Introduction

In Crohn’s Disease (CD),the natural history of post-operative recurrence (POR) after ileo-colonic (IC) anastomosis has been extensively investigated. Fewer evidences are available regarding the POR after other surgical resections for CD.

Aims & Methods

The primary aim was to investigate, in a retrospective study, the clinical outcome at 5 years (yrs) of patients (pts) with previous CD-related resection different from IC anastomosis. Secondary aim was to assess possible differences in terms of clinical outcome at 5-yrs between pts with small bowel anastomoses involving or not the colon. Data from all pts with CD-related resection different from IC anastomosis from Jan. 2002-Apr. 2018, were recorded.Inclusion criteria:1)age ≥18 yrs; 2)well-defined diagnosis of CD (Montreal)(1);3)history of CD-related bowel resection (index surgery);4) Available data 5-yrs after surgery.Exclusion criteria:1)IC resection; 2)ostomy; 3) strictureplasty. Parameters considered after surgery: need of corticosteroids (CS),biologics, immunomodulators (IMM),CD-related surgery, hospitalization. Data were expressed as median [range], Student-t-test or X² test to assess differences.

Results

The study population included 47 pts with CD-related surgery with anastomosis different from IC (females:18 [38.3%];age:50 [29-78] yrs; CD duration:26 [7-53] yrs; age at surgery:34 [14-63] yrs). CD characteristics A1 n=8 (17%), A2 n=34 (72.3%), A3 n=5 (10.6%) pts; L1 n=23 (48.9%), L2 n=5 (10.6%), L3 n=19 (40.4%); L4 n=14 (29.8%); B1 n=1 (2.1%), B2 n=25 (53.2%), B3 n=21 (44.7%), perianal disease in 5 (10.6%) pts. Time interval between CD diagnosis and index surgery: 8 [0-25] yrs.Surgical indication:penetrating CD in 15 (31.9%), occlusion in 27 (57.4%), perforation in 4 (8.5%), refractory CD in 1 (2.1%) pt. Surgical anastomoses were: ileo-ileal in 23 (48.9%), jejunum-ileal in 5 (10.6%) duodenum-jejunal in 1 (2.1%), jejunum-jejunal in 4 (8.5%), ileo-rectal in 9 (19.1%), colo-colonic in 5 (10.6%) pts. Anastomoses involved only the small bowel in 33 (70.2%) pts, while anastomoses involved also the colon-rectum (ileo-rectal or colo-colonic) in 14 (29.8%) pts. Clinical outcome after index surgery in the 47 pts (at 1-yr and 5-yrs, respectively): A) Additional CD-related surgery in 2 (4.4%) and in 6 (12.8%) pts; B) Clinical recurrence in 16 (34%) and in 34 (72.3%) pts; C) CD-related hospitalization in 7 (14.9%) and in 25 (53.2%) pts. Either CS or IMM were used in 11 (23.4%) pts at 1 yr and in 20 (42.5%) pts at 5 yrs, while biologics in 8 (17%) pts at 1-yr and in 29 (61.7%) at 5 yrs. When comparing pts with anastomoses involving only the small bowel or also the colon-rectum, a comparable clinical outcome was observed, including: additional CD-related surgery (at 1 yr: 1 [3%] vs 1 [7.1%]; p=0.87; at 5-yrs: 4 [12.1%] vs 2 [14.3%]; p=0.78), clinical recurrence (at 1 yr: 10 [30.3%] vs 6 [42.8%]; p=0.62; 5-yrs: 24 [72.7%] vs 11 [78.6%]; p=0.94), CD-related hospitalization (at 1-yr: 4 [8.5%] vs 3 [21.4%], p=0.71; at 5-yrs: 20 [60.6%] vs 6 [42.8%]; p=0.42), need of CS (at 1-yr; 10 [30.3%] vs 2 [14.2%], p=0.43; at 5-yrs:18 [54.5%] vs 5 [35.7%], p=0.38),IMM (at 1 yr:8 [24.2%] vs 2 [14.2%]; p=0.7; at 5 yrs: 17 [51.5%] vs 4 [28.6%]; p=0.26), biologics (at 1 yr: 5 [15.1%] vs 3 [21.4%]; p=0.92); 5 yrs: 21 [63.6%] vs 8 [57.1%]; p=0.92).

Conclusion

In a retrospective study, a severe clinical course characterized CD pts with a history of surgery different from ileo-colonic resection in the previous 5 yrs. Hospitalization or major treatments were required in more than half of cases.

References

1) Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006; 55 (6): 749-753.

Introduction

The clinical course after surgery in Crohn’s Disease (CD) patients ileo-colonic anastomosis (ICA) is well known. Differently, clinical outcome in patients with entero-enteric anastomosis (EEA) after isolated small bowel resection is undefined.

Aims & Methods

The primary aim of the present case-control study was to search for differences in terms of major clinical outcomes at 5 years between CD patients with EEA (Cases), when compared to CD patients with ICA (Controls) matched for age and smoking status before index surgery. Secondary aim was to compare the characteristics of CD and the disease course before index surgery in Cases versus Controls.
All CD patients with EEA were retrospectively enrolled and matched for age at diagnosis (+/- 5 years) and smoking status before index surgery with 2 CD Controls with ICA. Inclusion criteria: 1) age ≥18; 2) EEA or ICA for CD; 3) ≥5-years follow-up after index surgery. Exclusion criteria: 1) missing data; 2) ostomy; 3) stricturoplasty. Data were expressed as median [range]. The Student-t-test, X2 test, Kaplan-Meier curves and logistic regression analyses were used as appropriate.

Results

Cases included 51 CD patients with EEA (ileum-ileum 39 [76.5%], jejunum-ileum 6 [11.8%], jejunum-jejunum 5 [9.8%], duodenum-jejunum 1 [1.9%]). Matched Controls included 102 CD patients with ICA. At 3 and 5 years after surgery, clinical recurrence was more frequent in Cases (28 [54.9%] vs. 37 [36.3%], p=0.04; 34 [66.7%] vs. 43 [42.2%], p=0.007). Cases showed a higher frequency of CD-related hospitalization ≤5 years after surgery (25 [49%] vs. 23 [22.5%], p=0.001]) (Table). In Cases, corticosteroids use was more frequent at 1, 3 and 5 years (14 [27.5%] vs. 8 [7.8%], p=0.002; 21 [41.2%] vs. 15 [14.7%], p=0.0006; 26 [50.9%] vs. 18 [17.6%], p<0.0001) (Table). ISS and biologics use 3 and 5 years after surgery was more frequent in Cases (20 [39.2%] vs. 20 [19.6%], p=0.01; 21 [41.2%] vs. 24 [23.5%], p=0.03; (15 [29.4%] vs. 13 [12.7%], p=0.02 and 23 [45.1%] vs. 15 [14.7%], p=0.03) (Table). Cases showed a shorter time to survival from clinical recurrence and hospitalization (2.36 [1.29-4.35], p=0.0036; 1.71 [1.06-2.77], p=0.02). EEA and ISS use before index surgery were risk factors for CD-related hospitalization and clinical recurrence at 5 years (2.68 [1.11-6.45]; p=0.02, 2.61 [1.21-5.6]; p=0.01 and 2.53 [1.05-6.09]; p=0.03; 2.44 [1.18-5]; p=0.01).

Conclusion

The clinical outcome after surgery is more severe in CD patients with EEA versus ICA, being associated with a higher rate of clinical recurrence, hospitalization and need of major treatments for the disease. This suggests the need of a tight assessment after isolated small bowel surgery, in order to achieve a timely and appropriate treatment and possible prevention of complications.

References

1) Onali S, Petruzziello C, Calabrese E, Condino G, Zorzi F, Sica GS, Pallone F, Biancone L. Frequency, pattern, and risk factors of postoperative recurrence of Crohn's disease after resection different from ileo-colonic. J Gastrointest Surg. 2009; 13 (2): 246-252.
2) Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G, de Buck van Overstraeten A, Burke JP, Buskens CJ, Francesco C, et al. ECCO-ESCP Consensus on Surgery for Crohn’s Disease. J. Crohns Colitis. 2017; 12: 1-16.

Introduction

The Rutgeerts score, developed three decades ago, is used to assess postoperative endoscopic recurrence in patients with Crohn’s disease (CD) following ileocolonic resection with an end-to-end anastomosis.¹ However, contemporary surgical techniques have introduced new anatomical locations – the ileal body and ileal inlet – which were not accounted for in the original Rutgeerts score.² Additionally, the original Rutgeerts score has demonstrated limited inter-observer reliability.³ To address these limitations, an updated Rutgeerts score, incorporating new anatomical sites, has been proposed. According to the updated Rutgeerts score lesions restricted to the ileal inlet, or the ileal body can no longer be scored as i2a.² While the updated Rutgeerts score offers improved assessment of inflammation after an ileocolonic resection, its reproducibility has not yet been validated.

Aims & Methods

The aim of our study was to evaluate the inter- and intra-observer reliability of the updated Rutgeerts score.
We conducted a retrospective analysis of 183 patients with CD (48% male, median age 36.8 years) who underwent video-recorded ileocolonoscopy within 14 months of resection with ileocolonic anastomosis. An expert reader MF selected and scored videos of ileocolonoscopies, which were then used as the gold standard. After receiving a two-hour training with a set of ten videos eight expert gastroenterologists reviewed and scored the videos. Each reader assessed 92 videos, including 23 videos that were re-scored after at least one month. Based on the gold standard, inter- and intra-rater agreement was calculated across all score levels and for each score level. Inter-rater reliability was assessed using Fleiss' kappa, and intra-rater reliability using Cohen’s kappa, both with and without application of linear weights.

Results

The probability of perfect agreement between two readers across all scores was 0.604 (95% CI: 0.559-0.649). The chance-corrected inter-observer agreement based on Fleiss’ kappa with linear weights across all scores was 0.619 (95% CI: 0.562-0.676). The strongest inter-observer agreement was observed for the i2a score, with a value of 0.736 (95% CI: 0.647-0.826), while the weakest was seen for the i1 score (0.357, 95%CI: 0.225-0.489).
Intra-rater reliability with a Cohen’s kappa was 0.688 (0.609-0.767), and with weighted kappa was 0.831 (0.758-0.868). The overall agreement rate was 76.0% (69.1%-82.0%).

	Categorical		Ordinal
	Estimate	95%CI	Estimate	95%CI
All levels	0.604	(0.559;0.649)	0.882	(0.866;0.897)
i0	0.633	(0.467;0.800)	0.884	(0.824;0.945)
i1	0.357	(0.225;0.489)	0.829	(0.758;0.899)
i2a	0.736	(0.647;0.826)	0.925	(0.896;0.954)
i2b	0.502	(0.439;0.566)	0.856	(0.834;0.877)
i3	0.487	(0.351;0.623)	0.859	(0.798;0.920)
i4	0.715	(0.606;0.824)	0.894	(0.854;0.934)

Table 1. Summary of agreement across score levels: Agreement for all scores and by individual score levels, based on the gold standard (defined as the scores given by an expert reader MF). Categorical agreement reflects only perfect agreement. Ordinal agreement applies linear weights, assigning less weight to minor disagreements and more to larger ones.

Conclusion

The updated Rutgeerts score demonstrates good agreement and substantial inter- and intra-rater reliability in assessing postoperative endoscopic recurrence in CD, supporting its potential for broader adaptation in both clinical practice and research settings.

References

1. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology. 1990;99(4):956-963. doi:10.1016/0016-5085(90)90613-6
2. Rivière P, Bislenghi G, Vermeire S, et al. Postoperative Crohn’s Disease Recurrence: Time to Adapt Endoscopic Recurrence Scores to the Leading Surgical Techniques. Clin Gastroenterol Hepatol. 2022;20(6):1201-1204. doi:10.1016/j.cgh.2022.02.025
3. Marteau P, Laharie D, Colombel JF, et al. Interobserver Variation Study of the Rutgeerts Score to Assess Endoscopic Recurrence after Surgery for Crohn’s Disease. Journal of Crohn’s and Colitis. 2016;10(9):1001-1005. doi:10.1093/ecco-jcc/jjw082

Introduction

Inflammatory bowel disease (IBD) and endometriosis are immuno-mediated chronic inflammatory diseases observed in young women, sharing some of the clinical manifestations (i.e. abdominal pain). The possible association and the relationship between endometriosis and IBD is undefined.

Aims & Methods

In a multidisciplinary approach, we aimed to assess in patients with IBD and concomitant endometriosis, the clinical outcome in terms of abdominal pain and endometriosis-related symptoms at 6 and 12 months and characteristics of endometriosis. All female IBD pts in childbearing age referring symptoms compatible with endometriosis were enrolled and referred to dedicated gynecologists for transvaginal ultrasonography (TVS). Inclusion criteria: 1) female gender; 2) age ≥18 and ≤55 years; 3)well-defined diagnosis of IBD; 4) symptoms compatible with endometriosis; 6) consent. Exclusion criteria: 1) pregnancy; 2) menopause; 3) suspected pelvic malignancy at TVS. Characteristics of IBD, endometriosis and adenomyosis were classified according to standard criteria. Data were expressed as median [range]. The Student-t Test and χ2 test were used for comparisons.

Results

Endometriosis was diagnosed in 25 (71%) out of 35 IBD patients with compatible symptoms. These 25 IBD pts included 12 (48%) Crohn’s Disease (CD) and 13 (52%) Ulcerative Colitis (UC). CD and UC patients were comparable in terms of age (38 [28-47] vs 39 [25-53]; p=0.75). IBD characteristics included: IBD duration: 11.5 [1-35], CD 11 [1-25] vs UC 12 [1-35] years; p=0.8, CD localization: ileum 4 (33.3%), colon 1 (8.4%), ileum-colon 7 (58.3%), CD behavior: non-stricturing non-penetrating 6 (50%), stricturing in 3 (25%), penetrating in 3 (25%) pts, UC extent: proctitis 3 (23%), left-sided 5 (38.5%), pancolitis in 5 (38.5%) pts. Other IBD characteristics did not differ between CD and UC pts with endometriosis. In IBD patients with endometriosis, a comparable frequency of dysmenorrhea (9 [75%] vs 13 [100%] pts; p=0.47), dyschezia (5 [41.7%] vs 6 [46.1%] pts; p=0.85), dyspareunia (9 [75%] vs 10 [76.9%] pts; p=0.72), dysuria (0 [0%] vs 3 [23.1%] pts; p=0.24) was observed between CD and UC. At transvaginal ultrasonography, deep infiltrating endometriosis was observed in all thr 25 patients with IBD and endometriosis. Moreover, a high frequency of rectal endometriosis was detected in these 25 IBD pts (6 [24%]). Adenomyosis was observed in 19 (76%) IBD pts with endometriosis, with no differences between CD and UC (8 [66.6%] vs 11 [84.6%]; p=0.56).
Among the 25 IBD pts with endometriosis, 10 (40%) underwent dienogest or estroprogestinic treatment. At 6 months, gynecological follow up was available in 9 pts, of whom 7 were on dienogest or estroprogestinic treatment. Among these 7 pts, 4 reported no endometriosis-related symptoms and 5 no abdominal pain. At 12 months, gynecological clinical follow-up currently includes 6 pts (25%), all on progestinic treatment. Of these, only 2 pts reported abdominal pain while 3 pts reported recurrence of endometriosis-related symptoms.

Conclusion

In the tested population, endometriosis was present in half of IBD pts with compatible symptoms, particularly DIE, with a high rate of rectal endometriosis. After endometriosis treatment, a lower proportion of patients referred abdominal pain. Endometriosis, often mimicking IBD, should be searched and treated in IBD young patients in order to avoid ineffective treatments.

Introduction

Recurrence of Crohn’s disease (CD) lesions after surgery remains high. Identifying patients at high risk of recurrence who may benefit from prophylactic therapy would be relevant. However, data on specific preoperative risk factors remain scarce, while onset and severity of Post Operative Recurrence (POR) are assessed with the Rutgeerts score (RS)(1). Still, the value of early endoscopic lesions, and RSi2, to predict the later course of the disease and the risk of late (from 1 to 10 years) POR in any individual patient is unclear. Non-invasive Small Intestine Contrast Ultrasonography (SICUS) assesses intramural extension of CD lesions, their progression, and is as effective as RS in detecting early POR lesions (2).

Aims & Methods

1. To develop a risk score based on pre-operative clinical predictors to estimate POR likelihood;
2. to identify predictors of severity of mucosal lesion according to RS;
3. to assess the overtime progression of transmural lesion.
Prospective cohort study (1998-2022). CD patients were evaluated at ileo-colonic surgery and every 6-12 months thereafter. Sex, age at diagnosis/surgery, active smoking, CD behaviour (B)/location (L), perianal disease (PD), length of resected bowel, steroids, immunosuppressants/biologics therapy use, and CD duration before surgery were analysed using multivariable proportional hazards regression. Cumulative POR rates and risk score were calculated with Poisson models, taking for each predictor the integer part of the Poisson model parameter.

Results

Over a median follow-up of 7.6 years (IQR 4.1–12), 78 patients (32 F; median age 30 years; 60% smokers) were analysed. CD characteristics: B1 8%; B2 67%; B3 25%; L1 63%; L3 36%; PD 22%; immunosuppressive/biologics 17%; median CD duration pre-surgery 4.7 years; median resected bowel length 28 cm. Cumulative POR rates were 51.8% (IQR,41%-63.4%), 65.2% (54.4%-75.7%), 69% (58.6%-79%), 75.9% (65.8% -84.8%), 78.9% (69.0%-87.3%), at 1, 2, 3, 4, and 5 years. POR risk factors included active smoking, age ≥35 years at surgery, and marginally B1 (Table). Predictors of RS were PD (HR=3.39; 95% CI 1.12-10.26; p=0.03 and CD duration ≥5 years pre-surgery (3.45; 1.15–10.32; p=0.03). The estimated cumulative probability of POR increased with higher risk scores (from 1 to 3) being 22%, 58%, 83% and, respectively, 43%, 80% and 100% at 1 and 4 years. Lesion length at POR varied by RS (median, IQR): RSi1 (32%): 0.5 cm (0.5-0.5), RSi2 (35%): 4 cm (0.5-7), RSi3 (15%): 15 cm (8.5-21.5), RSi4 (5%): 16 cm (9.5-23.5). Lesions remained stable in patients with RSi1 and RSi3 (45%) but fluctuated in those with RSi2 and RSi4 (31% increased, 24% decreased).

		Univariate analysis				Multivariate analysis				Cumulative Risk Score
Variable		HR	95% CI		p	HR	95% CI		p	contribution
Age at surgery (years)	≥35 vs. <35	1.84	1.10	3.10	0.02	1.82	1.07	3.07	0.03	0.60
Sex	Female vs. Male	1.24	0.74	2.08	0.42	1.59	0.90	2.79	0.11	0.46
Active smoking	Yes vs. No	1.50	0.88	2.55	0.14	1.99	1.06	3.75	0.03	0.69
Disease behaviour	B2 vs. B1	2.28	0.81	6.44	0.12	2.53	0.89	7.19	0.08	0.93
	B3 vs. B1	2.01	0.66	6.09	0.22	3.01	0.94	9.61	0.06	1.10
Disease duration (years)	≥5 vs. <5	1.18	0.71	1.98	0.52	NI	NI	NI	NI	NI
Length of resection (cm)	≤ 25 vs. >25	1.15	0.69	1.92	0.60	NI	NI	NI	NI	NI
PD	Yes vs. No	1.10	0.63	1.92	0.74	NI	NI	NI	NI	NI

HR:hazard ratio;CI: confidence interval;*time dependent covariates; NI:not included in the final model selected through a backward selection (p<0.2)

Conclusion

The present score based on preoperative factors predicts the risk of postoperative recurrence. Patients with preoperative higher risk scores or RSi2 at recurrence would require early and close monitoring due to significant transmural lesion progression.

References

1.Rutgeerts R et al. 1990; 2. Pallotta N et al. 2010.

Disclosure

Nothing to disclosure

Introduction

Colorectal cancer (CRC) risk is increased in patients with long-standing colitis related to Inflammatory Bowel Disease (IBD). A higher frequency of mucinous and signet-ring colonic adenocarcinoma has been suggested in IBD, but risk factors for these histotypes of CRC are undefined.

Aims & Methods

Primary aim was to compare the frequency of mucinous and signet-ring adenocarcinoma in patients with vs without IBD. Secondary aims were to search for IBD-related risk factors for signet ring and mucinous adenocarcinoma and to compare the localization of these histotypes of CRC in patients with vs without IBD. From January 2002 to January 2023, all IBD patients with concomitant colorectal adenocarcinoma (Cases) were retrospectively enrolled. Each Case was matched with 2 patients with CRC and no IBD (Controls) for age at CRC diagnosis (±5 years). Inclusion criteria for Cases and Controls: 1) age ≥18; 2) well-defined diagnosis of CRC. Additional inclusion criteria for Cases: well-defined diagnosis of IBD, classified according to standard criteria. Exclusion criteria: Missing histological and surgical report. Data were expressed as median [range]. Student-t Test and χ2 test were used for comparisons. Univariate logistic regression model was applied for assessing risk factors for mucinous and signet-ring CRC (OR [95%CI]).

Results

The study population included 120 patients with colorectal adenocarcinoma: 40 IBD patients and 80 non-IBD Controls. CRC in the 40 IBD patients occurred in 24 (60%) patients with Ulcerative Colitis (UC) and in 16 (40%) with Crohn’s Disease (CD). In patients with CRC, no differences were observed between IBD and non-IBD Controls in terms of gender (F) (13 [32.5%] vs 35 [43.7%]; p=0.32) and median age at diagnosis of CRC (54 [29-80] vs 58 [31-83] years; p=0.19). CRC in IBD was histologically defined as mucinous/ signet-ring in 17 (42.5%) and standard adenocarcinoma in 23 (57.5%) patients. Mucinous/signet ring CRC more frequently occurred in patients with IBD vs non-IBD Controls (17 [42.5%] vs 18 [22.5%], p=0.03). In IBD patients, rectal localization of CRC was significantly more frequent in mucinous/signet-ring vs standard CRC (4 [17.4%] vs 8 [47.1%]; p=0.04). In stricturing CD, there was a significantly higher frequency of standard vs mucinous/signet-ring CRC (7 [77.8%] vs 1 [14.4%]; p=0.04). Other IBD characteristics did not differ in relation to the 2 CRC histotypes, including gender (F): 8 [34.8%] vs 5 [29.4%]; p=0.98 and IBD duration at CRC diagnosis (14 [1-45] vs 17 [1-36]; p=0.74). In IBD, CRC stage at diagnosis was comparable between patients with standard vs mucinous/signet-ring CRC (stage I: 6 [26.1%] vs 1 [5.9%]; p=0.21; II: 9 [39.1%] vs 4 [23.5%]; p=0.48; III: 5 [21.7%] vs 7 [41.2%]; p=0.71; IV: 3 [13.1%] vs 5 [29.4%]; p=0.37)). At univariate analysis, no IBD-related risk factors for mucinous/signet-ring CRC were detected.

Conclusion

In the tested cohort, mucinous and signet-ring adenocarcinoma was more frequently observed in IBD than in non-IBD controls, although no IBD-related risk factors were identified. A higher frequency of rectal involvement is suggested for mucinous/signet-ring vs standard adenocarcinoma in IBD.