Citations

SummaryBackgroundUp to 80% of patients with Crohn's disease require an abdominal operation in their lifetime. As the use of vedolizumab is increasing for the treatment of Crohn's disease, it is important to understand its potential association with post‐operative complications.AimWe sought to compare 30‐day postoperative infectious complication rate among vedolizumab‐treated Crohn's disease patients vs those who had received TNFα inhibitors or no biologic therapy.MethodsA retrospective review of all Crohn's disease patients who received vedolizumab within 12 weeks of a major abdominal or pelvic operation was performed. Two control cohorts consisted of Crohn's disease patients treated with TNFα inhibitors or no biologic therapy.ResultsOne hundred Crohn's disease patients received vedolizumab within 12 weeks of an abdominal operation. Vedolizumab‐treated patients underwent an equivalent rate of laparoscopic surgery (P = .25), had fewer anastomoses performed (P = .0002), and had equally frequent diversion in the setting of anastomoses (P = .47). Thirty‐two vedolizumab‐treated patients experienced postoperative infectious complications (32%), 26 of which were surgical site infections (26%). The vedolizumab‐treated group experienced no difference in nonsurgical site infections (6% vs 5% anti‐TNFα and 2% nonbiologic; P = .34), but significantly higher rates of surgical site infections (26% vs 8% and 11%; P < .001). On univariate and multivariate analysis, exposure to vedolizumab remained a significant predictor of postoperative surgical site infection (P < .001 and P = .002).ConclusionsTwenty‐six per cent of Crohn's disease patients who received vedolizumab within 12 weeks prior to a major abdominal operation experienced a 30‐day postoperative surgical site infection, significantly higher than that of patients receiving TNFα inhibitors or no biologic therapy. Vedolizumab within 12 weeks of surgery remained a predictor of 30‐day postoperative surgical site infection on multivariable analysis. While vedolizumab‐treated Crohn's disease patients may be a sicker cohort of patients, it is important to consider these findings with regard to preoperative counselling, operative timing and primary closure of wounds.

SummaryBackgroundThere are conflicting data on comparative effectiveness of adalimumab and infliximab in patients with Crohn's disease (CD).AimsTo compare the effectiveness and safety of adalimumab and infliximab in biologic‐naïve patients with CD, in a nationwide register‐based propensity score‐matched cohort study in Denmark.MethodsA total of 2908 Danish adults with CD had been treated with adalimumab or infliximab as their first biologic agent between 2005‐2014. By Cox regression, we compared rates of all‐cause hospitalisation, CD‐related hospitalisation, major abdominal surgery and serious infections after variable 2:1 propensity score matching, accounting for baseline disease characteristics, healthcare utilisation and use of CD‐related medications.ResultsAfter propensity‐score matching, we included 315 adalimumab‐ (34.9 ± 12.9 years, 41.9% males) and 512 infliximab‐treated (33.6 ± 12.6 years, 40.8% males) patients, with median disease duration 4.0 years; 36.9% had prior abdominal surgery. Over a median follow‐up 2.3 years after starting biological therapy, there were no significant differences in rate of CD‐related hospitalisation (hazard ratio [HR], 0.81 [95% CI, 0.55‐1.20]) or major abdominal surgery (HR, 1.24 [0.66‐2.33]) between adalimumab‐ and infliximab‐treated patients, though rate of all‐cause hospitalisation was lower in adalimumab‐treated patients (HR, 0.74 [0.56‐0.97]). There was no significant difference in incidence of serious infections requiring hospitalisation (HR, 1.06 [0.26‐4.21]). These results were stable in patients treated with biological monotherapy (all‐cause hospitalisation: HR, 0.75 [0.53‐1.05]; CD‐related hospitalisation: HR, 0.82 [0.51‐1.32], abdominal surgery: HR, 1.47 [0.63‐3.47]) or in combination with immunomodulators (all‐cause hospitalisation: HR, 0.70 [0.44‐1.11]; CD‐related hospitalisation: HR, 0.80 [0.42‐1.52], abdominal surgery: HR, 1.02 [0.39‐2.64]).ConclusionsIn this population‐based, propensity score matched, real‐life cohort study using administrative claims, there was no significant difference in effectiveness and safety of adalimumab and infliximab in biologic‐naïve patients with CD.

What is already known about this topic? Lower urinary tract obstruction is associated with high morbidity and mortality. Fetal cystoscopy may allow the correct identification of the etiology of the obstruction and may provide the adequate treatment. What does this study add? Three‐dimensional virtual navigation is a noninvasive approach that provides an immersive virtual reality in the assessment of fetal structures. Three‐dimensional virtual cystoscopy provides a noninvasive evaluation of fetal lower urinary tract obstruction that in the future may help in the selection of candidates for fetal cystoscopy.

Fibrillary GN (FGN) is a rare primary glomerular disease. Histologic and histochemical features of FGN overlap with those of other glomerular diseases, and no unique histologic biomarkers for diagnosing FGN have been identified. We analyzed the proteomic content of glomeruli in patient biopsy specimens and detected DnaJ heat shock protein family (Hsp40) member B9 (DNAJB9) as the fourth most abundant protein in FGN glomeruli. Compared with amyloidosis glomeruli, FGN glomeruli exhibited a >6-fold overexpression of DNAJB9 protein. Sanger sequencing and protein sequence coverage maps showed that the DNAJB9 protein deposited in FGN glomeruli did not have any major sequence or structural alterations. Notably, we detected DNAJB9 in all patients with FGN but not in healthy glomeruli or in 19 types of non-FGN glomerular diseases. We also observed the codeposition of DNAJB9 and Ig- γ . Overall, these findings indicate that DNAJB9 is an FGN marker with 100% sensitivity and 100% specificity. The magnitude and specificity of DNAJB9 overabundance in FGN also suggests that this protein has a role in FGN pathogenesis. With this evidence, we propose that DNAJB9 is a strong biomarker for rapid diagnosis of FGN in renal biopsy specimens.

Abstract In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo‐biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail‐out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail‐out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also included.