Conventional Frailty Index Does Not Predict Risk of Postoperative Complications in Patients With IBD: A Multicenter Cohort Study.

BACKGROUND: Frailty has been associated with adverse outcomes in patients with IBD. OBJECTIVE: This study aimed to evaluate the association between health deficit-defined frailty (using the 5-factor modified frailty index) and postoperative outcomes in patients with IBD. DESIGN: Prospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program, Inflammatory Bowel Diseases Module. PATIENTS: The included patients had IBD and underwent major abdominal surgery between 2016 and 2019. Patients were classified as frail (modified frailty index ≥2), prefrail (modified frailty index = 1), or normal (modified frailty index = 0) based on a validated, 5-factor modified frailty index. MAIN OUTCOME MEASURES: The association was evaluated between frailty and risk of 30-day severe postoperative complications, prolonged hospital stay, and risk of readmission using multivariable logistic regression. RESULTS: Of 3172 patients with IBD who underwent major abdominal surgery (42.7 ± 16.4 y, 49.3% female, 57.7% with Crohn's disease, 43.9% on biologics), 116 (3.7%) were classified as frail and 477 as prefrail (15%). After adjustment for age, sex, race/ethnicity, smoking, BMI, type of surgery, corticosteroid use, and biologic and immunomodulator use, frailty was not associated with increased risk for severe postoperative complications (adjusted OR, 1.24; 95% CI, 0.81-1.90), mortality (adjusted OR, 1.38 [0.44-3.6]), or 30-day readmission (adjusted OR, 1.35 [0.77-2.30]). Nonelective surgery, significant weight loss, corticosteroid use, and need for ileostomy were associated with increased risk of severe postoperative complications. LIMITATIONS: Limited information regarding IBD-specific characteristics. CONCLUSIONS: In patients with IBD undergoing major abdominal surgery, frailty measured by a conventional abbreviated health deficits index is not predictive of adverse postoperative outcomes. Biologic and functional measures of frailty may better risk-stratify surgical candidacy in patients with IBDs. See Video Abstract at http://links.lww.com/DCR/C108 . EL NDICE DE FRAGILIDAD CONVENCIONAL NO PREDICE EL RIESGO DE COMPLICACIONES POSOPERATORIAS EN PACIENTES CON ENFERMEDADES INFLAMATORIAS DEL INTESTINO UN ESTUDIO DE COHORTE MULTICNTRICO: ANTECEDENTES:La fragilidad se ha asociado con resultados adversos en pacientes con enfermedades inflamatorias del intestino.OBJETIVO:Examinamos la asociación entre la fragilidad definida por déficit de salud (utilizando el índice de fragilidad modificado de 5 factores) y los resultados postoperatorios en pacientes con enfermedades inflamatorias del intestino.DISEÑO:Estudio de cohorte prospective.ESCENARIO:Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos, Módulo de Enfermedades Inflamatorias del Intestino.PACIENTES:Pacientes con enfermedades inflamatorias intestinales inscritos en la cohorte que se sometieron a cirugía abdominal mayor entre 2016-19.EXPOSICIÓN:Los pacientes se clasificaron como frágiles (índice de fragilidad modificado ≥2), prefrágiles (índice de fragilidad modificado = 1) o normales (índice de fragilidad modificado = 0) según un índice de fragilidad modificado de 5 factores validado.PRINCIPALES MEDIDAS DE RESULTADO:Examinamos la asociación entre la fragilidad y el riesgo de complicaciones postoperatorias graves a los 30 días, la estancia hospitalaria prolongada y el riesgo de reingreso, mediante regresión logística multivariable.RESULTADOS:De 3172 pacientes con enfermedades inflamatorias intestinales que se sometieron a cirugía abdominal mayor (42,7 ± 16,4 años, 49,3% mujeres, 57,7% con enfermedad de Crohn, 43,9% con biológicos), 116 (3,7%) fueron clasificados como frágiles y 477 como pre- frágil (15%). Después de ajustar por edad, sexo, raza/origen étnico, tabaquismo, índice de masa corporal, tipo de cirugía, uso de corticosteroides, uso de biológicos e inmunomoduladores, la fragilidad no se asoció con un mayor riesgo de complicaciones postoperatorias graves (odds ratio ajustado, 1,24; 95 % de confianza intervalos, 0,81-1,90), mortalidad (odds ratio ajustado, 1,38 [0,44-3,6]) o reingreso a los 30 días (odds ratio ajustado, 1,35 [0,77-2,30]). La cirugía no electiva, la pérdida de peso significativa, el uso de corticosteroides y la necesidad de ileostomía se asociaron con un mayor riesgo de complicaciones posoperatorias graves.LIMITACIONES:Información limitada sobre las características específicas de la enfermedad inflamatoria intestinal.CONCLUSIONES:En pacientes con enfermedades inflamatorias del intestino sometidos a cirugía abdominal mayor, la fragilidad medida por un índice de déficit de salud abreviado convencional no es predictivo de resultados postoperatorios adversos. Las medidas biológicas y funcionales de fragilidad pueden estratificar mejor la candidatura quirúrgica en pacientes con enfermedades inflamatorias del intestino. Consulte el Video Resumen en http://links.lww.com/DCR/C108 . (Traducción-Yesenia Rojas-Khalil ).

Disease- and Treatment-related Complications in Older Patients With Inflammatory Bowel Diseases: Comparison of Adult-onset vs Elderly-onset Disease.

BACKGROUND: The incidence and prevalence of inflammatory bowel diseases (IBD) in older adults are rising. There is a limited comparative assessment of risk of disease- and treatment-related complications in older patients (older than 60 years) with adult-onset (age at disease onset, 18-59 years; AO-IBD) vs elderly-onset IBD (age at disease onset, older than 60 years; EO-IBD). We compared clinical outcomes in older patients with IBD with AO-IBD vs EO-IBD. METHODS: We conducted a retrospective cohort study comparing risk of disease-related complications (IBD-related surgery, hospitalization, treatment escalation, clinical flare, or disease complication) and treatment-related complications (serious infection, malignancy, or death) in older patients with AO-IBD vs EO-IBD through Cox proportional hazard analysis, adjusting for age at cohort entry, disease phenotype, disease duration, prior surgery and/or hospitalization, medication use, disease activity at cohort entry, and comorbidities. RESULTS: We included 356 older patients with IBD (AO-IBD, 191 patients, 67 ± 5 y at cohort entry; EO-IBD, 165 patients, 72 ± 8 y at cohort entry). No significant differences were observed in the risk of disease-related complications in older patients with prevalent vs incident IBD (adjusted hazard ratio [aHR], 0.85; 95% CI, 0.58-1.25), although risk of IBD-related surgery was lower in older patients with prevalent IBD (aHR, 0.47; 95% CI, 0.25-0.89). Older patients with prevalent IBD were significantly less likely to experience treatment-related complications (aHR, 0.58; 95% CI, 0.39-0.87). CONCLUSION: Patients with AO-IBD have lower risk of treatment-related complications as they age compared with patients with EO-IBD, without a significant difference in risk of disease-related complications.

Effect of Lifestyle Factors on Outcomes in Patients With Inflammatory Bowel Diseases.

Various lifestyle factors including physical activity and obesity, stress, sleep, and smoking may modify the risk of developing inflammatory bowel diseases (IBDs). In patients with established IBD, these lifestyle factors may significantly impact the natural history and clinical outcomes. Recreational exercise decreases the risk of flare and fatigue in patients with IBD. In contrast, obesity increases the risk of relapse and is associated with higher anxiety, depression, fatigue, and pain and higher health care utilization. Obesity also modifies pharmacokinetics of biologic agents unfavorably and is associated with a higher risk of treatment failure. Sleep disturbance is highly prevalent in patients with IBD, independent of disease activity, and increases the risk of relapse and chronic fatigue. Similarly, stress, particularly perceived stress rather than major life events, may trigger symptomatic flare in patients with IBD, although its impact on inflammation is unclear. Cigarette smoking is associated with unfavorable outcomes including the risk of corticosteroid dependence, surgery, and disease progression in patients with Crohn's disease; in contrast, smoking does not significantly impact outcomes in patients with ulcerative colitis, although some studies suggest that it may be associated with a lower risk of flare. The effect of alcohol and cannabis use in patients with IBD is inconsistent, with some studies suggesting that cannabis may decrease chronic pain in patients with IBD, without a significant effect of biological remission. Although these lifestyle factors are potentially modifiable, only a few interventional studies have been conducted. Trials of structured exercise and psychological therapy including mindfulness-based therapies such as meditation and yoga and gut-directed hypnotherapy have not consistently demonstrated benefit in clinical and/or endoscopic disease activity in IBD, although may improve overall quality of life.

Progression of Elderly Onset Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis of Population-Based Cohort Studies.

BACKGROUND & AIMS: The incidence of inflammatory bowel diseases (IBDs) in older adults is increasing. We performed a systematic review and meta-analysis to evaluate progression of elderly onset (EO) IBD in population-based cohorts and compared it with adult onset (AO) IBD. METHODS: In a systematic review through June 1, 2019, we identified population-based cohort studies of EO IBD reporting the cumulative risk of hospitalization, surgery, mortality, treatment patterns, escalation, and/or malignancy. Data were synthesized using random-effects meta-analysis as cumulative risk of events at 1 year, 5 years, and 10 years, and compared with data from patients with AO IBD in the same cohorts. RESULTS: We identified 9 studies, comprising 14,765 patients with EO IBD. In patients with EO Crohn's disease (CD), the cumulative 5-year risk of surgery was 22.6% (95% CI, 18.7-27.2) and was similar to that of patients with AO CD (relative risk [RR], 1.04; 95% CI, 0.80-1.34). Overall exposure to corticosteroids was comparable between patients with EO CD vs AO CD (5-year risk: 55.4%; 95% CI, 53.4-57.4; RR, 0.88; 95% CI, 0.78-1.00), but exposure to immunomodulators (31.5%; 95% CI, 29.7-33.4; RR, 0.62; 95% CI, 0.51-0.77) or biologic agents (6.5%; 95% CI, 5.6-7.6; RR, 0.36; 95% CI, 0.25-0.52) was significantly lower for patients with EO CD than for patients with AO CD. Similarly, in patients with EO ulcerative colitis (UC), the cumulative 5-year risk of surgery was 7.8% (95% CI, 5.0-12.0), similar to the risk for patients with AO UC (RR, 1.29; 95% CI, 0.79-2.11). Overall exposure to corticosteroids was comparable between patients with EO UC vs AO UC (5-year risk: 57.2%; 95% CI, 55.6-58.7; RR, 0.98; 95% CI, 0.91-1.06), but exposure to immunomodulators (16.1%; 95% CI, 15.0-17.2; RR, 0.58; 95% CI, 0.54-0.62) or biologic agents (2.0%; 95% CI, 1.6-2.5; RR, 0.36; 95% CI, 0.24-0.52) was significantly lower for patients with EO UC than for patients with AO UC. Patients with EO IBD appeared to have increased mortality, but not malignancy, compared with the general population. There were few data on comorbidities or adverse effects of medications. CONCLUSIONS: In a systematic review and meta-analysis, we found that patients with EO IBD have a similar risk of surgery as patients with AO IBD. However, patients with EO IBD are less likely to receive treatment with immunomodulators or biologic agents.