Joint ESCP - ECCO Symposium
Chairs: André D’Hoore (BE), Lilli Lundby (DK), Michel Adamina (CH)
In one of the last sessions of the day, attendees gathered in the Convention Centre Dublin’s Liffey B room for some engaging talks and discussions delivered by both ESCP and the European Crohn’s and Colitis Organisation (ECCO) in a joint symposium.
First to the stage was Pär Myrelid (Sweden), who led a fascinating talk on IBD Surgery During Pregnancy – Ecco Guidelines and Results from The Scar Study.
He introduced his talk with a case study of a 28-year-old pregnant patient to share an example of how and when Crohn’s and Colitis symptoms can manifest, and how pregnancy can impact treatment.
Pär delivered some clear advice on how to ensure the best health of the patient, and to avoid unnecessary surgery during pregnancy. He said that it is important to put together a multidisciplinary team – including a gastroenterologist, and obstetrician, a paediatrician and an experienced surgeon – if a pregnant patient with IBD develops a flare.
He also stated that the risks of active disease should be weighed against the risks of surgery throughout pregnancy, and urgent surgery should be performed if clinically indicated, regardless of gestational age.
Fascinating studies were presented, reporting on success rates of IBD surgery during pregnancy, which raised a key consideration: is surgery, or an underlying disease, a bigger risk factor?
Among his take home messages were to try to get young female patients in remission before pregnancy if possible.
Alaa El-Husuna (Denmark) was up next to discuss Perioperative Optimization in IBD, and gave a great overview of a complex topic.
A key take-away from Alaa’s talk was that properly preparing the patient and surgeon for surgery and recovery decreases the patient’s length of stay in hospital and enhances the overall experience.
Alaa also made a strong argument for having dedicated IBD surgeons, stating that there should be more surgeon involvement in the patients’ pre-operative optimisation – and indeed the whole treatment path. He proclaimed that we should think of IBD surgeons in the way that we do oncological surgeons; we need someone with the knowledge and complex understanding of IBD. He made the point that good surgical treatment is not simply about carrying out an operation – it’s about having the wealth of knowledge needed to make the right treatment decisions for complicated IBD cases.
When discussing data to inform decision-making around pre-operative care, Alaa highlighted some of the limitations of existing metanalyses from studies that categorised treatment into basic boxes of ‘biological’ and ‘non biological’, expressing that, in reality, the situation is far more complex than that. Type of medications, anti-drug antibodies, strength of medications, type of surgical intervention, nutrition and many other factors all play a role.
In a conclusion, to support his arguments for better pre-operative care and dedicated IBD surgeons, Alaa quoted Shakespeare’s ‘Timing is everything’, as he made the point that patients in specialised centres will experience the best patient outcomes, as the practitioners understand the many factors to take into consideration.
While there is not currently enough evidence to support the argument for IBD surgeons, Alaa declared the need for more research in this area, to support the shift to better IBD care.
Following Alaa’s talk was Christiane Buskens (Netherlands) who took to the stage to discuss Early Surgery in Ileocecal Crohn’s Disease.
Christiane started off by reminding the audience that surgical resection was first advised as a treatment in Ileocecal Crohn’s Disease 100 years ago – a practice that then carried high morbidity and mortality rates.
So, she said, it was a relief when in the 60s and 90s new options were developed. And yet, following complications and limitations with these new developments, more recent studies are starting to show that, in fact, early surgery does perhaps offer the best option in many cases, as operating after medication and other treatment paths can come with complications.
Christiane summarised some of the arguments for early surgery as: reduced risk of complications, reduced need for post-operative medication, reduced rates of re-operation, improved quality of life, prolonged clinical remission and reduced costs.
To finish up the symposium, Janindra Warusavitarne (UK) delivered his talk on Complex Perianal Crohn’s Fistula.
Janindra began by asking the audience “Who can we cure? Who can be palliated? Who needs a prostatectomy?”, asserting that these are the realistic goals that we need to look at in perianal personalised treatment.
He then went on to set out five key messages that we should pay attention to in cases of complex perianal Crohn’s disease.
The first key message was not to delay sharing a diagnosis, so that you don’t delay anti-TNF (Tumour Necrosis Factor) treatment.
His second key message – which he highlighted as the most important – was to work in a team and not in isolation. There should not be any to-ing and fro-ing between colorectal surgeons and gastroenterologists, for example – joined up thinking is essential. Every study has different outcomes, and goal posts are changing, which is why multidisciplinary teams for individualised patient care is so important. And as part of this teamwork, patients reported outcomes must be included, and the patient’s ideas must be merged with the surgeon’s to ensure care needs are responded to in according to the patient’s desires.
His third key message was to understand and ensure adequate drainage though clear understanding the fistula anatomy. Though he noted that there are no clear definitions for simple and complex fistulas, which is often part of the problem.
The fourth key message was to ensure local control of the fistula, as this helps the drugs to work better.
And finally, his last and fifth key message – during which he discussed potential STEM cell options - was to have a plan for when things aren’t working locally.
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