No abstract

Objective: To assess time trends in intestinal resection and re-resection in Crohn's disease (CD) patients. Summary of Background Data: CD treatment has changed considerably over the past decades. The effect of these advances on the necessity of intestinal resections and the risk of re-resection is unclear. Methods: In this nationwide cohort study, adult CD patients with ileocolonic, small bowel, colon, or rectum resections between 1991 and 2015 were included. Data were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology (PALGA). Time trends were analyzed with a broken stick model and Cox proportional hazard model with smoothing splines. Results: The identified cohort comprised 8172 CD patients (3293/4879 male/female) in whom 10,315 intestinal resections were performed. The annual intestinal resection rate decreased nonlinearly from 22.7/100,000 CD patients (1991) to 2.5/100,000 (2015). A significantly steeper decrease was observed before 1999 (slope −1.56) as compared to subsequent years (slope −0.41) (P < 0.001). Analogous trends were observed for ileocolonic, small bowel, and colon resections. Overall cumulative risk of re-resection was 10.9% at 5 years, 18.6% at 10 years, and 28.3% at 20 years after intestinal resection. The hazard for intestinal re-resection showed a nonlinear decreasing trend, with hazard ratio 0.39 (95% confidence interval 0.36–0.44) in 2000 and hazard ratio 0.25 (95% confidence interval 0.18–0.34) in 2015 as compared to 1991. Conclusion: Over the past 25 years, intestinal resection rate has decreased significantly for ileocolonic, small bowel, and colonic CD. In addition, current postoperative CD patients are at 75% lower risk of intestinal re-resection.

Background and Aim Myosteatosis is a prognostic factor in cancer and liver cirrhosis. It can be determined noninvasively using computed tomography or, as shown recently, by magnetic resonance (MR) imaging. The primary aim was to analyze the reproducibility of skeletal muscle signal intensity on routine MR‐enterographies, as indicator of myosteatosis, in Crohn's disease (CD) and to explore the association between skeletal muscle signal intensity at diagnosis with time to intestinal resection. Methods CD patients undergoing MR‐enterography within 6 months from diagnosis and having a maximum of 5 years follow‐up were included. Skeletal muscle signal intensity was analyzed on T1‐weighted fat‐saturated post‐contrast images. Intra‐observer and inter‐observer reproducibilities were assessed by intra‐class correlation coefficient and Cohen's kappa. Intra‐observer and inter‐observer variabilities were determined by Pearson correlation coefficient and displayed by Bland–Altman plots. Time to intestinal resection was studied by Kaplan–Meier analysis. Results Median time between diagnosis and MR‐enterography was 5 weeks (inter‐quartile range 1–9) in 35 CD patients. Skeletal muscle signal intensity showed good intra‐class correlation and substantial agreement (for intra‐observer, intraclass correlation coefficient = 0.948, κ = 0.677; and inter‐observer reproducibility, intraclass correlation coefficient = 0.858, κ = 0.622). Resection free survival was shorter in the low skeletal muscle signal intensity group (P = 0.037). Conclusion Skeletal muscle signal intensity on routine MR‐enterographies is reproducible and was associated with unfavorable disease outcome, indicating potential clinical relevance.

No abstract

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.Objective Postoperative endoscopic recurrence in patients with Crohn's disease (CD) is commonly classified using the Rutgeerts score. Ulcerations in the ileal blind loop are not taken into account in the Rutgeerts score, and the clinical relevance of these lesions is unknown. This study aimed to assess the outcome of isolated ileal blind loop inflammation (IBLI) in postoperative CD patients. Methods Adult CD patients who underwent intestinal surgery with ileocolonic anastomosis between 1997 and 2017 were included and postoperative endoscopy reports were retrospectively reviewed. IBLI was defined as isolated inflammation of the ileal blind loop with or without ulcera confined to the anastomosis. Outcome was assessed using endoscopic recurrence (Rutgeerts >i2) and surgical recurrence (re-resection). Results A total of 341 CD patients were included. In 125 out of 341 (37%) patients, the ileal blind loop was described in the endoscopy reports. IBLI was reported in 43 of 341 (13%) patients. Start or step-up drug therapy was initiated in 10 of 32 (31%) IBLI patients with abdominal symptoms within a median of 0.9 months [interquartile range (IQR) 0.7-1.4] after ileocolonoscopy. Endoscopic recurrence occurred in 4 out of 38 (11%) IBLI patients without re-resection, within a median of 12.4 months ). Intestinal re-resection was performed in 5 out of 43 (16%) IBLI patients within a median of 3.7 months (IQR 3.5-10.8). Conclusion IBLI is associated with symptoms and an unfavorable outcome, with a high risk of endoscopic recurrence in the neoterminal ileum and intestinal re-resection during short-term follow-up. Therefore, the blind ileal loop needs to be assessed during endoscopy in postoperative CD patients.

Background A considerable proportion of Crohn’s disease patients that undergo ileocecal resection (ICR) have failed anti-tumor necrosis factor (TNF) therapy preoperatively. This study aimed to assess the effectiveness of retreatment of anti-TNF therapy in patients with postoperative recurrence. Methods A real-world cohort study was performed on Crohn’s disease patients who underwent primary ICR after anti-TNF therapy failure, and who were retreated with anti-TNF therapy for postoperative symptomatic Crohn’s disease. The primary outcome was treatment failure (the need for (re)introduction of corticosteroids, immunosuppressants, or biologicals or the need for re-resection). Sub-analyses were performed on the nature of preoperative anti-TNF failure (primary non-response, secondary loss of response, intolerance), indication for ICR (refractory, stricturing, penetrating disease), combination therapy with immunomodulators, retreatment with the same anti-TNF agent and preoperative exposure to 1 vs. >1 anti-TNF agents. Results In total, 66 of 364 patients retreated with anti-TNF therapy following ICR. Cumulative rates of treatment failure at 1 and 2 years were 28% and 47%. Treatment failure rate at 2 years was significantly lower in patients receiving combination therapy as compared to anti-TNF monotherapy (30% vs. 49%, P = 0.02). No difference in treatment failure was found with regards to the nature of preoperative anti-TNF failure (P = 0.76), indication for ICR (P = 0.88) switch of anti-TNF agent (P = 0.55) agent, and preoperative exposure to 1 vs. >1 anti-TNF agents (P = 0.88). Conclusion Retreatment with anti-TNF therapy for postoperative Crohn’s disease recurrence is a valid strategy after preoperative failure. Combination therapy is associated with a lower rate of treatment failure.

Background The risk of gallstone disease necessitating cholecystectomy after ileal resection (IR) in Crohn’s disease (CD) patients is not well established. We studied the incidence, cumulative and relative risk of cholecystectomy after IR in CD patients, and associated risk factors. Methods CD patients with a first IR between 1991 and 2015 were identified in PALGA, a nationwide pathology database in the Netherlands. Details on subsequent cholecystectomy and IR were recorded. Yearly cholecystectomy rates from the general Dutch population were used as a reference. Results A cohort of 8302 (3466 (41.7%) males) CD patients after IR was identified. During the 11.9 (IQR 6.3–18.0) years median follow-up, the post-IR incidence rate of cholecystectomy was 5.2 (95% CI 3.5–6.4)/1000 persons/year. The cumulative incidence was 0.5% at 1 year, 2.4% at 5 years, 4.6% at 10 years, and 10.3% after 20 years. In multivariable analyses, female sex (HR 1.9, CI 1.5–2.3), a later calendar year of first IR (HR /5-year increase , HR 1.27, CI 1.18–1.35), and ileal re-resection (time-dependent HR 1.37, CI 1.06–1.77) were associated with cholecystectomy. In the last decade, cholecystectomy rates increased and were higher in our postoperative CD population than in the general population (relative incidence ratio 3.13 (CI 2.29–4.28; p < 0.0001) in 2015). Conclusions Although higher in females, increasing in recent years, and higher than in the general population, the overall risk of cholecystectomy in CD patients following IR is low and routine prophylactic measures seem unwarranted. Electronic supplementary material The online version of this article (10.1007/s11605-018-4028-y) contains supplementary material, which is available to authorized users.

Background Crohn’s disease (CD) phenotype differs between Asian and Western countries and may affect disease management, including decisions on surgery. This study aimed to compare the indications, postoperative management, and long-term prognosis after ileocecal resection (ICR) in Hong Kong (HK) and The Netherlands (NL). Methods CD patients with primary ICR between 2000 and 2019 were included. The endpoints were endoscopic (Rutgeerts’ score ≥i2b and/or radiologic recurrence), clinical (start or switch of IBD medication) and surgical recurrences. Cumulative incidences of recurrence were estimated with a Bayesian multivariable proportional hazards model. Results Eighty HK and 822 NL patients were included. The most common indication for ICR was penetrating disease (HK 32.5%, NL 22.5%) in HK versus stricturing disease (HK 32.5%, NL 48.8%) in NL (P&lt;0.001). Postoperative prophylaxis was prescribed to 65 (81.3%) HK (28 [35.0%] amino salicylates [5-ASA]; 30 [37.5%] immunomodulators [IM]; 0 biologicals) versus 388 (47.1%) NL patients (67 [8.2%] 5-ASA; 187 [22.8%] IM; 69 [8.4%] biologicals; 50 [6.1%] combination therapy, P&lt;0.001). Endoscopic or radiologic evaluation within 18 months was performed in 36.3% HK versus 64.1% NL (P&lt; 0.001) patients. No differences between both populations were observed for endoscopic (hazard ratio [HR]: 0.53 (95% confidence interval [CI]: 0.24–1.21), clinical (HR: 0.91 (95% CI: 0.62–1.32), or surgical (HR: 0.61 (95% CI: 0.31–1.13)) recurrence risks. Conclusion The main indication for ICR in CD patients is penetrating disease in HK patients and stricturing disease in NL patients. Although considerable pre- and post-operative management differences were observed between the two geographical areas, the long-term prognosis after ICR is similar.