Colitis, Ulcerative Clinical Trial
— COSTAOfficial title:
The Effect of Appendectomy in Ulcerative Colitis Patients With Active Disease: COlonic Salvage by Therapeutic Appendectomy
Rationale: The annual incidence of ulcerative colitis (UC) amounts to 6-8 new cases per
100.000. Patients are initially treated medically, and colitis refractory to medical
management is treated surgically, mostly by means of an (emergency) colectomy or a
proctocolectomy with ileal J-pouch anastomosis. Over the past 10 years evidence has been
accumulating indicating that the appendix has an immunomodulatory role in patients with UC
reducing the need for medication and perhaps even colectomy.
Objective: The objective of this prospective observational cohort study is to evaluate the
effect of appendectomy on the disease course of patients with active ulcerative colitis
despite standard step-up treatment including biologicals. The second objective is to
determine if histological inflammation in the appendix resection specimens can be reliably
predicted by pre-operative endoscopic biopsies of the appendix and correlated to clinical and
pathological response after appendectomy.
Study design: The design of the study is a prospective observational cohort study of 80
consecutive patients.
Study population: Sixty patients of 18 years and older, with established diagnosis of UC and
ongoing disease activity despite standard step-up treatment including biologicals.
Furthermore, histological characteristics in appendix biopsies of 10 patients with non-active
UC and 10 'healthy control' patients (e.g. patients undergoing endoscopy for polyps) will be
evaluated and used as a reference control group.
Intervention: Patients will undergo laparoscopic appendectomy in clinical or day care
setting.
Main study parameters/objectives: The primary outcome parameter is the number of patients
achieving remission (Total Mayo score ≤2) 12 months after appendectomy. Secondary endpoints
are reduction of medical therapy, the disease activity as measured with the Mayo score,
colectomy rate, the health related quality of life and costs (EQ-5D, EORTC-QLQ-C30-QL and
IBDQ), and histological appendix characteristics predictive of response.
Status | Recruiting |
Enrollment | 80 |
Est. completion date | September 2020 |
Est. primary completion date | September 2020 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years and older |
Eligibility |
Inclusion criteria (study group) - Age 18 years and older - Established diagnosis of UC - Active disease (defined both clinically and endoscopically as Mayo-score =5 with endoscopy score of 2 or 3) despite standard step-up treatment including biologicals - Obtained written informed consent Inclusion criteria (control group) - Age 18 years and older - UC patients with non-active disease (defined both clinically and endoscopically as Mayo-score =5 with endoscopy score of 0 or 1) or non-UC patients with polyps - Planned colonoscopy - Open appendix lumen with diameter large enough to slide scope in - Obtained written informed consent Exclusion criteria (study group) - Prior appendectomy or other abdominal surgery by laparotomy. - Suspicion of Crohn's disease. - Toxic megacolon or severe acute colitis necessitating clinical admission - Patients with active extra-intestinal infections, liver or kidney failure, mayor lung and heart co-morbidity. - Insufficient command of Dutch or cognitively unable to complete Dutch questionnaires Exclusion criteria (control group) - Prior appendectomy. - Suspicion of Crohn's disease. |
Country | Name | City | State |
---|---|---|---|
Netherlands | Amsterdam UMC | Amsterdam |
Lead Sponsor | Collaborator |
---|---|
Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA) | University Hospital Birmingham |
Netherlands,
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Endoscopic remission rate | Remission rate after appendectomy according to the MAYO score defined as 0-1 (including endoscopic remission) | 12 months | |
Secondary | Stoppage of medical therapy. | Downscaling of medical therapy including corticosteroids (number of patients that stop medication). | Every 3 months, up to 12 months | |
Secondary | Disease activity, as measured with the full Mayo score | Using this 12-point scoring system, disease activity is evaluated based on stool frequency, rectal bleeding, the physician's global assessment, and endoscopic appearance. Each subscale is ranging from 0-3 and higher values represent worse outcomes. The full Mayo score is computed by the sum of the four subscores. | 6 and 12 months | |
Secondary | Failure | Defined as colectomy or start of trial medication. | Every 3 months, up to 12 months | |
Secondary | Health related quality of life (EQ-5D) | This questionnaire is a simple, generic instrument for describing and valuing health related quality of life. It includes 5 items (mobility, personal care, daily activities, pain, and anxiety/ depression) that are answered on a 3-point scale ranging from no problems (level 1) to extreme problems (level 3). | 3, 6 and 12 months | |
Secondary | Disease specific quality of life (IBDQ) | A disease-specific questionnaire that measures quality of life in 4 domains (bowel symptoms, systemic symptoms, social function, and emotional function). The IBDQ consists of 32 questions which are rated on a scale from 1 to 7, resulting in a total score ranging from 32 to 224 and a higher score represents a better quality of life. | 3, 6 and 12 months | |
Secondary | Global quality of life (ORTC-QLQ-C30-QL) | This sub questionnaire contains the 2 items of the global quality of life dimension of the EORTC-QLQ-C30 questionnaire. It includes 30 questions, and answers are ranging from no problems (1 point) to extreme problems (4 points). | 3, 6 and 12 months | |
Secondary | Time to remission | Time between inclusion and remission | Every 3 months, up to 12 months | |
Secondary | Pathological analysis of resection specimen to determine histological characteristics according to the Geboes score, predictive of response . | Geboes score less than 3: (grade 0-5: architectural changes, increase of chronic inflammatory infiltrate, increase of eosinophils in the lamina propria, increase of neutrophils in the lamina propria, involvement of neutrophils in the epithelium (cryptitis), crypt destruction, and erosion or ulcerations) | Baseline |
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