Resection Provides Better Long-Term Outcomes in Early Ileocecal CD
Manasi Agrawal, MD, MS, and colleagues aimed to examine the long-term benefit of ileocecal resection
compared with anti-TNF therapy in early Crohn’s disease. They used data from Danish registries over a
15-year period (2003–2018) that included patients with CD who were treated with one of these options as
primary treatment between 30 days before and 1 year after diagnosis. The primary outcome consisted of a
composite of CD-related hospitalization, CD-related surgery, perianal CD, and use of systemic corticosteroids.
The study criteria requiring pathology-confirmed ileocecal CD location and exclusion of perianal disease
led to a final cohort of 581 patients with resection and 698 with first-line anti-TNF treatment. “The
incidence rate for the primary outcome was 110/1,000 patient years in the resection group and 202/1,000
patient years in the anti-TNF group,” Dr. Agrawal stated. The regression analysis resulted in a
corresponding adjusted HR of 0.67 favoring resection. Differentiating between the individual components
of the primary outcome, significant results were found for two of four factors: exposure to systemic
corticosteroids was 29% lower and CD-related surgery was 44% lower in the resection group. Of note, half
of the patients who underwent resection were on no treatment at 5 years post-surgery, 17% had anti-TNF
therapy, and 48% were on immunomodulators. In her summary, Dr. Agrawal suggested discussing the option of
ileocecal resection as a first-line therapeutic option with patients with early ileal and ileocecal CD.
Novel AI Tool Proves Valuable in Scoring Histological Images in UC
Mucosal healing is an emerging treatment goal in the management of ulcerative colitis. One of the most
widely used scores to evaluate this endpoint is the Nancy score, which allows assessment of acute and
chronic inflammatory disease activity in the mucosa. However, scoring histological images is not only
time-consuming but also requires pathologist training. Moreover, there is inter- and intra-observer
variability. Laurent Peyrin-Biroulet, MD, PhD, and his team assessed whether an artificial intelligence
(AI) tool using image processing and machine learning algorithms that assigns a Nancy index value to \
histopathology slides might be helpful in assessing histological disease activity. Eight global sites
submitted 600 UC histological images, which were added to the 200 images used in a smaller preliminary
study. Almost all probes (90%) were used for training the algorithm and 10% for testing. Cell and tissue
regions of each training image were manually assessed by three histopathologists and assigned a Nancy
index. These results were used to further train the AI, allowing it to fully characterize histological
images, identify tissue types, cell types, cell numbers and locations, and measure the Nancy Index for
each image. The average intra-class correlation was 92.1% among the histopathologists and 91.1% between
the histopathologists and the AI tool in all stages of disease progression. An even higher consensus was
achieved at the extremes of the Nancy index.
Most CD Strictures Respond to Drug Treatment
The randomized STRIDENT study aimed to assess the response of Crohn’s disease strictures to drug therapy.
Julien Schulberg, MD, and colleagues presented 2-year data, in which patients were randomized either to
receive a high dose adalimumab induction (160 mg weekly for 4 weeks) followed by 40 mg every 2 weeks plus
thiopurine, with an adalimumab dose increase at 4 and/or 8 months if there was evidence of ongoing
inflammation (N=52), or standard dose adalimumab monotherapy (N=25). The primary study endpoint—obstructive
symptoms score at 12 months—was achieved by 79% of patients in the intensive arm compared with 64% in the
standard arm. “The majority of patients had symptomatic improvement and improvement was more likely in the
intense treatment arm,” Dr. Schulberg said. In addition, fewer patients had treatment failure at 12
months in the intense treatment arm. Between 12 and 24 months, only three patients in the intensive arm
stopped adalimumab, but 13 decreased the dose. In the first 12 months, 9% of patients had surgery, and a
further 10% in the next 12 months. Patients with a clinical response at 12 months were less likely to
have surgery at 2 years (9% vs 42%; P=0.003). However, rates of surgery were not different between arms
at 2 years. Intense treat-to-target treatment results in reduced treatment failure, less inflammation,
and better stricture morphology. Moreover, stricture bowel damage is often reversible, with 20% of patients
achieving objective complete stricture resolution.
Biologic Therapy Has No Impact on Early Postop Complications in CD
Although it is widely recognized that TNF blockers are not associated with an increased risk for postoperative
complications, data from patients with CD treated with newer agents like vedolizumab and ustekinumab are
more limited, heterogenous, and controversial. Therefore, Mathurin Fumery, MD, and colleagues evaluated
the impact of preoperative biological therapy with TNF blockers, vedolizumab, and ustekinumab on the risk
for postoperative complications. In addition, they aimed to identify patient- and surgery-related factors
that might impact outcomes. In their retrospective nationwide study across 23 centers, they assessed all
consecutive patients who underwent intestinal resection for CD between July 2014 and April 2022 and
assessed early post-operative complications (≤30 days) in different cohorts according to intake of TNF
blockers, vedolizumab, or ustekinumab. Data for 1,201 patients was analyzed. Strictures were the most
frequent reasons for surgery (52%). In total, 26.4% of patients suffered from an early post-operative
complication and 10% had at least one severe complication. Regardless of the receipt of biologics,
abdominal septic complications were the most frequent complication. Factors associated with complications
in the multivariate analysis were age (OR, 1.17), disease activity (OR, 8.36), abscess (OR, 2.01), and
an initial stoma (OR, 1.07). In contrast, preoperative exposure to TNF blockers and the newer biologics
vedolizumab and ustekinumab within 3 months before surgery was not associated with an increased risk for
early post-operative complications. Conversely, preoperative enteral nutrition could be identified as a \
protective factor associated with a relative risk reduction of 88% for intra-abdominal infectious
complications.
IBD Procedures Decline Overall During COVID-19 Pandemic
Iris Nagtegaal, PhD, and colleagues used data from the Dutch pathology result registry PALGA to investigate
the influence of the COVID-19 pandemic on healthcare use by patients with IBD. The investigation
addressed endoscopic and surgical procedures, as well as new diagnoses of IBD or neoplasms. Findings from
patients with IBD within the registry during the pandemic (March 2020 to February 2022) were compared
with incidences from March 2018 to February 2020. Out of nearly 95,000 IBD-related procedures, 94.2% were
endoscopic; the rest were surgical. Overall, during the pandemic, procedures occurred 2.9% less frequently.
This reduction was mainly influenced by fewer endoscopies. However, the net difference did not stem from
a constant reduction over the 2 pandemic years, but from two opposing trends. The first COVID-19 year led
to 6.2% fewer endoscopic and 1.3% fewer surgical procedures. In the second year, a net increase followed,
leading to +0.02% (endoscopies) and +2.7% (surgeries). Years 1 and 2 also saw a decline in new IBD diagnoses
: -0.8% and -1.0%, respectively. No net difference in the detection of colorectal cancers and high-grade
dysplasia were observed. However, the 2 COVID-19 years differed substantially in diagnoses of indefinite \
or low-grade dysplasias: -10.9% (year 1) and +7.1% (year 2). The data demonstrated that the meaningful
lessening of IBD-related healthcare utilization between the time before the pandemic and the first 12
months of COVID-19 was somewhat alleviated during the pandemic’s second year.
