The impact of sarcopenia on outcomes in patients with inflammatory bowel disease undergoing colorectal surgery.

INTRODUCTION: Sarcopenia is an independent predictor of poor post-operative outcomes following major surgery. Inflammatory bowel disease (IBD) consists of Crohn's disease (CD) and ulcerative colitis (UC), which are chronic inflammatory conditions involving the gastrointestinal system. Evidence demonstrates that up to 60% of patients with IBD have sarcopenia. Despite advances in medical management, more than 15% of patients with UC and 80% with CD eventually require surgical intervention. The primary aim of the study was to assess the impact of sarcopenia on post-operative anastomotic leak rates. METHODS: A retrospective cohort study of patients at Royal Perth Hospital who underwent major abdominal surgery for management of IBD between January 2010 and December 2020 was performed. Sarcopenia was assessed according to the skeletal muscle index at the level of the third lumbar vertebrae using the cut off 52.4 and 38.5 cm2 /m2 for men and women, respectively. RESULTS: A total of 147 patients were included. The prevalence of sarcopenia within the study population was 36.1%. Patients with sarcopenia were significantly taller (P = 0.025) and were more likely to be on pre-operative steroid medications (P = 0.045). There was no difference in the remaining baseline characteristics between sarcopenic and non-sarcopenic patients. Patients with sarcopenia were more likely to develop a post-operative anastomotic leak (OR:11.303, 95% CI, 1.53-83.51, P = 0.017), grade IV complications (OR:6.79, 95%CI:1.1-43.6, P = 0.044) and require total parenteral nutrition (TPN) (OR:3.212, 95% CI:1.3-8.1, P = 0.013). CONCLUSIONS: Sarcopenia significantly increases the risk of major post-operative complications for patients with IBD undergoing colorectal surgery.

Assessing the efficacy of TNF-alpha inhibitors in preventing emergency and emergent colectomies.

BACKGROUND AND AIM: Severe ulcerative colitis (UC) is potentially life threatening and is associated with significant morbidity. TNF-∝ inhibitors (Infliximab) were introduced in Australia for the management of medically resistant, acute, severe flares of UC in 2008. The aim of this study is to assess the efficacy of Infliximab in preventing emergent and emergency colectomies for patients with moderate to severe UC by comparing colectomy rates before and after its introduction at our institution. METHODS: This was a retrospective cohort study of all patients who were admitted to the Royal Perth Hospital with a flare of UC between 2002 and 2017. Patients were divided into two cohorts: those admitted prior to the introduction of Infliximab (pre-2008) and those admitted after. We compared data between these two groups, including age, gender, length of admission, use of Infliximab, colectomy, and complications of surgery. We defined emergency surgery as requiring surgery during the index admission and emergent surgery as an operation within 54 weeks. RESULTS: A total of 313 UC cases from 2002 to 2017 were analyzed. There was a decrease in emergency and emergent colectomies from 19.4 to 8% in the post-2008 cohort (P = 0.008). Furthermore, there was a decrease in the proportion of operations performed as emergencies, from 36 to 20%. This resulted in a significantly reduced length of stay (13.4-9.7 days, P < 0.05) and complication rate (36 to 20%, P < 0.05). CONCLUSION: Overall, the need for emergency and emergent operations has drastically reduced at our institution with the introduction of Infliximab. This study has confirmed the efficacy of Infliximab in reducing colectomy rates at our institution.

Evaluation of the trauma triage accuracy in a Level 1 Australian trauma centre.

OBJECTIVES: To assess the rate of undertriage of major trauma patients and to assess factors contributing to undertriage in a modern Australian Level 1 trauma centre. METHODS: A retrospective case series of 600 consecutive major trauma (injury severity score [ISS] >15) patients admitted to Royal Perth Hospital (RPH) during 2015 was performed. Data were compiled via the prospectively maintained hospital trauma registry for all patients admitted with a major trauma during the study period. Results were analysed for patient demographics, mechanism and outcomes. The primary outcome of the study was to determine the rate of undertriage of major trauma at RPH by establishing whether or not the trauma team activation page was correctly sent at the time of patient arrival based on hospital criteria. RESULTS: The average age of patients in the study population was 46.5 (±21.5) years and the mean ISS was 24.7 (±9.3). The most common mechanism of injury was falls, motor vehicle accidents and motorbike accidents. One hundred and sixty-nine patients (28%) did not have trauma team activation on arrival to the ED. Among these patients, 132 did not fulfil the RPH trauma activation criteria. The remaining 37 patients (6.1%) did meet the criteria and were considered undertriaged. Subgroup analysis showed a statistically significant difference in age between the patients who had trauma team activation (42.7 ± 19.5 years) and those who did not (55.9 ± 23.3 years). CONCLUSION: In this cohort of major trauma, a 6.1% undertriage performance of the triage tool was observed. Sub-analysis of the data showed that elderly patients were more likely to be undertriaged.

Efficacy of adalimumab for the management of inflammatory bowel disease in the clinical setting.

BACKGROUND: Anti-tumor necrosis factor (TNF)-alpha medications are effective in Crohn's Disease (CD) and efficacious in ulcerative colitis (UC). Adalimumab has been available through the Australian Pharmaceutical Benefits Scheme since August 2008, but clinical experience for inflammatory bowel disease (IBD) in Australia is limited. AIMS: To determine adalimumab efficacy for IBD in the Australian setting. METHODS: Crohn's disease or UC/IBD unclassified (UC/IBDU) patients received adalimumab after failure of disease control with conventional therapies or loss of control by infliximab. Response/remission at 8 and 12 weeks were determined by the Crohn's Disease Activity Index (CDAI) and Colitis Activity Index (CAI). All patients received 160 mg (week 0), 80 mg (week 2), followed by 40 mg every-other-week (eow). Patients with a limited response at 8 weeks were considered for weekly adalimumab. RESULTS: Of 38 CD patients 86.8% (33/38) had active luminal and 23.7% (9/38) fistulising disease at inclusion. Response occurred in 81.8% and 84.4% of luminal CD at 8 and 12 weeks, while 54.5% and 63.6% remitted respectively. 77.8% of fistulising CD responded and 55.6% remitted at 12 weeks. Fifteen CD patients had previously lost response to infliximab, and 86.7% of these responded and 53.3% remitted at 12 weeks. Of the seven UC/IBDU patients 43% and 14% responded, while 29% and 0% remitted at 8 and 12 weeks. CONCLUSION: In CD, adalimumab is as, if not more, effective in the clinical setting than in the trials, and is effective in patients with an attenuated response to infliximab. Its efficacy is not as good in UC, but this requires further clarification.