Time Of Colectomy Research Articles

P0612 Postoperative outcomes in tofacitinib-treated patients with acute severe ulcerative colitis undergoing total abdominal colectomy

Abstract Background Up to 30% of patients with acute severe ulcerative colitis (ASUC) require urgent colectomy despite IV corticosteroids and rescue therapies with infliximab or cyclosporin. JAK-inhibitors, like tofacitinib, have emerged as effective treatments for ASUC, but data on postoperative complications are limited.1, 2 Methods We conducted a multicenter, retrospective, case-control (1:2) study of patients hospitalized with ASUC who underwent colectomy, comparing patients treated with tofacitinib (cases) prior to their colectomy with those treated with usual care (controls).1 The primary outcome was rate of serious postoperative complications within 30 days of colectomy defined as Clavien-Demartines-Dindo classification grade ≥3. Outcomes were compared between the tofacitinib-treated cases and controls using adjusted multivariable regression analysis. Results In all, 41 tofacitinib-treated ASUC patients were compared to 83 patients with ASUC who received usual stand of care. Among patients treated with usual care, 68 (82%) patients received rescue infliximab, 1 (1%) had rescue cyclosporine, and 80 (96%) had corticosteroids within 24 hours of colectomy compared to patients in the tofacitinib-treated group, where 5 (12%) had rescue infliximab, 4 (10%) rescue cyclosporine, and 34 (83%) corticosteroids. Compared to tofacitinib-treated patients, patients who received usual care had higher rates of serious postoperative complications (24 [29%] vs 5 [12%], p=0.023) and overall postoperative complications (51 [61.4%] vs 13 [31.7%], p=0.003). Multivariable regression adjusted for CRP, albumin, age at the time of colectomy, open surgery, preoperative length of stay, ASA classification, as well as concomitant corticosteroid and infliximab use did, however, not demonstrate a significantly different risk for developing both serious postoperative complications (OR 0.52 [95% CI 0.07-3.11], p=0.5) or overall postoperative complications (OR 1.00 [0.28-3.55], p>0.9) between the tofacitinib-treated group and usual care group. Overall rates of 30-day VTE were also similar in the two groups (tofacitinib group: 2 [4.9%] vs usual-care group: 5 [6.0%], p=0.16), but numerically higher for delayed VTE within 31-90 days in the usual-care group (2 [2.4%] vs 0 [0%], p=0.81). One patient (2%) treated with tofacitinib died from septic shock secondary to infectious pneumonia 14 days after surgery, whereas no deaths occurred in the usual care group (p=0.72). Postoperative length of stay was similar between groups (5 [4-8] vs 7 [4-11], p=0.14). Conclusion No difference in postoperative complications was observed between tofacitinib-treated and usual care ASUC patients. Larger prospective trials are needed to confirm these findings.

Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis.

Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state. We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery. During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%). In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.

Ileal Paneth Cell Phenotype is a Cellular Biomarker for Pouch Complications in Ulcerative Colitis.

Biomarkers that integrate genetic and environmental factors and predict outcome in complex immune diseases such as inflammatory bowel disease (IBD; including Crohn's disease [CD] and ulcerative colitis [UC]) are needed. We showed that morphologic patterns of ileal Paneth cells (Paneth cell phenotype [PCP]; a surrogate for PC function) is one such cellular biomarker for CD. Given the shared features between CD and UC, we hypothesized that PCP is also associated with molecular/genetic features and outcome in UC. Because PC density is highest in the ileum, we further hypothesized that PCP predicts outcome in UC subjects who underwent total colectomy and ileal pouch-anal anastomosis (IPAA). Uninflamed ileal resection margins from UC subjects with colectomy and IPAA were used for PCP and transcriptomic analyses. PCP was defined using defensin 5 immunofluorescence. Genotyping was performed using Immunochip. UC transcriptomic and genotype associations of PCP were incorporated with data from CD subjects to identify common IBD-related pathways and genes that regulate PCP. The prevalence of abnormal ileal PCP was 27%, comparable to that seen in CD. Combined analysis of UC and CD subjects showed that abnormal PCP was associated with transcriptomic pathways of secretory granule maturation and polymorphisms in innate immunity genes. Abnormal ileal PCP at the time of colectomy was also associated with pouch complications including de novo CD in the pouch and time to first episode of pouchitis. Ileal PCP is biologically and clinically relevant in UC and can be used as a biomarker in IBD.

Severe Disease Activity May Predispose Patients to Post-colectomy Duodenitis Associated with Ulcerative Colitis

Objective Diffuse mucosal inflammation in the duodenum, distinct from peptic ulcer disease, has been repeatedly reported in patients with ulcerative colitis (UC). The pathogenesis of this complication remains uncertain; however, colectomy for medically refractory UC appears to trigger duodenitis. Cases in which colectomy was performed for UC were analyzed to characterize UC-related duodenitis after colectomy. Methods A retrospective case-control study of UC-related duodenitis that developed after colectomy in medically refractory UC between January 2011 and June 2020 was conducted. UC-related duodenitis was diagnosed based on typical clinical, endoscopic, and histological findings, and no duodenitis was endoscopically defined by the normal duodenal mucosa. Clinical and laboratory data, disease severity, and medications used were collected and compared between the UC-related and non-duodenitis cases. Results Ten UC-related duodenitis and 35 non-duodenitis cases were identified among 45 patients with UC who underwent esophagogastroduodenoscopy after colectomy. Disease severity, defined by the C-reactive protein level and partial Mayo score prior to colectomy, was significantly higher in duodenitis patients than in non-duodenitis patients. In comparison to non-duodenitis patients, duodenitis patients more frequently received rescue therapies with calcineurin inhibitors or anti-TNF-α agents at the time of colectomy (100% vs. 65.7%). Conclusion Patients with UC with higher disease activity, especially those who require rescue therapies with calcineurin inhibitors and anti-TNF-α agents, may be prone to developing UC-related duodenitis after colectomy.

P304 Endoscopic cuffitis is associated with severe inflammatory pouch phenotypes

Abstract Background Ulcerative colitis (UC) patients who undergo ileal pouch-anal anastomosis (IPAA) without mucosectomy may develop inflammation of the rectal cuff (cuffitis). Studies have suggested that cuffitis is associated with clinical pouch inflammation (pouchitis), but it remains unclear if cuffitis is associated with specific endoscopic phenotypes of pre-pouch inflammation (ileitis), pouch body inflammation, and diffuse pouch inflammation. Therefore, this aim of this study is to identify if endoscopic cuffitis is a predictor of more severe pouch phenotypes, which may warrant earlier or more aggressive treatment. Methods In this cohort study, charts were reviewed of patients who underwent IPAA at a tertiary care center from 01/2010 to 12/2021. Inclusion criteria for this study were a diagnosis of UC and ≥18 years old at time of colectomy. Exclusion criteria were lack of endoscopic evaluations after the peri-operative period (defined as 6 months following ileostomy closure) and diagnoses other than UC requiring IPAA. Patients were divided into cohorts based on whether they had cuffitis identified on ≥1 endoscopy following IPAA, which was confirmed by two researchers. Outcomes for this study included pre-pouch ileitis, pouch body inflammation, and diffuse inflammation (inflammation of the pouch body, inlet, and pre-pouch ileum). A multivariate logistic regression was used to test for association between cuffitis and each outcome while controlling for potentially confounding variables suggested to be significant on univariate analyses. Results A total of 363 patients were included in this study with an overall median follow-up time of 2.4 (IQR 1.2-3.8) years after ileostomy closure. 149 (41.0%) patients had cuffitis on ≥1 endoscopy following IPAA. 65 (17.9%) patients developed pre-pouch ileitis (Table 1), which was significantly associated with cuffitis (aOR = 3.85; 95% CI 2.15-6.91; p < 0.0001) and age (aOR = 0.98, 95% CI = 0.96-1.00, p = 0.0254). Pouch body inflammation occurred in 201 (55.4%) patients and was associated with cuffitis (aOR = 2.69, 95% CI = 1.69-4.29, p < 0.0001), PSC (aOR = 6.60, 95% CI = 1.85-23.49, p = 0.0036), extraintestinal manifestations (EIMs) other than PSC (aOR = 2.35, 95% CI = 1.45-3.79, p = 0.0005), and age (aOR = 0.98, 95% CI = 0.97-1.00, p = 0.0359). Finally, diffuse inflammation occurred in 20 (5.5%) patients and was associated with cuffitis (aOR = 6.24, 95% CI = 2.04-19.08, p = 0.0013). Conclusion Endoscopic cuffitis is associated with the development of severe inflammatory pouch phenotypes. Future studies are needed to investigate whether treatment of cuffitis reduces this risk and whether the incidence of cuffitis is rising similar to pouchitis in the post-biologic era.

Colectomy in patients with ulcerative colitis is not associated to future diagnosis of primary sclerosing cholangitis.

Primary Sclerosing Cholangitis (PSC) is a hepatobiliary disease closely related to ulcerative colitis (UC). In PSC patients, colectomy has been linked to improved prognosis, especially following liver transplantation. This suggests an involvement of the gut-liver axis in PSC etiology. We aimed to investigate the association between colectomy and the risk of future PSC in an epidemiological setting. Through nationwide registers, we identified all adults diagnosed with UC in Sweden 1990-2018 and retrieved information on PSC diagnosis and colectomy. Within the UC cohort (n=61,993 patients), we matched 5577 patients with colectomy to 15,078 without colectomy. Matching criteria were sex, age at UC onset (±5years), year of UC onset (±3years), and proctitis at the time of colectomy. Incidence rates of PSC per 1000-person year were calculated, and the Cox proportional hazard regression model estimated hazard ratios (HRs) for PSC until 31 December 2019. During the follow-up, 190 (3.4%) colectomized UC patients and 450 (3.0%) UC comparators developed PSC, yielding incidence rates of 2.6 and 2.4 per 1000 person-years (HR 1.07 [95% CI 0.90-1.28]). The cumulative incidence of colectomy decreased remarkably over calendar periods, but the cumulative incidence of PSC remained unchanged. The risk of developing PSC in colectomized versus comparators changed over time (HR 0.68 [95% CI; 0.48-0.96] in 1990-97 and HR 2.10 [95% CI; 1.37-3.24] in 2011-18). In UC patients, colectomy was not associated with a decreased risk of subsequent PSC. The observed differences in the risk of PSC development over calendar periods are likely due to changes in PSC-diagnosis and UC-treatment.

Acute Severe Ulcerative Colitis Is Associated With an Increased Risk of Acute Pouchitis.

Pouchitis occurs in up to 80% of patients after total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) and has been associated with microbial and host-related immunological factors. We hypothesized that a more robust immune response at the time of colectomy, manifested by acute severe ulcerative colitis (ASUC), may be associated with subsequent acute pouchitis. This was a retrospective cohort analysis of all patients with UC or indeterminate colitis complicated by medically refractory disease or dysplasia who underwent TPC with IPAA at Mount Sinai Hospital between 2008 and 2017 and at least 1 subsequent pouchoscopy. Acute pouchitis was defined according to the Pouchitis Disease Activity Index. Cox regression was used to assess unadjusted relationships between hypothesized risk factors and acute pouchitis. A total of 416 patients met inclusion criteria. Of the 165 (39.7%) patients who underwent urgent colectomy, 77 (46.7%) were admitted with ASUC. Acute pouchitis occurred in 228 (54.8%) patients a median of 1.3 (interquartile range, 0.6-3.1) years after the final surgical stage. On multivariable analysis, ASUC (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.04-2.17) and a greater number of biologics precolectomy (HR, 1.57; 95% CI, 1.06-2.31) were associated with an increased probability of acute pouchitis, while older age at colectomy (HR, 0.98; 95% CI, 0.97-0.99) was associated with a decreased probability. Time to pouchitis was significantly less in patients admitted with ASUC compared with those not (P = .002). A severe UC disease phenotype at the time of colectomy was associated with an increased probability of acute pouchitis.

Appendiceal inflammation in colectomy is independently correlated with early pouchitis following ileal pouch anal anastomosis in ulcerative colitis and indeterminate colitis

BackgroundAppendiceal inflammation in colectomy is one of the histologic predictors of pouchitis in ulcerative colitis (UC) following ileal pouch anal anastomosis (IPAA). Fecal calprotectin level has been shown to increase 2 months prior to the onset of pouchitis. We evaluated whether inflammation and calprotectin expression in appendiceal specimens correlate with early-onset pouchitis in UC and indeterminate colitis (IC). Materials and methodsIPAA (2000-2018) cases with appendix blocks available in colectomy specimens were identified (n = 93, 90 UC, 3 IC). Histologic features thought to predict pouchitis were evaluated. The degree of appendiceal inflammation was scored. Calprotectin immunostain was performed on the appendix blocks and the extent of mucosal staining was quantified. Electronic medical records were reviewed for demographics, smoking history, clinical pouchitis, time of onset of pouchitis, and clinical and endoscopic components of the Pouchitis Disease Activity Index (PDAI) score. Follow-up pouch biopsies were reviewed and scored to generate histologic PDAI score, when available. ResultsAmong the patients with clinical pouchitis (n = 73), moderate to severe appendiceal inflammation independently correlated with earlier pouchitis compared to no/mild inflammation (median time to pouchitis 12.0 vs. 23.8, log rank p = 0.016). Calprotectin staining correlated with inflammatory scores of the appendix (Spearman's rho, r = 0.630, p < 0.001) but not with early pouchitis (p > 0.05). ConclusionsThe presence of moderate to severe appendiceal inflammation at the time of colectomy was associated with a shorter time to pouchitis following IPAA. Calprotectin immunostain may be used to demonstrate the presence of inflammation in the appendix but its role in predicting early pouchitis remains limited.

Transmural Inflammation, Ileitis, and Granulomas at the Time of Proctocolectomy in Patients with Ulcerative Colitis Do Not Predict Future Development of Pouchitis

Background: The most common complication following ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC) is pouchitis. Our study aimed to investigate the relationship between histopathologic findings of ileitis, granuloma, or transmural inflammation on the colectomy specimen of patients with clinically and endoscopically diagnosed UC and the development of pouchitis within the first 2 years after IPAA. Methods: We performed a retrospective cohort study evaluating patients undergoing colectomy with IPAA for UC between January 1, 2004 and December 31, 2016. Bivariate analyses were conducted to evaluate the relationship between clinical factors and the development of pouchitis. We performed multivariate logistic regression to evaluate the relationship between histologic, clinical, and demographic factors at the time of colectomy and subsequent development of pouchitis. Results: Among 626 patients, pouchitis occurred in 246 (39%). Patients with primary sclerosing cholangitis were more likely to develop pouchitis (adjusted odds ratio [aOR] 2.81, 95% confidence interval [CI] 1.02–7.72), as were patients with a family history of inflammatory bowel disease (aOR 1.75, 95% CI 1.11–2.77). Histologic findings of ileitis, granuloma, or transmural inflammation were not associated with an increased odds of developing pouchitis (aOR 0.70, 95% CI 0.45–1.08). Discussion/Conclusion: Patients with ileitis, granulomas, or transmural inflammation at the time of colectomy were not at greater risk for development of pouchitis in the 2 years after IPAA. These pathological findings should not preclude IPAA for UC.

The relationship between preoperative T helper cytokines in the ileal mucosa and the pathogenesis of pouchitis

BackgroundAlthough the etiology of pouchitis remains unknown, inflammatory cytokines are significantly associated with the pathogenesis of pouchitis. The cytokine responses that characterize inflammatory bowel diseases (IBD) are key pathogenic components of the disease. Although cytokine profiles in the colonic mucosa have been investigated in experimental colitis models or IBD patients, cytokine profiles in the ileal mucosa at colectomy have been rarely assessed.AimTo assess the relationship between pouchitis and T helper (Th) cytokines in the ileal mucosa collected at the time of colectomy and pouch construction.MethodsThis retrospective study involved 68 consecutive patients from January 2004 to May 2011 who underwent ileal pouch–anal anastomosis for ulcerative colitis. Samples were obtained from the terminal ileum of resected specimens at time of total colectomy or subtotal colectomy. mRNA expression levels of Th cytokines (IFN-γ, IL-23A, IL-5, IL-13 and IL-17A) were determined.ResultsForty of 68 patients (58.8%) developed pouchitis. There was no association between IL-23A expression levels and incidence of pouchitis (p = 0.301). Patients with elevated IFN-γ had a significantly higher incidence of pouchitis compared with low IFN-γ patients (p = 0.043). Univariate analysis demonstrated a total dose of prednisolone > 7000 mg administered before colectomy (p = 0.04) and high IFN-γ expression (p = 0.02) were significant risk factors for pouchitis onset. In multivariate analysis, elevated IFN-γ messenger(m)RNA levels were significantly associated with pouchitis onset (p = 0.03).ConclusionIFN-γ expression in the normal ileal mucosa at the time of colectomy may be an important factor in the pathophysiology of pouchitis.

Pediatric ulcerative colitis: three- versus two-stage colectomy with ileal pouch-anal anastomosis.

Despite advancements in medical therapy for ulcerative colitis (UC), a significant proportion of children progress to colectomy with ileal pouch-anal anastomosis (IPAA). Procedural related complications between two- and three-stage operations in children have not been well described. We performed a retrospective review of patients who underwent a colectomy for UC or inflammatory bowel disease unclassified between 2008 and 2018. Forty-nine children underwent an IPAA at the time of colectomy (two stage) or during a subsequent operation (three stage). Preoperative hemoglobin and albumin concentrations were lower among those undergoing three-stage procedures. The rate of early complications (≤30days) was similar between the two groups (p = 0.46); however, late complications (>30days) were more commonly associated with three-stage procedures (p = 0.03). Time with a stoma was 3.2months longer among those who underwent a three-stage procedure. While three-stage procedures were more often performed during the first half of the study period (2008-2012), two-stage procedures became more common during the second half (2013-2018). During this transition to favor two-stage procedures, complication rates did not significantly change. Although three-stage procedures were thought to be associated with fewer complications, we found comparable complication rates as we transition to two-stage procedures.

Does Age Affect Surgical Outcomes After Ileal Pouch–Anal Anastomosis in Children?

BackgroundYounger children are referred for surgical intervention in the treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Outcome data in this population after a laparoscopic restorative proctocolectomy and Ileal pouch-anal anastomosis (LRS-IPAA) are limited. We reviewed our experience to determine if younger children would have similar functional outcomes. MethodsAfter institutional review board approval, a review of children with FAP and UC undergoing LRS-IPAA at a children's hospital from 2002 to 2017 occurred. The study groups were defined based on age: young group (YG; 5-12 y) and older group (OG; 13-18 y). Data points included demographics, postprocedure course, and outcomes. Statistical analysis was performed. ResultsSixty-five children were identified and grouped by age: YG (n = 22, average age 9 y) and OG (n = 43, average age 15.4 y). Thirteen children in YG had UC, and nine had FAP. Twenty-eight children in OG were diagnosed with UC, and 15 with FAP. After LRS-IPAA, continence, appetite recovery, and use of antidiarrheal medications were not significantly different between groups. The incidence of pouch stricture, diagnosis of pouchitis, and complications were also not significantly different. Two children (YG), aged 11 and 12 y at the time of colectomy, were initially diagnosed with UC and then reassigned as having Crohn's disease because of persistent symptoms. One child, who underwent colectomy at 17 y for FAP, had invasive rectal cancer and died 3 y later from metastatic disease. Time of follow-up for OG is 8-61 mo (average: 37 mo). Period of follow-up for YG is 11-73 mo (average: 43 mo). ConclusionsThere are no significant differences in the functional outcomes between groups after LRS-IPAA. Although numbers are small, these data suggest younger age should not be a deterrent when contemplating LRS-IPAA in the treatment of UC and FAP in the pediatric population. Younger patients with FAP may benefit from early intervention.

Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program

Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC). Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities. Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC. Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.

Patchy colitis, and young age at diagnosis and at the time of surgery predict subsequent development of Crohn's disease after ileal pouch-anal anastomosis surgery for ulcerative colitis.

Background and AimA proportion of patients having total proctocolectomy and ileal pouch‐anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC.MethodsA retrospective case–control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed.ResultsFifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6–31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3–16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1–41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C‐reactive protein (CRP), albumin, family history, and smoking status.ConclusionPredictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.

Rapid Immunohistochemistry of resected bowel margins at the time of Colectomy: Defining the presence of premalignant Cells undetected by H&amp;E

Rapid Immunohistochemistry of resected bowel margins at the time of Colectomy: Defining the presence of premalignant Cells undetected by H&amp;E

Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer.

Purpose Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care. Methods We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends. Results Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, -11.88 to -0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states. Conclusion The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.

PWE-042 Incidence and Risk Factors of Post Liver Transplant Colorectal Malignancy in PSC: Abstract PWE-042 Table 1

<h3>Introduction</h3> Patients with primary sclerosing cholangitis (PSC) and co-existing colonic inflammatory bowel disease (IBD) have an increased lifetime risk of developing colorectal cancer (CRC); a risk that persists after liver transplantation. Aim: Assess the incidence rate (I.R.) of colonic dysplasia and/or cancer in patients transplanted for PSC, and determine any factors specific to post-transplant care associated with an increased CRC risk. <h3>Methods</h3> The cohort included all patients transplanted from 1987 to 2015 for PSC with concomitant colitis. Time zero was set as the point of first liver transplant. The study end-point was the time to first dysplasia or any higher lesion. Patients were censored at time of colectomy (for a non-CRC indication), death or last date of CRC-free follow up. Statistical methods employed for determining potential risk factors included Cox-proportional hazards and Kaplan-Meier estimates. <h3>Results</h3> Overall, 306 patients were transplanted during this time period. 202 patients (66%) had underlying IBD and of this group 191 patients (95%) had co-existing colitis. The final study population was 163 patients who had colitis with an intact colon. The I.R. of developing colonic dysplasia or higher lesions was 18.9 cases per 1,000 patient years and of colonic high grade dysplasia (HGD) or neoplasia was 10.4 cases per 1,000 patient years. There has been an increase in incidence rates by year of transplant (Table 1). No risk factors for the development of colonic dysplasia or above post liver transplantation were statistically significant. These risk factors included the number of colitis flares (&gt;0, &gt;1, &gt;2), the use of cyclosporine (versus tacrolimus), the use of azathioprine (versus mycophenolate mofetil), thiopurine use, use of ursodeoxycholic acid, advancing age and male gender. <h3>Conclusion</h3> The incidence of colonic dysplasia in the PSC post-transplant population is rising. Further review of specific colitis findings need to be evaluated in order to aid in any potential risk factors for CRC development. <h3>Disclosure of Interest</h3> None Declared

PTH-063 Different colectomy rates for ulcerative colitis across ethnic groups in england: Abstract PTH-063 Table 1

Introduction Previous epidemiological studies suggest a higher rate of pan-colonic disease in South Asians (SA) compared with Caucasians. There is limited data on disease severity across ethnic groups. Refractory disease and development of dysplasia indicate aggressive disease and are both indications for colectomy. The aim of the study was to compare the risk of colectomy for ulcerative colitis (UC) in SA migrants to Caucasians. Method Patients with UC were identified from a national administrative dataset (Hospital Episode Statistics – HES) between 1997–2012 according to ICD-10 diagnosis code K51 for UC. From the cases coded for ethnicity, colectomy cases were identified according to the Office of Population Censuses and Surveys (OPCS) codes. The colectomy rate for each ethnic group was calculated as the proportion of patients who underwent colectomy from the total UC cases for that group. The median age at time of colectomy was calculated for each ethnic group. Chi-squared testing was used to determine significant differences in colectomy rate and Kruskal-Wallis test to ascertain differences in age at colectomy between ethnic groups. Results Of 212,430 UC cases, 74,988 (35.3%) were coded for ethnicity. Of these cases most were White Europeans (Caucasians) 69,208/74,988 (92.3%). The SA group consisted of: 1,954/74,988 (2.6%) Indian, 832/74,988 (1.1%) Pakistani and 129/74,988 (0.2%) Bangladeshi ([Table 1][1]). Indians had a significantly higher colectomy rate than White Europeans (10.8% vs 7.4%, p < 0.001). In contrast Pakistanis had a similar (7.0%) and Bangladeshis a significantly lower (4.7%) colectomy rate than the White European group. (7.4%, p < 0.001). SAs undergoing colectomy were significantly younger than White Europeans for each ethnic group (median age; Bangladeshis - 29 years, Pakistanis - 37 years and Indians – 41 years, compared with White Europeans – 49 years, p < 0.001). View this table: Abstract PTH-063 Table 1 Colectomy rate in UC patients by ethnicity Conclusion The colectomy rate is higher in Indians compared to White Europeans. Across SA ethnic groups there are differences in colectomy rate. All SA groups required a colectomy for UC at a younger age than White Europeans. These findings suggest a more aggressive phenotype in SAs and should be validated with a prospectively recruited ethnic cohort. This will also allow examination of contributing factors. Disclosure of interest None Declared. [1]: #T1

FK506-Binding Protein 5 mRNA Levels in Ileal Mucosa Are Associated with Pouchitis in Patients with Ulcerative Colitis.

Although the pathogenesis of pouchitis is incompletely understood, steroid and FK506 therapy are significantly associated with pouchitis. These medical treatments are regulated by the FK506-binding protein (FKBP) 4 and FKBP5 genes. This study aimed to evaluate the relationship between pouchitis and FKBP4 and FKBP5 mRNA expression in ileal mucosa at the time of colectomy. Ileal mucosa specimens were collected from 71 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis. FKBP4 and FKBP5 mRNA expression was evaluated. The relationship between mRNA expression and clinicopathological factors, including developed pouchitis, was investigated. Of these 71 patients, 25 (35.2 %) patients developed pouchitis in a mean duration of 20.2 months (range 0-68 months). FKBP4 mRNA levels in patients who received an immunomodulator were significantly higher than those in untreated patients (0.167 ± 0.060 vs 0.131 ± 0.065, p = 0.009). However, FKBP5 mRNA levels in patients who received a three-stage operation were significantly lower than those in the other patients (1.97 ± 1.15 vs 2.70 ± 1.12, p = 0.02). A total dose of prednisolone >9.4 g (HR 2.84, p = 0.02) before colectomy and FKBP5 mRNA level higher than the median (HR 4.49, p = 0.01) were identified as factors related to pouchitis. FKBP5 mRNA levels in ileal mucosa at the time of colectomy are significantly associated with pouchitis and may be a predictive factor for developing pouchitis.

Dysplasia in ulcerative colitis as a predictor of unsuspected synchronous colorectal cancer.

Endoscopic surveillance of patients with ulcerative colitis aims to prevent cancer-related morbidity through the detection and treatment of dysplasia. The literature to date varies widely with regard to the importance of dysplasia as a marker for colorectal cancer at the time of colectomy. The aim of this study was to accurately characterize the extent to which the preoperative detection of dysplasia is associated with undetected cancer in patients with ulcerative colitis. A retrospective chart review was conducted of patients undergoing surgery for colitis within the Mayo Clinic Health System between August 1993 and July 2012. Patient demographics and pre- and postoperative dysplasia were tabulated. The relationship between pre- and postoperative dysplasia/cancer in surgical pathology specimens was assessed. A total of 2130 patients underwent abdominal colectomy or proctocolectomy; 329 patients were identified (15%) as having at least 1 focus of dysplasia preoperatively. Of these 329 patients, the majority were male (69%) with a mean age of 49.7 years. Unsuspected cancer was found in 6 surgical specimens. Indeterminate dysplasia was not associated with cancer (0/50). Preoperative low-grade dysplasia was associated with a 2% (3/141) risk of undetected cancer when present in random surveillance biopsies and a 3% (2/79) risk if detected in endoscopically visible lesions. Similarly, 3% (1/33) of patients identified preoperatively with random surveillance biopsy high-grade dysplasia harbored undetected cancer. Unsuspected dysplasia was found in 62/1801 (3%) cases without preoperative dysplasia. This study is limited by its retrospective nature and by its lack of evaluation of the natural history of dysplastic lesions that progress to cancer. The presence of dysplasia was associated with a low risk of unsuspected cancer at the time of colectomy. These findings will help inform the decision-making process for patients with ulcerative colitis who are considering intensive surveillance vs surgical intervention after a diagnosis of dysplasia.