Pritesh Morar

Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures

Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohns strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies.

Determining Predictors for Intra-abdominal Septic Complications Following Ileocolonic Resection for Crohn’s Disease—Considerations in Pre-operative and Peri-operative Optimisation Techniques to Improve Outcome

BACKGROUND AND AIMS Intra-abdominal septic complications [IASC] following ileocolonic resection for Crohns disease are common. Determining risk factors for these complications can aid pre-operative and peri-operative strategies to reduced morbidity. This study aims to determine the incidence and predictors of intra-abdominal septic complications following ileocolonic resection for Crohns disease. METHODS A single-centre, retrospective study was conducted. The clinical case notes of patients with histopathologically proven Crohns disease, who underwent an ileocolonic resection as a one-stage or two-stage procedure, were reviewed. The primary endpoint was the formation of intra-abdominal septic complications within a 30-day post-operative time frame. RESULTS Overall 163 patients underwent 175 ileocolonic procedures. Post-operative intra-abdominal septic complications were demonstrated in 9% [13/142] of one-stage procedures and 12% [4/33] of two-stage procedures [p = 0.2]. Post-operative IASCs following a one-stage procedure demonstrated associations with smokers [p = 0.004], intraoperative abdominal sepsis [p = 0.005], concomitant upper gastrointestinal Crohns [p = 0.015], the presence of peri-operative anaemia [p = 0.037], hypoalbuminaemia [< 25g/l] [p = 0.04], and histologically involved margins [p = 0.001]. Multivariate analysis demonstrated the presence of intra-abdominal sepsis (hazard ratio [HR] 8.6, 95% confidence interval [CI]: 1.2 60.1] and the use of peri-operative biologicals [HR 24.6, 95% CI: 2.0-298] as independent predictors of post-operative intra-abdominal septic complications. CONCLUSIONS This study highlights specific variables that may be contributory to poor outcome. These findings may be important when optimising patients for surgery, as well as planning an appropriate operative strategy. Further prospective studies and a larger sample size are required to validate these findings.

Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial

BACKGROUND Treatment of patients with ileocaecal Crohns disease who have not responded to conventional therapy is commonly scaled up to biological agents, but surgery can also offer excellent short-term and long-term results. We compared laparoscopic ileocaecal resection with infliximab to assess how they affect health-related quality of life. METHODS In this randomised controlled, open-label trial, in 29 teaching hospitals and tertiary care centres in the Netherlands and the UK, adults with non-stricturing, ileocaecal Crohns disease, in whom conventional therapy has failed were randomly allocated (1:1) by an internet randomisation module with biased-coin minimisation for participating centres and perianal fistula to receive laparoscopic ileocaecal resection or infliximab. Eligible patients were aged 18-80 years, had active Crohns disease of the terminal ileum, and had not responded to at least 3 months of conventional therapy with glucocorticosteroids, thiopurines, or methotrexate. Patients with diseased terminal ileum longer than 40 cm or abdominal abscesses were excluded. The primary outcome was quality of life on the Inflammatory Bowel Disease Questionnaire (IBDQ) at 12 months. Secondary outcomes were general quality of life, measured by the Short Form-36 (SF-36) health survey and its physical and mental component subscales, days unable to participate in social life, days on sick leave, morbidity (additional procedures and hospital admissions), and body image and cosmesis. Analyses of the primary outcome were done in the intention-to-treat population, and safety analyses were done in the per-protocol population. This trial is registered at the Dutch Trial Registry (NTR1150). FINDINGS Between May 2, 2008, and October 14, 2015, 73 patients were allocated to have resection and 70 to receive infliximab. Corrected for baseline differences, the mean IBDQ score at 12 months was 178·1 (95% CI 171·1-185·0) in the resection group versus 172·0 (164·3-179·6) in the infliximab group (mean difference 6·1 points, 95% CI -4·2 to 16·4; p=0·25). At 12 months, the mean SF-36 total score was 112·1 (95% CI 108·0-116·2) in the resection group versus 106·5 (102·1-110·9) in the infliximab group (mean difference 5·6, 95% CI -0·4 to 11·6), the mean physical component score was 47·7 (45·7-49·7) versus 44·6 (42·5-46·8; mean difference 3·1, 4·2 to 6·0), and the mean mental component score was 49·5 (47·0-52·1) versus 46·1 (43·3-48·9; mean difference 3·5, -0·3 to 7·3). Mean numbers of days of sick leave were 3·4 days (SD 7·1) in the resection group versus 1·4 days (4·7) in the infliximab group (p<0·0001), days not able to take part in social life were 1·8 days (6·3) versus 1·1 days (4·5; p=0·20), days of scheduled hospital admission were 6·5 days (3·8) versus 6·8 days (3·2; p=0·84), and the number of patients who had unscheduled hospital admissions were 13 (18%) of 73 versus 15 (21%) of 70 (p=0·68). Body-image scale mean scores in the patients who had resection were 16·0 (95% CI 15·2-16·8) at baseline versus 17·8 (17·1-18·4) at 12 months, and cosmetic scale mean scores were 17·6 (16·6-18·6) versus 18·6 (17·6-19·6). Surgical intervention-related complications classified as IIIa or worse on the Clavien-Dindo scale occurred in four patients in the resection group. Treatment-related serious adverse events occurred in two patients in the infliximab group. During a median follow-up of 4 years (IQR 2-6), 26 (37%) of 70 patients in the infliximab group had resection, and 19 (26%) of 73 patients in the resection group received anti-TNF. INTERPRETATION Laparoscopic resection in patients with limited (diseased terminal ileum <40 cm), non-stricturing, ileocaecal Crohns disease in whom conventional therapy has failed could be considered a reasonable alternative to infliximab therapy. FUNDING Netherlands Organisation for Health Research and Development.

Concomitant colonic disease (Montreal L3) and re-resectional surgery are predictors of clinical recurrence following ileocolonic resection for Crohn's disease.

Ileocolonic resection is reserved for patients with moderate to severe Crohns disease. Postoperative clinical recurrence can occur in up to 55% of patients within 5 years. Predicting the risk of recurrence is key in deciding upon appropriate treatment strategies. This study aims to determine the incidence of postoperative clinical recurrence and predictors of recurrence in a specialist institution.

Establishing Key performance indicators [KPIs] and their importance for the surgical management of inflammatory bowel disease - Results from a Pan-European, Delphi Consensus Study

Background and Aims Key performance indicators [KPIs] exist across a range of areas in medicine. They help to monitor outcomes, reduce variation, and drive up standards across services. KPIs exist for inflammatory bowel disease [IBD] care, but none specifically cover inflammatory bowel disease [IBD] surgical service provision. Methods This was a consensus-based study using a panel of expert IBD clinicians from across Europe. Items were developed and fed through a Delphi process to achieve consensus. Items were ranked on a Likert scale from 1 [not important] to 5 [very important]. Consensus was defined when the inter quartile range was ≤ 1, and items with a median score > 3 were considered for inclusion. Results A panel of 21 experts [14 surgeons and 7 gastroenterologists] was recruited. Consensus was achieved on procedure-specific KPIs for ileocaecal and perianal surgery for Crohns disease, [N = 10] with themes relating to morbidity [N = 7], multidisciplinary input [N = 2], and quality of life [N = 1]; and for subtotal colectomy, proctocolectomy and ileoanal pouch surgery for ulcerative colitis [N = 11], with themes relating to mortality [N = 2], morbidity [N = 8], and service provision [N = 1]. Consensus was also achieved for measures of the quality of IBD surgical service provision and quality assurance in IBD surgery. Conclusions This study has provided measurable KPIs for the provision of surgical services in IBD. These indicators cover IBD surgery in general, the governance and structures of the surgical services, and separate indicators for specific subareas of surgery. Monitoring of IBD services with these KPIs may reduce variation across services and improve quality.

Defining the optimal design of the inflammatory bowel disease multidisciplinary team: results from a multicentre qualitative expert-based study

Objective To elicit expert views to define the aims, optimal design, format and function of an inflammatory bowel disease (IBD) multidisciplinary team (MDT) with the overall purpose of enhancing the quality of MDT-driven care within an IBD service provision. Design This study was a multicentre, prospective, qualitative study using a standard semistructured interview methodology. Participants A multidisciplinary sample of 28 semistructured interviews of which there are six consultant colorectal surgeons, six IBD nurse specialists, seven consultant gastroenterologists, five consultant radiologists and four consultant histopathologists. Setting Participants were recruited from 10 hospitals, which were a mixture of community hospitals and specialist IBD centres between June and October 2013. Results Experts argued that the main goal of MDT-driven IBD care is to improve patient outcomes via sharing collective expertise in a formalised manner. Themes regarding the necessary requirements for an IBD MDT to occur included good attendance, proactive contribution, a need to define core members and appropriate and functional computer facilities. Emergent themes regarding the logistics of an effective IBD MDT included an eligibility criterion for case selection and discussion and appropriate scheduling. Themes regarding the overall design of the IBD MDT included a ‘hub-and-spoke’ model versus a ‘single-centre’ model. Conclusions Defining key elements for an optimal design format for the IBD MDT is necessary to ensure quality of care and reduce variation in care standards. This study has produced a set of expert-based standards that can be used to structure the IBD MDT. These standards now require larger scale validation and consensus prior to becoming a practical guideline for the management of IBD care.

Establishing the aims, format and function for multidisciplinary team-driven care within an inflammatory bowel disease service: a multicentre qualitative specialist-based consensus study

Objective To obtain a specialist-based consensus on the aims, format and function for MDT-driven care within an inflammatory bowel disease (IBD) service. Design This was a prospective, multicentre study using a Delphi formal consensus-building methodology. Setting Participants were recruited nationally across 13 centres from July to August 2014. Participants 24 participants were included into the Delphi Specialist Consensus Panel. They included six consultant colorectal surgeons, six gastroenterologists, five consultant radiologists, three consultant histopathologists and 4 IBD nurse specialists. Interventions Panellists ranked items on a Likert scale (1=not important to 5=very important). Items with a median score >3 were considered eligible for inclusion. Main outcome measures Consensus was defined with an IQR ≤1. Consensus on categorical responses was defined by an agreement of >60%. Results A consensus on items (median; IQR) that described the aims of the MDT-driven care that were considered very important included: advance patient care (5;5-5), provide multidisciplinary input for the patient’s care plan (5;5-5), provide shared experience and expertise (5;5-5), improve patient outcome (5;5-5), deliver the best possible care for the patient (5;5-5) and to obtain consensus on management for a patient with IBD (5;4-5). A consensus for being a core MDT member was demonstrated for colorectal surgeons (24/24), radiologists (24/24), gastroenterologists (24/24), nurse specialists (24/24), dieticians (14/23), histopathologists (21/23) and coordinators (21/24). Conclusions This study has provided a consensus for proposed aims, overall design, format and function MDT-driven care within an IBD service. This can provide a focus for core members, and aid a contractual recognition to ensure attendance and proactive contribution.

PWE-094 Setting Standards By Defining The Aims And Optimal Design Of The Inflammatory Bowel Disease (ibd) Multidisciplinary Team (mdt) Meeting

Introduction The National IBD Audit revealed 75% of participating institutions undertake a weekly MDT meeting for IBD patients. There is however little evidence of its efficacy in this context and currently there is no guidance on how this intervention may be standardised and used effectively.1–3 Providing a standardised framework for the IBD MDT meeting will enhance its capacity to establish effective quality improvement. The aim of this study is to use national expert consensus to define the aims, optimal design, format and function of an IBD MDT meeting. Methods 25 semistructured interviews were undertaken with a multidisciplinary sample (5 surgeons, 5 gastroenterologists, 5 IBD nurse specialists, 5 pathologists and 5 radiologists), from 2 UK regions: the Southwest of England and London. Interviews were audiotaped and transcribed verbatim. A standardised interview protocol with a clearly defined coding framework was used. The interview protocol explored key themes encompassing the optimal design format of the IBD MDT: Purpose Processes Logistics Redesign Results 28 interviews were performed across a multidisciplinary sample of healthcare professionals. Thematic analysis and coding demonstrated common markers for each theme. High ranking markers for each theme included: Purpose: Requires multi-disciplinary input; to share collective expertise; and to improve patient outcome. Processes: Good attendance; sharing workload with colleagues; proactive discussions; core members being clinicians, surgeons, radiologists, pathologists and nurse specialists all with IBD interests; facilities required including IT and an appropriate space to meet; provisions for internal feedback to the IBD MDT on MDT decision outcomes; submitting names in advance; an MDT coordinator. Logistics: Duration of 1 h; once a week; protected time; selective cases. Redesign: Single centre each running their own IBD MDT; ‘hub and spoke’ model. Conclusion Defining key elements for an optimal design format for the IBD MDT is necessary to ensure quality of care and reduce variation in care standards. This study demonstrates the methodology used for construction of provisional standards for the IBD MDT through interviews from a multidisciplinary group. Selection and adjustments of these standards through expert consensus are required to validate measures. References UK IBD Steering Group 2007 IBD Audit 2006: National Results for the Organisation and Process of IBD Care in the UK Group 2009 IBD Audit 2008: National Results for the Organisation and Process of IBD Care in the UK IBD Standards Working Group 2009 Quality Care: Service Standards for the Healthcare of People who have Inflammatory Bowel Disease (IBD) Disclosure of Interest None Declared.

Issues Surrounding Postoperative Therapy in Crohn's Disease to Prevent Recurrence

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Letter of Response to Article: Preoperative Magnetic Resonance Enterography in Predicting Findings and Optimizing Surgical Approach in Crohn’s Disease

We commend Spinelli and colleagues on their study on preoperative MRI enterography for presurgical planning in patients with Crohn’s disease. The independent blind reporting provides strength to the study. We have several points for the author’s consideration. Firstly, did the authors consider the use of magnetic resonance enteroclysis? Another study of preoperative MRI interpretation achieved 100 % sensitivity and 100 % specificity usingMR enteroclysis (MRE) with nasojejunal administration of polyetylenglycol solution. This can significantly improve preoperative diagnostic accuracy of preoperative planning. Second, the specificity and sensitivity of any study are dependent on the incidence of complex pathology. Your series predominantly comprises of small bowel and ileocolic stenosis. Therefore, we would recommend further validation with a more complex disease case mix. In addition to test the generalizability of this study, we suggest validation with generalist as well as specialist IBD radiologists and possibly external validation of the cases and images at another centre. Was there any correlation between scans with radiologist disagreement and change in the operative approach? If so, this could highlight cases which possibly require further imaging, possibly by MRE. Third, there was excellent agreement in the identification of stenosis and fistula (k>0.80), but less so for the detection of abscesses (k=0.61–0.80). This is clinically important as patients with intra-peritoneal abscesses identified on MR were operated directly by the open approach. One can convert from laparoscopic to open, but not vice versa. Was there any data to suggest that cases of false positive MRI findings could have been approached laparoscopically in retrospect? In recent years, we have favoured a laparoscopic first approach in our institution in the hands of experienced laparoscopic IBD surgeons. We thank the authors again for their contribution to the important issue of preoperative imaging to assist surgical planning in patients with Crohn’s disease.