Research presented at ECCO 2023 focused on resection in Crohn’s disease, the role of AI for scoring histological images in ulcerative colitis, and more.

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 (OSS) 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.

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.

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 postoperative 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 postoperative 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 postoperative 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.