patients. In a logistic regression analysis, surgery in CD patients was associated with age (OR: 0.89, 95% CI: 0.8-1.0, P=0.05) and hsCRP concentration (OR: 1.02, 95% CI: 1.0-1.04, P=0.03) at diagnosis. HsCRP might be a useful diagnostic marker in differentiating active IBD from other diseases. Particularly important however seems to be the predictive value of hsCRP at diagnosis in prognosing the clinical outcome of the disease in CD patients.

The Efficacy and Safety of Endoscopic Balloon Dilation in the Treatment of Stricturing Crohnʼs Disease

Purpose: To assess the efficacy and safety of endoscopic balloon dilation (EBD) for the treatment of Crohn's disease (CD)-related strictures in a tertiary care population. Methods: All patients who underwent EBD for the treatment of stricturing CD from 2005 through 2012 were identified. Demographic and clinical information were obtained from a clinical data repository and from review of medical records. A technically successful dilation was defined as the ability to traverse a stricture following EBD. Primary outcomes assessed included the technical success rate of EBD, the percent of EBD-treated patients who required further endoscopic or surgical therapy, and complications of EBD. Results: Seventy-five CD patients underwent 131 dilations on 83 strictures. The average patient age was 25+/-11 years. Sixty percent of patients were women, and 68% were Caucasian. Sixty percent, 28%, and 12% had ileocolonic, ileal, and colonic disease location, respectively. Forty-seven percent, 44%, and 9% had penetrating, stricturing, and inflammatory disease behavior, respectively. The majority of treated strictures were located at a surgical anastomosis (69%), with the ileocolonic location being the most common site. Technical success rate of EBD was 70%. Factors associated with technical success included maximum balloon diameter of 18 mm and non-Caucasian race. Forty-nine percent of patients underwent repeat EBD an average of 3 months after the first dilation. Maximum balloon diameter of 18 mm, female gender, non-Caucasian race, and use of concurrent immune suppressant were negatively associated with repeat EBD. Eighty percent of patients underwent surgical resection an average of 8 months after EBD. Inflammatory-type strictures, anastomotic-type strictures, ileal disease location, male gender, and lack of obstructive symptoms were negatively associated with resection after EBD. Complications occurred after three procedures (2%), including admissions for post-procedure pain, bleeding, and microperforation. Surgery was not required as a result of any complication. Conclusion: EBD was technically successful in the majority of CD patients; however, 80% underwent surgical resection less than a year after EBD. Inflammatory-type strictures, anastomotic-type strictures, ileal disease, male gender, and lack of obstructive symptoms were negatively associated with stricture resection after EBD; thus, EBD in CD patients with these features may have better long-term outcomes. EBD was safe, with only 2% of patients experiencing procedure-related complications. Providers should consider EBD to delay or prevent surgery in CD patients.

Multidimensional Prognostic Risk Assessment Identifies Association Between IL12B Variation and Surgery in Crohn’s Disease

The ability to identify patients with Crohn's disease (CD) at highest risk of surgery would be invaluable in guiding therapy. Genome-wide association studies have identified multiple IBD loci with unknown phenotypic consequences. The aims of this study were to: (1) identify associations between known and novel CD loci with early resective CD surgery and (2) develop the best predictive model for time to surgery using a combination of phenotypic, serologic, and genetic variables. Genotyping was performed on 1,115 subjects using Illumina-based genome-wide technology. Univariate and multivariate analyses tested genetic associations with need for surgery within 5 years. Analyses were performed by testing known CD loci (n = 71) and by performing a genome-wide association study. Time to surgery was analyzed using Cox regression modeling. Clinical and serologic variables were included along with genotype to build predictive models for time to surgery. Surgery occurred within 5 years in 239 subjects at a median time of 12 months. Three CD susceptibility loci were independently associated with surgery within 5 years (IL12B, IL23R, and C11orf30). Genome-wide association identified novel putative loci associated with early surgery: 7q21 (CACNA2D1) and 9q34 (RXRA, COL5A1). The most predictive models of time to surgery included genetic and clinical risk factors. More than a 20% difference in frequency of progression to surgery was seen between the lowest and highest risk groups. Progression to surgery is faster in patients with CD with both genetic and clinical risk factors. IL12B is independently associated with need and time to early surgery in CD patients and justifies the investigation of novel and existing therapies that affect this pathway.

Has There Been a Change in the Natural History of Crohn's Disease? Surgical Rates and Medical Management in a Population-Based Inception Cohort from Western Hungary Between 1977–2009

Medical therapy for Crohn's disease (CD) has changed significantly over the past 20 years with increasing use of immunosuppressives. In contrast, surgery rates are still high and there is little evidence that disease outcomes for CD have changed over the past decades. The objective of this study was to analyze the evolution of the surgical rates and medical therapy in the population-based Veszprem province database. Data of 506 incident CD patients were analyzed (age at diagnosis: 31.5 years, s.d. 13.8 years). Both hospital and outpatient records were collected and comprehensively reviewed. The study population was divided into three groups by the year of diagnosis (cohort A: 1977-1989, cohort B: 1990-1998 and cohort C: 1999-2008). Overall, azathioprine (AZA), systemic steroid, and biological (only available after 1998) exposure was 45.8, 68.6, and 9.5%, respectively. The 1- and 5-year probability of AZA use were 3.2 and 6.2% in cohort A, 11.4 and 29.9% in cohort B, and 34.8 and 46.2% in cohort C. In a multivariate Cox-regression analysis, decade of diagnosis (P < 0.001, hazard ratio (HR)(cohorts B-C): 2.88-6.53), age at onset (P = 0.008, HR: 1.76), disease behavior at diagnosis (P < 0.001, HR(complicated): 1.76-2.07), and need for systemic steroids (P < 0.001, HR: 2.71) were significantly associated with the time to initiation of AZA therapy. Early AZA use was significantly associated with the time to intestinal surgery in CD patients; in a multivariate Cox analysis (HR: 0.43, 95% confidence interval (CI): 0.28-0.65) and after matching on propensity scores for AZA use (HR: 0.42, 95% CI: 0.26-0.67). This population-based inception cohort has shown that the recent reduction in surgical rates was independently associated with increased and earlier AZA use.

Risk Factors for Repeat Abdominal Surgery in Korean Patients with Crohn's Disease: A Multi-Center Study of a Korean Inflammatory Bowel Disease Study Group

PurposeThe purpose of this study was to assess the risk factors for repeated abdominal surgery in Crohn's disease (CD) patients after the first abdominal surgery. Prior studies have tried to identify the risk factors for postoperative recurrence in CD patients, but the results of the studies have been inconsistent. Furthermore, few data on the risk factors for repeated abdominal surgery are available.MethodsClinical data on CD patients who underwent abdominal surgery from January 2000 to December 2009 were collected from seventeen university hospitals and one colorectal clinic. Data from a total of 708 patients were analyzed to find the risk factors for repeated abdominal surgery in CD patients. The mean follow-up period was 72 months.ResultsThe risk of repeated abdominal surgery was 3 times higher in young patients (below 16 years old) than in older patients (odds ratio [OR], 3.056; 95% confidence interval [CI], 1.021 to 9.150); P = 0.046). Stricturing behavior at diagnosis was also a risk factor for repeated abdominal surgery (OR, 2.438; 95% CI, 1.144 to 5.196; P = 0.021). Among operative indications, only intra-abdominal abscess was associated with repeated abdominal surgery (OR, 2.393; 95% CI, 1.098 to 5.216; P = 0.028). Concerning type of operation, an ileostomy might be a risk factor for repeated abdominal surgery (OR, 11.437; 95% CI, 1.451 to 90.124; P = 0.021). Emergency surgery (OR, 4.994; 95% CI, 2.123 to 11.745; P < 0.001) and delayed diagnosis after surgery (OR, 2.339; 95% CI, 1.147 to 4.771; P = 0.019) also increased the risk of repeated abdominal surgery.ConclusionYoung age (below 16 years), stricturing behavior, intra-abdominal abscess, emergency surgery, and delayed diagnosis after surgery were identified as possible risk factors for repeated abdominal surgery in CD patients.

Predictive value of the CARD15 variant 1007fs for the diagnosis of intestinal stenoses and the need for surgery in Crohnʼs disease in clinical practice: Results of a Prospective Study

The diagnostic and therapeutic relevance of CARD15 genotyping in Crohn's disease (CD) for daily clinical practice has not been investigated so far. We therefore analyzed whether CARD15 variants are independent predictive factors for small bowel stenosis in CD evaluated by magnetic resonance enteroclysis (MRE). On the basis of these findings, the potential implications for patient management were investigated. Eighty CD patients with clinical symptoms suggestive of small bowel stenosis were included. All patients were genotyped for the CARD15 variants c.2104C > T (p.R702W), c.2722G > C (p.G908R), and c.3019_3020insC (p.Leu1007fsX1008) and examined by MRE of the small bowel. CARD15 variants were found in 40 (50%) patients. MRE identified 31 (38%) patients with small bowel stenoses. Twenty-five of the 40 (62%) patients with at least one CARD15 variant were diagnosed of intestinal stenosis by MRE (odds ratio [OR] = 9.44; confidence interval [CI] 3.21-27.77; P = 0.00028, Bonferroni corrected). Particularly, the presence of the 1007fs variant was associated with an increased risk of an intestinal stenosis (OR = 12.00, CI 3.47-41.54, P = 0.00042, Bonferroni corrected). Twenty-one of 31 (68%) patients with stenoses required surgical intervention, with 13 of these 21 (62%) patients carrying the 1007fs variant. In the largest prospective study analyzing the diagnostic value of CARD15 variants in CD patients performed so far, we identified the 1007fs variant as strong predictor for intestinal stenoses with need for surgery in CD patients. Genotyping could therefore be an important diagnostic tool in clinical practice for identifying high-risk patients with specific diagnostic and therapeutic needs. Moreover, MRE is an excellent technique for diagnosing small bowel stenoses.