|
1
|
Sun Z, Li Y. After nonsurgical treatment of penetrating Crohn's disease: indications for subsequent surgical intervention. Eur J Gastroenterol Hepatol 2024; 36:1353-1354. [PMID: 39324880 DOI: 10.1097/meg.0000000000002853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Affiliation(s)
- Zhenya Sun
- Department of Colon and Rectum Surgery, Center for Inflammatory Bowel Diseases, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| |
Collapse
|
|
2
|
Wang C, Tu S, Yang F, Qin Y, Qian J, Yao J. Complex intestinal fistula treated with colon‑indwelling drainage stent under prostate resection endoscopy instrumentation guidance: A case report. Exp Ther Med 2024; 28:384. [PMID: 39161612 PMCID: PMC11332139 DOI: 10.3892/etm.2024.12673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/08/2024] [Indexed: 08/21/2024] Open
Abstract
The treatment of complex intestinal fistulas has been a challenge in general surgery. A complex fistula is defined as a fistula with more than one abnormal connection between the gastrointestinal tract and skin, or a fistula with multiple bowel loops. The present case report describes the minimally invasive treatment of a complex intestinal fistula. Briefly, a 51-year-old man presented with an intestinal fistula. Following adequate anti-infective drainage of the abdominal abscess, transurethral prostate resection instrumentation was used to flush and drain the intestinal drainage tubes. On reduction of leakage, a drainage tube was inserted into the intestinal tract to serve as an internal stent. Imaging confirmed the successful cessation of intestinal leakage and a satisfactory recovery. The drainage tube was removed under colonoscopy, restoring normal small intestine function. To summarize, after sufficient drainage, the leakage gradually decreased, promoting healing; the patient achieved full recovery upon removal of the internal stent via colonoscopy and the establishment of a small intestinal stoma. In conclusion, transurethral prostate resection instrumentation enables safe and minimally invasive placement of intestinal stents, ensuring effective drainage for managing intestinal fistulas.
Collapse
Affiliation(s)
- Caihong Wang
- Department of Nursing, Hexi University Affiliated Zhangye People's Hospital, Zhangye, Gansu 734000, P.R. China
| | - Song Tu
- Department of General Surgery II, Hexi University Affiliated Zhangye People's Hospital, Zhangye, Gansu 734000, P.R. China
| | - Faying Yang
- Department of Urology, Hexi University Affiliated Zhangye People's Hospital, Zhangye, Gansu 734000, P.R. China
- Institute of Urology, Hexi University, Zhangye, Gansu 734000, P.R. China
| | - Yujie Qin
- Department of Endoscopy Center, Hexi University Affiliated Zhangye People's Hospital, Zhangye, Gansu 734000, P.R. China
| | - Jun Qian
- Institute of Urology, Hexi University, Zhangye, Gansu 734000, P.R. China
| | - Jiaxi Yao
- Department of Urology, Hexi University Affiliated Zhangye People's Hospital, Zhangye, Gansu 734000, P.R. China
- Institute of Urology, Hexi University, Zhangye, Gansu 734000, P.R. China
| |
Collapse
|
|
3
|
Solar H, Ortega ML, Gondolesi G. Current Status of Chronic Intestinal Failure Management in Adults. Nutrients 2024; 16:2648. [PMID: 39203785 PMCID: PMC11356806 DOI: 10.3390/nu16162648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Chronic intestinal failure (CIF) is a heterogeneous disease that affects pediatric and adult populations worldwide and requires complex multidisciplinary management. In recent years, many advances in intravenous supplementation support, surgical techniques, pharmacological management, and intestinal transplants have been published. Based on these advances, international societies have published multiple recommendations and guidelines for the management of these patients. The purpose of this paper is to show the differences that currently exist between the recommendations (ideal life) and the experiences published by different programs around the world. METHODS A review of the literature in PubMed from 1980 to 2024 was carried out using the following terms: intestinal failure, CIF, home parenteral nutrition, short bowel syndrome, chronic intestinal pseudo-obstruction, intestinal transplant, enterohormones, and glucagon-like peptide-2. CONCLUSIONS There is a difference between what is recommended in the guidelines and consensus and what is applied in real life. Most of the world's countries are not able to offer all of the steps needed to treat this pathology. The development of cooperative networks between countries is necessary to ensure access to comprehensive treatment for most patients on all continents, but especially in low-income countries.
Collapse
Affiliation(s)
- Héctor Solar
- Nutritional Support, Intestinal Rehabilitation and Intestinal Transplant Unit, Hospital Universitario Fundación Favaloro, Buenos Aires C1093AAS, Argentina; (M.L.O.); (G.G.)
| | | | | |
Collapse
|
|
4
|
Shehab M, De Marco D, Lakatos PL, Bessissow T. The potential for medical therapies to address fistulizing Crohn's disease: a state-of-the-art review. Expert Opin Biol Ther 2024; 24:733-746. [PMID: 39045643 DOI: 10.1080/14712598.2024.2383882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/25/2024] [Accepted: 07/20/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic, relapsing immune mediated disease, which is one of the two major types of inflammatory bowel disease (IBD). Fistulizing CD poses a significant clinical challenge for physicians. Effective management of CD requires a multidisciplinary approach, involving a gastroenterologist and a GI surgeon while tailoring treatment to each patient's unique risk factors, clinical representations, and preferences. AREAS COVERED This comprehensive review explores the intricacies of fistulizing CD including its manifestations, types, impact on quality of life, management strategies, and novel therapies under investigation. EXPERT OPINION Antibiotics are often used as first-line therapy to treat symptoms. Biologics that selectively target TNF-α, such infliximab (IFX), have shown high efficacy in randomized controlled trials. However, more than 50% of patients lose response to IFX, prompting them to explore alternative strategies. Current options include adalimumab and certolizumab pegol combination therapies, as well as small-molecule drugs targeting Janus kinases such as Upadacitinib. Furthermore, a promising treatment for complex fistulas is mesenchymal stem cells such as Darvadstrocel (Alofisel), an allogeneic stem cell-based therapy. However, surgical interventions are necessary for complex cases or intra-abdominal complications. Setons and LIFT procedures are the most common surgical options.
Collapse
Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Al-Kabeer University Hospital, Kuwait University, Kuwait City, Kuwait
| | - Davide De Marco
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| |
Collapse
|
|
5
|
Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignass A, Ehehalt R, Germer CT, Grunert PC, Helwig U, Horisberger K, Herrlinger K, Kienle P, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) (Version 4.1) – living guideline. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1229-1318. [PMID: 39111333 DOI: 10.1055/a-2309-6123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2024]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Minden, Deutschland
| | - Axel Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | | | - P C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | - Karoline Horisberger
- Universitätsmedizin Johannes Gutenberg, Universität Klinik f. Allgemein-,Visceral- und Transplantationschirurgie, Mainz, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | - Christian Maaser
- Gastroenterologie, Ambulanzzentrum Lüneburg, Lüneburg, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| |
Collapse
|
|
6
|
Sun Z, Cao L, Chen Y, Zhu W, Li Y. Long-term outcomes of intestinal penetrating Crohn's disease following successful nonoperative management. Eur J Gastroenterol Hepatol 2024; 36:867-874. [PMID: 38625818 DOI: 10.1097/meg.0000000000002775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
There is a paucity of data on the surgical or medical treatment for abscess/fistula complicating Crohn's disease after successful nonsurgical management. We conducted a cohort study to investigate the long-term outcomes and the risk factors for the requirement of subsequent surgical intervention in Crohn's disease patients with complicating fistulas/abscess following successful nonsurgical management. Data were collected on penetrating Crohn's disease experiencing successful nonsurgical treatment between December 2012 and December 2021. Long-term outcomes and risk factors of surgery were assessed by univariate and multivariate analysis, and subgroup analysis was performed based on penetrating phenotype including abscess, fistula, and phlegmon. A total of 523 penetrating Crohn's disease patients; there were 390, 125, and 60 patients complicated with fistulas, abscess, and phlegmon, respectively. Long-term outcomes showed that BMI < 18.5 (kg/m 2 ), the recurrent abscess, and stricture were independent risk factors of surgery. Biologics and resolution of abscess were independent protective factors of surgery. Furthermore, in 399 patients undergoing early surgery, stricture and BMI < 18.5 (kg/m 2 ) were independent risk factors, and biologics and abscess resolution were protective of the early surgery. Subgroup analysis based on fistula, abscess, and phlegmon phenotype also demonstrated that concomitant stricture was an independent risk factor and the use of biologics was protective of surgical resection. Our data indicate that biologics can delay the requirement of surgery and may be given to patients with penetrating complicating Crohn's disease who have been successfully treated nonoperatively, but surgical resection should be considered in the setting of malnutrition and stenosis formation.
Collapse
Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| | - Yusheng Chen
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| | - Weiming Zhu
- Department of Anorectal Surgery, IBD Therapeutic Center, Nanjing University of Chinese Medicine, Nanjing, PR China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University
| |
Collapse
|
|
7
|
Kopczynska M, Crooks B, Deutsch L, Conley T, Stansfield C, Bond A, Soop M, Carlson G, Lal S. Disease Recurrence and Long-term Outcomes Following the Development of Intestinal Failure in Crohn's Disease: Over 20 Years of Experience from a National Reference Centre. J Crohns Colitis 2023; 17:1910-1919. [PMID: 37343184 DOI: 10.1093/ecco-jcc/jjad105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND AND AIMS Intestinal failure [IF] is a recognised complication of Crohn's disease [CD]. The aim of this study was to identify factors predicting the development and recurrence of CD in patients with IF [CD-IF], and their long-term outcomes. METHODS This was a cohort study of adults with CD-IF admitted to a national UK IF reference centre between 2000 and 2021. Patients were followed from discharge with home parenteral nutrition [HPN] until death or February 28, 2021. RESULTS In all, 124 patients were included; 47 [37.9%] changed disease location and 55 [44.4%] changed disease behaviour between CD and CD-IF diagnosis, with increased upper gastrointestinal involvement [4.0% vs 22.6% patients], p <0.001. Following IF diagnosis, 29/124 [23.4%] patients commenced CD prophylactic medical therapy; 18 [62.1%] had a history of stricturing or penetrating small bowel disease; and nine [31.0%] had ileocolonic phenotype brought back into continuity. The cumulative incidence of disease recurrence was 2.4% at 1 year, 16.3% at 5 years and 27.2% at 10 years; colon-in-continuity and prophylactic treatment were associated with an increased likelihood of disease recurrence. Catheter-related bloodstream infection [CRBSI] rate was 0.32 episodes/1000 catheter days, with no association between medical therapy and CRBSI rate. CONCLUSIONS This is the largest series reporting disease behaviour and long-term outcomes in CD-IF and the first describing prophylactic therapy use. The incidence of disease recurrence was low. Immunosuppressive therapy appears to be safe in HPN-dependent patients with no increased risk of CRBSI. The management of CD-IF needs to be tailored to the patient's surgical disease history alongside disease phenotype.
Collapse
Affiliation(s)
- Maja Kopczynska
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Benjamin Crooks
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Liat Deutsch
- Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Conley
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Ashley Bond
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Mattias Soop
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
- Department of Inflammatory Bowel Disease and Intestinal Failure Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gordon Carlson
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
- School of Health Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
|
8
|
Iglay K, Bennett D, Kappelman MD, Reynolds K, Aldridge M, Karki C, Cook SF. A systematic review of epidemiology and outcomes of Crohn's disease-related enterocutaneous fistulas. Medicine (Baltimore) 2022; 101:e30963. [PMID: 36397360 PMCID: PMC10662878 DOI: 10.1097/md.0000000000030963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Enterocutaneous fistulas (ECF) are rare sequelae of Crohn's disease (CD) that occur either postoperatively or spontaneously. ECFs are associated with high morbidity and mortality. This systematic literature review assesses the disease burden of CD-related ECF and identifies knowledge gaps around incidence/prevalence, treatment patterns, clinical outcomes, healthcare resource utilization (HCRU), and patient-reported outcomes (PROs). METHODS English language articles published in PubMed and Embase in the past 10 years that provided data and insight into the disease burden of CD-related ECF (PROSPERO Registration number: CRD42020177732) were identified. Prespecified search and eligibility criteria guided the identification of studies by two reviewers who also assessed risk of bias. RESULTS In total, 582 records were identified; 316 full-text articles were assessed. Of those, eight studies met a priori eligibility criteria and underwent synthesis for this review. Limited epidemiologic data estimated a prevalence of 3265 persons with ECF in the USA in 2017. Clinical response to interventions varied, with closure of ECF achieved in 10% to 62.5% of patients and recurrence reported in 0% to 50% of patients. Very little information on HCRU is available, and no studies of PROs in this specific population were identified. CONCLUSION The frequency, natural history, and outcomes of ECF are poorly described in the literature. The limited number of studies included in this review suggest a high treatment burden and risk of substantial complications. More robust, population-based research is needed to better understand the epidemiology, natural history, and overall disease burden of this rare and debilitating complication of CD.
Collapse
Affiliation(s)
| | - Dimitri Bennett
- Takeda Pharmaceuticals, Cambridge, MA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kamika Reynolds
- CERobs Consulting, LLC, Chapel Hill, NC
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | |
Collapse
|
|
9
|
Barreiro-de Acosta M, Riestra S, Calafat M, Soto MP, Calvo M, Sánchez Rodríguez E, Caballol B, Vela M, Rivero M, Muñoz F, de Castro L, Calvet X, García-Alonso FJ, Utrilla Fornals A, Ferreiro-Iglesias R, González-Muñoza C, Chaparro M, Bujanda L, Sicilia B, Alfambra E, Rodríguez A, Pérez Fernández R, Rodríguez C, Almela P, Argüelles F, Busquets D, Tamarit-Sebastián S, Reygosa Castro C, Jiménez L, Marín-Jiménez I, Alcaide N, Fernández-Salgado E, Iglesias Á, Ponferrada Á, Pajares R, Roncero Ó, Morales-Alvarado VJ, Ispízua-Madariaga N, Sáinz E, Merino O, Márquez-Mosquera L, García-Sepulcre M, Elorza A, Estrecha S, Surís G, Van Domselaar M, Brotons A, de Francisco R, Cañete F, Iglesias E, Vera MI, Mesonero F, Lorente R, Zabana Y, Cabriada JL, Domènech E, Rodríguez-Lago I. Management and Long-term Outcomes of Crohn's Disease Complicated with Enterocutaneous Fistula: ECUFIT Study from GETECCU. J Crohns Colitis 2022; 16:1049-1058. [PMID: 35104314 DOI: 10.1093/ecco-jcc/jjac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Crohn's disease [CD] can develop penetrating complications at any time during the disease course. Enterocutaneous fistulae [ECF] are disease-related complications with an important impact on quality of life. Our aim was to describe the outcomes of this complication, including its medical and/or surgical management and their temporal trends. The primary endpoint was fistula closure, defined as the absence of drainage, with no new abscess or surgery, over the preceding 6 months. METHODS Clinical information from all adult patients with CD and at least one ECF-excluding perianal fistulae-were identified from the prospectively-maintained ENEIDA registry. All additional information regarding treatment for this complication was retrospectively reviewed. RESULTS A total of 301 ECF in 286 patients [January 1970-September 2020] were analysed out of 30 088 records. These lesions were mostly located in the ileum [67%] and they had a median of one external opening [range 1-10]. After a median follow-up of 146 months (interquartile range [IQR], 69-233), 69% of patients underwent surgery. Fistula closure was achieved in 84%, mostly after surgery, and fistula recurrence was uncommon [13%]. Spontaneous and low-output fistulae were associated with higher closure rates (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.17-1.93, p = 0.001, and HR 1.49, 95% CI 1.07-2.06, p = 0.03, respectively); this was obtained more frequently with medical therapy since biologics have been available. CONCLUSIONS ECF complicating CD are rare but entail a high burden of medical and surgical resources. Closure rates are high, usually after surgery, and fistula recurrence is uncommon. A significant proportion of patients receiving medical therapy can achieve fistula closure.
Collapse
Affiliation(s)
- Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Sabino Riestra
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - María Pilar Soto
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Marta Calvo
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Berta Caballol
- Gastroenterology Department, Hospital Clinic, Barcelona, Spain
| | - Milagros Vela
- Gastroenterology Department, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Montserrat Rivero
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla and IDIVAL, Santander, Spain
| | - Fernando Muñoz
- Gastroenterology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Luisa de Castro
- Gastroenterology Department, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Xavier Calvet
- Gastroenterology Department, Corporació Parc Taulí, Sabadell, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | | | | | - Rocío Ferreiro-Iglesias
- Gastroenterology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - María Chaparro
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa IIS-IP, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Luis Bujanda
- Gastroenterology Department, Biodonostia Health Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], and Universidad del País Vasco [UPV/EHU], San Sebastián, Spain
| | - Beatriz Sicilia
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Erika Alfambra
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Andrés Rodríguez
- Gastroenterology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Rubén Pérez Fernández
- Gastroenterology Department, Complejo Asistencial Universitario de León, León, Spain
| | - Cristina Rodríguez
- Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Pedro Almela
- Gastroenterology Department, Hospital General Universitari de Castelló, Castelló, Spain
| | - Federico Argüelles
- Gastroenterology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - David Busquets
- Gastroenterology Department, Hospital Universitari Girona Dr. Josep Trueta, Girona, Spain
| | | | - Cristina Reygosa Castro
- Gastroenterology Department, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Spain
| | - Laura Jiménez
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Ignacio Marín-Jiménez
- Gastroenterology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Noelia Alcaide
- Gastroenterology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Estela Fernández-Salgado
- Gastroenterology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Águeda Iglesias
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Ángel Ponferrada
- Gastroenterology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ramón Pajares
- Gastroenterology Department, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Óscar Roncero
- Gastroenterology Department, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | | | | | - Empar Sáinz
- Gastroenterology Department, Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Olga Merino
- Gastroenterology Department, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - Ainara Elorza
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | - Sandra Estrecha
- Gastroenterology Department, Hospital Universitario Araba, Vitoria, Spain
| | - Gerard Surís
- Gastroenterology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Manuel Van Domselaar
- Gastroenterology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Alicia Brotons
- Gastroenterology Department, Hospital Vega Baja, Orihuela, Spain
| | - Ruth de Francisco
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Eva Iglesias
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María Isabel Vera
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Francisco Mesonero
- Gastroenterology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Rufo Lorente
- Gastroenterology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Yamile Zabana
- Gastroenterology Department, Hospital Universitari Mútua Terrassa, Terrassa, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - José Luis Cabriada
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Iago Rodríguez-Lago
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | |
Collapse
|
|
10
|
Treatment of enterocutaneous fistula: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:863-874. [PMID: 35915291 DOI: 10.1007/s10151-022-02656-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/20/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Enterocutaneous fistula (ECF) is an abnormal communication between the gastrointestinal tract and skin, with a myriad of etiologies and therapeutic options. Management is influenced by etiology and specifics of the ECF, and patient-related factors. The aim of this study was to assess overall success, recurrence, and mortality rates of treatment for ECF. MATERIALS A systematic search of PubMed and Google Scholar was performed through October 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports, reviews, animal studies, studies not reporting outcomes, had no available English text, included patients < 16 years old or those assessing other abdominocutaneous/internal fistulas were excluded. RESULTS Fifty-three studies, between 1975 and 2020, incorporating 3078 patients were included. Patient age ranged between 16 and 87 years with a male:female ratio of 1.14:1. ECF developed postoperatively in 89.4%. Other common etiologies were inflammatory bowel disease, trauma, malignancy, and radiation. At least 28% of patients had complex fistulae (reported in 18 studies). Most common fistula site was small bowel. In 34 publications, 62.4% (n = 1371) patients received parenteral nutrition. In 45 publications, 72.5% underwent surgery to treat the fistula. Meta-analysis revealed an 89% healing rate; recurrence rate after initial successful treatment was 11.1%, and mortality rate was 8.5%. In a subgroup of patients who underwent combined ECF takedown and abdominal wall reconstructions (n = 315), 78% achieved fascial closure, mesh was used in 72%, hernia, and fistula recurrence rates were 19.7% and 7.6%, respectively. CONCLUSIONS Treatment of ECF must be individualized according to specific etiology and location of the fistula and the patient's associated conditions.
Collapse
|
|
11
|
Vilchez V, Lightner AL. Surgical Management of Crohn's Disease. Gastroenterol Clin North Am 2022; 51:353-367. [PMID: 35595419 DOI: 10.1016/j.gtc.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Treatment of Crohn's disease (CD) focuses on providing acceptable quality of life for the affected individual by optimizing medical therapy, endoscopic procedures, and surgical intervention. Biologics have changed the medical management of moderate to severe CD. However, despite their introduction, the need for surgical resection in CD has not drastically changed, with two-thirds of the patients still requiring an intestinal resection. Patient outcomes are optimized by focusing on preoperative management and intraoperative technical aspects to maximize bowel preservation. This article reviews some of the important principles of Crohn's surgery to help guide surgeons when approaching this challenging patient population.
Collapse
Affiliation(s)
- Valery Vilchez
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA; Center for Regenerative Medicine and Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Center for Immunotherapy, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
| |
Collapse
|
|
12
|
Wetwittayakhlang P, Al Khoury A, Hahn GD, Lakatos PL. The Optimal Management of Fistulizing Crohn's Disease: Evidence beyond Randomized Clinical Trials. J Clin Med 2022; 11:3045. [PMID: 35683433 PMCID: PMC9181669 DOI: 10.3390/jcm11113045] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Fistulizing Crohn's disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30-50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.
Collapse
Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Alex Al Khoury
- Division of Gastroenterology, University of Florida, Jacksonville, FL 32209, USA;
| | - Gustavo Drügg Hahn
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- Graduate Course Sciences in Gastroenterology and Hepatology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-002, Brazil
| | - Peter Laszlo Lakatos
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- First Department of Medicine, Semmelweis University, 1085 Budapest, Hungary
| |
Collapse
|
|
13
|
Abstract
BACKGROUND Management of enterocutaneous fistulas in Crohn's disease is challenging. Most patients still need intestinal resection in the biologic era. OBJECTIVE The aim of this study was to evaluate the efficacy of endoscopic treatment for enterocutaneous fistulas. DESIGN This is a retrospective study of medical records. SETTINGS This study was conducted in a single institution. PATIENTS All consecutive patients with Crohn's disease with an enterocutaneous fistula who underwent endoscopic fistula closure with the use of an over-the-scope clip or a hemostatic clip were included. MAIN OUTCOME MEASURES The main outcome measured was the clinical success 3 months after the procedure, which was defined as the complete closure of all fistulas at physical examination and complete cessation of the drainage from the external opening, without surgery. RESULTS Eight patients (men, 25%; median age 45 years [interquartile range, 33-51]) were followed. Fistulas were localized at the ileocolonic or colocolonic anastomosis in 7 patients and at the stomach in 1 patient. Seven patients were treated with an over-the-scope clip, and one was treated with a hemostatic clip. Technical success was achieved in all cases. Clinical success at 3 months was achieved in 75% of cases (6/8 patients). After a median 16-month (interquartile range, 13-23) follow-up, 3 of 8 (37.5%) patients had enterocutaneous fistula closure and 2 of 8 (25%) needed intestinal resection. No complications were observed. LIMITATIONS The retrospective nature, the small sample size of the study, and the heterogeneity of the population limit the interpretation of the results. CONCLUSIONS Endoscopic treatment of enterocutaneous fistulas is feasible with a short-term effectiveness. Additional studies are needed to confirm these results. See Video Abstract at http://links.lww.com/DCR/B614. TRATAMIENTO ENDOSCPICO DE FSTULAS ENTEROCUTNEAS EN ENFERMEDAD DE CROHN ANTECEDENTES:Es desafiante el manejo de las fístulas enterocutáneas en enfermedad de Crohn. En la era biológica, la mayoría de los pacientes todavía requieren de resección intestinal.OBJETIVO:Evaluar la eficacia por tratamiento endoscópico de fístulas enterocutáneas.ENTORNO CLINICO:Estudio retrospectivo de registros médicos.AJUSTE:Realizado en una sola institución.PACIENTES:Se incluyeron todos los pacientes consecutivos con fístula enterocutánea en enfermedad de Crohn, sometidos a cierre endoscópico de la fístula con clip sobre el endoscopio o clip hemostático.PRINCIPALES MEDIDAS DE VALORACION:El éxito clínico a los 3 meses después del procedimiento. Definido al examen físico, como el cierre completo de todas las fístulas y cese completo del drenaje por la abertura externa, sin cirugía.RESULTADOS:Se estudiaron a ocho pacientes (hombres, 25%, mediana de edad de 45 años (rango intercuartílico, 33-51)). En 7 pacientes, las fístulas se localizaron en la anastomosis ileocolónica o colocolónica y un paciente, en el estómago. Siete pacientes fueron tratados con clip sobre el endoscopio y uno con clip hemostático. Se logró éxito técnico en todos los casos. Se logró éxito clínico a los 3 meses en 75% de los casos (6/8 pacientes). Después de una mediana de 16 meses (rango intercuartílico, 13-23), de seguimiento 3/8 (37,5%) pacientes presentaron cierre de fístulas enterocutáneas y 2/8 (25%) requirieron resección intestinal. No se observaron complicaciones.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de la muestra y heterogeneidad de la población, limitaron la interpretación de los resultados.CONCLUSIONES:Es posible el tratamiento endoscópico de fístulas enterocutáneas con efectividad a corto plazo. Se requieren nuevos estudios para confirmar estos resultados. Consulte Video Resumen en http://links.lww.com/DCR/B614. (Traducción-Dr. Fidel Ruiz Healy).
Collapse
|
|
14
|
Chandrasinghe P. Surgical Management of Small Bowel Crohn's Disease. Front Surg 2022; 9:759668. [PMID: 35495760 PMCID: PMC9051431 DOI: 10.3389/fsurg.2022.759668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.
Collapse
|
|
15
|
Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | | |
Collapse
|
|
16
|
Vuyyuru SK, Desai D, Kedia S, Dhoble P, Sahu P, Kante B, Agarwal S, Bopanna S, Dhingra R, Venigalla PM, Sharma R, Gupta SD, Makharia G, Sahni P, Ahuja V. Long-term outcomes of anti-tumor necrosis factor therapy and surgery in nonperianal fistulizing Crohn's disease. JGH OPEN 2021; 5:420-427. [PMID: 33860091 PMCID: PMC8035465 DOI: 10.1002/jgh3.12370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 11/23/2022]
Abstract
Background Unlike perianal fistula, long‐term outcomes of nonperianal fistulae (NPF) in Crohn's disease (CD) are not clear. We aimed to compare the outcomes of medical and surgical therapies in patients with NPF. Methods We retrospectively analyzed the records of patients of CD with NPF who were prospectively followed from January 2005 to December 2018. Results Of the 53 patients with NPF [mean age at presentation:29 ± 14 years; 54.7% male; median duration of follow‐up: 47 months (interquartile range [IQR]:26–76 months)], enteroenteric fistula (37.8%) was the most common presentation. Of 22 patients treated with anti‐tumor necrosis factor (TNF) therapy, complete response was achieved in 40.9% (n = 9). Overall probability of maintaining response was similar between the anti‐TNF and surgical groups (95.2% vs 82.4%; 71% vs 76%; and 63% vs 69%% [P = 0.8] at 1, 2, and 3 years, respectively), with only 13.6% of patients treated with biologicals requiring surgery over 56 months. Twenty‐one patients required upfront surgery (small bowel or ileocolonic resection with/without diversion; 28.5% emergent), with 47.6% postoperative recurrence over 36 months, of which nine patients required biologicals (77.7% response to anti‐TNF therapy). Long‐term outcome was comparable between medically and surgically treated patients; 6.4% developed tuberculosis on anti‐TNF therapy. Two patients (3.7%) developed malignancy (one ‐ enteroenteric, one ‐ colovesical). Conclusion Anti‐TNF therapy appears to be as effective as surgery in this retrospective analysis of patients with NPFCD, and it may be indicated in the absence of abscess and other complications. These patients are at higher risk of fistula‐associated malignancy, which requires a lower threshold for suspicion, especially over the long term in the presence of nonresponse to medical therapy.
Collapse
Affiliation(s)
- Sudheer K Vuyyuru
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Devendra Desai
- Department of Gastroenterology P. D. Hinduja National Hospital & Medical Research Centre Mumbai India
| | - Saurabh Kedia
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Pavan Dhoble
- Department of Gastroenterology P. D. Hinduja National Hospital & Medical Research Centre Mumbai India
| | - Pabitra Sahu
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Bhaskar Kante
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Samagra Agarwal
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Sawan Bopanna
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Rajan Dhingra
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | | | - Raju Sharma
- Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi India
| | | | - Govind Makharia
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| | - Peush Sahni
- Department of Gastrointestinal Surgery and Liver Transplant All India Institute of Medical Sciences New Delhi India
| | - Vineet Ahuja
- Department of Gastroenterology All India Institute of Medical Sciences New Delhi India
| |
Collapse
|
|
17
|
Moreno Sánchez N, Paredes JM, Ripollés T, Sanz de la Vega J, Latorre P, Martínez MJ, Richart J, Vizuete J, Moreno-Osset E. Treatment of abdominal fistulas in Crohn's disease and monitoring with abdominal ultrasonography. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:240-245. [PMID: 33226252 DOI: 10.17235/reed.2020.6884/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE to assess the usefulness of medical treatment to achieve closure of internal fistulas detected on abdominal ultrasound in a series of patients with fistulizing Crohn's disease. MATERIAL AND METHODS a retrospective analysis was performed of the medical records of patients with Crohn's disease with a fistula detected on abdominal ultrasound from 2010 to 2018. The study included patients who received medical treatment after the diagnosis of this complication and underwent ultrasonographic monitoring of the therapeutic response. The factors associated with the response to medical treatment or the need for surgery were investigated. RESULTS forty-six patients were included in the study. Enteromesenteric (69.6 %) was the most common type of fistula and associated abscesses were found in 14 (30.4 %) patients. Fistulas were classified as complex in 20 patients. Treatment with immunosuppressants was started in 14 (30.4 %) cases and a biologic drug was added in 18 (39.1 %) patients. Complete closure of the abdominal fistula was observed with ultrasonography in 24 (52.2 %) of the 46 patients. The only factor related to fistula closure was the type of fistula and was more likely to occur in patients with an enteromesenteric fistula. Thirteen (28 %) of the 46 patients needed a surgical resection. The only factor with a significant correlation with a lower need for surgery was fistula closure after treatment (8.3 % vs 50 %, p = 0.002). CONCLUSION medical treatment achieves internal fistula closure in more than half of cases and almost a third require surgical treatment. Abdominal ultrasound can detect abdominal fistulas at an earlier stage and allow prompt treatment changes.
Collapse
Affiliation(s)
| | | | | | | | | | | | - José Richart
- Cirugía General, Hospital Universitario Dr. Peset
| | | | | |
Collapse
|
|
18
|
Alkhatry M, Al-Rifai A, Annese V, Georgopoulos F, Jazzar AN, Khassouan AM, Koutoubi Z, Nathwani R, Taha MS, Limdi JK. First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus. World J Gastroenterol 2020; 26:6710-6769. [PMID: 33268959 PMCID: PMC7684461 DOI: 10.3748/wjg.v26.i43.6710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.
Collapse
Affiliation(s)
- Maryam Alkhatry
- Gastroenterology and Endoscopy Department, Ibrahim Bin Hamad Obaid Allah Hospital, Ministry of Health and Prevention, Ras Al Khaiman, United Arab Emirates
| | - Ahmad Al-Rifai
- Department of Gastroenterology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic, Dubai, United Arab Emirates
- Department of Gastroenterology and Endoscopy, American Hospital, Dubai, United Arab Emirates
| | | | - Ahmad N Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ahmed M Khassouan
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Zaher Koutoubi
- Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Rahul Nathwani
- Department of Gastroenterology, Mediclinic City Hospital, Dubai, United Arab Emirates
- Department of Gastroenterology, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Mazen S Taha
- Gastroenterology and Hepatology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Jimmy K Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester M8 5RB, United Kingdom
| |
Collapse
|
|
19
|
Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
|
|
20
|
Papa A, Lopetuso LR, Minordi LM, Di Veronica A, Neri M, Rapaccini G, Gasbarrini A, Papa V. A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn's disease patients. Expert Rev Gastroenterol Hepatol 2020; 14:857-865. [PMID: 32673498 DOI: 10.1080/17474124.2020.1797484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn's disease (CD) that is challenging to treat and has considerable morbidity and mortality rates. AREAS COVERED This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients. EXPERT OPINION Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.
Collapse
Affiliation(s)
- Alfredo Papa
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Loris Riccardo Lopetuso
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy.,Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy
| | - Laura Maria Minordi
- Dipartimento di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| | - Alessandra Di Veronica
- Dipartimento di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| | - Matteo Neri
- Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy.,Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy
| | - Gianludovico Rapaccini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Antonio Gasbarrini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Valerio Papa
- Università Cattolica del Sacro Cuore , Roma, Italia.,Dipartimento di Chirurgia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| |
Collapse
|
|
21
|
Madarame A, Kimura H, Kunisaki R. Successful Treatment With Ustekinumab for Enterocutaneous Fistulas in Crohn's Disease. J Crohns Colitis 2020; 14:569-570. [PMID: 31616911 DOI: 10.1093/ecco-jcc/jjz161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Akira Madarame
- Inflammatory Bowel Disease Centre, Yokohama City University Medical Centre, Yokohama, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Centre, Yokohama City University Medical Centre, Yokohama, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Centre, Yokohama City University Medical Centre, Yokohama, Japan
| |
Collapse
|
|
22
|
Na SY, Moon W. Perspectives on Current and Novel Treatments for Inflammatory Bowel Disease. Gut Liver 2020; 13:604-616. [PMID: 31195433 PMCID: PMC6860034 DOI: 10.5009/gnl19019] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/22/2019] [Accepted: 03/02/2019] [Indexed: 12/13/2022] Open
Abstract
New therapeutic strategies in inflammatory bowel disease (IBD) have shifted from symptom control towards treat-to-target algorithms in order to optimize treatment results. The treatment of IBD has evolved with the development of tumor necrosis factor-α inhibitors beyond the conventional therapies. In spite of their long-term effectiveness, many patients do not respond to or cannot sustain treatment with these drugs, which have various side effects. Therefore, the development of new drugs targeting specific pathways in the pathogenesis of IBD has become necessary. Some novel biologics and small molecule drugs have shown potential in IBD clinical trials, providing safe and effective results. In addition, clinicians are now trying to target the dysbiotic microbiome of patients with IBD using fecal microbiota transplantation. New tools such as stem cells have also been developed. The available therapeutic options for IBD are expanding rapidly. In the next few years, physicians will face an unprecedented number of options when choosing the best treatments for patients with IBD. This review provides an overview of recent advances in IBD treatment options.
Collapse
Affiliation(s)
- Soo-Young Na
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| |
Collapse
|
|
23
|
Bouguen G, Huguet A, Amiot A, Viennot S, Cholet F, Nachury M, Flamant M, Reimund JM, Desfourneaux V, Boureille A, Siproudhis L. Efficacy and Safety of Tumor Necrosis Factor Antagonists in Treatment of Internal Fistulizing Crohn's Disease. Clin Gastroenterol Hepatol 2020; 18:628-636. [PMID: 31128337 DOI: 10.1016/j.cgh.2019.05.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/01/2019] [Accepted: 05/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few data are available on the effects of tumor necrosis factor (TNF) antagonist therapy for patients with internal fistulizing Crohn's disease (CD) and there is debate regarding the risk of abscess. We aimed to assess the long-term efficacy and safety of anti-TNF therapy for patients with internal fistulas. METHODS We performed a retrospective study of data collected from the Groupe d'Etude Thérapeutique des Affections Inflammatoires Digestives trial, from January 1, 2000, through December 31, 2017. Our final analysis included 156 patients who began treatment with an anti-TNF agent for CD with internal fistula (83 men; median disease duration, 4.9 y). The primary end point was the onset of a major abdominal surgery. Secondary analysis included disappearance of the fistula tract during follow-up evaluation and safety. The Kaplan-Meier method was used for statistical analysis. RESULTS After a median follow-up period of 3.5 years, 68 patients (43.6%) underwent a major abdominal surgery. The cumulative probabilities for being surgery-free were 83%, 64%, and 51% at 1, 3, and 5 years, respectively. A concentration of C-reactive protein >18 mg/L, an albumin concentration <36 g/L, the presence of an abscess at the fistula diagnosis, and the presence of a stricture were associated independently with the need for surgery. The cumulative probabilities of fistula healing, based on imaging analyses, were 15.4%, 32.3%, and 43.9% at 1, 3, and 5 years, respectively. Thirty-two patients (20.5%) developed an intestinal abscess and 4 patients died from malignancies (3 intestinal adenocarcinomas). One patient died from septic shock 3 months after initiation of anti-TNF therapy. CONCLUSIONS In a retrospective analysis of data from a large clinical trial, we found that anti-TNF therapy delays or prevents surgery for almost half of patients with CD and luminal fistulas. However, anti-TNF therapy might increase the risk for sepsis-related death or gastrointestinal malignancies.
Collapse
Affiliation(s)
- Guillaume Bouguen
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France; INSERM, CIC1414, Institut Nutrition Metabolisms and Cancer, Rennes, France.
| | - Audrey Huguet
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France
| | - Aurélien Amiot
- Department of Gastroenterology, Henri Mondor Hospital, APHP, EC2M3-EA 7375, Université Paris-Est Créteil (UPEC) Val de Marne University, Creteil, France
| | - Stéphanie Viennot
- Hépato-Gastro-Entérologie et Nutrition, Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris de Caen, Caen, France
| | - Franck Cholet
- Centre Hospitalier Universitaire Brest, Service d'Hépato-gastro-entérologie, Brest, France
| | - Maria Nachury
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Lille, University of Lille 2, Inserm Unit 995, Lille, France
| | - Mathurin Flamant
- Clinique Jules Verne, Institut des Maladies de l'Appareil Digestif, Hotel Dieu, Nantes, France
| | - Jean-Marie Reimund
- Hôpitaux Universitaires de Strasbourg (Hôpital de Hautepierre), INSERM U1113 Interface de Recherche Fondamentale et Appliquée en Cancérologie, Université de Strasbourg, Strasbourg, France
| | - Véronique Desfourneaux
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France
| | - Arnaud Boureille
- Inserm, U1235, University Nantes, Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris de Nantes, Institut des Maladies de l'Appareil Digestif, Hotel Dieu, Nantes, France
| | - Laurent Siproudhis
- Centre Hospitalier Universitaire, Instead of APHP: Assistance Publique - Hôpitaux de Paris Rennes, University Rennes, Rennes, France; INSERM, CIC1414, Institut Nutrition Metabolisms and Cancer, Rennes, France
| | | |
Collapse
|
|
24
|
Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1452] [Impact Index Per Article: 242.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
Collapse
Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | | |
Collapse
|
|
25
|
Kuo T, Kuo C, Lin W, Chiu C, Su M, Lin W, Lin C, Hsu J, Tsai W, Wu R. Clinical characteristics and outcome of fistulizing Crohn's disease: One single‐center experience in Taiwan. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Tony Kuo
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Chia‐Jung Kuo
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Wey‐Ran Lin
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Cheng‐Tang Chiu
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Ming‐Yao Su
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Wei‐Pin Lin
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Chun‐Jung Lin
- Department of Gastroenterology and HepatologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
- College of MedicineChang Gung University Taoyuan Taiwan
| | - Jun‐Te Hsu
- College of MedicineChang Gung University Taoyuan Taiwan
- Division of General Surgery, Department of SurgeryLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
| | - Wen‐Sy Tsai
- College of MedicineChang Gung University Taoyuan Taiwan
- Division of Colon and Rectal Surgery, Department of SurgeryLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
| | - Ren‐Chin Wu
- College of MedicineChang Gung University Taoyuan Taiwan
- Department of PathologyLinkou Chang Gung Memorial Hospital Taoyuan Taiwan
| |
Collapse
|
|
26
|
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
Collapse
|
|
27
|
Ma C, Almutairdi A, Tanyingoh D, Seow CH, Novak KL, Lu C, Panaccione R, Kaplan GG, Kotze PG. Reduction in surgical stoma rates in Crohn's disease: a population-based time trend analysis. Colorectal Dis 2019; 21:1279-1287. [PMID: 31206974 DOI: 10.1111/codi.14731] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/10/2019] [Indexed: 12/12/2022]
Abstract
AIM Trends in surgical rates for Crohn's disease (CD) in the biological era are controversial. We aim to assess modern trends in the formation rates of surgical stomas. METHOD Population-based surveillance in the Calgary Health Zone (CHZ), Canada, was conducted between 1 April 2002 and 31 March 2011, using the Discharge Abstract Database to identify adult patients with CD admitted to hospital and treated with surgical stoma formation (n = 545). Annual stoma incidence was calculated by dividing the number of incident stomas by the prevalence of CD in the CHZ. Time trend analysis of the stoma-formation rate was performed, expressed as annual percentage change (APC) with 95% CI. Stoma-formation rates were stratified according to procedure (emergency vs elective) and duration of stoma [temporary (reversed within 2 years of formation) vs permanent]. RESULTS The overall rate of stoma formation between 2002 and 2011 showed a downwards trend, of a mean of 5.2% (95% CI: -8.5 to -1.8) per year, from a rate of 2.30 stomas/100 person-years (PY) in 2002 to 1.51 stomas/100 PY in 2011. The rate of emergency stoma formation decreased significantly from 2002 to 2011 (mean APC = -9.4%; 95% CI: -15.6 to -2.8), while the rate of elective ostomies essentially showed no change (mean APC = -0.9%; 95% CI: -5.3 to 3.8). The rate of temporary stoma formation decreased significantly, by 4.6% (95% CI: -7.3 to -1.8) per year, while permanent stoma formation was stable (APC = 1.0%; 95% CI: -4.0 to +6.3). CONCLUSION A reduction in the overall rate of stoma formation in CD has been driven by fewer emergency stomas, although rates of permanent stoma have remained stable.
Collapse
Affiliation(s)
- C Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Robarts Clinical Trials, Inc., London, Ontario, Canada
| | - A Almutairdi
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - D Tanyingoh
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - C H Seow
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - K L Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - C Lu
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - R Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - G G Kaplan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - P G Kotze
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Inflammatory Bowel Disease Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, Brazil
| |
Collapse
|
|
28
|
Huda T, Pandya B. Treatment of Colocutaneous Fistula in the Left Thigh. Surg J (N Y) 2019; 5:e113-e119. [PMID: 31548992 PMCID: PMC6754747 DOI: 10.1055/s-0039-1696728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/17/2019] [Indexed: 11/07/2022] Open
Abstract
Aim
There are few publications on the surgical management of a colocutaneous fistula in the thigh. Here, we describe a patient who presented with a 2-year history of fecal fistula in the left thigh, following a history of drainage of a psoas abscess. This is followed by a discussion of appropriate treatment modalities for this type of fistula.
Methods
To determine the appropriate treatment for our patient with chronic fistula, we thoroughly reviewed the relevant literature in an Internet-based search and selected a staged operative approach for our patient.
Results
Using a staged surgical procedure, we were able to resolve the colocutaneous fistula without the occurrence of comorbidities.
Conclusion
Substantial morbidity is associated with the presence of colocutaneous fistulas. The best possible approach is prevention of its occurrence, but this is not always feasible. Measures for management of an acute fistula differ from those in patients with chronic fistula. Medical management can be more effective in acute cases, while chronic cases require surgical management. We used a staged surgical method with a few risks for our patient and he is in good health 1 year after treatment.
Collapse
Affiliation(s)
- Tanweerul Huda
- Department of General Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bharati Pandya
- Department of General Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| |
Collapse
|
|
29
|
Yzet C, Brazier F, Fumery M. Post-operative Entero-cutaneous Fistula Closure by Over-the-Scope Clip in Crohn's Disease. J Crohns Colitis 2019; 13:954-955. [PMID: 30596973 DOI: 10.1093/ecco-jcc/jjy227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/27/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Clara Yzet
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Franck Brazier
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Mathurin Fumery
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| |
Collapse
|
|
30
|
Bruckner RS, Nissim-Eliraz E, Marsiano N, Nir E, Shemesh H, Leutenegger M, Gottier C, Lang S, Spalinger MR, Leibl S, Rogler G, Yagel S, Scharl M, Shpigel NY. Transplantation of Human Intestine Into the Mouse: A Novel Platform for Study of Inflammatory Enterocutaneous Fistulas. J Crohns Colitis 2019; 13:798-806. [PMID: 30590414 DOI: 10.1093/ecco-jcc/jjy226] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Enteric fistulas represent a severe and medically challenging comorbidity commonly affecting Crohn's disease [CD] patients. Gut fistulas do not develop in animal models of the disease. We have used transplantation of the human fetal gut into mice as a novel platform for studying inflammatory enterocutaneous fistulas. METHODS Human fetal gut segments were transplanted subcutaneously into mature SCID mice, where they grew and fully developed over the course of several months. We first analysed the resident immune cells and inflammatory response elicited by systemic lipopolysaccharide [LPS] in normal, fully developed human gut xenografts. Thereafter, we used immunostaining to analyse fully developed xenografts that spontaneously developed enterocutaneous fistulas. RESULTS Resident human innate and adaptive immune cells were demonstrated in gut xenografts during steady state and inflammation. The expression of human IL-8, IL-1β, IL-6, TNF-α, A20, and IkBα was significantly elevated in response to LPS, with no change in IL-10 gene expression. Approximately 17% [19/110] of fully developed subcutaneous human gut xenografts spontaneously developed enterocutaneous fistulas, revealing striking histopathological similarities with CD fistula specimens. Immunohistochemical analyses of fistulating xenografts revealed transmural lymphocytic enteritis associated with massive expansion of resident human CD4+ lymphocytes and their migration into the intraepithelial compartment. Regionally, mucosal epithelial cells assumed spindle-shaped mesenchymal morphology and formed fistulous tracts towards chronic non-healing wounds in the host mouse skin overlying the transplants. CONCLUSIONS Inflammation and fistulas developed in human gut xenografts lacking IL-10 gene response. This novel model system will enable systematic studies of the inflamed and fistulating human gut in live animals.
Collapse
Affiliation(s)
- Ramona S Bruckner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Einat Nissim-Eliraz
- Department of Basic Sciences, Koret School of Veterinary Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Noga Marsiano
- Department of Basic Sciences, Koret School of Veterinary Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Eilam Nir
- Department of Basic Sciences, Koret School of Veterinary Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Hadar Shemesh
- Department of Basic Sciences, Koret School of Veterinary Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Martin Leutenegger
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Claudia Gottier
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Lang
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Marianne R Spalinger
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Sebastian Leibl
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology, University of Zurich,Zurich, Switzerland
| | - Simcha Yagel
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
| | - Michael Scharl
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology, University of Zurich,Zurich, Switzerland
| | - Nahum Y Shpigel
- Department of Basic Sciences, Koret School of Veterinary Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| |
Collapse
|
|
31
|
Mao R, Chen YJ, Chen BL, Xie XH, He Y, Chen SL, Xu M, Li XH, Zhang J, Song XM, Zeng ZR, Rimola J, Rieder F, Ben-Horin S, Chen MH, Xie XY. Intra-Cavitary Contrast-Enhanced Ultrasound: A Novel Radiation-Free Method for Detecting Abscess-Associated Penetrating Disease in Crohn's Disease. J Crohns Colitis 2019; 13:593-599. [PMID: 30544185 DOI: 10.1093/ecco-jcc/jjy209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Penetrating disease is a common condition complicating Crohn's disease [CD]. Establishing the presence of a fistula and the anatomical definition of the fistulous tracts are essential for deciding on appropriate treatment strategies. We aimed to assess the diagnostic accuracy of intra-cavitary contrast-enhanced ultrasound [IC-CEUS] for the detection of a fistulous tract associated with abscesses in CD patients. METHODS In this prospective cohort study, consecutive CD patients suspected of having an intra-abdominal abscess, who were referred for US-guided aspiration were recruited. IC-CEUS was performed by injecting diluted contrast agent [SonoVue] into the abscess cavity immediately following the ultrasound-guided needle abscess aspiration and drainage. The diagnostic accuracy of IC-CEUS in demonstrating the presence of fistulous tracts was compared with that of computed tomography enterography/magnetic resonance enterography [CTE/MRE], using surgical and gross pathological findings as the reference standard. RESULTS Thirty-one patients who underwent IC-CEUS and subsequent surgery were included in the final analysis. IC-CEUS demonstrated fistulous/sinus tracts in 26 of 31 participants with a sensitivity and specificity of 86.7 % (95% confidence interval [CI], 68.4-95.6%) and 100% [95% CI, 5.5-100.0%], respectively. Moreover, IC-CEUS correctly demonstrated fistulous/sinus tracts in 13 participants without delineation of fistulous/sinus tracts on CTE/MRE. Combining IC-CEUS and CTE/MRE, the fistula/sinus tract was clearly demonstrated in 29 patients [93.5%, 29/31]. The mean duration of the IC-CEUS procedure was 8.6 min [range 5.0-12.0]. No severe adverse events occurred during the IC-CEUS procedure. CONCLUSION In this pilot study, IC-CEUS accurately delineated the anatomical definition of fistulous/sinus tracts associated with intra-abdominal abscesses in CD patients. As a radiation-free and safe technique, IC-CEUS may be used as an alternative/adjunctive method to CTE/MRE for detecting penetrating disease in patients with CD.
Collapse
Affiliation(s)
- Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Yu-Jun Chen
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bai-Li Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-Hua Xie
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shu-Ling Chen
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ming Xu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xue-Hua Li
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jian Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Xin-Ming Song
- Department of General Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhi-Rong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Shomron Ben-Horin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Min-Hu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yan Xie
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
|
32
|
Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
Collapse
Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | |
Collapse
|
|
33
|
Núñez-Gómez L, Mesonero-Gismero F, Albillos-Martínez A, López-Sanromán A. Anti-tumor necrosis factor agents in Crohn's disease and ulcerative colitis: Beyond luminal disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:576-582. [PMID: 30054143 DOI: 10.1016/j.gastrohep.2018.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 12/31/2022]
Abstract
Anti-tumor necrosis factor agents (anti-TNF) drugs are commonly used in patients with inflammatory bowel disease (IBD) and have proven effective in both induction and maintenance therapy in luminal Crohn's disease and ulcerative colitis. Their efficacy has also been proven in fistulising perianal Crohn's disease. However, the evidence in other scenarios, such as stricturing, penetrating and non-fistulising perianal Crohn's disease, extraintestinal IBD manifestations and ileoanal reservoir complications, is not as robust. The aim of this review was to perform an analysis of the available literature and to determine the role of anti-TNF drugs in common clinical practice in patients affected by these complications.
Collapse
Affiliation(s)
- Laura Núñez-Gómez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Madrid, España.
| | | | | | - Antonio López-Sanromán
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Madrid, España
| |
Collapse
|
|
34
|
Icht O, Yanai H, Ron Y, Rosner G, Yaron A, Waizbard A, Ziv-Baran T, Fishman S, Dotan I. Comparative Study of Two Cohorts of Newly Diagnosed Crohn's Disease Demonstrates Change in Therapeutic Strategies. Digestion 2018; 96:135-141. [PMID: 28848118 DOI: 10.1159/000477438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/09/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND There has been a paradigm shift in the treatment of Crohn's disease (CD) involving the rapid introduction of biologics and/or immunomodulators after diagnosis. We wished to assess whether this was applied to patients with newly diagnosed CD in a tertiary inflammatory bowel disease referral centre in Israel. METHODS Newly diagnosed CD patients were stratified into 2 groups: the early group was diagnosed between 2005 and 2007 and the late group was diagnosed between 2010 and 2012. Baseline demographics, medical and surgical treatments, disease course and complications during those 2 periods were analyzed. RESULTS Each group included 60 patients. Significantly higher rates of immunomodulators and biologics were administered to patients in the late group compared to the early group (81.7 and 36.7% compared to 56.7 and 18.3%, p = 0.004 and p = 0.021, respectively). On the other hand, steroid therapy was less prevalent in the late (36.7%) group compared to that of the early group (56.7%), p = 0.059. Medical and surgical CD outcomes, including exacerbations/hospitalizations and surgeries, were comparable for both groups. CONCLUSIONS There was a change in treatment strategy between 2005-2007 and 2010-2012, as reflected in higher proportions of biologics/immunomodulators for patients with newly diagnosed CD. This was associated with a steroid-sparing effect.
Collapse
Affiliation(s)
- Oded Icht
- IBD Centre, Department of Gastroenterology and Liver Diseases, Dana's Children Hospital, Tel Aviv Sourasky Medical Centre, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | | | | | | |
Collapse
|
|
35
|
Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
Collapse
Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| |
Collapse
|
|
36
|
Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, Kato J, Kobayashi K, Kobayashi K, Koganei K, Kunisaki R, Motoya S, Nagahori M, Nakase H, Omata F, Saruta M, Watanabe T, Tanaka T, Kanai T, Noguchi Y, Takahashi KI, Watanabe K, Hibi T, Suzuki Y, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol 2018; 53:305-353. [PMID: 29429045 PMCID: PMC5847182 DOI: 10.1007/s00535-018-1439-1] [Citation(s) in RCA: 363] [Impact Index Per Article: 51.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.
Collapse
Affiliation(s)
- Katsuyoshi Matsuoka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Taku Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumiaki Ueno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
- Ofuna Central Hospital, 6-2-24 Ofuna, Kamakura-shi, Kanagawa, 247-0056, Japan.
| | - Toshiyuki Matsui
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumihito Hirai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Nagamu Inoue
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Jun Kato
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kiyonori Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazutaka Koganei
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Reiko Kunisaki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Satoshi Motoya
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masakazu Nagahori
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroshi Nakase
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumio Omata
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masayuki Saruta
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Tanaka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takanori Kanai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshinori Noguchi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Ken-Ichi Takahashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshifumi Hibi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yasuo Suzuki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kentaro Sugano
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| |
Collapse
|
|
37
|
Hiraoka S, Takashima S, Kondo Y, Inokuchi T, Sugihara Y, Takahara M, Kawano S, Harada K, Kato J, Okada H. Efficacy of restarting anti-tumor necrosis factor α agents after surgery in patients with Crohn's disease. Intest Res 2018; 16:75-82. [PMID: 29422801 PMCID: PMC5797275 DOI: 10.5217/ir.2018.16.1.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 12/23/2022] Open
Abstract
Background/Aims The efficacy of anti-tumor necrosis factor α (anti-TNFα) antibodies for postoperative Crohn's disease (CD) in patients who were treated with these agents prior to surgery is largely unknown. Methods CD patients who underwent intestinal resection and received anti-TNFα agents after surgery were divided into 2 groups according to the presence or absence of preoperative anti-TNFα treatment: anti-TNFα restart group or anti-TNFα naïve group. Endoscopic recurrence after surgery was examined according to the preoperative conditions, including administration of anti-TNFα agents before surgery. Results Thirty-six patients received anti-TNFα antibody after surgery: 22 in the anti-TNFα restart group and 14 in the anti-TNFα naïve group. Endoscopic recurrence after surgery was more frequently observed in the anti-TNFα restart group than in the anti-TNFα naïve group (68% vs. 14%, P<0.001). Multivariate analysis revealed the following significant risk factors of endoscopic recurrence after surgery: anti-TNF restart group (odds ratio [OR], 28.10; 95% CI, 3.08-722.00), age at diagnosis <23 years (OR, 24.30; 95% CI, 1.67-1,312.00), serum albumin concentration at surgery <3.3 g/dL (OR, 34.10; 95% CI, 1.72-2,804.00), and presence of inflammation outside of the surgical site (OR, 21.40; 95% CI, 1.02-2,150.00). Treatment intensification for patients with endoscopic recurrence in the anti-TNFα restart group showed limited responses, with only 1 of 12 patients achieving endoscopic remission. Conclusions The efficacy of restarting anti-TNFα antibody treatment after surgery was limited, and treatment intensification or a change to different classes of biologics should be considered for those patients.
Collapse
Affiliation(s)
- Sakiko Hiraoka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shiho Takashima
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshitaka Kondo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshihiro Inokuchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuusaku Sugihara
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiro Takahara
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keita Harada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jun Kato
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| |
Collapse
|
|
38
|
Hindryckx P, Vande Casteele N, Novak G, Khanna R, D'Haens G, Sandborn WJ, Danese S, Jairath V, Feagan BG. The Expanding Therapeutic Armamentarium for Inflammatory Bowel Disease: How to Choose the Right Drug[s] for Our Patients? J Crohns Colitis 2018; 12:105-119. [PMID: 28961959 DOI: 10.1093/ecco-jcc/jjx117] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The therapeutic landscape for inflammatory bowel disease [IBD] is rapidly evolving. Two new biologic drugs, vedolizumab and ustekinumab, have recently entered the marketplace, the first biosimilars have been introduced, and several other agents are at an advanced stage of clinical development. In parallel, therapeutic goals have shifted from symptom control towards mucosal healing and prevention of bowel damage. In the coming years, gastroenterologists will be faced with unprecedented choices when selecting the best treatment for their patients with IBD. In this article, we review existing data on the mechanisms of action, efficacy, and safety of recently approved and late-stage pipeline therapies, and use this information to speculate on the positioning of these drugs, alone or in combination, in therapeutic algorithms for Crohn's disease and ulcerative colitis.
Collapse
Affiliation(s)
- Pieter Hindryckx
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - Niels Vande Casteele
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Gregor Novak
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Department of Gastroenterology, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Reena Khanna
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Geert D'Haens
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Inflammatory Bowel Disease Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | - William J Sandborn
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Vipul Jairath
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Western Ontario, London, ON, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| | - Brian G Feagan
- Robarts Clinical Trials, Inc., University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Western Ontario, London, ON, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| |
Collapse
|
|
39
|
Real-world Experience of Anti-tumor Necrosis Factor Therapy for Internal Fistulas in Crohn's Disease: A Retrospective Multicenter Cohort Study. Inflamm Bowel Dis 2017; 23:2245-2251. [PMID: 29084079 DOI: 10.1097/mib.0000000000001276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Internal fistula in Crohn's disease is a condition likely to require surgery, although few reports showed successful medical treatments such as anti-tumor necrosis factor (TNF) therapy. We performed a multicenter retrospective cohort study to investigate the outcome of anti-TNF therapy for internal fistula in Crohn's disease. METHODS Data were retrospectively collected from patients with Crohn's disease diagnosed with internal fistula treated with anti-TNF agents (infliximab or adalimumab) between January 2002 and November 2015. Need for surgery and fistula closure were assessed as primary and secondary endpoints. Cumulative rate of surgery was evaluated by the Kaplan-Meier analysis. Prognostic factors for the outcomes were also assessed by univariate and multivariate analyses. RESULTS A total of 93 Crohn's disease cases were included in the study with a mean follow-up period of 1452.8 days. Fistula locations were entero-entero/colonic (n = 72, 77.4%), enterovesical (n = 16, 17.2%), or enterovaginal (n = 5, 5.4%). Cumulative surgery rate was 47.2%, and fistula closure rate was 27.0% at 5 years from the induction of anti-TNF agents. Lower Crohn's Disease Activity Index and shorter duration from the diagnosis of fistula were independently associated with the lower risk of surgery (P = 0.017 and 0.048, respectively). Single fistula was associated with the successful fistula closure. Second-line surgical treatments were mostly successful for anti-TNF failures. CONCLUSIONS In the present retrospective cohort study, approximately half of patients with internal fistulas avoided surgery for long periods. It may be reasonable to treat quiescent single internal fistulas with anti-TNF agents soon after the diagnosis of internal fistulas.
Collapse
|
|
40
|
Tonolini M, Magistrelli P. Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI. Insights Imaging 2017; 8:537-548. [PMID: 28963700 PMCID: PMC5707219 DOI: 10.1007/s13244-017-0572-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 12/16/2022] Open
Abstract
Abstract Enterocutaneous fistulas (ECFs) represent abnormal communications between the gastrointestinal tract and the skin. Nowadays, the majority (~80%) of ECFs develops secondary to abdominal surgeries; alternative, less common causes include chronic inflammatory bowel diseases (IBD) such as Crohn’s disease, tumours, and radiation enteritis in descending order of frequency. These rare disorders require thorough patient assessment and multidisciplinary management to limit the associated morbidity and mortality. This pictorial review includes an overview of causes, clinical manifestations, complications and management of ECFs. Afterwards, the imaging appearances, differential diagnoses, and therapeutic options of post-surgical, IBD-related, and malignant ECFs are presented with case examples. Most of the emphasis is placed on the current pivotal role of CT and MRI, which comprehensively depict ECFs providing cross-sectional information on the underlying postsurgical, neoplastic, infectious, or inflammatory conditions. Radiographic fistulography remains a valid technique, which rapidly depicts the ECF anatomy and confirms communication with the bowel. The aim of this paper is to increase radiologists’ familiarity with ECF imaging, thus allowing an appropriate choice between medical, interventional, or surgical treatment, ultimately resulting in higher likelihood of therapeutic success. Teaching Points • Enterocutaneous fistulas may complicate abdominal surgery, sometimes Crohn’s disease and tumours. • The high associated morbidity and mortality result from sepsis, malnutrition and metabolic imbalance. • The multidisciplinary management of ECFs requires thorough imaging for correct therapeutic choice. • Radiographic fistulography rapidly depicts fistulas and communicating bowel loops in real-time. • Multidetector CT and MRI provide cross-sectional information on fistulas and underlying diseases.
Collapse
Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Paolo Magistrelli
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy
| |
Collapse
|
|
41
|
Papamichael K, Cheifetz AS. Defining and predicting deep remission in patients with perianal fistulizing Crohn’s disease on anti-tumor necrosis factor therapy. World J Gastroenterol 2017; 23:6197-6200. [PMID: 28974885 PMCID: PMC5603485 DOI: 10.3748/wjg.v23.i34.6197] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
Perianal fistulas can occur to up to one-third of patients with Crohn’s disease (CD) leading to significant disabling disease and morbidity. Fistulising perianal CD treatment often necessitates a combined pharmacological and surgical approach. Anti-tumor necrosis factor (anti-TNF) therapy, particularly infliximab, has been shown to be very effective for both perianal and internal fistulising CD. Nevertheless, current data suggest that sustained remission and long-term complete fistula healing can be achieved in only 30% to 50% of patients. Moreover, these percentages refer mostly to clinical rather than deep remission, defined as endoscopic and radiologic remission, which is quickly emerging as the preferred goal of therapy. Unfortunately, the therapeutic options for perianal fistulising CD are still limited. As such, it would be of great value to be able to predict, and more importantly, prevent treatment failure in these patients by early and continued optimization of anti-TNF therapy. Similar to ulcerative colitis and luminal CD, recent data demonstrate that higher infliximab concentrations are associated with better clinical outcomes in patients with perianal fistulising CD. This suggests that therapeutic drug monitoring and a treat-to-trough therapeutic approach may emerge as the new standard of care for optimizing anti-TNF therapy in patients with perianal fistulising CD.
Collapse
Affiliation(s)
- Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| |
Collapse
|
|
42
|
Allocca M, Bonifacio C, Fiorino G, Spinelli A, Furfaro F, Balzarini L, Bonovas S, Danese S. Efficacy of tumour necrosis factor antagonists in stricturing Crohn's disease: A tertiary center real-life experience. Dig Liver Dis 2017; 49:872-877. [PMID: 28416240 DOI: 10.1016/j.dld.2017.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Stenosis is the most common complication of Crohn's disease (CD). Long-term outcome of patients receiving tumour necrosis factor (TNF) antagonists for such disease complication is poorly understood. METHODS 51 CD patients (from July 2006 to November 2015) who had a diagnosis of small bowel or colonic stenosis, diagnosed by colonoscopy and/or MRI enterography, and were treated with TNF antagonists (adalimumab or infliximab) were enrolled. The primary outcome was to assess the rate of success of TNF antagonists on avoiding abdominal surgery for stricturing CD patients. RESULTS 20 patients (39.2%) underwent surgery during the follow-up period. The overall incidence of abdominal surgery was 1.8 per 100 person-months at risk, while the median time to surgery was 37.9 months. The univariable and multivariable Cox's proportional hazards analysis of baseline parameters indicated that disease location (colonic vs ileal, HR: 28.2, 95% CI: 2.45-324, p=0.007; ileocolonic vs ileal, HR: 3.38, 95% CI: 1.09-10.5, p=0.035), prestenotic dilatation (per 1-mm increase, HR: 1.08, 95% CI: 1.01-1.15, p=0.022) and the existence of non-perianal fistula (HR: 9.77, 95% CI: 2.99-31.9, p<0.001) are independent risk factors for abdominal surgery. CONCLUSIONS In stricturing CD, anti-TNFs are effective in up to about two-thirds of the patients.
Collapse
Affiliation(s)
| | | | - Gionata Fiorino
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | | | - Stefanos Bonovas
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | - Silvio Danese
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy.
| |
Collapse
|
|
43
|
|
|
44
|
Park JJ, Yang SK, Ye BD, Kim JW, Park DI, Yoon H, Im JP, Lee KM, Yoon SN, Lee H. [Second Korean Guidelines for the Management of Crohn's Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:29-54. [PMID: 28135790 DOI: 10.4166/kjg.2017.69.1.29] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of the Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.
Collapse
Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kang Moon Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Nam Yoon
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | | |
Collapse
|
|
45
|
Baji P, Gulácsi L, Brodszky V, Végh Z, Danese S, Irving PM, Peyrin-Biroulet L, Schreiber S, Rencz F, Lakatos PL, Péntek M. Cost-effectiveness of biological treatment sequences for fistulising Crohn's disease across Europe. United European Gastroenterol J 2017; 6:310-321. [PMID: 29511561 DOI: 10.1177/2050640617708952] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 04/15/2017] [Indexed: 12/18/2022] Open
Abstract
Background In clinical practice, treatment sequences of biologicals are applied for active fistulising Crohn's disease, however underlying health economic analyses are lacking. Objective The purpose of this study was to analyse the cost-effectiveness of different biological sequences including infliximab, biosimilar-infliximab, adalimumab and vedolizumab in nine European countries. Methods A Markov model was developed to compare treatment sequences of one, two and three biologicals from the payer's perspective on a five-year time horizon. Data on effectiveness and health state utilities were obtained from the literature. Country-specific costs were considered. Calculations were performed with both official list prices and estimated real prices of biologicals. Results Biosimilar-infliximab is the most cost-effective treatment against standard care across the countries (with list prices: €34684-€72551/quality adjusted life year; with estimated real prices: €24364-€56086/quality adjusted life year). The most cost-effective two-agent sequence, except for Germany, is the biosimilar-infliximab-adalimumab therapy compared with single biosimilar-infliximab (with list prices: €58533-€133831/quality adjusted life year; with estimated prices: €45513-€105875/quality adjusted life year). The cost-effectiveness of the biosimilar-infliximab-adalimumab-vedolizumab three-agent sequence compared wit biosimilar-infliximab -adalimumab is €87214-€152901/quality adjusted life year. Conclusions The suggested first-choice biological treatment is biosimilar-infliximab. In case of treatment failure, switching to adalimumab then to vedolizumab provides meaningful additional health gains but at increased costs. Inter-country differences in cost-effectiveness are remarkable due to significant differences in costs.
Collapse
Affiliation(s)
- Petra Baji
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - Zsuzsanna Végh
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Silvio Danese
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Peter M Irving
- IBD Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Stefan Schreiber
- Department Internal Medicine I, Kiel University, University Hospital, Kiel, Germany
| | - Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary.,Semmelweis University Doctoral School of Clinical Medicine, Budapest, Hungary
| | - Péter L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| |
Collapse
|
|
46
|
Park JJ, Yang SK, Ye BD, Kim JW, Park DI, Yoon H, Im JP, Lee KM, Yoon SN, Lee H. Second Korean guidelines for the management of Crohn's disease. Intest Res 2017; 15:38-67. [PMID: 28239314 PMCID: PMC5323307 DOI: 10.5217/ir.2017.15.1.38] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 01/15/2017] [Accepted: 01/16/2017] [Indexed: 02/07/2023] Open
Abstract
Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.
Collapse
Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kang Moon Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Nam Yoon
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | | |
Collapse
|
|
47
|
Yamamoto-Furusho J, Bosques-Padilla F, de-Paula J, Galiano M, Ibañez P, Juliao F, Kotze P, Rocha J, Steinwurz F, Veitia G, Zaltman C. Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
|
48
|
Yamamoto-Furusho J, Bosques-Padilla F, de-Paula J, Galiano M, Ibañez P, Juliao F, Kotze P, Rocha J, Steinwurz F, Veitia G, Zaltman C. Diagnóstico y tratamiento de la enfermedad inflamatoria intestinal: Primer Consenso Latinoamericano de la Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:46-84. [PMID: 27979414 DOI: 10.1016/j.rgmx.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/23/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023]
|
|
49
|
Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
Collapse
|
|
50
|
Lelli F, Nuhoho S, Lee XY, Xu W. Systematic review: treatment pattern and clinical effectiveness and safety of pharmaceutical therapies for Crohn's disease in Europe. Clin Exp Gastroenterol 2016; 9:311-323. [PMID: 27785086 PMCID: PMC5063598 DOI: 10.2147/ceg.s109696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Although many clinical trials have been conducted in treatments of Crohn’s disease (CD), whether the trial results were representative of daily practice needs to be supported by studies conducted in real-world settings. Aim This study aims to identify how CD is treated and what are the clinical effectiveness and safety of the pharmaceutical therapies of CD in real-world settings. Methods A systematic literature review was conducted based on Medline®, Embase®, and Cochrane. All publications were assessed for title/abstract and full-text according to a predefined study protocol. Data were extracted and reported. Results A total of 1,998 publications were identified. Fifty studies including six publications reporting treatment pattern and 44 studies reporting clinical effectiveness and safety of pharmaceutical therapies in CD management in Europe were included. 5-Aminosalicylic acid and corticosteroids were reported to be used among 14%–74% of CD patients. Immunomodulators were used by 14%–25% and 29%–31% of CD patients as an initial and follow-up treatment, respectively. Biological therapies were used by 25%–33% of CD patients. A trend toward an increasing use of immunomodulators and biological therapies in Europe has been reported in recent years. Approximately 50% of patients achieved remission on immunomodulator or biologic treatment, although a relapse rate of up to 23% has been reported. Conclusion There is a trend of treatment shift to immunomodulators and biologics in CD management. Clinical effectiveness of immunomodulators and biologics has been demonstrated, though with a lack of sustainability of the effectiveness.
Collapse
Affiliation(s)
| | - Solomon Nuhoho
- Health Economics, Market Access and Reimbursement, Johnson & Johnson Middle East FZ LLC, Dubai, United Arab Emirates
| | | | - Weiwei Xu
- Pharmerit International, Rotterdam, the Netherlands
| |
Collapse
|