Colorectal surgery

This chapter studies colorectal surgery. It begins with ulcerative colitis, Crohn’s disease, and other forms of colitis, before looking at colorectal polyps and colorectal cancer. Ulcerative colitis is an acute and chronic inflammatory disease originating in the co-lonic columnar mucosa; it is often precipitated by an apparent acute GI infection. Meanwhile, Crohn’s disease is a chronic inflammatory non-caseating, granulomatous disease affecting any part of the GI tract; it is associated with several extraintestinal disorders. The chapter then explains restorative pelvic surgery and minimally-invasive colorectal surgery. It also discusses diverticular disease of the colon; rectal prolapse; pilonidal sinus disease; fistula-in-ano; haemorrhoids; acute anorectal pain; acute rectal bleeding; acute severe colitis; and post-operative anastomotic leakage.

Optimising Early Management of Acute Severe Ulcerative Colitis in the Biologics Era: Admission Model for Intensification of Therapy in Acute Severe Colitis (ADMIT-ASC)

Background & aims: We aimed to determine whether changes in ulcerative colitis management have translated to improved outcomes, in order to develop a simple model to predict steroid non-response on admission. Methods: Outcomes of 131 adult ASC admissions (117 patients) in Oxford, UK between 2015-19 were compared with prospectively collected data from 1992-3. All patients received standard treatment with intravenous corticosteroids and endoscopic disease activity scoring (UCEIS). Steroid non-response was defined as receiving rescue medical therapy or surgery. A predictive model created in the Oxford cohort was validated in Australia and India (110 hospitalised patients Gold Coast University Hospital 2015-20; 62 hospitalised patients AIIMS, New Delhi 2018-20). Results: In the 2015-19 Oxford cohort, 71 (54%) patients received medical rescue therapy (27% ciclosporin, 27% anti-TNF), compared to 27% ciclosporin in 1992-3, p=0.0015. Only 15% required colectomy during admission vs 29% in 1992-3 (p=0.033). Admission CRP, albumin, and UCEIS scores predicted steroid non-response (FDR p=0.00066, 0.0066 and 0.015). A four-point model was developed involving CRP ≥ 100mg/L (1 point), albumin ≤ 25g/L (1 point), UCEIS ≥ 4 (1 point) or ≥ 7 (2 points). Scoring 0 or 4 was 100% predictive of steroid response and non-response, respectively, in all three cohorts. Patients scoring 3-4 had 83% risk of steroid non-response in Oxford and 84% (0.70-0.98) in the validation cohorts -- OR 11.9 (10.8-13). Conclusion: Colectomy rates for ASC have halved in 25 years, while use of rescue medical therapy has doubled. Patients who are highly unlikely to respond to parenteral steroid treatment alone may be readily identified on admission, to be prioritised for early intensification of therapy.

Endoscopic and Histologic Predictors of Outcomes in Pediatric Ulcerative Colitis—Caveat Emptor

The impact of endoscopic and histological mucosal healing on outcomes in adult settings is impressive. Despite many clinical parallels, pediatric ulcerative colitis (UC) is set apart from adult disease in several respects. Many frequently used indices are not fully validated, especially in pediatric settings, and consensus on precise definitions in clinical settings are lacking. Endoscopic mucosal healing is an acceptable long-term treatment goal in pediatrics, but not histologic normalization. Early prediction of disease course in UC may allow treatment stratification of patients according to risks of relapse, acute severe colitis, and colectomy. Putative endoscopic and histologic predictors of poor clinical outcomes in adults have not held true in pediatric settings, including baseline endoscopic extent, endoscopic severity, and specific histologic characteristics which are less prevalent in pediatrics at diagnosis. In this mini-review we appraise predictive endoscopic and histologic factors in pediatric UC with reference to relapse, severe colitis, and colectomy risks. We recommend that clinicians routinely use endoscopic and histologic sores to improve the quality of clinical and research practice. The review summarizes differences between adult and pediatric prediction data, advises special consideration of those with primary sclerosing cholangitis, and suggests areas for future study in this field.

DOP50 Recommencement of Inflammatory Bowel Disease medications following colectomy for Ulcerative Colitis

Background Total colectomy (TC) is often considered a curative procedure for patients with chronic refractory ulcerative colitis (UC) or acute severe colitis. Chronic pouchitis and de novo Crohn’s disease (CD) are well recognized sequelae following TC, yet the true incidence of these are poorly characterized in large population models. We assessed the rate of subsequent utilization of IBD medications as a proxy marker of clinically significant pouchitis or de novo CD following TC for UC. Methods This study utilized data from the Epi-IIRN project, a meta-database incorporating patient data from all four health maintenance organisations (HMO) in Israel, representing 98% of the population. We included all patients identified in the prevalence cohort with an initial diagnosis of UC who underwent TC from January 2000, with ≥ 6 month follow-up. Primary outcome was utilization of IBD medications (including thiopurines, methotrexate, infliximab, adalimumab, vedolizumab, ustekinumab and tofacitinib) following TC. Secondary outcomes were time to commencement of medications, hospitalizations and repeated surgery. Potential predictors of IBD medication use were identified using multivariable models. Results Overall 23,506 patients with UC were identified in the prevalence cohort of whom 456 patients underwent TC for UC and were included in our analysis. 51% of our sample were female, with a median follow up of 8.5 years (IQR 3.8–13.2) and 3956 patient-years. Median age at UC diagnosis was 44.1 (26.5–56.2) years and at TC was 50.2 (34.2–61.7). IBD medications were commenced in 88 (19%) of patients, including 54 (12%) biologics, 56 (12%) immunomodulators and 3 (1%) tofacitinib. A diagnosis of CD was formally assigned to 65 (75%) of these patients. The need for IBD medications was gradual (figure 1). Patients recommenced on IBD medications were younger at diagnosis (30.3 years (18.3–49.7) vs 41.4 (24.2–55.6), p<0.001), at colectomy (34.3 (21.5–54.1) vs 47.5 (30.4–60.6), p<0.001) and with shorter interval from UC diagnosis to TC (2.2 years (1.0–3.3) vs 2.8 (1.4–5.1), p=0.03). TC during childhood was performed in 33 (7%) patients and these had higher utilization of IBD medications post TC (16/33 (49%) vs 72/423 (17%), p=0.001). Conclusion In this nationwide analysis we show that almost 20% of patients require ongoing IBD medications following TC for UC. Younger age is associated with higher rate of subsequent medication use. Patient expectations need be adjusted to account for the potential ongoing requirement of long-term medication following TC.

P391 Antibiotics in pediatric Inflammatory Bowel Diseases: a systematic review

Background Dysbiosis is the central concept in the current thinking regarding IBD pathogenesis. Current available therapies in pediatric Inflammatory Bowel Disease (IBD) focus on targeting the immune system by suppressing the immune response and often fail to sustain long term remission. Antibiotics directly target bacteria but are underrepresented in current (pediatric and adult) IBD treatment guidelines. We aimed to describe available evidence concerning the use of antibiotics in the treatment of pediatric IBD. Methods We systematically assessed efficacy and safety of antibiotics in pediatric IBD. CENTRAL, EMBASE (Ovid) and Medline (Pubmed) were searched for Randomized Controlled Trials (RCTs). Quality assessment of included articles was conducted with the Cochrane risk-of-bias tool. Results Two RCT’s (n=101, 4.4-18 years, 43% male) were included. Both studies had overall low risk of bias. In mild-to-moderate Crohn’s disease, azithromycin+metronidazole (AZ+MET) (n=35) compared to metronidazole (MET) alone (n=38) did not induce a significantly different response (PCDAI drop ≥12.5 points or remission) (p=0.07). For induction of remission (PCDAI≤10), AZ+MET was more effective than MET (p=0.025). In Acute Severe Colitis, the mean 5-day PUCAI was significantly lower in the antibiotic (vancomycin, amoxicillin, metronidazole, doxycycline)+intravenous corticosteroids (IVCS) group (n=16) compared to IVCS (n=12) alone (p=0.037), whereas remission (PUCAI<10) did not differ (p=0.61). No significant drug-related adverse events were reported. Conclusion Our results highlight the lack of evidence in pediatric IBD. More evidence is needed to assess if implementation in daily practice is necessary.

P186 Inflammatory Bowel Disease Care in the Covid-19 pandemic era: Experience from a Tunisian gastroenterology department

Background The coronavarius disease (COVID-19) pandemic has brought forth a multitude of challenges for both patients having inflammatory bowel disease (IBD) and clinicians involved in their care. The national-wide lockdown in Tunisia, from Mars to Mai 2020 had substantially decreased healthcare accessibility and drugs availability. In addition, the uncertainty caused by the COVID-19 pandemic was likely to lead to anxiety and negative emotional and behavioral reactions which are thought to be predictors of active IBD and relapses. We aimed to assess the hospital admission and complication rates in patients with IBD during the first wave of COIVD-19 infection in Tunisia and to compare them to those observed during the same period one year earlier. Methods We retrospectively analyzed the clinical features of patients with IBD admitted to our department during the period of time following the national lock-down in Tunisia ( from Mai, the 4th to August, the 31th). We compared the total global admission rate, IBD related complications, surgery rates and postoperative complications between the study period (P1) and the corresponding period of the previous year (P2 : from Mai, the 4th to August, the 31th, 2019). The Chi square test and Fisher exact test were used for analysis of categorical data. Results Eighty patients with IBD were included in this study (44 patients in P1 and 36 patients in P2), 73.7% of which (n=59) had Crohn disease. The sex ratio was 1.16 and the mean age was33.8 years ± 11.9. The mean follow-up period was 5 years. In 17.5% of cases (n=14), the IBD was diagnosed during the admission. None of the P1 patients had tested positive for SARS-CoV-2. The incidence of hospitalizations during P1 was 2.6 per week. It was greater than that of P2 but without the difference being statistically significant (2.1 admissions per week; incidence rate ratio: 0.34; 95% CI: 0.67-1.2; p = 0, 54). A total of 31 complications were noted (19 in P1 vs 12 in P2; p=0,489). The complications were as follows: 19 cases of acute severe colitis (12 in P1 vs 7 in P2 ; p= 0,234), 8 cases of intra-abdominal abscesses (6 in P1 vs 2 in P2 ; p=0,234), 4 cases of acute intestinal obstruction (1 in P1 vs 3 in P2 ; p=0,322). Among patients who had presented an acute severe colitis, 6 had undergone subtotal colectomy (6 in P1 vs 0 in P2, p=0,006). Conclusion Our study showed that during the pandemic period, there was an increase in the incidence of hospitalizations of patients with IBD as well as a significant increase in the need for surgery in severe acute colitis. These results should be taken into account so that IBD management strategies can be adjusted accordingly, if the COVID-19 pandemic persists or recurs, or in case of future outbreaks.

Managing IBD therapy during pregnancy demands a multidisciplinary approach

Crohn’s disease and ulcerative colitis are both chronic inflammatory bowel diseases (IBD). This article summarizes current best practice in treating pregnant patients with IBD, ranging from conservative therapy to endoscopy and imaging methods, including a description of surgical therapy indications. Female patients with IBD should ideally plan their pregnancies for when their disease is in remission. Patients in remission may also have complications during pregnancy, however the risk of complications is lower than in patients with active disease. Any chronic medications they were on before becoming pregnant (with the exception of teratogenic methotrexate) should remain unchanged. According to the current literature, pregnancy does not itself complicate the course of IBD. In cases of a severe relapse or an occurrence of complications in these patients, careful multidisciplinary cooperation is required, especially between the gastroenterologist, surgeon, radiologist, and gynaecologist. Surgical treatment is required only in cases of acute complications of IBD (such as acute severe colitis resistant to medical therapy, perianal abscess, and complications of IBD in the sense of such acute abdomen events as perforations, ileus due to a stenosis, or massive haemorrhage).