Introduction

Early surgical intervention in Crohn’s disease (CD) with inflammatory (B1) phenotype has been shown to be equally successful compared to biologic treatment in the LIR!C study. A recent work by PREDICT IBD group reconfirmed these findings. On the other hand, the prospective multicenter CREOLE study demonstrated long term (>4 years) surgery free survival in stricturing (B2) CD in over 50% of patients, treated with medical and endoscopic therapy. These conflicting findings complicate decision making in the individual patient, and data on conservative management of penetrating CD is lacking.

Aims & Methods

To compare long term outcomes between the early surgery and conservative treatment approach in patients presenting with penetrating (B3) CD.
​This was a retrospective, single tertiary center study, including adult CD patients hospitalized with penetrating abdominal CD, between 1/8/2010 to 30/6/2018. Demographic and clinical data including medical treatment, hospitalization duration, medical and surgical treatments during hospitalization and subsequent hospitalizations and treatments were collected from hospital records. Patients were divided into 2 groups: (1) early surgery (<12 weeks from index hospitalization), and (2) conservative treatment.
Multivariable logistic regression model adjusted for age, sex and smoking status was used for statistical analysis.

Results

A total of 43 CD patients [21 male (48.8%), age 37.9±15.1 years, disease duration 14.1±12.0 years] were hospitalized during the study period for first presentation of penetrating CD [14 (32.6%) with a sinus tract and 29 (67.4%) with an abscess]. Twenty-three patients (53.5%) underwent early surgery (69.5% of whom manifested with abscesses), and the rest were managed non-surgically.
Both groups were similar in terms of CD Montreal classification, smoking status, and type of penetrating complication. Follow up duration was comparable (median 5.2±2.3 years vs 5.3±2.3 years for early surgery vs conservative treatment, respectively, p=0.855).
Exposure to biologics, immunomodulators and glucocorticoids was comparable between the groups before and after index hospitalization.
During the follow up after discharge from the index hospitalization, patients in the surgical group had significantly lower incidence rates of recurrent abscesses (45% vs 4.5%, odds-ratio (OR) 0.04, 95% confidence interval (CI) 0.003-0.40, p=0.006), need for recurrent courses of antibiotics (55.0% vs 14.3%, OR 0.09, 95% CI 0.02-0.53, p=0.07) and recurrent hospitalizations (70.0% vs 39.1%, OR 0.16, 95% CI=0.03-0.72, p=0.017). Two patients (8.7%) in the early surgery group underwent abdominal surgery during follow-up compared to six patients (30.0%) of the conservative treatment group (OR 0.11, 95% CI 0.01-0.92, p=0.04).

Conclusion

In CD patients hospitalized with a penetrating complication, early surgery resulted in significantly less adverse long-term outcomes, such as recurrent abscesses, need for antibiotic treatment, hospitalizations, and surgeries than patients managed conservatively over a median follow up period of 5 years.

Introduction

Physical activity (PA) is associated with improved quality of life in patients with Crohn’s disease (CD). However, there is limited evidence of its impact on the clinical course of the disease and the separate effects of aerobic and anaerobic-resistance PA.

Aims & Methods

We aimed to evaluate the association between PA and the incidence of relapse in patients with CD in clinical remission and to assess the role of PA in patients with CD using patient-reported outcome measures (PROMs), with separate analyses for PA type. A prospective cohort study of adult patients with CD in clinical remission followed for one year or until relapse according to the Harvey Bradshaw Index. At baseline, participants completed a detailed PA questionnaire, nutritional questionnaires, and a patient-reported outcomes measurement information system (PROMIS). Multivariable Cox proportional hazards models were used to assess the association between PA and relapse risk, adjusted for confounders, including dietary factors and fecal calprotectin levels.

Results

A total of 106 patients (mean age 37.9 ± 13.9 years) were included and followed for 9.9±3.2 months, during which 23 (21.7%) experienced clinical relapse. PA at least twice a week was associated with a reduced risk of relapse (HR = 0.26, 95% CI 0.09–0.79). Specifically, only aerobic activity was significantly associated with a reduced risk of relapse (HR = 0.31, 95% CI 0.10-0.95). High-resistance PA was significantly associated with better quality of life parameters, including pain interference (P=0.013), sleep disturbance (P=0.040), better physical function (P=0.029), and enhanced social roles (P=0.020). While aerobic PA showed benefit in physical function (P=0.016).

Conclusion

PA in general and specifically aerobic PA, is associated with a reduced risk of relapse in patients with CD in remission. Additionally, resistance PA is associated with a better quality of life. These findings highlight the importance of incorporating PA into the management of CD in remission state.

Disclosure

None

Introduction

Previous studies have shown benefit in performing video capsule endoscopy (VCE) in Crohn’s disease (CD) diagnosis, especially in cases of an unremarkable ileo-colonoscopy, however data on the role of VCE in postsurgical follow-up of CD patients is lacking.

Aims & Methods

Our aim was to evaluate CD endoscopic activity in the small bowel (SB) of patients presenting with disease remission at the ileo-colonic anastomosis.
We retrospectively obtained data on patients with CD older than 18 years of age, who underwent ileo-colonoscopy between the dates 1/10/2012 through 31/09/2022. Patients in whom VCE was performed within 8 months of ileo-colonoscopy were eligible for analysis. Lewis and Rutgeerts scores were calculated based on VCE images and endoscopy reports, respectively. Disease remission was deemed as Rutgeerts score of i0-i1 at the ileo-colonic anastomosis, and Lewis score (LS) of<135 on VCE.

Results

A total of 1,334 ileo-colonoscopies were performed in CD patients with ileo-colonic anastomosis during the study period, of whom 31 patients (male gender 58.06%; mean age 41.77±14.19 years) were referred to VCE within 8 months of ileo-colonoscopy, (median 124.81 days). Twenty patients exhibited endoscopic remission at the anastomosis, 3 of them failed passage of a patency capsule and 17 successfully completed VCE. Only 5 patients (29.4%) had a normal LS, while 12 (70.6%) exhibited an active SB disease (LS≥135, mean 791.3±1254.9). Patients with a discrepancy between the two scores, were characterized by a shorter disease duration (P=0.011) and showed a trend towards a shorter time since surgery (P=0.06). No correlation was found between SB disease activity and concurrent medical therapy (P=0.898). Treatment modification was applied in 7 patients (41.2%) and was associated with a higher LS (biserial correlation coefficient 0.51, P=0.037).

Conclusion

Endoscopic remission at the ileo-colonic anastomosis is not an accurate indicator for CD remission in the SB, especially in a new-onset disease and soon after the surgery. VCE has an added value to ileo-colonoscopy in postsurgical follow-up and treatment adjustment in patients with CD.

Introduction

There is an increasing diversification in the treatment landscape for Crohn’s disease (CD) driven by heterogeneity of individual phenotypes, disease courses and previous treatments. This complexity makes universal evidence-based algorithms challenging. A “treat-to-target approach” with tight inflammation monitoring after starting biologics or small molecules therapy is recommended. Intestinal ultrasound (IUS) has proven effective in monitoring treatment response in large CD cohorts. Transmural healing (TH) is a robust but puzzling endpoint that can be achieved in about one-fourth of patients treated with biological therapy and few prognostic indicators to predict it were analyzed.

Aims & Methods

We aimed to describe treatment patterns and effective therapeutic sequences to achieve TH. Secondary aim was to identify prognostic factors to predict TH. This retrospective analysis included CD patients treated with biological and small molecules therapies according to the ECCO recommendations. Patients received biological and small molecules therapies across up to four treatment lines. Biological and small molecules treatment pathways prior to achieve TH were visualized using a Sankey diagram. IUS outcomes were evaluated one year after each biological and small molecules therapy. Logistic regression analysis was performed to identify clinical predictive factors of TH, that was defined as bowel wall thickness <3 mm and no vascularization at IUS.

Results

Among 139 patients treated with biological and small molecules therapies, TH was achieved in 25.9% (n = 36). Infliximab was used as the first-line agent in 55 patients (39.6 %), adalimumab in 69 (49.6%), vedolizumab in 6 (4.4%), certolizumab pegol in 1 (0.7%), Ustekinumab in 8 (5.7%). Twenty-five patients (20%) achieved TH after the first-line therapy (n=10 with infliximab; n=9 with adalimumab; n=3 with vedolizumab; n=3 with ustekinumab). TH rates declined with each additional line of therapy. The median time to achieve TH was 25.6 months (range 12–60). Treatment sequencing analysis revealed a progressive shift toward ustekinumab in later lines, with anti-TNFs remaining the most frequent first-line agents. Multivariate analysis showed that colonic lesion and early treatment (within 2 years from diagnosis) were associated with a higher likelihood of achieving TH [OR = 7.76, p<0.001; OR 6.705, p<0.001, respectively], while perianal disease was associated with a lower likelihood of TH [OR 0.151, p=0.02].

Conclusion

This study highlights a progressive decline in TH rates with successive lines of biological and small molecule therapies in CD patients and identifies several clinical factors that influence this outcome. Long-term follow-up and prospective studies specifically designed to evaluate sequencing in patients exposed to anti-TNFs are needed to guide challenging decisions.

Introduction

Patients diagnosed with Crohn's disease (CD) often undergo ileo-colonic resection (ICR) due to disease activity and complications. Post-operative weight gain is common, secondary to reduction in inflammatory burden, resolution of strictures and improved nutrition, yet may result in overweight and obesity (oBMI). Recent studies have shown that obesity in CD may lead to disease exacerbation and decreased response to medical treatment.

Aims & Methods

In this retrospective, case control, single tertiary center study, we aimed to identify risk factors for post-ICR oBMI and to explore the association of post-ICR overweight and obesity with disease recurrence in CD patients. All adult patients with CD who underwent ICR between 1/1/2010 to 31/12/2022 were included. Data collected from hospital records included patients and disease characteristics, post-ICR adverse events and endoscopic recurrence (Rutgeerts score), medical treatment before and after ICR. BMI was recorded at 6-12 months prior to disease exacerbation leading to surgery (baseline-BMI), at ICR and at 12-months post-ICR. Patients with (1) protective or end ileostomy, (2) non-CD exacerbation related surgery (e.g. neoplasia, ischemia), (3) lack of in-hospital IBD clinic follow up, and (4) incomplete BMI records, were excluded. The cohort was divided into two groups by post-ICR BMI [non-overweight BMI (nBMI)<25 kg/m² or oBMI≥25 kg/m²]. Logistic regression model was used and two-sided p-value <0.05 was considered significant.

Results

A total of 94 patients met the inclusion criteria and were included in the study. At 12 months post-ICR, 32 (33.7%) patients had oBMI (mean BMI 28.1±2.8 kg/m²) and 62 (66.3%) had nBMI (mean BMI 21.5±2.1 kg/m²). Groups were comparable in baseline characteristics [Table 1]. Mean baseline-BMI and ICR-BMI were higher in oBMI group compared to nBMI group (26.6±3.3 kg/m² vs. 21.4±2.9 kg/m² at baseline and 24.2±4.0 kg/m² vs. 19.6±2.6 kg/m² at ICR, p<0.001 for both). oBMI patients had a higher rate of ileocolonic (L3) disease (vs. ileal (L1) disease) compared to the nBMI group (62.5% vs 32.3%, p=0.005). No differences were observed in post-operative complications and re-hospitalizations within 12 months of follow up. The rate of endoscopic disease recurrence was comparable within 18 months of ICR (Rutgeerts≥i2b 30.8% for oBMI vs 43.1% for nBMI, p=NS). A logistic regression analysis adjusted to age, gender, and disease location, demonstrated that baseline-BMI, but not ICR-BMI was associated with 12 months post-ICR-oBMI (baseline-BMI: OR 1.699, 95%CI 1.242-2.326, p<0.001; ICR-BMI: OR 1.208, 95%CI 0.932-1.565, p=0.153).

Table 1: Patients' characteristics

Conclusion

BMI≥25 kg/m² prior to CD exacerbation is associated with post-ICR overweight and obesity. Though at short term follow-up, no increase in postoperative complications and endoscopic disease recurrence were observed, longer follow-up may be needed to assess possible effects of post-ICR overweight and obesity on CD's course.