Exabis Library

Surgery is highly effective in treating Crohn’s disease, but is not curative, and up to half of the patients would suffer from surgical recurrence, and will require additional surgery. Redo surgery for Crohn’s is challenging, and may include cases who already had multiple surgeries, potentially with intraperitoneal mesh ventral hernia repairs, and imminent short bowel, and this is where sound surgical judgment, combined with superb technical skills are required.

Laparoscopy is a valid option for redo cases. However, even in experienced laparoscopic teams, approximately ¼ to 1/3 of the redo Crohn’s cases are being converted. Convertion should be pre-emptive, before complication occurs, instead of converting because an intraoperative complication has already been occurred.

In redo case, the length of the bowel becomes a prominent issue, and the surgeon should be as bowel preserving as possible on one hand, yet effective to induce remission on the other. Strictureplasty should be considered whenever possible.  Side-to-side isoperistaltic strictureplasty results in 37% surgical recurrence in a mean follow-up of 11 years, 1/3 of them were amenable for a second strictureplasty. In Strictureplasty over the ileocecal valve,  14% required additional surgery.

If strictureplasty is not feasible, and resection is mandatory, the common belief is that a large side-to-side anastomosis is associated with better long-term patency. However, The Kono-S anastomosis, preserving the mesentery, has been recently assessed in the SuPREMe-CD trial. At 18 months follow-up, endoscopic recurrence was found in only 25% of the Kono-S patients, compared to 67% in the conventional anastomosis group. This was translated to a significantly lower rate of surgical recurrence in 2 years. On the other hand, Coffey suggested that radical mesenteric resection was associated with significantly lower rate of surgical recurrence compared to historical control. Redo Crohn’s surgery requires experience and expertise, and should be done by dedicated and experienced IBD surgeons.

1. To understand the challenges of redo surgery for Crohn's disease 
2. To review the use of laparoscopy for redo surgery for Crohn's disease 
3. To discuss bowel length preserving techniques in surgery for Crohn's disease 
4. To discuss the long term results of different types of anastomosis for  surgery for Crohn's disease 

1. To understand why relationships, intimacy and sexuality are important to those living with IBD
2. To discuss the sexual well-being concept
3. To review the current evidence on sexual well-being concerns from patient perspective
4. To review the current evidence of meeting sexual well-being and family planning care needs
5. To have an overview of optimal strategies to provide holistic care incorporating aspects of sexual well-being

 
 1.  To introduce changing targets for remission 

  2. To discuss  impact of `deep` remission in UC and CD

  3.  Describe challenges to meeting new targets 

In asymptomatic patients with inflammatory bowel disease, monitoring involves repeated testing aimed at early recognition of a disease flare. The ultimate goal is to restore disease remission as early as possible and to prevent disease progression. Commonly used biomarkers to assess IBD activity include C-reactive protein (CRP) and fecal calprotectin (FC).

Classically, these diagnostic tests are performed in hospital laboratories where quality-control procedures apply. Recently, FC home testing has become available, allowing patients to measure IBD activity themselves. To establish a remote monitoring service that provides reliable results for correct clinical decision-making, a number of essential quality criteria must be met. In this presentation I outline the principles to good remote monitoring and illustrate those principles with an example from practice.

Educational objectives: 

1. To discuss 10 things to know before starting a remote monitoring service
2. To understand that setting up a remote FC monitoring service requires cooperation between health professionals, laboratory and medical IT specialists.
3. To emphasise that measuring biomarkers without accepting the consequences of the result is a waste of money.

Educational Objectives:


1. Definition of remote monitoring

2. Patient´s view: what would I expect

3. Early relevant telemedicine IBD papers

4. Role of calprotectin (point of care testing, POCT)

5. Does POCT affect medical therapy?

6. Lipocalin 2: a new fecal stool marker in IBD?

7. Patient´s view: where do I see the future?

8. Remaining challenges

Educational objectives:
1. To understand the process of research application preparation
2. To have an overview of good research application for funding
3. To have an overview of the research funder's requirements 

4. To continue the networking in the Senior group of nurses in research
5. To find different kind of collaborations in the group

Educational objectives: 

1. To develop a Patient-reported outcome measures (PROM) to assess disease activity in microscopic colitis (MC) fulfilling the requirements of the Food and Drug Administration (FDA).

The European Microscopic Colitis Activity Index (E-MCAI) was developed in four steps: 1) A list of symptoms associated with active MC was created by a group of experts in the field. 2) Content validity of the symptoms was performed by experts (n=14) and patients (n=79) using the Content Validity Index. 3) Questions and response alternatives were created for each symptom, and validity of the E-MCAI was evaluated with cognitive interviews with patients (n=7) and by the experts. 4) A pilot postal survey was performed to ensure usability.

Seven of the symptoms related to active MC fulfilled the criteria for content validity and were included in the E-MCAI: stool consistency, stool frequency, stools at night, feel a need to pass more stools shortly after a bowel movement, urgent need to empty the bowel, leakage of stool, and abdominal pain. The development and validation process resulted in the current version of the E-MCAI consisting of six questions related to MC.

The E-MCAI was developed using the methods advocated by the FDA. The evaluation indicates good content validity. Further evaluation will be performed to accomplish construct validity, reliability, and responsiveness in future cross-sectional and longitudinal studies.

Educational objectives: 

1. To develop a Patient-reported outcome measures (PROM) to assess disease activity in microscopic colitis (MC) fulfilling the requirements of the Food and Drug Administration (FDA).

The European Microscopic Colitis Activity Index (E-MCAI) was developed in four steps: 1) A list of symptoms associated with active MC was created by a group of experts in the field. 2) Content validity of the symptoms was performed by experts (n=14) and patients (n=79) using the Content Validity Index. 3) Questions and response alternatives were created for each symptom, and validity of the E-MCAI was evaluated with cognitive interviews with patients (n=7) and by the experts. 4) A pilot postal survey was performed to ensure usability.

Seven of the symptoms related to active MC fulfilled the criteria for content validity and were included in the E-MCAI: stool consistency, stool frequency, stools at night, feel a need to pass more stools shortly after a bowel movement, urgent need to empty the bowel, leakage of stool, and abdominal pain. The development and validation process resulted in the current version of the E-MCAI consisting of six questions related to MC.

The E-MCAI was developed using the methods advocated by the FDA. The evaluation indicates good content validity. Further evaluation will be performed to accomplish construct validity, reliability, and responsiveness in future cross-sectional and longitudinal studies.

Educational objectives:
- To know the main nursing intervention in caring and management of patients with IBD
- To review the evidence about the impact of these interventions on patients' outcomes
- To have an overview of the methodology that will be used in this project: the network meta-analysis

Summary:
Specialist nurses dedicated to the care and management of patients with Inflammatory Bowel Disease (IBD) are increasing in number and roles across Europe. Despite the increased interest in the opportunities connected to this emerging healthcare professional, both from patients’ and clinicians’ perspectives, scarce evidence is available on the effectiveness of specialist nursing interventions. A deep review of the impact of specialist nursing interventions on the management and care of patients with IBD, especially on their health-related (HR) quality of life (QoL), is needed.
The main aim of this project is to systematically review studies assessing the impact of specialist nursing interventions in improving care and management of IBD patients and their QoL.
This project also aims to:
- identify which skills and types of nursing interventions should be developed to respond more effectively to patients' health needs;
- assess the effects of nursing interventions also on different outcomes such as (i) the proportion of patients entering remission, (ii) the proportion of patients in whom remission is maintained, (iii) the duration of remission, (iv) patients’ compliance and satisfaction, (v) number/rate of hospital admissions, (vi) costs savings.

These objectives will be reached through the conduction of  a systematic review and network meta-analysis.

With the grant of the NECCO we started at the Erasmus MC sophia children's hospital a multicenter study into validation of the Transition Success Score (TSS). The TSS was developed using an international Delphi procedure (van den Brink; 2019). Hopefully after this validation study the TSS can be used to measure the success/failure of transition in care.

Data from Phase 3 studies in Crohn’s disease (CD) demonstrated significant improvements in endoscopic outcomes with risankizumab (RZB) versus placebo (PBO) following 12-weeks (wks) induction therapy. Continued maintenance therapy with 360mg RZB SC led to significantly higher rates of endoscopic response and remission at Wk52 compared to withdrawal/placebo. This post-hoc analysis examined the durability of SC RZB maintenance therapy for endoscopic outcomes among patients achieving these endpoints at the end of induction

Patients achieving clinical response with 12-wks IV RZB induction therapy in ADVANCE or MOTIVATE entered the maintenance study, FORTIFY, and received either RZB SC or had RZB withdrawn and received placebo for 52 wks. Forthis analysis, endoscopic outcomes in the RZB 360 mg SC (N=141) and withdrawal/placebo (N=164) arms are reported. Maintenance of endoscopic response, endoscopic remission, and/or an SES-CD score of 0-2 were assessed at Wk52 in patients who achieved these endpoints at Wk0 of maintenance (Wk12 of induction). Safety was assessed throughout the study.

Following 12-wks of IV RZB induction therapy (FORTIFY Wk0), 141 patients were randomized to RZB 360 mg (patients achieving endoscopic response, 55/141; endoscopic remission, 39/141; SES-CD score of 0-2, 29/141) and 164 were randomized to withdrawal (PBO SC) (patients achieving endoscopic response, 73/164; endoscopic remission, 46/164; SES-CD 0-2, 32/164). Maintenance of endoscopic response at Wk52 was demonstrated in 70.2% (39/55) of patients receiving RZB 360 mg SC versus 38.4% (28/73) of patients in the withdrawal (PBO SC) arm (P<0.001).  Maintenance of endoscopic remission at Wk52 was demonstrated in 74.4% (29/39) of patients receiving RZB 360 mg versus 23.9% (11/46) of patients in the withdrawal (PBO SC) arm (P<0.001).  Maintenance of an SES-CD score from 0-2 at Wk52 was demonstrated in  65.5% (19/29) of patients receiving RZB 360 mg versus 21.9% (7/32) of patients in the withdrawal (PBO SC) arm (P<0.001).RZB maintenance treatment was well-tolerated and no new safety signals were observed. The safety profile of RZB has been reported previously.^1–5

RZB IV induction followed by SC maintenance therapy led to sustained improvements in endoscopic outcomes, demonstrating the durability of efficacy with continued RZB treatment in patients with moderate to severe CD.  

References:
1 Feagan, B. G. et al.Lancet 389, 1699–1709 (2017) 2 Feagan, B. G. et al.Lancet Gastroenterol Hepatol 3, 671–680 (2018) 3 Ferrante, M. et al.Journal of Crohn’s and Colitis jjab093 (2021) 4 Ferrante, M. et al. in UEGW 2021 5 D’Haens, G. et al. in DDW 2021  

We used the postoperative recurrence model to better understand the role of AIEC bacteria in Crohn’s disease (CD), taking advantage of a well-characterized postoperative cohort.

From the REMIND prospective, multicenter cohort of operated CD patients (ileocolonic resection), AIEC identification was performed within the surgical specimen (M0) (N=181 patients) and the neo-terminal ileum (n=119 patients/181) during colonoscopy performed 6 months after surgery (M6). Endoscopic postoperative recurrence was graded using Rutgeerts’ index, which was interpreted, either from a clinical point of view (postoperative endoscopic recurrence ≥ i2b or severe ≥ i3), or from a pathophysiological point of view (reappearance of the first ileal lesions = i1 and more advanced postoperative ileal recurrence = i2b + i3). The mucosa-associated microbiota was analyzed by 16S sequencing at M0 and M6. Relative risks (RR) or odds ratios (OR) were adjusted on potential confounders ((gender, smoking, CD duration, CD phenotype, prior bowel resection, indication for surgery, granuloma, preventive treatment, antibiotics).

Among the 228 patients included at the time of the analyzes, the search for AIEC was carried out in 181 patients at M0, and 119 patients at M6. Among these 181 patients included in our study, 46.3% did not receive any preventive treatment for endoscopic postoperative endoscopic recurrence while 24.3% have been treated with anti-TNF to prevent postoperative recurrence.

AIEC prevalence was two-fold higher within the neo-terminal ileum at M6 (30.3%) than within the surgical specimen (14.9%) (p<0.001). AIEC within the neo-terminal ileum at M6 was associated with higher rate of early ileal lesions (i1) (41.6% vs 17.1%; aRR=3.49[1.01-12.04], p=0.048) or ileal lesions (i2b + i3) (38.2% vs 17.1%; aRR=3.45[1.06-11.30], p=0.040) compared to no lesion (i0). AIEC within the surgical specimen was predictive of higher risk of i2b-endoscopic POR (aOR=2.54[1.01-6.44], p=0.049) and severe endoscopic POR (aOR=3.36 [1.25-9.06], p=0.017). While only 5.0% (6/119) of the patients were AIEC-positive at both M0 and M6, 43.7% (52/119), patients with history of AIEC infection (M0 or M6) had higher risk of ileal endoscopic POR (aOR=2.32 [1.01-5.39], p=0.048]), i2b-endoscopic postoperative recurrence (aOR = 2.41[1.01-5.74]; p=0.048) and severe endoscopic postoperative (aOR = 3.84[1.32-11.18], p=0.013). AIEC colonization was associated with a specific microbiota signature including increased abundance of Ruminococcus gnavus.

Based on the postoperative recurrence model, our data support the role of AIEC in the early steps of ileal CD.