Background Postoperative recurrence of Crohn's disease (CD) is common. While most patients undergo resection with undiverted anastomosis (UA), some individuals also have creation of an intended temporary diversion (ITD) with an ileostomy followed by ostomy takedown (OT) due to increased risk of anastomotic complications. We assessed the association of diversion with subsequent CD recurrence risk and the influence of biologic prophylaxis timing to prevent recurrence in this population. Methods This was a retrospective cohort study of CD patients who underwent ileocolic resection between 2009 and 2020 at a large quaternary health system. Patients were grouped by continuity status after index resection (primary anastomosis or ITD). The outcomes of the study were radiographic, endoscopic, and surgical recurrence as well as composite recurrence postoperatively (after OT in the ITD group). Propensity score-weighted matching was performed based on risk factors for diversion and recurrence. Multivariable regression and a Cox proportional hazards model adjusting for recurrence risk factors were used to assess association with outcomes. Subgroup analysis in the ITD group was performed to assess the impact of biologic timing relative to OT (no biologic, biologic before OT, after OT) on composite recurrence. Results A total of 793 CD patients were included (mean age 38 years, body mass index 23.7 kg/m(2), 52% female, 23% active smoker, 50% penetrating disease). Primary anastomosis was performed in 67.5% (n = 535) and ITD in 32.5% (n = 258; 79% loop, 21% end) of patients. Diverted patients were more likely to have been males and to have had penetrating and perianal disease, prior biologic use, lower body mass index, and lower preoperative hemoglobin and albumin (all P < .01). After a median follow-up of 44 months, postoperative recurrence was identified in 83.3% patients (radiographic 40.4%, endoscopic 39.5%, surgical 13.3%). After propensity score matching and adjusting for recurrence risk factors, no significant differences were seen between continuity groups in radiographic (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 0.91-1.91) or endoscopic recurrence (aHR, 1.196; 95% CI, 0.84-1.73), but an increased risk of surgical recurrence was noted in the ITD group (aHR, 1.61; 95% CI, 1.02-2.54). Most (56.1%) ITD patients started biologic prophylaxis after OT, 11.4% before OT, and 32.4% had no postoperative biologic prophylaxis. Biologic prophylaxis in ITD was associated with younger age (P < .001), perianal disease (P = .04), and prior biologic use (P < .001) but not in recurrence (P = .12). Despite higher rates of objective disease activity identified before OT, biologic exposure before OT was not associated with a significant reduction in composite post-OT recurrence compared with starting a biologic after OT (52% vs 70.7%; P = 0.09). Conclusions Diversion of an ileocolic resection is not consistently associated with a risk of postoperative recurrence and should be performed when clinically appropriate. Patients requiring diversion at time of ileocolic resection are at high risk for recurrence, and biologic initiation prior to stoma reversal may be considered.

Purpose of Review The management of patients with Crohn’s disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach. Recent Findings Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. Summary This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.

Goals: Assess the outcomes of various therapeutic regimens to treat initial endoscopic postoperative recurrence despite biologic prophylaxis. Background: Postoperative biologic prophylaxis reduces postoperative Crohn’s disease (CD) recurrence rates. Optimal treatment strategies for endoscopic recurrence have not been elucidated. Study: Retrospective cohort study of adult CD patients who underwent ileocolonic resection between 2009 and 2020. Patients with endoscopic postoperative recurrence despite prophylactic biologic therapy and ≥1 subsequent colonoscopy were included. Treatment changes after recurrence were categorized as (1) therapy optimization or continuation or (2) new biologic class. The primary outcome was composite endoscopic or surgical recurrence at the time of or prior to subsequent follow-up colonoscopy. Results: Eighty-one CD patients with endoscopic recurrence (54.3% i2b, 22.2% i3, and 23.5% i4) despite biologic prophylaxis (86.4% anti-tumor necrosis factor, 8.6% vedolizumab, 4.9% ustekinumab) were included. Most patients received therapy optimization or continuation (76.3%, n=61) following recurrence compared to being started on a new biologic class. Sixty patients (N=48 therapy optimization; N=12 new biologic class) experienced composite recurrence (78.3% endoscopic, 21.7% surgical). On multivariable modeling, initiation of a new biologic class was associated with reduced risk for composite recurrence compared to therapy optimization or continuation (aOR: 0.26; P=0.04). Additionally, initiation of a new biologic class was associated with endoscopic improvement when adjusting for endoscopic severity at the time of recurrence (aOR: 3.4; P=0.05). On sensitivity analysis, a new biologic class was associated or trended with improved rates of endoscopic healing and composite recurrence when directly compared to therapy optimization or continuation. Conclusion: In patients with CD who experience endoscopic recurrence despite biologic prophylaxis, changing the mechanism of biologic action may promote endoscopic improvement.

INTRODUCTION:Following ileocolic resection (ICR), the clinical importance and prognostic implications of histologic activity on biopsies in Crohn's disease (CD) patients with endoscopic remission are not well defined. The aim of this study was to determine if histologic activity in patients with endoscopic remission is associated with future risk of endoscopic and/or radiologic postoperative recurrence (POR). METHODS:In this multicenter retrospective cohort study, adult patients with CD who underwent ICR between 2009 and 2020 with endoscopic biopsies of ileal mucosa from Rutgeerts i0 on index colonoscopy were included. The composite rate of endoscopic (Rutgeerts score ≥i2b) and radiologic (active inflammation on imaging) recurrence was compared in patients with and without histologic activity using a Kaplan-Meier survival analysis. A multivariable Cox proportional hazard regression model including clinically relevant risk factors of POR, postoperative biologic prophylaxis, and histology activity was designed. RESULTS:A total of 113 patients with i0 disease on index colonoscopy after ICR were included. Of these, 42% had histologic activity. Time to POR was significantly earlier in the histologically active versus normal group ( P = 0.04). After adjusting for clinical risk factors of POR, histologic activity (HR 2.37, 95% CI 1.17-4.79; P = 0.02) and active smoking (HR 2.54, 95% CI 1.02-6.33; P = 0.05) were independently associated with subsequent composite POR risk. DISCUSSION:In patients with postoperative CD, histologic activity despite complete endoscopic remission is associated with composite, endoscopic, and radiographic recurrence. Further understanding of the role of histologic activity in patients with Rutgeerts i0 disease may provide a novel target to reduce disease recurrence in this population.

Acetaminophen (APAP) overdose is the most common cause of acute liver failure (ALF) in the United States. Liver transplantation (LT) is potentially lifesaving for patients with ALF, but its feasibility in clinical practice is limited. Liver assist devices, such as the Molecular Adsorbent Recirculating System (MARS), are used in some centers as a “bridge” to liver transplantation or as a means of liver recovery, but their role in the treatment of ALF is not well-defined. We present the case of a 44-year-old man with APAP-associated ALF who experienced hepatic recovery after treatment with MARS.

BACKGROUND:Extrahepatic, abdominal surgery in patients with cirrhosis is associated with high morbidity and mortality. This systematic review presents the current evidence available on the utility of a preoperative transjugular intrahepatic portosystemic shunt (TIPS), assessed by its effect on surgical candidacy and postoperative mortality and morbidity in patients with cirrhosis undergoing extrahepatic, abdominal surgery. METHODS:MEDLINE, EMBASE, Cochrane Library and Web of Science databases were searched till 2022 to identify studies. Studies that reported characteristics and outcomes of participants with cirrhosis that had a TIPS inserted in preparation for extrahepatic, abdominal surgery, were included. RESULTS:Twenty-one studies (292 patients) were included, of which three were comparative studies and the remaining case series or case reports. A TIPS was inserted in 190 patients prior to surgery. At least one clinical sign of portal hypertension identified by ascites, varices, and/or hepatic encephalopathy were present in all patients except one patient. Fifty eight percent had decompensated cirrhosis. TIPS insertion was successful in all patients. Eighty-nine percent of patients underwent surgery. The cumulative 30-day postoperative mortality was 2% (3/148). There were 97 complications reported in 168 patients (57%). In the three comparative studies, there was no difference in mortality or morbidity among patients who underwent TIPS prior to surgery compared to those who did not undergo TIPS prior to surgery. CONCLUSION:Preoperative TIPS has been used to improve surgical candidacy in patients with cirrhosis undergoing extrahepatic, abdominal surgery, while reducing complications of portal hypertension. However, there is not enough evidence to support that TIPS insertion prior to extrahepatic, abdominal surgery significantly improves surgical outcomes in patients with cirrhosis and further studies are needed.

Introduction: Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease characterized by circulating autoantibodies which may progress to chronic liver disease and cirrhosis. Inflammatory myopathies such as polymyositis (PM) and dermatomyositis (DM) are autoimmune inflammatory muscle disorders characterized by the development of proximal symmetrical muscle weakness. There are case reports in the literature hypothesizing an association between autoimmune hepatitis and inflammatory muscle disorders but large studies assessing the association are lacking. We aim in our study to investigate this possible association using a large national database. Methods: We conducted a retrospective cohort study using the National Inpatient Sample (NIS) of all adult patients for the years 2016-2020. Using the 10th version of the International Classification of Diseases codes (ICD-10), we identified all patients with AIH. The prevalence of PM and DM was then calculated among AIH patients and compared to those without AIH. Multivariate logistic regression was conducted to assess the risk of having a diagnosis of PM or DM after adjusting for demographics and possible confounders. Discharge weights were applied to generate national estimates. Results: Among 148,767,786 adult discharges, 96,104 (0.06%) had a diagnosis of AIH. Using bivariate analysis, AIH patients had a higher prevalence of PM (0.20% vs 0.03%) and DM (0.07% vs 0.01%) when compared to patients without AIH (P< 0.001). Baseline characteristics and comorbidities of patients with AIH and without AIH were reported. We confirmed the association using multivariate logistic regression (Table 1), and after adjusting for potential confounding factors (age, race, gender, hypothyroidism, alcohol, and tobacco use), patients with AIH had 5.53 higher odds to have a diagnosis of DM when compared to non-AIH patients (OR 5.53, 95% CI 3.08-9.92; P < 0.001). Similarly, AIH patients had higher odds for PM compared to those without AIH (OR 6.92, 95% CI 4.99-9.59; P < 0.001). Conclusion: In our study, AIH was significantly associated with DM and PM after accounting for several possible confounders. This association warrants further prospective studies to investigate and understand the mechanism underlying this association. Table 1. - Multivariate analysis for risk factors of Polymyositis and Dermatomyositis Factors aOR for Polymyositis (95% CI) P-value aOR for Dermatomyositis (95% CI) P-value AIH 6.92 (4.99-9.59) < 0.001 5.53 (3.08-9.92) < 0.001 Female 1.31 (1.24-1.38) < 0.001 1.60 (1.47-1.74) < 0.001 Age 1.01 (1.01-1.02) < 0.001 1.00 (1.002-1.005) < 0.001 Black (compared to whites) 2.76 (2.61-2.92) < 0.001 1.53 (1.38-1.70) < 0.001 Hispanic (compared to whites) 1.11 (1.01-1.21) =0.031 1.42 (1.25-1.60) < 0.001 Hypothyroidism 1.53 (1.43-1.63) < 0.001 1.50 (1.36-1.66) < 0.001 Alcohol Use 0.46 (0.39-0.54) < 0.001 0.30 (0.22-0.41) < 0.001 Tobacco Use 0.75 (0.71-0.79) < 0.001 0.93 (0.85-1.01) =0.082

INTRODUCTION: Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated. METHODS: A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection. RESULTS: A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection. DISCUSSION: AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.

BACKGROUND:The incidence of early-onset colorectal cancer (EOCRC) is rapidly increasing. Pathogenic germline variants (PGVs) are detected in 16% to 20% of patients who have EOCRC, highlighting a need for genetic counseling (GC) and multigene panel testing in these patients. We aimed to determine the rate of referral to GC and uptake and outcomes of germline testing in patients with EOCRC.METHODS:We conducted a retrospective cohort study of patients aged <50 years diagnosed with colorectal cancer (CRC) from 2010 to 2019 at Cleveland Clinic. Demographic data were extracted, including age, sex, self-reported race, and family history of CRC. The proportions of patients with GC referral and completion of GC and genetic testing were investigated, and genetic testing results were analyzed. Multivariable logistic regression analysis was conducted to identify factors independently associated with GC referral and uptake.RESULTS:A total of 791 patients with EOCRC (57% male and 43% female) were included; 62% were referred for GC, and of those who were referred, 79% completed a GC appointment and 77% underwent genetic testing. Of those who underwent testing, 21% had a PGV detected; 82% were in known CRC-associated genes, with those associated with Lynch syndrome and familial adenomatous polyposis the most common, and 11% were in other actionable genes. Referral to GC was positively associated with family history of CRC (odds ratio [OR], 2.11; 95% CI, 1.51-2.96) and more recent year of diagnosis (2010-2013 vs 2017-2019; OR, 5.36; 95% CI, 3.59-8.01) but negatively associated with older age at diagnosis (OR, 0.89; 95% CI, 0.86-0.92).CONCLUSIONS:Referral to GC for patients with EOCRC is increasing over time; however, even in recent years, almost 25% of patients were not referred for GC. We found that 1 in 5 patients with EOCRC carry actionable PGVs, highlighting the need for health systems to implement care pathways to optimize GC referral and testing in all patients with EOCRC.

Introduction: Majority of individuals with Crohn's disease (CD) who undergo ileocolonic resection (ICR) will develop endoscopic postoperative recurrence (ePOR) within one year. However, the rates of early severe ePOR, its predictors, and the response to therapeutic interventions have not been defined in real-world data. Methods: We performed a multi-center retrospective observational cohort study of CD patients who underwent ICR between 2009-2021. Patients who had ileocolonoscopy within 18 months of ICR were included. The primary outcome of the study was early, severe ePOR defined as a Rutgeerts score (RS) of i3 or i4 on postoperative ileocolonoscopy within 18 months. Association between perioperative risk factors and early severe ePOR was evaluated. Rates of surgical recurrence, therapy changes, and subsequent ileocolonoscopy findings were assessed. Results: 737 patients with CD who had an ileocolonoscopy within 18 months of their index ICR were identified. Overall, 6.4% of patients had RS i3 (n=34, 4.6%) or i4 (n=13, 1.8%) ePOR within 18 months (Table 1). On univariable and multivariable analysis, there was no significant association found between severe ePOR and age (< 30 years vs > 30 years), history of ≥2 prior ICR, absence of diverting stoma or use of post-operative biologic prophylaxis. Rates of surgical recurrence in patients with severe ePOR diagnosed within 6 months (0%), 12 months (5.1%) and 18 months (6.4%) were similar to patients with i0-i2a and i2b disease in their respective time periods (P > 0.05 ). The median time to surgery in patients with severe ePOR within 18 months (458 [424,561] days) was much shorter than patients with i0-i2a (1371 [420, 1967] days) and i2b (1491 [796,2006] days). The most common treatment change following diagnosis of early severe ePOR was initiation of a new biologic (38.3%), followed by new immunomodulator (6.4%), optimized current biologic (4.3%) or immunomodulator (2.1%). Among those for whom follow-up ileocolonoscopy data was available after treatment change (n=9) the median time to next ileocolonoscopy was 182 [132-233] days and all patients started on a new biologic had endoscopic improvement. Conclusion: The incidence of early severe ePOR in patients with CD is low. This severe subgroup of patients appears responsive to biologic treatment changes. Prospective studies are needed to identify predictors for ePOR and refine treatment algorithms for these patients. Table 1. - Proportion of Rutgeert’s scores on ileocolonoscopy over 6, 12 and 18 months post ICR RUTGEERTS SCORE 6 MONTHS (%, N=152) 12 MONTHS (%, N=549) 18 MONTHS (%, N=737) I0 49.3 42.3 40.8 I1 7.9 7.5 7.2 I2 6.6 9.5 9.4 I2A 15.1 16.9 17.9 I2B 12.5 16.8 18.3 I3 7.2 5.3 4.6 I4 1.3 1.8 1.8

Introduction: Risk factors for delayed postoperative recurrence (POR) of Crohn’s disease (CD) have not been fully elucidated. This study aimed to identify risk factors for late endoscopic and surgical POR in patients who are in endoscopic remission at their index postoperative ileocolonoscopy. Methods: Retrospective study of CD patients who underwent ileocolonic resection (ICR) between 2009-2020 across three tertiary care medical centers. Patients with index postoperative ileocolonoscopy with modified Rutgeerts score of ≤ i2a disease within 18 months of surgery were included. Primary composite outcome was defined as either endoscopic (Rutgeerts score ≥ i2b) or repeat ICR after index endoscopic remission. Results: 331 adult CD patients with endoscopic remission on index postoperative ileocolonoscopy within 18 months of ICR. Of these patients, 117 (35%) experienced total composite POR (77.8% endoscopic). On univariate analysis assessing impact of active smoking at time of ICR, age at CD diagnosis, gender, prior history of ICR, history of perianal disease, and postoperative biologic prophylaxis, no variables were associated with composite POR. On multivariable logistic regression, active smoking at time of ICR was associated with a 2.5 times increased risk of composite POR (aOR 2.55 [1.10-6.03]; P=0.03) compared to never smokers. On sensitivity analysis evaluating impact on endoscopic POR, active smoking remained associated with a significantly elevated risk for endoscopic POR compared to non-smokers (aOR 2.73 [1.13-6.56]; P=0.02). In patients who had endoscopic remission on index colonoscopy, the use of postoperative biologic prophylaxis did not offer increased protection against late composite and endoscopic POR (P=0.49; P=0.15). Conclusion: Delayed postoperative recurrence in patients previously in postoperative endoscopic remission is relatively common and associated with active smoking. Multidisciplinary smoking cessation interventions should be incorporated into routine practice and may prevent POR (see Table 1). Table 1. - Multivariable Logistic Regression of Composite POR Risk Factor aOR (95% CI) P value History of ≥2 prior ICR 1.12 (0.61-2.05) 0.13 Postoperative Biologic Prophylaxis 0.69 (0.22-1.87) 0.53 History of perianal disease 0.74 (0.45-1.22) 0.49 Former Tobacco User (Reference: Never) 1.41 (0.82-2.40) 0.21 Active Tobacco User (Reference: Never) 2.56 (1.10-6.03) 0.03 Younger than 30 years of age at time of CD Diagnosis 0.90 (0.53-1.57) 0.28

Introduction: Metastatic Crohn’s disease (MCD) is a rare cutaneous extra-intestinal manifestation (EIM) mimicking crohn's disease (CD). Literature concerning MCD is limited to case reports and small case series. We performed a systematic review of biopsy proven MCD cases to characterize the clinical features and risk factors of this entity. Methods: We searched Medline, Embase, Cochrane Central, and Web of Science from inception through April 2021 for English publications describing MCD. Studies were screened by four independent reviewers who then extracted study data. A skin biopsy revealing histologic features consistent with MCD was required for inclusion. Case series without individual level data were excluded. Missing data was not imputed. We summarized data with medians, ranges, and percentages. Results: In 321 included cases, MCD occurred at median of 28 years, mostly in females (65%) and within a median of 2 years (range -11; 43) from CD diagnosis. About 27% of cases occurred within 3 months of CD diagnosis. MCD lesions mostly involved genital (68%) and gluteal (18%) areas, but were multifocal in 75% of cases. Perianal MCD was present in 53/165 (32%) of patients, 29% had prior IBD-related surgeries. Most patients (59%) had non-stricturing, non-penetrating disease, especially in pediatric patients, and 61% were on no IBD therapy at time of MCD diagnosis. Peristomal MCD was present in 10% of ostomized patients. Genital lesions were predominantly characterized by ulceration and erythematous induration, non-genital areas typically were ulcers, nodules and plaques. Endoscopic CD assessment when available was active in 70% of cases, and interestingly, IBD was either not investigated or not found on endoscopy in 38/303 (12.5%). Additional EIMs were present in 13% of patients. Treatment characteristics for MCD are summarized in Table 1. Hospitalization was required in 18% of patients. Biologic (76/299; 25%) and non-biologic immunosuppressive therapies (90/299; 30%) were relatively common MCD treatments. CD long-term therapy changes occurred in 60/227 (26%) patients. MCD recurrence rate was 26%. Conclusion: MCD is rare and occurrence in genital and gluteal areas makes it a challenging diagnosis for clinicians. MCD can occur in children and adults, tends to occur early in the course of IBD, seems to parallel active CD, and typically triggers medical therapy changes to control both diseases. Table 1. - Treatment and Outcomes of MCD Therapies N (%) Steroids and any type of steroid Received treatment (%) 206 (68.9) Local 51 (25.5) PO 103 (51.5) IV (with any other form) 9 (4.5) Local + PO 37 (18.5) Median number of steroid days (Range) 36.00 [14.00, 240.00] Other treatments Colchicine 1 (0.3) Dapsone 3 (0.9) Oral retinoid 1 (0.3) Indomethacin or NSAIDs 2 (0.6) Use of antibiotics as MCD-directed therapy 103 (34.4) Tacrolimus 18 (5.6) Mesalazine 27 (8.4) Sulfasalazine 27 (8.4) Hyperbaric oxygen 3 (0.9) Azathioprine 66 (20.6) Other immunomodulator 8 (2.5) Cyclosporine 10 (3.1) Methotrexate 18 (5.6) Thalidomide 4 (1.2) Adalimumab 27 (8.4) Infliximab 51 (15.9) Ustekinumab 9 (2.8) Other biologic 7 (2.2) Surgical debridement (%) 44 (15.1) Outcomes of treatment (%) Lesion resolved 123 (56.7) Among those with biologic therapy 29 (52.7) Among those with non-biologic immunomodulators 32 (47.1) Among both biologics and non-biologic immunomodulators 14 (58.3) With neither (corticosteroids allowed) 76 (64.4) Lesion did not resolve 22 (10.1) Among those with biologic therapy 4 (7.3) Among those with non-biologic immunomodulators 9 (13.2) Among both biologics and non-biologic immunomodulators 2 (8.3) With neither (corticosteroids allowed) 11 (9.3) Spontaneous recovery without treatment 3 (1.4) Lesions improved but did not resolve 69 (31.8) Among those with biologic therapy 22 (40) Among those with non-biologic immunomodulators 26 (38.2) Among both biologics and non-biologic immunomodulators 8 (33.3) With neither (corticosteroids allowed) 29 (24.6) Recurrence (%) 57 (25.2) Among those with biologic therapy 12 (19) Among those with non-biologic immunomodulators 19 (25.7) Among both biologics and non-biologic immunomodulators 8 (28.6) With neither (corticosteroids allowed) 34 (29.1) Reason for recurrence (%) During Steroid taper 12 (22.2) After non-steroid therapy stopped 12 (22.2) After steroid therapy stopped 15 (27.8) IBD re-flare 2 (3.7) MCD not treated on first presentation 13 (24.1)

Introduction: Gastrointestinal (GI) symptoms are common in patients with diabetes mellitus (DM) and are often associated with underlying dysmotility, which may be related to autonomic neuropathy. Wireless Motility Capsule (WMC) allows assessment of transit times of the entire GI tract in a single study. The prevalence of dysmotility and its distribution in patients with DM have not been well described. We aimed to investigate the prevalence and patterns of GI dysmotility and identify associated factors using WMC testing in patients with DM. Methods: A retrospective observational cohort study was done on patients with Type 1 Diabetes (T1D) and Type 2 Diabetes (T2D) undergoing WMC testing. The primary aim of the study was presence of dysmotility defined as delayed WGTT (whole gut transit time), gastric emptying time (GET), SBTT (small bowel transit time), CTT (colon transit time) as seen on WMC testing in patients with DM. Univariate and multivariate analyses were conducted to assess for risk factors associated with dysmotility in diabetic patients. Results: Four hundred and eighty-two patients were included with a mean age of 54.2 ± 13.9 years. 74.1% were female and 73.9% were White. 20.2% (n=88) had T1D and 79.8% (n=348) had T2D with a median disease duration of 1.8 [0.32, 6.1] years. Overall, 75.7% (n= 365) of the patients had dysmotility; delayed GET (58.8%) being the most common followed by WGTT (38.5%), CTT (34.3%) and SBTT (23.1%). In all multivariable models, increasing BMI was associated with lower rates of dysmotility (OR 0.96 [0.93, 0.99]; P-value < 0.002). This was further demonstrated in individual measures of motility (Table 1). In addition, in the multivariable models, increasing age, female gender, and diabetes duration of 1-4.99 years (relative to less than 1 year) were associated with increased CTT delay (Table 1), while diabetes duration of 1-4.99 years and 5-9.99 years (both relative to less than 1 year) were associated with greater risk of SBTT delay (Table 1). Conclusion: We conclude that gastric dysmotility is the most prevalent with a high rate of WGTT, CTT, and SBTT delay. Furthermore, we demonstrated that increasing BMI was associated with lower rates of dysmotility. These findings support the need for and utility of WMC testing to evaluate global dysmotility in diabetic patients. Large prospective studies are needed to assess the prevalence and patterns of GI dysmotility to guide proper management strategies for patients with diabetes. Table 1. - Multivariate analysis of smartpill dysmotility measures by patient characteristics WGTT Delay GET Delay CTT Delay SBTT Delay Characteristics N OR (95% CI)1 P-value N OR (95% CI)1 P-value N OR (95% CI)1 P-value N OR (95% CI)1 P-value Age 475 1.01 (1.00, 1.03) 0.15 478 0.99 (0.98, 1.01) 0.42 464 1.03 (1.01, 1.04) 0.001 472 0.99 (0.97, 1.01) 0.27 BMI 469 0.97 (0.94, 0.99) 0.012 471 0.97 (0.94, 0.99) 0.008 458 0.97 (0.94, 1.00) 0.022 465 0.96 (0.93, 0.99) 0.015 Race White 345 — — 348 — — 337 — — 342 — — Black 84 1.11 (0.67, 1.84) 0.67 84 1.06 (0.65, 1.75) 0.81 82 1.06 (0.63, 1.80) 0.81 84 1.46 (0.85, 2.51) 0.17 Other 24 0.85 (0.35, 2.05) 0.71 25 1.12 (0.47, 2.64) 0.8 23 0.89 (0.36, 2.22) 0.81 24 0.48 (0.13, 1.83) 0.28 Gender Female 351 — — 353 — — 343 — — 351 — — Male 124 0.69 (0.44, 1.08) 0.11 125 1.06 (0.68, 1.64) 0.8 121 0.53 (0.32, 0.86) 0.011 121 1.16 (0.71, 1.92) 0.55 Diabetes Type I 86 — — 87 — — 81 — — 85 — — II 343 0.74 (0.45, 1.22) 0.24 345 0.69 (0.41, 1.17) 0.17 337 1.08 (0.63, 1.86) 0.78 341 1.21 (0.66, 2.22) 0.54 DM Duration Less than 1 year 170 — — 173 — — 168 — — 172 — — 1-4.99 years 130 1.50 (0.94, 2.37) 0.088 132 1.16 (0.72, 1.84) 0.54 126 1.64 (1.01, 2.64) 0.044 128 2.34 (1.35, 4.05) 0.003 5-9.99 years 89 0.75 (0.42, 1.31) 0.31 89 1.51 (0.85, 2.68) 0.15 87 0.83 (0.46, 1.48) 0.52 89 1.96 (1.04, 3.71) 0.038 10+ years 40 0.67 (0.32, 1.41) 0.29 38 0.89 (0.44, 1.83) 0.76 37 0.51 (0.22, 1.19) 0.12 37 1.37 (0.54, 3.49) 0.51 HbA1c Group < 6.5 191 — — 192 — — 185 — — 191 — — 6.5-7.99 142 1.10 (0.68, 1.77) 0.7 143 0.79 (0.49, 1.25) 0.31 139 0.90 (0.54, 1.50) 0.7 141 1.14 (0.66, 1.95) 0.64 8-9.99 years 90 1.05 (0.60, 1.84) 0.85 91 1.68 (0.95, 2.98) 0.077 88 1.13 (0.63, 2.03) 0.67 88 0.78 (0.41, 1.48) 0.44 10+ 52 1.05 (0.54, 2.04) 0.89 52 0.74 (0.39, 1.41) 0.36 52 1.15 (0.57, 2.29) 0.7 52 0.50 (0.21, 1.19) 0.12

BACKGROUND & AIMS: Preoperative risk strati fi cation may help guide prophylactic biologic utilization for the prevention of postoperative Crohn ' s disease (CD) recurrence; however, there are limited data exploring and validating proposed clinical risk factors. We aimed to explore the preoperative clinical risk pro fi les, quantify individual risk factors, and assess the impact of biologic prophylaxis on postoperative recurrence risk in a real-world cohort. METHODS: In this multicenter retrospective analysis, patients with CD who underwent ileocolonic resection (ICR) from 2009 to 2020 were identi fi ed. High-risk (active smoking, >= 2 prior surgeries, penetrating disease, and/or perianal disease) and low-risk (nonsmokers and age > 50 y) features were used to stratify patients. We assessed the risk of endoscopic (Rutgeert score, >= i2b) and surgical recurrence by risk strata and biologic prophylaxis ( <= 90 days postoperatively) with logistic and time-to-event analyses. RESULTS: A total of 1404 adult CD patients who underwent ICR were included. Of the high-risk factors, 2 or more ICRs (odds ratio [OR], 1.71; 95% CI, 1.13 - 2.57), active smoking (OR, 1.73; 95% CI, 1.17 - 2.53), penetrating disease (OR, 1.41; 95% CI, 1.02 - 1.94), and history of perianal disease alone (OR, 1.99; 95% CI, 1.42 - 2.79) were associated with surgical but not endoscopic recurrence. Surgical recurrence was lower in high-risk patients receiving prophylaxis vs not (10.2% vs 16.7%; P = .02), and endoscopic recurrence was lower in those receiving prophylaxis irrespective of risk strata (high-risk, 28.1% vs 37.4%; P = .03; and low-risk, 21.1% vs 38.3%; P = .002). CONCLUSIONS: Clinical risk factors accurately illustrate patients at risk for surgical recurrence, but have limited utility in predicting endoscopic recurrence. Biologic prophylaxis may be of benefit irrespective of risk strati fi cation and future studies should assess this.