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Long-term outcomes after appendectomy for maintenance of remission in ulcerative colitis: Five-year NL-results from the ACCURE randomized controlled trial

I. Van Dijk, E. Visser, G. D’Haens, W. Bemelman, C.J. Buskens, AUMC

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Slides compiled by Dr. Cynthia Seow 

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Introduction

Background & Objectives

    • The ACCURE trial demonstrated that appendectomy significantly reduced clinical relapse within one year in patients with ulcerative colitis (UC) in remission compared with standard medical therapy alone
    • Objective: Evaluate the long-term clinical effectiveness of laparoscopic appendectomy for maintenance of remission in UC.

UC, ulcerative colitis; HR, hazard ratio; CI, confidence interval.

Van Dijk I et al. ECCO 26; (Abstract citation ID: jjaf231.034, OP34).

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Methods

    • Design: Long-term (5 year) analysis of participants from the ACCURE trial (n=163)
    • Clinical and endoscopic remission at inclusion �(Mayo score ≤2, endoscopic subscore ≤1 or Fcal <150)
    • Follow-up: Prospective follow-up for 5 years after randomization, with assessments every 6 months.
    • Primary outcome: Initiation of advanced medical therapy
    • Secondary outcomes:
      • Colectomy
      • Colorectal neoplasia
      • Endoscopic and biochemical remission at 36 months �(MES ≤1 or FCP<150)
    • Statistics:
      • Time-to-event and repeated binary outcome analyses

Assessments

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Results:

  • N=80 (appendectomy group); N=83 (control group)
  • Baseline characteristics comparable�Mean age 43.9 (SD 12.3) years, median disease duration 5.2 (IQR 1.5-11.3) years, 5-ASA use ~80%
  • Median follow-up period was 5 years
  • Primary outcome: �Individuals undergoing appendectomy were less likely to escalate to advanced medical therapy than those managed with medical therapy alone.
  • 8.8% appendectomy group (7/80) vs. �25.3% control group (21/83)�Difference: 16.5% (p=0.012)

mITT, modified intention-to-treat; SD, standard deviation; IQR, interquartile range; HR, hazard ratio; CI, confidence interval; UC, ulcerative colitis

Note: Adjusted for age, sex, smoking, disease extent, time since most recent exacerbation

Van Dijk I et al. ECCO 26; (Abstract citation ID: jjaf231.034, OP34).

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�Adjusted HR 0.30; 95% CI, 0.13-0.73; p = 0.003

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Results:

Secondary outcomes:

  • Colectomy in 3 individuals (in the control group), �incidental finding of dysplasia in one patient.
  • No evidence of an increased neoplasia risk associated with appendectomy over 5 years

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Fcal, fecal calprotectin.

Van Dijk I et al. ECCO 26; (Abstract citation ID: jjaf231.034, OP34).

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Outcome

Appendectomy group

Control group

P-value

Colectomy

0/80

3/83 (3.6%)

0.09

Dysplasia

0/80

1/83 (1.2%)

0.325

Remission at 36 months

Appendectomy group

Control group

P-value

Endoscopic subscore (MES ≤1) or Fcal <150

51/61 (83.6%)

38/53 (71.7%)

0.125

Endoscopic subscore (MES ≤1)

28/33 (83.8%)

19/32 (59.4%)

0.022

Fcal <150

23/28 (82.1%)

19/21 (90.5%)

0.409

Note that not all patients underwent endoscopy nor completed fecal calprotectin

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Conclusions

    • Individuals with UC in remission who underwent appendectomy were significantly less likely to require escalation to advanced medical therapy.
    • There was no increased risk of colectomy or neoplasia at 5 years in the appendectomy group.

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Significance to clinical practice

    • Appendectomy may be an effective adjunct to standard medical therapy for maintaining disease remission in individuals with UC.
    • A detailed discussion of the benefits and risks of undertaking elective surgery (appendectomy) in an asymptomatic individual needs to be undertaken.
    • Await further data to determine which patients benefit most from appendectomy.

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Van Dijk I et al. ECCO 26; (Abstract citation ID: jjaf231.034, OP34).

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