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.

Introduction

Features and management of post operative recurrence (POR) of Crohn’s Disease (CD) after ileocecal resection (ICR) are well defined, but POR after colectomy is scarcely described.

Aims & Methods

Multicenter, nationwide, retrospective study promoted by the Spanish Working Group on Crohn's and Colitis (GETECCU). CD patients who underwent segmental colectomy (SC) or subtotal colectomy (STC) between 2012 and 2023 were included. Primary endpoint was clinical POR, defined as CD-related symptoms requiring salvage therapy despite POR prophylaxis. Secondary endpoints included endoscopic POR (anastomotic and/or perianastomotic CD-associated lesions at endoscopy), association between clinical and endoscopic POR, comparison of clinical and endoscopic POR-free survival among different types of colectomy, surgical recurrence (need for reoperation) depending on colectomy subtypes; and identification of factors associated with post-colectomy POR.

Results

224 patients were included: 157 (70%) underwent SC and 67 (30%) underwent STC. In the SC group, patients were older [44 (SD 15) vs 39 (SD 14) years old, p=0.01] and B3 phenotype was more frequent [68/157 (43%) vs 14/67 (21%), p = 0.003]. POR prophylaxis was prescribed in 119/157 (76%) SC patients and in 47/67 (70%) STC patients, with no significant differences regarding the choice of agent (main baseline characteristics of the study population are described in Table 1). The main indication for surgery was stenosing disease [both in SC group (83/157, 53%) and STC group (34/67, (51%)]. Median follow-up was 19.5 [3.7–67.9] months to clinical POR and 14.0 [5.9–54.1] months to endoscopic POR. Clinical POR developed in 60/157 (38%) in the SC group and 42/67 (63%) in the STC group (p = 0.001). Endoscopic evaluation was available in 190/224 patients (85%) [131/157 SC (83%) and 59/67 (88%) STC]; endoscopic POR was detected in 66/131 (50%) SC patients and 42/59 (71%) STC patients (p=0.012). Among patients with endoscopic POR, 76/108 (70%) also presented clinical POR: 43/66 (65%) patients in the SC group and 33/42 (79%) in the STC group (p=0.203). Clinical and endoscopic POR-free survival was higher for SC than for STC (p log-rank <0.05). Surgical recurrence occurred in 17/157 patients (11%) in the SC group and in 8/67 patients (12%) in the STC group (p=0.992). Multivariate stepwise Cox proportional hazards regression showed significant association of STC, smoking and myenteric plexitis with both clinical POR (HR 2.36, 95%CI [1.45 - 3.82]; HR 1.34, 95%CI [1.03 - 1,75] and HR 1.71, 95%CI [1.01 - 2.91] respectively) and endoscopic POR (HR 2.47, 95%CI [1.49 - 4.10], HR 1.36, 95%CI [1.03 - 1.79] and HR 1.83, 95% CI [1.01 - 3.29], respectively); and immunomodulator prophylaxis with endoscopic POR (HR 1.72, 95%CI [1.02 - 2.90]) (all p-values <.05).

Conclusion

POR remains common after colectomy in patients with CD. Clinical and endoscopic POR rates are higher following STC compared to SC in patients under similar prophylactic regimes. Although prospective research is still warranted, our data support favoring segmental resection of colonic CD when feasible.

Disclosure

J.L.R.G. has received financial support for traveling and educational activities or has received fees as a speaker from Abbvie, Kern Pharma, Janssen, Takeda, Pfizer, Lilly, Galapagos, Adacyte, Ferring, Tillotts Pharma, Faes Farma, Norgine and Casen. C.S.F. has received financial support for traveling and educational activities or has received fees as a speaker or consultant from Abbvie, Kern Pharma, Lilly, Ferring, MSD, Janssen, Takeda and Tillotts Pharma. YZ has received financial support for travelling and educational activities from or has served as an advisory board member for AbbVie, Adacyte, Alfasigma, Almirall, Amgen, Boehringer Ingelheim, Dr Falk Pharma, Faes Pharma, Fresenius Kabi, Ferring, Galapagos, Janssen, Johnson&Johnson, Kern, Lilly, MSD, Otsuka, Pfizer, Sanofi, Shire, Takeda, and Tillotts Pharma. The rest of the authors have no conflicts of interest to declare regarding this study.

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

Lifetime risk of surgery in Crohn's disease (CD) is substantial. In order to reduce risk of recurrence after surgery, initiation of medical prophylaxis based on assessment of risk of relapse is generally recommended (1) although specific criteria for risk assessment is debatable (2).

Aims & Methods

Aims: The objectives were to assess adherence to guideline recommendations as regards post-operative prophylaxis and to evaluate efficacy of profylaxis.
Methods: Population-based, single-center prospective study of all CD patients undergoing intestinal resection between February 1^st, 2017, and January 31st, 2022. Based on medical records,patients were classified as either high or low risk of relapse. Treatment received and outcome of treatment was registered and correlated to known prognostic factors such as smoking status, age, previous surgical resection.

Results

A total of 216 patients were included in the study, out of which 104 and 112 were in the high and low-risk groups, respectively. Only 61% of the patients in the high-risk group received post-operative prophylaxis (POP). There was no significant difference in relapse rates between those who received POP and those who did not. Forty-two out of 63 patients (67%, CI: 55-78) who received post-operative prophylaxis, experienced either clinical, endoscopic and/or MR-relapse while the numbers were 22/41 (53%, CI: 38-69, p=0.218) for those who did not receive any.
Seventy-four out of 112 (66%) of patients in the low risk group received POP in spite of being low risk. Also in this group, there was no significant difference in relapse rates between patients receiving POP (66%, CI: 55-77) and those not receiving POP (47%, CI: 31-63, p=0.067).
Relapse risk in patients not receiving POP was only numerically but non-significantly smaller for low risk patients (47%) compared to high risk patients (54%).

Conclusion

Adherence to recommendations for POP in CD was relatively low. In patients not receiving POP, risk of relapse was not statistically significantly higher in high risk patients compared to low risk patients. Compared to patients not receiving POP, patients who received POP (irrespective of low or high presumed risk) did not seem to benefit in terms of reduced risk of relapse. These finding question the clinical usefulness and predictive capacity of the current risk stratification as well as currently used medications for POP

References

[1] Sulz M, Burri E, Michetti P, Rogler G, Peyrin-Biroulet L, Seibold F. Treatment Algorithms for Crohn’s Disease. Digestion. 2020;101(Suppl. 1):43-57.
[2] Cohen-Mekelburg S, Schneider Y, Gold S, Scherl E, Steinlauf A. Risk Stratification for Prevention of Recurrence of Postoperative Crohn's Disease. Gastroenterol Hepatol (N Y). 2017;13(11):651-658.

Disclosure

Rangeena Paiman, Zahra Ahmar Butt: No CoI
Mark A. Ainsworth: Consulting for Abbvie and Janssen

Introduction

Side-to-side antiperistaltic ileo-colonic anastomosis (APICA) is wildly used technique in Crohn's disease (CD) patients. Its configuration makes the neo-terminal ileum intubation difficult, and might reduce rates of appropriate scoping, as required for assessment of disease relapse. The isoperistaltic ileo-colonic anastomosis (IPICA) may improve post-surgical endoscopic follow up of CD patients.

Aims & Methods

Our aim was to compare safety, efficacy, recurrence rates and feasibility of ileo-colonoscopy (IC) between the two anastomotic configurations.
​Data on all consecutive CD patients aged ≥18 years at a single tertiary center, who underwent ileo-colonic resection from 1/4/12 to 31/3/22, were collected retrospectively. Patients with anastomotic types other than APICA and IPICA and lack of IC within 18 months from surgery, were excluded.

Results

A total of 143 patients were included [82 males (57.3%), age 38.2±14.3 years, disease duration 10.1±9.5 years]. Twenty-six patients (18.5%) underwent IPICA and 117 patients (81.8%) APICA surgery. Patients did not differ in age, gender, BMI, smoking status, biologic treatment exposure and disease duration at time of surgery (p=NS). Duration of surgery was significantly longer for IPICA than APICA (295.4±70.2 min vs 249.3±60.6 min, p<0.001, respectively). Rates of laparoscopic, lap-to-open and open procedures differed (57.7%, 30.8% and 11.5% for IPICA vs. 40.2%, 13.7% and 46.2%, for APICA, respectively; p=0.003). Hospitalization duration and post-surgical complications (Clavien-Dindo classification) were comparable (p=NS). Fifteen patients were re-admitted with post-surgical complications within 90 days [1/26 (3.8%) in IPICA vs. 14/117 (12.0%) in APICA group, p=0.12]. At post-surgical IC, clinically significant anastomotic disease recurrence (Rutgeerts score≥2b) was observed in 38.5% of IPICA vs. 34.2% of APICA, (p=0.820). Excluding patients with stricture at anastomosis (Ri=4s), no failure of small bowel (SB) intubation was observed in IPICA vs. 11 patients (10.5%) in APICA group, yet statistical significance was not met (p=0.216). SB intubation time (defined as time from first image of anastomosis to first image of SB) was significantly shorter for IPICA (1.2±0.9 min) vs. APICA (3.0±3.0 min, p<0.001).

Conclusion

IPICA and APICA are comparable in procedural safety, anastomotic disease recurrence and rate of re-admissions. IPICA necessitates longer surgery time yet allows for significantly easier SB intubation with no intubation failure.

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).

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