Guest Commentary

IBD: Creating a Clearer Picture of a Fuzzy Disease

Conor P. Delaney, MD, PhD
Conor P. Delaney

In this exclusive guest commentary, Tracy Hull, MD, Surgical Section Chief for Inflammatory Bowel Disease, Bo Shen, MD, Medical and Endoscopic Management Director of the Inflammatory Bowel Disease Program, and Conor P. Delaney, MD, PhD, Chairman of Digestive Disease and Surgery at Cleveland Clinic, discuss the latest advancements in inflammatory bowel disease, and the need for a multidisciplinary approach to improve patient outcomes.

Promising advancements, both medicinal and surgical, are beginning to ease the burden for patients with inflammatory bowel disease.

These innovations promise long overdue relief from conditions that are oftentimes frustrating and life-altering for some patients. Additionally, many novel best practices are emerging because the growing IBD community of gastroenterologists, surgeons, radiologists and pathologists are taking steps to tackle the disease in a similar manner to cancer practitioners through a multidisciplinary and multimodality approach.

Those of us who specialize in IBD – ongoing inflammation of the digestive tract, which usually manifests as ulcerative colitis (UC) or Crohn’s disease (CD) – often find it to be a complex condition to treat. Unlike many conditions in medicine that are more “black and white,” IBD is awash in fuzzy or gray areas, and thus making pinpoint diagnoses, treatments and even predictions of long-term prognoses can be extraordinarily challenging and often elusive. It is in this space that a collective effort is duly needed to maximize patient outcomes.

Therefore, it makes sense to emerge from our clinical, research and surgical silos more frequently by taking a more collaborative approach to overcoming these challenging diseases.

Tackling a tough, tricky disease

Ongoing research has enabled the development of new drug therapies and treatments less invasive than surgery for IBD. These innovative approaches are important because patients with IBD are extremely complex, and have historically been difficult to predict, diagnose and treat. Furthermore, with the potential for recurrent disease, functional considerations should be delicately balanced with disease-related conditions in decision-making.

Tracy Hull
Bo Shen

As a result, many individuals who have long-suffered from these diseases endure frequent recurrence and the sometimes life-altering side effects of multiple surgeries. Even for experienced surgeons performing these highly-complex and technically-precise operations, complications may occur. Resulting disease-related conditions can arise that may affect function and quality of life. As an example, a patient with advanced CD may require a segmental or total colectomy (removal of all or part of the colon), while a patient with UC may need the entire colon and rectum removed. Patients with previous surgeries may require a variety of other resections or reconstructive procedures. These procedures can sometimes require the individual to wear a pouch or stoma bag on the abdomen to collect stool, either temporarily or permanently.

In 1982, Cleveland Clinic began performing pelvic pouch surgeries, an advanced technique to create a “J”-shaped reservoir, or J-pouch, out of an individual’s small intestine, and optimized this procedure over the next three decades to perfect the technique. The pouch procedure is complex and may require a few separate surgeries to complete. However, based on our experience, the ultimate outcome provides most patients with significant benefits that outweigh the risks and possible complications.

Patients with a J-pouch may experience a condition called pouchitis, pouch inflammation that increases the frequency of having bowel movements. While pouchitis can be treated successfully with antibiotics, in some cases it requires anti-inflammatory therapy involving steroids, immunomodulatory drugs or biological therapy.

Understanding the disease process and walking patients through all possibilities, as well as having the expertise and experience to treat resultant disease and more importantly complications from the initial surgery, is critical to success.

Encouraging alternatives

We are encouraged that research has led to improvements in interventional therapy procedures, especially through the advanced use of endoscopy. Cleveland Clinic physicians recently published the first study illustrating the safety and efficacy of endoscopic needle knife therapy for intestinal strictures in patients with IBD. More effective than drug treatments and much less invasive than surgery, endoscopic needle knife therapy may not ultimately eliminate the need for surgery, but it oftentimes delays or reduces its frequency.

Moreover, new and improved biologic drugs that target specific molecules in the immune system are showing great promise in slowing IBD advancement. This is also true for therapies in which the patient’s own stem cells are isolated, purified and re-injected; this may prove to be particularly effective in treating severe refractory CD.

Tumor board-like collaboration

The rapidly changing ecosystem encompassing IBD furthers the need for more collaborative approaches to tackling these conditions, much as the cancer community has perfected in recent decades. Here, at Cleveland Clinic, we have implemented twice-monthly multidisciplinary conferences that bring together all IBD physicians and support staff.

This is a fairly established practice around the country for cancer specialists, and we thought ‘Why aren’t we doing this for our particularly difficult IBD cases?’ As a team, we review patient data, debate approaches and often develop clearer pathways to treatment that we may not have reached if only toiling in our respective practice areas.

With everyone around the table, multiple ideas and approaches are generated. Is there a need to review the diagnosis, from pathology and radiology perspective? Do we start alternate drug therapy or do surgery? What kind of surgery do we do? Do we need to alter it? Perform other testing before surgery? What is best for patients? What about endoscopic treatment of IBD-related complications, such as stricture and fistula? The ultimate goal of the IBD Board is to provide better patient care through multidisciplinary evaluation. The Cleveland Clinic IBD Board, one of the first in the country, can give physicians new ideas and offer consensus that their thinking is or is not in line with that of others in the IBD field. Further, it can offer them reassurance about their treatment decisions.

While IBD remains a challenging condition to diagnose and effectively treat, its haziness is becoming more transparent. With the advent of alternatives, and more multidisciplinary collaboration, we are heightening our ability to successfully treat the disease with fewer side effects.

That is a welcome relief for patients who are eager to regain a sense of normalcy in their day-to-day lives. And it presents a great opportunity for IBD specialists to ease the pathway forward for those patients.

Disclosures: Delaney, Hull and Shen report no relevant financial disclosures.

Conor P. Delaney, MD, PhD
Conor P. Delaney

In this exclusive guest commentary, Tracy Hull, MD, Surgical Section Chief for Inflammatory Bowel Disease, Bo Shen, MD, Medical and Endoscopic Management Director of the Inflammatory Bowel Disease Program, and Conor P. Delaney, MD, PhD, Chairman of Digestive Disease and Surgery at Cleveland Clinic, discuss the latest advancements in inflammatory bowel disease, and the need for a multidisciplinary approach to improve patient outcomes.

Promising advancements, both medicinal and surgical, are beginning to ease the burden for patients with inflammatory bowel disease.

These innovations promise long overdue relief from conditions that are oftentimes frustrating and life-altering for some patients. Additionally, many novel best practices are emerging because the growing IBD community of gastroenterologists, surgeons, radiologists and pathologists are taking steps to tackle the disease in a similar manner to cancer practitioners through a multidisciplinary and multimodality approach.

Those of us who specialize in IBD – ongoing inflammation of the digestive tract, which usually manifests as ulcerative colitis (UC) or Crohn’s disease (CD) – often find it to be a complex condition to treat. Unlike many conditions in medicine that are more “black and white,” IBD is awash in fuzzy or gray areas, and thus making pinpoint diagnoses, treatments and even predictions of long-term prognoses can be extraordinarily challenging and often elusive. It is in this space that a collective effort is duly needed to maximize patient outcomes.

Therefore, it makes sense to emerge from our clinical, research and surgical silos more frequently by taking a more collaborative approach to overcoming these challenging diseases.

Tackling a tough, tricky disease

Ongoing research has enabled the development of new drug therapies and treatments less invasive than surgery for IBD. These innovative approaches are important because patients with IBD are extremely complex, and have historically been difficult to predict, diagnose and treat. Furthermore, with the potential for recurrent disease, functional considerations should be delicately balanced with disease-related conditions in decision-making.

Tracy Hull
Bo Shen

As a result, many individuals who have long-suffered from these diseases endure frequent recurrence and the sometimes life-altering side effects of multiple surgeries. Even for experienced surgeons performing these highly-complex and technically-precise operations, complications may occur. Resulting disease-related conditions can arise that may affect function and quality of life. As an example, a patient with advanced CD may require a segmental or total colectomy (removal of all or part of the colon), while a patient with UC may need the entire colon and rectum removed. Patients with previous surgeries may require a variety of other resections or reconstructive procedures. These procedures can sometimes require the individual to wear a pouch or stoma bag on the abdomen to collect stool, either temporarily or permanently.

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In 1982, Cleveland Clinic began performing pelvic pouch surgeries, an advanced technique to create a “J”-shaped reservoir, or J-pouch, out of an individual’s small intestine, and optimized this procedure over the next three decades to perfect the technique. The pouch procedure is complex and may require a few separate surgeries to complete. However, based on our experience, the ultimate outcome provides most patients with significant benefits that outweigh the risks and possible complications.

Patients with a J-pouch may experience a condition called pouchitis, pouch inflammation that increases the frequency of having bowel movements. While pouchitis can be treated successfully with antibiotics, in some cases it requires anti-inflammatory therapy involving steroids, immunomodulatory drugs or biological therapy.

Understanding the disease process and walking patients through all possibilities, as well as having the expertise and experience to treat resultant disease and more importantly complications from the initial surgery, is critical to success.

Encouraging alternatives

We are encouraged that research has led to improvements in interventional therapy procedures, especially through the advanced use of endoscopy. Cleveland Clinic physicians recently published the first study illustrating the safety and efficacy of endoscopic needle knife therapy for intestinal strictures in patients with IBD. More effective than drug treatments and much less invasive than surgery, endoscopic needle knife therapy may not ultimately eliminate the need for surgery, but it oftentimes delays or reduces its frequency.

Moreover, new and improved biologic drugs that target specific molecules in the immune system are showing great promise in slowing IBD advancement. This is also true for therapies in which the patient’s own stem cells are isolated, purified and re-injected; this may prove to be particularly effective in treating severe refractory CD.

Tumor board-like collaboration

The rapidly changing ecosystem encompassing IBD furthers the need for more collaborative approaches to tackling these conditions, much as the cancer community has perfected in recent decades. Here, at Cleveland Clinic, we have implemented twice-monthly multidisciplinary conferences that bring together all IBD physicians and support staff.

This is a fairly established practice around the country for cancer specialists, and we thought ‘Why aren’t we doing this for our particularly difficult IBD cases?’ As a team, we review patient data, debate approaches and often develop clearer pathways to treatment that we may not have reached if only toiling in our respective practice areas.

With everyone around the table, multiple ideas and approaches are generated. Is there a need to review the diagnosis, from pathology and radiology perspective? Do we start alternate drug therapy or do surgery? What kind of surgery do we do? Do we need to alter it? Perform other testing before surgery? What is best for patients? What about endoscopic treatment of IBD-related complications, such as stricture and fistula? The ultimate goal of the IBD Board is to provide better patient care through multidisciplinary evaluation. The Cleveland Clinic IBD Board, one of the first in the country, can give physicians new ideas and offer consensus that their thinking is or is not in line with that of others in the IBD field. Further, it can offer them reassurance about their treatment decisions.

While IBD remains a challenging condition to diagnose and effectively treat, its haziness is becoming more transparent. With the advent of alternatives, and more multidisciplinary collaboration, we are heightening our ability to successfully treat the disease with fewer side effects.

That is a welcome relief for patients who are eager to regain a sense of normalcy in their day-to-day lives. And it presents a great opportunity for IBD specialists to ease the pathway forward for those patients.

Disclosures: Delaney, Hull and Shen report no relevant financial disclosures.

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