Optimising outcomes following surgery in Crohn’s Disease

SurgeryProject: Optimising outcomes following surgery in Crohn’s Disease

Year: 2013 – IN PROGRESS. See Sept 2014 Update below.

Researcher: Guy’s & St Thomas’ Hospital

Background: Propose to introduce a protocol which would optimise all aspects of treatment prior to and after surgery for Crohn’s Disease with the aim to reduce both immediate post-operative and long-term complications including long-term recurrence rates. By reducing complications, it is hoped that both short-term and long-term outcomes improve and that the approach will be shown to be cost-effective. Surveillance of post-operative recurrence, and appropriate conventional medical prophylaxis will also be adhered to strictly in keeping with current European Guidelines.

Aims:
– To introduce a protocol which would optimise all aspects of treatment prior to and after surgery for Crohn’s Disease with the aim to reduce both immediate post-operative and long-term complications including long-term recurrence rates.
– The aim of the protocol would also be to optimise all aspects of conventional care during the inpatient stay and therefore throughout the pre-operative, peri-operative (the time period describing the duration of a patient’s surgical procedure; this commonly includes ward admission, anaesthesia, surgery, and recovery), and post-operative periods, by providing regular joint care between both the medical and surgical teams, specifically with joint ward rounds, and joint consultation clinics.
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Anticipated Outcome: Peri-operative and 30 day post-operative complication rates and length of stay will be measured prospectively in patients undergoing surgery under the new protocol. Longer term recurrence rates will also be assessed by endoscopy. These main outcome measures will be compared to those in a 5 year retrospective cohort of patients undergoing surgery for Crohn’s Disease at GSTT. A health economic analysis will be undertaken to compare cost efficacy of the different approaches.

Latest Update – September 2014:
There are 3 main components to this projects.
1) Optimisation of Crohn’s disease patients requiring luminal abdominal surgery
2) Nutritional survey of Crohn’s disease patients requiring luminal abdominal surgery
3) The use of exclusive enteral nutrition with antibiotics in Crohn’s disease patients presenting with both obstructive and penetrating disease

The first aspect of the project is to optimise patients requiring luminal surgery for Crohn’s. Via a standard protocol, treatment prior to surgery, during the immediate peri-operative period and after surgery are standardised, and optimised (as detailed in the application for the grant). More than 50 patients have been recruited, and significant improvement with respect to steroid withdrawal pre-surgery, joint medical and surgical peri-operative care, and the institution of post-operative medical treatment has been observed. Surveillance for post-operative Crohn’s after the first year of surgery with colonoscopy has also significantly improved. All patients have direct access to the research doctor, to ensure all aspects of management are understood and optimised.

The second aspect of the project is to perform baseline nutritional surveys in all patients needing luminal surgery. Baseline electrolytes (sodium, potassium, magnesium and calcium), lipids (cholesterol and triglycerides), trace elements (copper, zinc and selenium), and haematinics (iron, ferritin, transferrin saturations, B12, folate) have been obtained in 35 patients. Deficiencies are corrected where required. The aim of the nutritional survey is to gain further understanding with respect to specific deficiencies in patients requiring luminal surgery.
The third aspect of the project is to offer patients presenting as emergencies with both obstructive and penetrating disease secondary to limited ileocaecal disease exclusive enteral nutrition (EEN, via modulen or elemental 108, both Nestle) in-conjunction with antibiotics to control symptoms and negate the need for emergency surgery. This treatment option also ensures that steroids are avoided or a rapid steroid wean can be commenced. The treatment is thereafter continued up to the point of elective surgery, aiming to reduce both perioperative complications, and the need for stomas.

10 patients have been enrolled and the majority have been able to delay surgery. We have seen improvements in the ability to avoid stomas compared with historical controls. Whilst these data are fairly limited due to numbers at the moment, the results look promising.

Recruitment in all three aspects of the study will continue until the end of August 2015.

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