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IntroductionBenefits of immunosuppressive therapy in Crohn's disease have been demonstrated in controlled trials; however, it is unclear whether these drugs alter the longer-term natural history of this condition.Aims and MethodsTo assess changes in disease outcomes in a population-based cohort of patients diagnosed in Cardiff from 1986 to 2003. Case notes from Crohn's disease incidence studies in Cardiff were reviewed retrospectively for disease characteristics and follow-up information on drug therapy, and the need for surgery for Crohn's disease. The study population was divided into three groups by year of diagnosis (Group A=1986–1991, Group B=1992–1997 and Group C=1998–2003).Results341 patients were included. Kaplan–Meier (KM) analysis showed increasing use of immunosuppressants over time. At 5 years after diagnosis this was 11% in Group A, 28% in Group B, and 45% in Group C (p=0.001) and the median time to start of thiopurines was 77, 21 and 11 months in Group A, B and C respectively. There was a significant reduction in long-term steroid use at 5 years post diagnosis: 45 (44%), 31 (31%) and 24 (19%) patients in Group A, B and C respectively (p=0.001). KM analysis showed a significant reduction in the cumulative probability of intestinal surgery: At 5 years this was 59% (Group A), 37% (Group B) and 25% (Group C) (p=0.001). In a multivariate Cox analysis, year of diagnosis, disease location, oral corticosteroids within 3 months of diagnosis and early thiopurine use (within the first year of diagnosis) were all independent factors affecting likelihood of intestinal surgery.ConclusionThis population-based cohort shows marked changes in rates of surgery, and the reduction is independently associated with year of diagnosis, and associated temporally with increased and earlier thiopurine use.

Introduction When Crohn and his colleagues first described regional ileitis in 1932, 1 intestinal resection was the only effective treatment available for these patients. [...]the introduction of steroids during the 1950s, medical treatments for Crohn's disease (CD) were limited to digestive rest or 'High vitamin, high protein, high carbohydrate, low residue diet with liver, iron and calcium supplements and the judicious use of sedatives and antispasmodics'. [...]the authors used an empirical definition of early CD. 39 A formal definition of early CD is eagerly awaited. 40 In the SONIC trial, the rates of surgery have not been published. 41 A disease modification trial comparing a top-down approach (anti-TNFα with concomitant immunosuppressant) with a step-up approach according to current recommendations 42 and enrolling several hundred patients with a well-defined definition of early CD and with long-term follow-up could address this issue further.

Background The purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery. Methods We conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay. Results A total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p =  0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance. Conclusion Racial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

Background/Aim: Immunosuppressants are now used much earlier in the course of Crohn’s disease; however their effect on the natural history of the disease, especially on the need for surgery, is not known. The aim of this study was to assess the evolution of the need for surgery in Crohn’s disease during the last 25 years. Patients and Methods: The medical charts of 2573 patients were reviewed retrospectively. The use of immunosuppressants (azathioprine or methotrexate), the need for intestinal resection, and the occurrence of intestinal complications were assessed using Kaplan-Meier analysis in five consecutive cohorts of patients defined by the date of diagnosis of Crohn’s disease (1978–82; 1983–87; 1988–92; 1993–97; 1998–2002). Results: In 565 patients seen in the authors’ unit within the first three months after diagnosis, characteristics of Crohn’s disease at diagnosis did not differ from one cohort to another. The five year cumulative probability to receive immunosuppressants increased from 0 in the 1978–82 cohort to 0.13, 0.25, 0.25, and 0.56 in the 1983–87, 1988–92, 1993–97, and 1998–2002 cohorts, respectively (p<0.001). Concomitantly, the cumulative risk of intestinal resection remained unchanged (from 0.35 to 0.34 at five years; p = 0.81). The cumulative risk of developing a stricturing or a penetrating intestinal complication remained also unchanged. Similar results were obtained in the 2008 patients seen during the same period who were referred to us more than three months after diagnosis. Conclusion: Although immunosuppressants have been used more frequently over the last 25 years, there was no significant decrease of the need for surgery, or of intestinal complications of Crohn’s disease.

Trends in the utilization of Heller myotomy for achalasia in the U.S. over time have not been previously described. Using the Nationwide Inpatient Sample (NIS) database, we analyzed patients undergoing Heller myotomy for achalasia over a 20-year period (1992–2011) to estimate rates of Heller myotomy, locations where the procedures were performed (rural, urban or teaching) and changes in technique (laparoscopic vs open) as well as outcomes of length of stay and in-hospital mortality. Over the last 20 years, the total number of Heller myotomies performed in the U.S. has increased (1576 cases in 1992 to 5046 cases in 2011, p = 0.001). These procedures are now being performed laparoscopically (0.9%–67.0%, p < 0.001) and at urban teaching hospitals (45.4%–77.1%, p < 0.001). In-hospital mortality has decreased (0.9%–0.3%, p = 0.006). Hospital length of stay has decreased from 7 days to 2 days (p < 0.001). These data show a trend of increasing utilization of laparoscopic Heller myotomy at teaching institutions with decreased in-hospital mortality and shorter LOS.

Aim. To evaluate the clinical risk factors influencing overall survival of patients with duodenal adenocarcinoma after potentially curative resection. Methods. A series of 201 patients with primary duodenal adenocarcinoma who underwent surgery from 1999 to 2014 at Chinese Medical Academic Cancer Hospital were studied by retrospective chart review and subsequent telephone follow-up. Results. Resectional surgery was performed in 138 of the 201 patients to attempt curative treatment, while 63 patients were treated with palliative surgery. Median survival of patients who underwent resectional operation was 57 months, whereas that of patients who had palliative surgery was shorter, 7 months (p<0.001). For patients who underwent radical resection, the overall 1-, 3-, and 5-year survival rates were 87.3, 59.1, and 44.1%, respectively. Multivariate Cox regression analysis revealed that lymph node metastasis (HR 31.76, 2.14 to 470.8; p=0.012) and vascular invasion (HR 3.75, 1.24 to 11.38; p=0.020) were independent prognostic factors negatively associated with survival in patients undergoing curative resection. There was no survival difference between the groups treated by the pancreaticoduodenectomy (n=20) and limited resection (n=10) for early-stage duodenal adenocarcinoma (p=0.704). Conclusions. Duodenal adenocarcinoma is a rare disease. Curative resection is the best treatment for appropriate patients. Lymph node metastases and vascular invasion are negative prognostic factors.

Background International comparison of outcomes of surgical diseases has become a global focus because of widespread concern over surgical quality, rising costs and the value of healthcare. Acute diverticulitis is a common disease potentially amenable to optimization of strategies for operative intervention. The aim was to compare the emergency operative intervention rates for acute diverticulitis in USA, England and Australia. Methods Unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2014 for hospitals in USA, England and Australia. The primary outcome measured was emergency operative intervention rate. Secondary outcomes included inpatient mortality and percutaneous drainage rate. Multivariable analysis was performed after development of a weighted comorbidity scoring system. Results There were 15,150 unplanned admissions for acute diverticulitis. The emergency operative intervention rates were 16, 13 and 10% for USA, England and Australia. The percutaneous drainage rate was highest in USA at 10%, while the mortality rate was highest in England at 2.8%. The propensity for emergency operative intervention was higher in USA (OR 1.45, p  < 0.001) and England (OR 1.49, p  < 0.001) than in Australia. The risk of 7-day mortality was higher in England than in Australia (OR 2.79, p  < 0.001). Percutaneous drainage was associated with reduced 7-day mortality risk. Conclusion Australia has a lower propensity for emergency operative intervention, while England has a greater risk of mortality for acute diverticulitis. International variations raise the issue of healthcare value in terms of differing resource use and outcomes.

Aim To investigate whether a diagnostic delay is associated with a poor outcome in Crohn’s disease (CD). Methods Medical and socioeconomic characteristics as well as medications and need for surgery of consecutive CD adults patients followed in three referral centers were prospectively recorded using an electronic database (Focus_MICI ® ). A long diagnostic delay was defined by the upper quartile. We compared patients with long diagnostic delay to those with earlier diagnosis regarding the time to: (1) first intestinal surgery, (2) first use of immunosuppressants (IMSs), and (3) first use of anti-tumor necrosis factor (anti-TNF) therapy using the Kaplan–Meier test and the log-rank test. Results A total of 497 patients with CD (53.6 % women) were analyzed. Median diagnostic delay was 5 months (IQR 25–75 %: 2–13 months). Median follow-up was 9 years (IQR 4–16.2), and 148 (29.8 %) patients had major surgery. There were no significant differences between patients with late and early diagnosis regarding age at diagnosis, disease phenotype, need for IMS therapy, and need for anti-TNF therapy. Time to first major surgery was shorter in patients with late diagnosis ( p  = 0.05). Conclusion In this large multicenter prospective cohort of French CD patients, a long diagnostic delay (>13 months) increased the risk of early surgery. No associated factors could be identified in this study.

Background Inflammatory bowel diseases (IBDs) are considered immune-mediated disorders with dysregulated innate and adaptive immunities. Secondary immunogloblin deficiency can occur in IBD and its impact on the disease course of IBD is not clear. Aims We sought to determine associations between low IgG/G1 levels and poor clinical outcomes in IBD patients. Methods This historic cohort study was performed on IBD patients with obtained IgG/IgG1 levels. The primary outcome was defined as any IBD-related bowel resection surgery and/or hospitalization. Subgroup analyses assessed particular surgical outcomes in Crohn’s disease (CD), ulcerative colitis (UC) or indeterminate colitis (IC), and ileal pouch–anal anastomosis (IPAA). The secondary outcomes included IBD drug escalations and C. difficile or cytomegalovirus infections. Results A total of 136 IBD patients had IgG/G1 levels checked and adequate follow-up, 58 (42.6 %) with normal IgG/G1 levels and 78 (57.4 %) having low levels. A total of 49 patients (62.8 %) with low immunoglobulin levels had IBD-related surgeries or hospitalizations, compared to 33 patients (56.9 %) with normal levels [odds ratio (OR) 1.28, 95 % confidence interval (CI) 0.64–2.56; p  = 0.49]. Low IgG/G1 levels were associated with IBD-related surgery in CD in univariate analysis [hazard ratio (HR) 4.42, 95 % CI 1.02–19.23; p  = 0.048] and in Kaplan–Meier survival curve analysis ( p  = 0.03), with a trend toward significance on multivariate analysis (HR 3.07, 95 % CI 0.67–14.31; p  = 0.15). IBD patients with low IgG/G1 levels required more small bowel resections (12.8 vs. 1.7 %, p  = 0.024) and 5-aminosalicylate initiations (28.2 vs. 13.8 %, p  = 0.045). Conclusions Our study demonstrated a possible association between low IgG/G1 levels and poor outcomes in CD including surgery. Future implications include using immunoglobulin levels in IBD patients as a prognostic indicator or boosting humoral immunity as a treatment in this subset.

BackgroundRacial disparities in utilization of major surgical procedures have been well documented in the United States over the last decade. Crohn's disease (CD) is a chronically relapsing disorder that leads to significant morbidity and, in most cases, surgery. Our objective was to characterize health disparities in CD-related bowel resection among hospitalized CD patients.MethodsWe analyzed discharge records from the Nationwide Inpatient Sample, the largest nationally representative database of acute-care hospitals throughout the United States. A total of 41,918 discharges with CD from 1998 to 2003 were included. Bowel resection and in-hospital mortality rates for non-Hispanic whites, African Americans, Hispanics, and non-Hispanic Asians were calculated.ResultsAfter adjusting for age, sex, health insurance, comorbidity, median neighborhood income, and hospital characteristics, the relative rate ratio of undergoing bowel resection for African Americans, Hispanics, and Asians compared to whites was 0.68 (95% confidence interval [CI]: 0.61–0.76), 0.70 (95% CI: 0.60–0.83), and 0.31 (95% CI: 0.16–0.59), respectively. Compared to those with private insurance, the relative risk of surgery for those with Medicare, those with Medicaid, and those who were “self-pay” was 0.48 (95% CI: 0.44–0.54), 0.52 (95% CI: 0.46–0.59), and 0.67 (95% CI: 0.58–0.77), respectively. Women were less likely than men to undergo bowel resection (incidence rate ratio [IRR] = 0.80; 95% CI: 0.76–0.85). The in-hospital mortality of individuals who resided in neighborhoods whose median income was above the national median was lower (IRR = 0.71; 95% CI: 0.50–0.99).ConclusionsBowel resection among hospitalized CD patients varies by race, health insurance, and sex. Further mechanistic studies are needed to elucidate the social and biological underpinnings of these variations.