Introduction

The majority of patients with Crohn`s disease (CD) undergo surgery at some point of their disease evolution. Timing of surgical procedure is currently at the centre of discussion, with the concept of surgery first showing promising results with regards to short-term quality of life and cost-effectiveness but it is unclear whether this approach can have long-term modifying effect on disease behaviour. With the enlargement of CD therapeutic armamentarium during the past years, the surgical procedure is often being delayed with unclear benefit for the patient.

Aims & Methods

The aim of this study was to determine whether the time to first surgery differ between patients with uncomplicated disease course compared with difficult-to-treat patients. All patients with CD followed at one tertiary IBD centre by March 2024 were identified through automated medical record system and patients with the history of IBD-related surgery were further analysed. Basic demographics, disease phenotype, surgical procedures and biologic use were retrieved from medical records. Surgical procedure of interest for this study purpose was defined as bowel resection of any localisation, stricturoplasty, proctectomy, gastro-enteroanastomosis. Patients with more than one surgical procedure and/or two or more biologics were categorized as difficult-to-treat; patients with one surgical procedure and no or one biologic were considered as patients with uncomplicated disease course. The differences in basic demographics, disease phenotype and time to surgery between the two groups were analysed statistically.

Results

In total 152 patients with a history of CD-related surgery were included; mean age 40 years (range 19-81), 57 (38%) men, mean duration of the disease 14,9 years (range 1-42), the majority of patients had stenosing or stenosing and penetrating disease behaviour (54% and 33%, respectively) and ileal or colonic localisation (53% and 38%, respectively). Thirty-nine patients (26%) had history of two or more surgeries.
Seventy-seven patients (51%) were considered as difficult-to-treat, there were no differences in disease localisation and behaviour between these patients and patients with uncomplicated disease course. Time to surgery was significantly longer in the difficult-to-treat group (6.5 ± SD 5.6 yrs) compared with the patients with uncomplicated disease course (3.8 ± SD 5.5 yrs); p=0.003. Among patients with uncomplicated disease course, significantly higher proportion of patients have been operated during the first year after diagnosis compared with difficult-to-treat patients (38 pts, 51% vs. 18 pts, 23%; p=0.000488).

Conclusion

Difficult-to-treat patients with Crohn`s disease have significantly longer time to surgery than patients with uncomplicated disease course. Considering the finding that these two groups do not differ in disease phenotype as risk factor for difficult-to-treat disease, delayed first surgery might be an independent factor for complicated disease course in these patients at long term.

Introduction

Several guidelines for the management of Crohn's disease (CD) recommend surgery in the presence of acute complications. However, in the absence of emergency situations, the optimal time to refer patients for resection surgery has not been established and the impact of delayed surgery remains unclear, especially outside the context of clinical trials.

Aims & Methods

Our study aims to assess the impact of the timing of resection surgery on early endoscopic recurrence. We conducted a single-center, retrospective study evaluating endoscopic outcomes of CD patients who underwent their first ileo-colonic resection. All patients underwent the first endoscopic evaluation within 6-12 months after surgery to assess post-operative recurrence (POR), using the Rutgeerts score (RS), with POR defined as RS ≥ 2.

Results

We included 134 patients. The most frequent reason for surgery was the presence of stenosis. All patients had at least one risk factor for POR, including smoking or penetrating disease. All patients were given prophylactic biological therapy (22% Infliximab, 53% Adalimumab, 8% Vedolizumab and 17% Ustekinumab). POR was observed in 50% of the entire cohort at 6-12 months. No significant difference in POR was found between the drugs administered. The mean time between diagnosis and surgery was 7.35 years +-7.13 years (SD). 52 patients were operated within 2.5 years after diagnosis and 82 afterwards. Comparing the two intervention times, surgery within 2.5 years had a significantly lower endoscopic recurrence rate at 6-12 months (p=0.014, OR: 0.44, 95% CI 0.22, 0.93). This difference remained significant even on multivariate analysis including other risk factors for POR (p=0.022, OR 0.45, 95% CI 0.23, 0.89).

Conclusion

In our real-life cohort, we found that early surgery correlated with a reduced risk of early endoscopic post-operative recurrence. Further prospective analyses on larger cohorts are needed to confirm this finding.

Introduction

Despite new therapeutic strategies, substantial proportion of patients with ulcerative colitis (UC) undergo colectomy at some point. Restorative proctocolectomy with ileal pouch ano anastomosis (IPAA) is regarded as intervention of choice in these patients. However, the disease conversion to Crohn´s disease (CD) is reported in up to one third of these patients who necessitate immune suppressive treatment after IPAA. Considering the life-long need for immune suppressive therapy in these patients, ileo-rectal anastomosis (IRA) would represent a good alternative to IPAA in this specific group of patients. Todate, no data are available to predict the UC-CD conversion. One of the possibility to reduce the risk of performing IPAA in patients developing CD in pouch is to use the modified two-stage proctocolectomy approach and identify patients who develop CD endoscopically between colectomy and the restoration of continuity.

Aims & Methods

The aim of the present study was to assess the UC-CD conversion rate identified prior IPAA via ileoscopy.
All patients with UC operated in one tertiary IBD center between 2016 and 2021 were identified in medical records. The main outcome was CD detected at ileoscopy between the first stage operation, i.e. total colectomy with terminal ileostomy and the restoration of continuity either via IPAA or IRA. The ileoscopy was performed between three to six months after colectomy. The secondary outcome was the rate of conversion to CD after IPAA or IRA.

Results

Sixty patients underwent total colectomy (mean age 41 years, range 22-77; 62% were men); seven patients were lost to follow-up, finally the data from 53 patients were analysed. The majority of these patients (36 - 68%) underwent colectomy for therapy resistent chronically active UC, 9 (17%) patients for acute severe UC, 2 patients had benign colonic stenosis, 5 had high-grade dysplasia or colorectal cancer detected at surveillance colonoscopy and one patient had extensive pseudopolyposis.
All resection specimen were reviewed and no histopathological features of CD were found. Three out of the 53 (6%) ileoscopically assessed patients prior IPAA or IRA were diagnosed with CD in prestomal terminal ileum. During the further follow-up, additional 4 patients developped CD, two after IPAA, one with definitive ileostomy in prestomal ileum and one in neoterminal ileum after IRA.
In total 7 out of 53 patients in this cohort developped CD (13%). Using the two stage approach with ileoscopy between colectomy and restoration of continuity, three out of these seven patients with CD convertion in this cohort were detected prior the decision on the type of second-stage operation.

Conclusion

The conversion from ulcerative colitis to Crohn`s disease occurs in a significant proportion of IBD patients after colectomy. Ileoscopy performed between the two stages of restorative proctolectomy is helpfull in detecting these patients and guiding the decision on the type of surgical intervention to restore continuity.

Disclosure

Nothing to disclose.

Introduction

Endoscopic postoperative recurrence (POR) of Crohn's disease (CD) occurs in up to 70% of patients within the first 12 months after ileocecal resection (ICR) with anastomosis if no prophylactic therapy is started. Early postoperative prophylaxis with thiopurines or anti-TNF agents may lower this number to 30-50%. However, scarce data on POR are available in the long-term.

Aims & Methods

To evaluate the long-term outcomes of patients without endoscopic POR at the first endoscopic assessment.
We performed a retrospective, observational study including consecutive CD patients undergoing ICR with anastomosis at four European referral centres since 1998. All patients underwent a first endoscopic assessment within 18 months from ICR demonstrating no endoscopic POR (Rutgeerts score i0-i1), and had a clinical follow-up ³24 months including at least one further endoscopic assessment. Main outcomes were endoscopic (Rutgeerts >i1), clinical (development of digestive symptoms together with a disease recurrence seen at endoscopic or radiological examination that prompted changes in the treatment) and surgical (new intestinal resection) POR, need for rescue therapy and “delayed POR” (any need for rescue therapy or clinical or surgical POR) during follow-up.

Results

One-hundred eighty-five patients were included (133 Rutgeerts i0, 52 Rutgeerts i1), of whom 88 (48%) started thiopurines or 17 anti-TNF (9%) early after surgery and 80 (43%) patients did not start any prophylactic therapy. No clinical risk factors for POR were present in 38%, whereas 27% met ³1 (active smoking, penetrating disease, perianal disease and/or previous ICR). By the last endoscopic assessment that was performed a median (IQR) of 58 (24-133) months after the first one, endoscopic POR was observed in 39% (17% i3-i4). Cumulative probability of remaining free of endoscopic POR in the total cohort was 97% at 1 year, 68% at 5 years and 61% at 10 years, from the index colonoscopy. During a median follow-up of 104 (IQR, 55-196) months, 30% of the patients developed clinical POR and 31% required rescue treatment (thiopurines in 14 patients, biological therapies in 43 and dose-escalation in 1). Cumulative probability of remaining free of clinical POR for the total cohort was 97.5% at one year, 81.8% at 5 years and 72.1% at 10 years. Finally, 5% of the patients had surgical POR at the end of follow-up.
In multivariate analysis, no risk factors were observed for endoscopic, severe endoscopic and surgical POR. However, early prophylactic treatment was protective for clinical POR (OR 0.54 [95%CI 0.32-0.96]; p=0.026) and need for rescue therapy (OR 0.43 [95%CI 0.23-0.79]; p=0.007), whereas a Rutgeerts score i0 at index ileocolonoscopy was the only factor that prevented from “delayed POR” (OR 2.00 [95%CI 1.18-3.31]; p=0.009).

Conclusion

Most patients without endoscopic POR after ICR will remain free of endoscopic and clinical POR in the long-term, although the risk steadily increases over time. Moreover, early postoperative prophylactic therapy seems to prevent the long-term risk of clinical POR and reduces the need for rescue therapies. Therefore, periodical non-invasive monitoring seems a suitable strategy for patients without endoscopic POR at the first postoperative endoscopic assessment, particularly if early prophylaxis was started or no endoscopic lesions (i0) were observed at index ileocolonoscopy.

Introduction

The use of infliximab (IFX) is limited by low treatment persistence. Proactive therapeutic drug monitoring (pTDM) has been shown to increase the treatment persistence in inflammatory bowel disease (IBD) patients but the real-life data evaluating effectiveness, safety and costs of this approach are scarce.

Aims & Methods

The aim of this study was to assess survival on treatment, safety and costs of pTDM of IFX in the treatment IBD.
IBD patients who started IFX in a referral centre using pTDM between January 2018 and March 2021 were included. The main outcomes were treatment persistence, adverse events and incremental costs of pTDM.
IFX trough levels were assessed in the week 14 and subsequently every six months by commercially available ELISA kit (Ridascreen R-Biopharm) and the intensification of treatment the cut-off of 3μg/ml was used.
Costs related to the measurements of levels and the costs of intensified treatment were calculated. The costs of pTDM were compared costs of a modelled cohort using reactive TDM (rTDM) based on the data from the same cohort. The model used arbitrarily determined intensification regimen to 5mg/kg of IFX every 4 weeks in pharmacokinetically determined clinical or endoscopic loss of response. The calculation was performed for the first year of treatment.

Results

Overall, 99 patients with IBD were included (58 men – 59%; mean age 39,96 years, minimum-maximum, 20-73 years; 64% patients with Crohn´disease; mean disease duration 103 months, minimum – maximum, 8-402 months).
The treatment was intensified in 57 patients (58%). Overall treatment survival with pTDM was 87% at 6 months, 77% at one year, 66% at two years and 60% at both, the third and fourth year of treatment. There were no differences between patients on conventional regimen vs. intensified regimen with regards to adverse events.
The costs related to pTDM in this cohort of 99 patients were € 90 306,56 while the costs of the modelled cohort using rTDM were € 24 846,30. The overall incremental costs were thus € 65 460,26 with mean costs per patient for the first year of treatment of € 661,21.

Conclusion

Proactive TDM of IFX results in a steady 60% treatment persistence beyond the second year of treatment with no impact on the safety.
In the context of this solid treatment persistence, the incremental costs related to proactive TDM seem negligible when considering the costs of alternative biologicals used in case of loss of response to IFX.

Disclosure

nothing to disclose

Introduction

Crohn’s disease (CD) is a chronic inflammatory bowel disease that may result in progressive bowel damage and complications requiring surgery. Despite an increasing number of available advanced targeted therapies, the literature reveals conflicting results concerning the prevalence of surgeries in CD.

Aims & Methods

The aim of the study was to examine the number of intestinal and perianal fistula surgeries in patients with CD in Austria from 2011 through 2019. We conducted a retrospective analysis of real-world data on surgery in CD patients of the Austrian health insurance funds (covering 98% of the Austrian population) from 2011 through 2019. Data before 2011 were unavailable, and the years after 2019 were excluded due to a potential influence caused by the coronavirus pandemic. All patients with a recorded CD-specific intestinal (bowel resection and/or stricturoplasty) or perianal fistula surgery and an ICD-10 diagnosis of CD(K50.x) during the observation period were included. We calculated the absolute number of operations per year, the prevalence per 100,000 persons of the Austrian population (the prevalence of CD in Austria is unknown) and the change in the operation rate per year.

Results

During the observation period, 4,812 intestinal and 4,802 perianal fistula operations were performed. We observed an increase of +8.8% and +58.9%, respectively, in bowel and perianal fistula operations from 2011 through 2019, see Table. If the numbers were adjusted for the increase of the Austrian population, the number of bowel operations remained stable (+1.9%), however, the number of perianal fistula operations still increased significantly (+48.8%).

Conclusion

Despite novel therapies, the number of patients requiring intestinal surgery for CD remained stable while the number of perianal fistula operations increased. A potential increase in the prevalence of CD in Austria, as described in other European countries, might reveal a decrease in the rate of intestinal surgeries.