Chaired by Christianne Buskens (the Netherlands) and Antonia Spinelli (Italy), today’s joint symposium on ulcerative colitis elected many ‘aha moments’ from the audience as they were first challenged to consider the role of surgery in Crohn’s disease recurrence by Andre D’Hoore, who is Professor of Surgery at University Clinic Gasthuisberg in Belgium.
Professor D’Hoore introduced the audience to the Lehman score, a longitudinal tool which is currently being developed and validated prospectively. By measuring the progressive nature or cumulative structural bowel damage, independent of the current and fluctuating disease activity, this score could serve as a future methodology to assess fibrostenosing Crohn’s disease (CD) as it combines different diagnostic modalities) depending on the location of disease.
After considering both research and case studies which explained resection rates before and after surgery as well as biological events, D’Hoore concluded that, yes, surgeons do affect recurrence in CD and further research is needed to assess the role of Kono-S anastomosis, the extent of resection and the role for strictureplasty over the valve to understand what we can do make sure any influence surgery has in a case is positive.
Next, Omar Faiz (also standing in for Ailsa Hart’s part of the lecture due to her being unable to attend) delivered a thought-provoking and poignant presentation on the case for, and practicalities of centralising IBD care. He used analogies from popular culture including Miles Davies to introduce he concept that excellence in surgery comes from high volume practice. This leads to better decision-making, better technical proficiency, more efficient care, more research and more innovation.
After reviewing evidence and assumptions relating the high volume care centers’ superiority of care and practice (it should not be assumed this is the case unless stringent quality control measures are in place), Dr Faiz, who is Clinical Director and Consultant Colorectal Surgeon at St Mark’s Hospital & Academic Institute as well as Professor of Practice (Colorectal Surgery) at Imperial College in London, shared the results of Crohn’s & Colitis UK’s IBD Standards Group (2013). This shows that although patients overall prefer local care where possible, they also highly value being actively involved in the decision-making process of their own care and want better quality, more joined-up care. Further studies reveal several considerations to be taken of account of as well.
While the issue of centralization is more complex than it appears and Doctors Faiz and Hart (in absence) concluded that centralisation is necessary, especially for complex infrequently performed IBD surgery, but that to achieve this we must undertake a re-organisation of the healthcare structures surrounding IBD which will require professional and political support, the demand for which needs to be driven by patients themselves.
The final lecture of the session came from Krisztina Gecse (The Netherlands) and Jeremie Lefevre (France) who elegantly explained the impact of antibody therapy on surgical outcomes in IBD.
After a thorough review of advances in irritable bowel disease (IBD) therapeutics and the evolution of non-medical factors which have meant that overall, morbidity is decreased for IBD cases, the doctors explained that previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications.
Furthermore, conclusions from a large 2018 population-based study do not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.
The pair also introduced us to study which shows there is no significant difference in the risk of infectious complications, surgical site infections, need for reoperation, or major surgical complications in patients exposed to vedolizumab (VDZ) vs anti-TNFs.
Importantly, there were no significant differences in outcomes when comparing patients exposed to VDZ with those not given biologic therapy. The doctors concluded that surgical strategy should be adapted to the general condition of the patient and medical treatment, but if and when the decision for surgery made, anti-TNF treatment should be stopped.
