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Background and Aims: The treatment of chronic pouchitis remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in chronic pouchitis. Methods: Appropriateness of medical and surgical treatments in patients with chronic pouchitis was considered in 16 scenarios incorporating presence/absence of four variables: pouchitis symptoms, response to antibiotics, significant prepouch ileitis, and Crohn’s disease (CD)-like complications (i.e., stricture or fistula). Appropriateness of permanent ileostomy in patients refractory to medical treatments was considered in eight additional scenarios. Using the RAND/UCLA appropriateness method, international IBD expert panelists rated appropriateness of treatments in each scenario on a 1–9 scale. Results: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and inappropriate in all other scenarios. Ileal-release budesonide was rated appropriate in 6/16 scenarios including patients with significant prepouch ileitis but no CD-like complications. Probiotics were considered either inappropriate (14/16) or uncertain (2/16). Biologic therapy was considered appropriate in most scenarios (14/16) and uncertain in situations where significant prepouch ileitis or CD-like complications were absent (2/16). In patients who are refractory to all medications, permanent ileostomy was considered appropriate in all scenarios (7/8) except in asymptomatic patients with no CD-like complications. Conclusions: In the presence of significant prepouch ileitis or CD-like complications, chronic antibiotics and probiotics are inappropriate. Biologics are appropriate in all patients except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most medically refractory patients.

Anorectal strictures are a notoriously difficult to treat phenotype of perianal Crohn's disease. Quality of life is diminished due to ongoing pain, incontinence, difficulty with stool evacuation, and recurrent medical and surgical treatments. Medical therapy is aimed at treating luminal disease and mucosal ulceration to prevent worsening of fibrosis. Clinical examination and endoscopic intervention can be used for serial dilations of strictures. Unfortunately, despite optimal medical therapy and endoscopic intervention with serial anal dilations, surgery with intestinal diversion or proctocolectomy may be required as part of the treatment algorithm in a significant proportion of patients.

Background Precision or individualized medicine is increasingly pervasive across medical and surgical disciplines. However, the concept has not been introduced in regenerative medicine. Main body Targeted and engineered cellular and acellular therapy, specific to individuals or disease states, could significantly improve the efficacy of these autologous therapies. Currently, generic mesenchymal stem cell therapy is being widely used across multiple pathologies, some of which may not respond well to mesenchymal stem cell therapy. Engineered cell therapy may be a way to address this generic one-size-fits-all approach. Conclusions The future of regenerative medicine lies in the concept of precision cell-based therapy.

BACKGROUND There is no study to date examining the safety of initiating or restarting biologic therapy after major abdominal surgery for Crohn's disease. OBJECTIVE The purpose of this study was to determine differences in the rates of 90-day superficial surgical site infections, intra-abdominal sepsis, and overall postoperative infectious complications among patients who were initiated on or restarted a biologic within 90 days postoperatively compared with those who were not. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at an IBD referral center. PATIENTS Adult patients with Crohn's disease who received a biologic therapy within 90 days of a major abdominal operation between May 20, 2014, and December 31, 2018, were included. MAIN OUTCOMES MEASURES Ninety-day superficial surgical site infection, intra-abdominal sepsis, and overall postoperative infectious complications were measured. RESULTS A total of 680 patients with Crohn's disease were included: 351 were initiated on biologic therapy within 90 days after surgery and 329 were not. Patients exposed to biologic therapy postoperatively were younger (p < 0.001), had a lower BMI (p = 0.0014), were less often diabetic (p = 0.0011), and were more often exposed preoperatively to biologics (p < 0.0001) and immunomodulators (p < 0.0001) but not corticosteroids (p = 0.8399). Of those exposed postoperatively, nearly all (93.7%) had been on a biologics preoperatively, and most resumed the same biologic (68.0%). The median time to starting biologic therapy postoperatively was 31 days (range, 7-89 d). Postoperative biologic exposure was not associated with an increased risk of superficial surgical site infection (HR = 1.02 (95% CI, 0.95-1.09) per week; p = 0.59), intra-abdominal sepsis (HR = 1.07 (95% CI, 0.99-1.16); p = 0.73), or overall postoperative infectious complications (HR = 1.02 (95% CI, 0.98-1.07); p = 0.338); the overall rates of each at 90 days was 13%, 8%, and 28%. LIMITATIONS The study was limited by its retrospective design and single-center data. CONCLUSIONS Postoperative initiation or resumption of biologic therapy did not increase 90-day rates of superficial surgical site infection, intra-abdominal sepsis, or total infectious complications after major abdominal surgery for Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B207. ?SON SEGUROS LOS FARMACOS BIOLOGICOS EN EL POSTOPERATORIO INMEDIATO? UNA EVALUACION DE UN SOLO CENTRO DE PACIENTES QUIRURGICOS CONSECUTIVOS CON ENFERMEDAD DE CROHN: No hay ningun estudio hasta la fecha que examine la seguridad de iniciar o reiniciar la terapia biologica despues de una cirugia abdominal mayor en enfermedad de Crohn.Determinar las diferencias en las tasas a 90 dias de infecciones del sitio quirurgico superficial, sepsis intraabdominal y complicaciones infecciosas postoperatorias generales entre los pacientes en que se inicio o reinicio un biologico dentro de los 90 dias despues de la operacion en comparacion con aquellos que no lo recibieron.Estudio de cohorte retrospectivo.Centro de referencia de enfermedad inflamatoria intestinal.Pacientes adultos con enfermedad de Crohn que recibieron una terapia biologica dentro de los 90 dias de una operacion abdominal mayor entre el 20 de mayo de 2014 y el 31 de diciembre de 2018.Infeccion superficial del sitio quirurgico, sepsis intraabdominal y complicaciones infecciosas postoperatorias generales a 90 dias.Se incluyeron un total de 680 pacientes con enfermedad de Crohn: 351 se iniciaron en terapia biologica dentro de los 90 dias posteriores a la cirugia y 329 no. Los pacientes expuestos a terapia biologica despues de la operacion eran mas jovenes (p

Background Although biologic agents have revolutionized the medical management of severe ulcerative colitis (UC), there is considerable controversy regarding adverse effects of vedolizumab on surgical outcomes. We evaluated 30-day postoperative morbidity in UC patients undergoing abdominal colectomy (AC) treated with vedolizumab before surgery. Methods From 2007 to 2017, 285 patients were enrolled in prospectively maintained database evaluating the role of clinical, serologic markers with clinical phenotypes in UC. The patients treated with vedolizumab within 12 weeks of AC was queried, then matched 1:3:3 into 3 preoperative treatment groups based on age, gender and surgical treatment of UC; ileal pouch-anal anastomosis (IPAA) with ileostomy vs total colectomy with end stoma: a) vedolizumab (n = 25); b) anti-tumor necrosis factor (anti-TNF) (n = 74); and c) no biologics (n = 54). Thirty-day postoperative complications among patient groups were compared. Results The 3 patient groups were well-matched in other characteristics including disease duration, disease extent, medication history and preoperative serological data. There were no significant differences in the overall incidence of postoperative complications among patients treated preoperatively with vedolizumab, anti-TNFs, or no biologics (44% vs. 45% vs. 37%; p = 0.67). Although there was no significant difference between patient cohorts in infectious complications (p = 0.20), postoperative ileus (POI) was significantly more common among the vedolizumab group (n = 9; 36%) compared to anti-TNF (n = 12; 16%) or no biologics (n = 5; 9%) (p = 0.01). Multivariable analysis showed that vedolizumab treatment prior to surgery was an independent risk factor for POI (OR: 5.16, 95% CI; 1.71–15.52; p = .004). Conclusion Although preoperative vedolizumab exposure did not influence the rate of overall 30-day postoperative complications, vedolizumab tends to increase incidence of POI.

This study aimed to determine timing and risk factors for 30- and 90-day unplanned hospital readmissions and return to the operating room. Retrospective case series, including consecutive adult patients with Crohn's disease, undergoing a major abdominal surgical procedure during a 3.5-year inclusion period was performed. The primary outcomes were 0- to 30-day and 30- to 90-day readmission and return to the operating room rates. Univariate and multivariable risk factors for both outcomes at 30 and 90 days were assessed through Cox regression analysis. Of 680 included patients with Crohn's disease, 89 (13.1%) were readmitted within 30 days, 55 (8.1%) within 30-90 days, and 11 (1.6%) in both follow-up periods for a combined 90-day readmission rate of 24.4% (n = 166). Multivariable risk factors for 30-day readmissions were type of procedure performed, corticosteroid use (hazard ratio [HR] 1.71, P = .01), younger age (HR 0.98 per year, P = .01), and prolonged disease duration (HR 1.03 per year, P = .03). No significant risk factors identified for 30- to 90-day readmissions. By 90 days, 76 patients (11.2%) had a return to the operating room (of which 8.8% was within 30 days). Risk factors for 30-day return to the operating room included tobacco use (HR 1.86, P = .04), diabetes (HR 3.30, P = .01), corticosteroid use (HR 3.51, P

The Rochester Epidemiology Project (REP), a longitudinal population-based database, is the largest epidemiologic database in the world. Originally established at Mayo Clinic in Rochester, Minnesota, the REP has been instrumental in defining the natural history of disease states and the impact of treatment in a well-defined population. In the United States, the REP has made important contributions to the colon and rectal literature, largely because healthcare is fragmented with no unique identifier to longitudinally follow-up with a patient throughout the system over his or her lifespan. Investigation with the REP has provided insight to the economic burden associated with inflammatory bowel disease, the benefit of screening for colorectal cancer, and the natural history of Mekel's and diverticular disease. In addition to practice changing research, the REP can be used as a model for future linkage systems in the United States.

Inflammatory bowel disease (IBD) can be categorized as Crohn's disease (CD) or ulcerative colitis (UC). Both are chronic inflammatory diseases of the bowel resulting in significant alterations in quality of life due to remitting and relapsing symptoms of pain, increased stool frequency, and anemia. Before the era of biologic therapy, with the US Food and Drug Administration (FDA) approval of infliximab in 1998, the cornerstone of medical therapy was corticosteroids. Since 1998, however, biologic therapy has taken a prominent role in the treatment of IBD, and drugs in the anti-tumor necrosis factor a (infliximab, adalimumab, certolizumab pegol, golimumab), anti-integrin (natalizumab, vedolizumab), and anti-interleukin (ustekinumab) classes have since been FDA-approved for the treatment of IBD. However, all have side effect profiles that limit their use, potential to develop a loss of response, potential for adverse reactions, and, most importantly, are only effective in up to half of IBD patients. Patients who become refractory to medical management eventually require surgery; up to 60% of patients with CD will require a bowel resection,1 and 15% with UC undergo a colectomy.2 There is a clear need for improved treatment practices in order to avoid systemic complications with medical management and surgical intervention. Stem cell therapy is emerging as a promising treatment alternative. Herein we review key basic science articles to discuss important mechanistic aspects as to why stem cell therapy may be an effective treatment strategy to bring to the bedside.