NYU Langone’s Inflammatory Bowel Disease Center, led by Feza Remzi, MD, professor in the Department of Surgery and center director, and David P. Hudesman, MD, associate professor in the Department of Medicine and center co-director, provides personalized, multidisciplinary care and conducts extensive research, from basic and translational research studies to clinical trials. This bench-to-bedside model both benefits patients and advances the science in inflammatory bowel disease (IBD).
Clinical Trials Provide Access to Cutting-Edge Therapies
The Inflammatory Bowel Disease Center offer patients access to a full spectrum of advanced diagnostics, treatments, and procedures. For patients who have Crohn’s disease (CD) or ulcerative colitis (UC) and may be in need of new options for inducing or maintaining remission, the center’s participation in clinical trials is an important component in making investigational treatments and approaches available.
Dr. Hudesman is leading an investigator-initiated study that seeks to individualize UC treatment through the use of patients’ cellular and molecular profiles obtained from blood and stool samples. These samples are used to identify characteristics in patients with UC that may predict response to tofacitinib. “Over the past few years, new drugs for managing UC have come to market with novel mechanisms of action,” says Dr. Hudesman. “It is important to study how to incorporate these new medical options into clinical practice and find the right medication for the right patient.”
There are also opportunities for participation in ongoing research through other clinical trials and multicenter collaborative registries, such as the Vedolizumab Health Outcomes in Inflammatory Bowel Diseases, or VICTORY, Consortium, which uses patient data to establish the real-world efficacy and safety of current immunosuppressant and biologic agents. In general, active research programs such as these result in the rapid translation of findings in the lab to new treatment options in clinical care.
Research Suggests Potential Environmental Trigger for IBD Flares
Observational studies have demonstrated a correlation between dysbiosis in the gut microbiome and IBD; however, the mechanisms of dysbiosis remain unknown. In a recently published cross-sectional analysis of more than 9,000 patients experiencing a diarrheal illness, Jordan E. Axelrad, MD, MPH, instructor in the Department of Medicine and a translational researcher with the Inflammatory Bowel Disease Center, and colleagues used multiplex stool polymerase chain reaction testing to examine the role of non-Clostridium difficile gastrointestinal infections in IBD flares. The study findings appeared in The American Journal of Gastroenterology in October 2018.
The primary outcome was the identification of enteric infections with an exacerbation of symptoms in patients with IBD; these data were compared to patients without IBD during an episode of diarrhea. Secondary outcomes included identification of histological and endoscopic predictors of infection and clinical outcomes in patients with IBD following testing.
Analysis of the data for CD, UC, and patients without IBD demonstrated significant differences in the distribution of enteric pathogens. Patients with IBD were more likely to test negative for enteric infection than patients without IBD: Non-C. difficile infection was detected in 17 percent of IBD flares (CD 18 percent, UC 16 percent, and no IBD 27 percent). Compared to non-IBD patients with enteric infection, patients with CD showed a greater prevalence of norovirus and Campylobacter infection and patients with UC showed a greater prevalence of Campylobacter, Plesiomonas, and Escherichia coli subtypes.
IBD patients who were positive for enteric infection were less likely to be prescribed increased or additional IBD therapies. Enteric infection did not appear to affect long-term IBD outcomes. Finally, endoscopic and histological findings did not differentiate an IBD flare from an enteric infection suggesting that infections may trigger flares or they may occur in tandem with them. The authors recommend further investigation, in particular to shed light on the clinical relevance of specific non-C. difficile infections in patients with IBD.
Analysis Supports Surgical Options for the Elderly
A recent NYU Langone Health analysis of ileal pouch anal anastomosis (IPAA) surgeries by Shannon Chang, MD, assistant professor in the Department of Medicine and associate director of the gastroenterology and hepatology three-year clinical fellowship program, and colleagues challenged earlier studies that suggested worse outcomes in elderly patients. The continence-preserving procedure offers a viable alternative to end ileostomy for patients with UC and for select patients with CD.
Although older patients undergoing IPAA had increased length of hospital stay and higher readmission rates for dehydration, the incidence of major surgical complications was not increased in the elderly, and rates of fecal incontinence were similar in both younger and older patients. The study appeared in the September 2018 issue of Current Treatment Options in Gastroenterology.
Complex Case: Successful Laparoscopic Ileocolic Resection in Complicated Crohn’s Disease with Ileotransverse Fistula
Under the guidance of Dr. Remzi, surgeons at the Inflammatory Bowel Disease Center perform a high volume of ileocolic procedures. “Experience guides innovation and outcomes,” notes Dr. Remzi, “and complex operations should be performed by surgeons who do them every day.”
In a recent case, the multidisciplinary team was well equipped to diagnose and treat a patient with complicated CD who presented to NYU Langone with a reported history of irritable bowel syndrome (IBS). Believing that IBS was not the correct diagnosis, Mark B. Pochapin, MD, the Sholtz/Leeds Professor of Gastroenterology, director of the Division of Gastroenterology and Hepatology, and vice chair of clinical affairs in the Department of Medicine, immediately referred the patient to Dr. Hudesman. MR enterography showed complicated Crohn’s ileitis with a phlegmon.
Dr. Hudesman consulted Dr. Remzi, and together the two physicians discussed with the patient that she would likely need surgery, given her penetrating CD, but that medication could be tried first. She was started on infliximab, which led to an initial improvement in her symptoms, but her abdominal pain recurred and the phlegmon progressed. Dr. Remzi then performed a laparoscopic small bowel resection and found a large phlegmon, a small mesenteric abscess, and a fistula from the ileum to the transverse colon. Tissue friability and perforation, with extensive adhesions and fibrotic scar tissue, offered additional challenges.
Ultimately, Dr. Remzi and the team successfully resected the fistula and performed an ileocolic resection with drainage of the mesenteric abscess, followed by a primary end-to-side anastomosis without the need for ileostomy. The patient recovered without complications.
Because the patient was at high risk of Crohn’s recurrence, she was continued on infliximab postoperatively. Repeat colonoscopy at one year showed no evidence of recurrence of disease. Recently married, the patient has been referred to the IBD Center’s preconception counseling program to discuss pregnancy and IBD and the importance of remaining on medication throughout pregnancy.
Cultivating the Next Generation of Leadership in Inflammatory Bowel Disease
NYU Langone offers a one-year advanced fellowship in inflammatory bowel disease. Led by Lisa B. Malter, MD, associate professor in the Department of Medicine, director of education at NYU Langone’s Inflammatory Bowel Disease Center, and director of the Inflammatory Bowel Disease Program at NYC Health + Hospitals/Bellevue, the fellowship offers opportunities for both clinical care and research. The program also features clinical rotations among diverse populations of inpatients and outpatients who have IBD, focused complex case conferences, and mentored research individualized for each fellow’s unique goals.
Also reflecting a strong commitment to education, the Department of Surgery recently introduced a new ACGME-accredited colon and rectal surgery fellowship directed by Alexis L. Grucela, MD, assistant professor in the Department of Surgery, as well as an Accreditation Council for Graduate Medical Education–accredited surgical critical care fellowship directed by Greta L. Piper, MD, assistant professor in the Departments of Surgery and Anesthesiology, Perioperative Care, and Pain Medicine.
Disclosures: Shannon Chang, MD, is a consultant for Oshi Health. David P. Hudesman, MD, has received research grant funding from Pfizer to support his investigator-initiated clinical trial. He serves as a consultant for Abbvie, Janssen, Pfizer, Salix, and Takeda. The VICTORY Consortium is supported, in part, by Takeda.