Introduction

Endoscopic submucosal dissection (ESD) is an effective treatment for superficial esophageal cancer, but postoperative stenosis remains a significant concern. Particularly, probability of the stenosis is less investigated in cases with a 50%-75% circumferential mucosal defect.

Aims & Methods

This study aimed to identify influential factors for postoperative stenosis after the moderate circumferential resection in esophageal ESD. This multi-center retrospective observational study analyzed data from 513 patients across 19 institutions who underwent esophageal ESD from April 2018 to March 2022 and showed 50% to 75% of the circumferential mucosal defect. We firstly overviewed the current status on the postoperative stenosis, the steroid use, and postoperative adverse events in these patients. Subsequently, we identified influential factors for postoperative stenosis. Patients were categorized into stenosis and no stenosis groups, and univariate and multivariate analyses were performed for each parameter. We further investigated influential factors of stenosis in two cohorts: steroid and no steroid groups. Finally, the parameters were compared between the steroid and no steroid groups to assess the tendency of the steroid use in general practice.

Results

Postoperative stenosis was observed in 28 cases (5%). Univariate analysis comparing the stenosis group (n = 28) and no stenosis group (n = 485) revealed significant differences in the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), defect circumference (p =0.01), and procedure duration (p = 0.02). There was no significant difference in the steroid use between two groups. Multivariate analyses identified history of prior endoscopic treatment close to the lesion (p = 0.01, odds ratio [OR], 5.10), cervical esophageal lesions (p = 0.03, OR, 3.97), large circumferential defect (p <0.01, OR, 3.78), and longer procedure duration (p <0.01, OR, 3.83) as independent risk factors for stenosis formation. Among the steroid group, significant associations of the postoperative stenosis were revealed with the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), and >5/8 of defect circumference (p = 0.02). In the no steroid group, only the procedure duration (p = 0.01) showed a significant difference between the stenosis and non-stenosis groups. Comparison between the steroid (n = 223) and no steroid groups (n = 290) revealed significant differences in the prior endoscopic treatment near the lesion (p <0.01), cervical esophageal lesions (p <0.01), and resected specimen dimensions (p <0.01). The stenosis rates were 7% in the steroid group and 4% in the no steroid group, without a significant difference. No significant difference in adverse events was observed between the two groups.

Conclusion

In esophageal ESD with a 50%-75% circumferential mucosal defect, the steroid was used in over 40% of patients, and postoperative stenosis still occurred in 5%. Because wider circumference, location of the cervical esophagus, prior endoscopic treatment close to the lesion, and prolonged operative time were identified as independent risk factors on the stenosis, steroid therapy should be preferred in these cases. Particularly, lesions with a history of endoscopic treatment, on cervical esophagus, and with >5/8 of defect circumference should require more aggressive countermeasures than currently applied.

Introduction

Pregnancy is common in women with inflammatory bowel disease (IBD), a population in whom optimal obstetric management is essential to ensure maternal and neonatal well-being. Vaginal delivery is generally recommended as the preferred mode of birth due to its lower risk of complications and faster recovery. Unnecessary caesarean section (C-section) delivery increases the risk of maternal complications, such as infection and thrombosis, and may negatively impact neonatal outcomes, including respiratory distress and delayed breastfeeding. Identifying the precise prevalence of C-sections and the factors driving that prevalence in women with IBD is essential to improve care and promote safe, evidence-based delivery planning.

Aims & Methods

To assess the frequency of C-section, and to identify factors associated with the mode of delivery in pregnant women with IBD included in the DUMBO registry.
Patients from DUMBO registry, a prospective multicentre cohort study of pregnant women with IBD in Spain, were included. The registry systematically collects demographic characteristics, obstetric history, IBD phenotype and activity, treatments received during pregnancy, and pregnancy-related complications. Mode of delivery is recorded for all participants. In cases of C-section, investigators document whether the indication was obstetric or IBD-related, as well as the specific reason for the procedure. Logistic regression analysis was performed to identify clinical and disease-related variables independently associated with the likelihood of C-section.

Results

A total of 1,012 women had given birth at the time of data analysis; mean age 34 years (standard deviation 4.8); median IBD duration 8.8 years (interquartile range 4.5–13); 626 (57%) had Crohn’s disease (CD) (21% had perianal disease, 19% active), 216 (19%) had previous surgery due to IBD, 464 (42%) were exposed to biologics, and 122 (11%) had active disease during pregnancy. A total of 293 deliveries (29%) were by C-section. Among C-sections, 237 (81%) were indicated for obstetric reasons, and 56 (19%) for IBD. In univariate analysis, older maternal age, longer IBD duration, to have CD (vs. ulcerative colitis), prior IBD surgery, active perianal disease, and exposure to biologic therapy during pregnancy were significantly more frequent among patients undergoing C-section compared to those with vaginal delivery (table 1). In the multivariate analysis, older maternal age [Odds ratio (OR) = 1.05, 95% confidence interval (CI) = 1.02–1.08], biologic treatment during pregnancy (OR = 1.46, 95%CI 1.08–1.95), prior IBD surgery (OR = 1.47, 95%CI 1.47–2.95), and active perianal disease (OR = 4.89, 95% CI 1.86–12.8) were independently associated with a higher risk of C-section.

Conclusion

One-third of deliveries in women with IBD are by C-section (a figure higher than that in general population¹). In 20% of cases, the indication for C-section was directly related to IBD-specific conditions. Several factors associated with an increased risk of C-section were identified, which are also recognized as predictors of more severe disease. Further efforts are needed to assess the appropriateness of C-section indications and to reduce unnecessary procedures in women with IBD.

Table 1. Characteristics of the overall population and according to the mode of delivery.
Variable	Overall patients N= 1.012	Vaginal delivery N= 719	Caesarian section N=293	p
Mean maternal age at inclusion, years (SD) Median disease duration, years (IQR) Smoker during pregnancy, n (%)	34.5 (4.8) 8.8 (4.6-13-4) 71 (16)	34.2 (4.8) 8.0 (4.4-12.9) 49 (7)	35.2 (4.7) 8.0 (4.4-12.99) 40 (7)	0.02 0.0003 0.8
Type of IBD -Crohn’s disease -Ulcerative colitis -Unclassified colitis Crohn's disease Disease Location, n (%) -L1 -L2 -L3 -L4 Disease behaviour, n (%) -B1 -B2 -B3 Perianal disease, n (%) Ulcerative colitis Disease extension, n (%) -Extensive -Left-sided -Proctitis	626 (57) 465 (41) 17 (2) 304 (49) 63(10) 258 (41) 36 (6) 409 (65) 122 (20) 95 (15) 129 (21) 157 (34) 139 (30) 167 (36)	379 (53) 330 (46) 10 (1) 201 (53) 37 (10) 141 (37) 24 (6) 258 (68) 73 (19) 48 (13) 51 (14) 116 (34) 100 (30) 123 (36)	185 (64) 105 (36) 0 (0) 72 (39) 24 (13) 89 (48) 11 (6) 119 (64) 37 (20) 29 (16) 62 (34) 35 (33) 32 (30) 40 (37)	0.01 0.07 0.8 0.5 <0.001 0.9
Surgery due to IBD, n (%) Active disease during pregnancy, n (%) Adverse events during pregnancy, n (%) Active perianal disease, n (%)	216 (19) 122 (11) 232 (21) 25 (2)	100 (14) 82 (11) 152 (21) 6 (1)	84 (29) 32 (11) 69 (23) 18 (6)	<0.001 0.8 0.4 <0.001
Treatments during pregnancy, n (%) -Rectal 5-ASA -Oral 5-ASA -Intravenous steroids -Systemic oral steroids -Topical oral steroids -Rectal steroids -Thiopurines -Anti-TNFs -Biologics	238 (21) 436 (39) 11 (1) 52 (5) 45 (4) 9 (1) 323 (29) 340 (31) 464 (42)	170 (24) 312 (43) 10 (1.4) 32 (5) 32 (5) 8 (1) 207 (29) 211 (29) 273 (38)	50 (17) 94 (32) 1 (0.3) 16 (6) 12 (4) 1 (0.3) 83 (28) 95 (32) 147 (50)	0.02 <0.001 0.1 0.4 0.8 0.2 0.8 0.3 <0.001
SD, standard deviation; IQR, interquartile range; IBD: inflammatory bowel disease; 5-ASA, 5-aminosalicylates; TNF, tumour necrosis factor.

References

¹ Ministerio de Sanidad. Annual report on the National Health System of Spain 2023 [Internet]. Madrid: Ministerio de Sanidad; 2023 [accessed 2025 April 14]. p. 86. Available from: https://www.sanidad.gob.es/estadEstudios/estadisticas/sisInfSanSNS/tablasEstadisticas/InfAnualSNS2023/INFORME_ANUAL_2023.pdf

Disclosure

María José Casanova María José Casanova, has received education or research funding from Pfizer, Takeda, Janssen, MSD, Dr. Falk, Shire, Ferring, Galápagos, Abbvie and Lilly.
María Chaparro has served as speaker, consultant or research or education funding from MSD, Abbvie, Hospira, Pfizer, Takeda, Janssen, Ferring, Shire Pharmaceuticals, Dr. Falk Pharma, Tillotts Pharma, Biogen, Gilead and Lilly.
Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from MSD, Abbvie, Pfizer, Kern Pharma, Biogen, Mylan, Takeda, Janssen, Roche, Sandoz, Celgene/Bristol Myers, Gilead/Galapagos, Lilly, Ferring, Faes Farma, Shire Pharmaceuticals, Dr. Falk Pharma, Tillotts Pharma, Chiesi, Casen Fleet, Gebro Pharma, Otsuka Pharmaceutical, Norgine and Vifor Pharma.
Cristina Calvino-Suarez, has served as a speaker for or has received research funding from MSD, AbbVie, Janssen, Takeda and Adacyte.
Pilar López Serrano has received grants from MSD, Abbvie, Takeda, Janssen, Faes, Ferring and Dr Falk Pharma.
Noemí Manceñido Marcos has served as a speaker and consultant for or received financial support for educational activities from Janssen, Abbvie, Pfizer, Takeda, Ferring, Faes Farma, Dr. Falk Pharma, and Tillots Pharma.
Marta Maia Boscá Watts Conflictos de interés: MSD, Ferring, Abbvie, Janssen, Biogen, Pfizer, Galápagos, Otsuka, Kern pharma y Takeda.
Agnès Fernández-Clotet has served as a speaker, or has recieves education funding from Dr. Falk, Janssen, Takeda, Chiesi and Pfizer.
Lara Arias García has served as speaker or has received research or education funding from MSD; Abbvie; Kern Pharma; Ferring; Faes Farma; Shire Pharmaceuticals; Pfizer; Takeda; Janssen; Tillots Pharma and OtsuKa Pharmaceutical.
Lucía Marquez-Mosquera has been served as speaker and / or has received research or education funds from Abbvie, Pfizer, Takeda, Janssen.
Marta Calvo Moya has served as a speaker, consultant and advisory member for or has received research funding from MSD, Abbvie, Takeda, Jannsen, Pfizer, Lilly, Mylan, Kern Pharma, Ferring, Shire Pharmaceuticals, Tillots, Dr. Falk Pharma, Chiesi, and Gebro Pharma.
Miriam Mañosa has served as a speaker, consultant and advisory member for or has received research funding from AbbVie, Janssen, MSD, Pfizer, Faes, Takeda, Tillots, Ferring.
Vicent Hernández has served as consultant, has served as speaker, has received travel support or research funding from MSD, AbbVie, Ferring, Dr. Falk Pharma, Tillotts Pharma, Pfizer, Takeda, Janssen, KernPharma Biologics, Adacyte, Sandoz, Biogen, Fresenius-Kabi, FAES Farma and Galapagos.
Raquel Camargo-Camero, He recibido financiación para diferentes tipos de actividades formativas de Janssen, Ferring, Abbvie, Falk, Pfizer, Galápagos y Takeda.
Iván Guerra has served as speaker or has received education funding from Takeda and Tillots.
David Busquets declares educational activities, research projects and scientific meetings sponsored by Abbvie, Janssen, Ferring, Pfizer, Tillots Pharma and Takeda.
Montserrat Rivero has served as a speaker or advisory member from TaKeda, Janssen, Galapagos, Ferring and Pfizer.
Iago Rodríguez-Lago has received financial support for traveling and educational activities from or has served as an advisory board member for Abbvie, Adacyte, Celltrion, Chiesi, Danone, Ferring, Faes Farma, Janssen, Galapagos, MSD, Pfizer, Roche, Takeda, and Tillotts Pharma. Financial support for research: Tillotts Pharma.
Rest of authors have nothing to declare.

Introduction

The ORALEV randomized controlled trial demonstrated that preoperative oral antibiotics (OA) before colon surgery reduces surgical-site infections. However, concerns were raised about the potential risk of antibiotic resistance.

Aims & Methods

This study aimed to assess if OA in the ORALEV trial led to increased long-term infection-related complications due to antibiotic resistance.
This is a retrospective analysis of 3-year follow-up data from 529 patients in the ORALEV trial. Primary outcome: risk of infectious complications and antibiotic resistance in patients with vs without OA. Secondary: long-term complications, effect on COVID-19 risk.

Results

	[ALL]	Experimental	Control	p
	N=529	N=264	N=265
Hospital admission due to infection	14 (2.65%)	7 (2.65%)	7 (2.64%)	1.000
Need for antibiotic treatment	8 (1.51%)	3 (1.14%)	5 (1.89%)	0.715
COVID-19	5 (0.95%)	4 (1.52%)	1 (0.38%)	0.218
Long-term complication	16 (3.02%)	4 (1.52%)	12 (4.53%)	0.077
Long-term unplanned surgery	11 (2.08%)	1 (0.38%)	10 (3.77%)	0.015
Any type of hospital readmission	62 (11.7%)	33 (12.5%)	29 (10.9%)	0.674
3-year mortality	47 (8.88%)	24 (9.09%)	23 (8.68%)	0.989
Overall Survival (3-year)	90.6 (95%CI 88.1; 93.2)	90.4 (95%CI 86.8; 94.1)	90.9 (95%CI 87.4; 94.5)	0.819

536 patients from the ORALEV trial were assessed for eligibility, of whom 529 were included (265 no OA vs 264 OA). The incidence of infective complications resulting in hospital admissions (n=7, 2.6% vs n=7, 2.6%, no OA vs OA), antibiotic treatment (n=5, 1.9% vs n=3, 1.1%. p=0.715), and COVID-19 (n=1, 0.4% vs n=4, 1.5% p=0.22) did not differ. Two patients in each group required treatment with carbapenems. No differences were observed between the groups regarding readmissions for any complication (n=29, 10.9% vs n=33, 12.5%, p=0.67). After removing COVID-19 admissions, COPD was associated with need for antibiotic treatment in the long-term (HR 5.13, 95%CI 1.28-20.54) irrespective of OA administration. The rates of postoperative hernia (n=11, 4.1% vs n=4, 1.5% p=0.11) and indication for hernia repair (9/11, 81.8% vs 1/4, 25%, p=0.08) were higher in non-OA group, but not statistically different.

Conclusion

OA do not increase the risk of long-term infective complications and need for advanced antimicrobial treatment. COPD increased the risk of subsequent need for antibiotic treatment. Hernia rates and need for surgical repair might be higher in those patients who did not receive OA.

References

Espin Basany E, Solís-Peña A, Pellino G, Kreisler E, Fraccalvieri D, Muinelo-Lorenzo M, et al. Preoperative oral antibiotics and surgical-site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial. lancet Gastroenterol Hepatol. 2020 Aug;5(8):729–38.