A New Era of IBD Care

Cleveland Clinic’s enterprise-wide inflammatory bowel disease (IBD) program has entered a new era, combining novel medical and surgical therapies with pioneering research. The outcome is IBD care that is setting a high standard, exceeding that of traditional IBD centers of excellence.

IBD medical home and neighborhood

Perhaps the most fundamental shift has been the introduction of Cleveland Clinic’s IBD medical home.

“It takes a village” to care for the multifaceted needs of IBD patients, says Miguel Regueiro, MD, Chair of Cleveland Clinic Digestive Disease & Surgery Institute’s Department of Gastroenterology, Hepatology and Nutrition. And that’s what he has built.

The IBD medical home pairs patients with a team of colorectal surgeons, pain specialists, pharmacists, dietitians, social workers, psychologists and others, all led by a gastroenterologist.

“Teams go beyond focusing on IBD and look at whole-person care,” says Dr. Regueiro. “We can manage an IBD patient’s preventive care, nutrition, mental health and other needs that typically aren’t in the realm of GI specialty care. It’s one-stop shopping for an IBD patient.”

Although too soon to report metrics, Dr. Regueiro and others have observed decreased disease activity and prolonged effects of medication and surgical treatments. Early indication is that a medical home can improve quality of life, decrease emergency department visits and hospitalizations, and reduce the total cost of care.

This fall, Dr. Regueiro’s team began extending the IBD medical home into a larger IBD neighborhood. In this first-of-its-kind concept, primary care providers and regional gastroenterologists access their IBD patients’ medical home through the electronic medical record. There they can communicate and coordinate care with medical home providers, ideally keeping patients in their community and preventing unnecessary trips to the hospital.

Surgical advances

Multidisciplinary care teams, as in the IBD medical home model, help customize IBD treatment plans, especially when it comes to determining a patient’s need for surgery.

“There is no question that minimally invasive procedures have changed the manner for which we approach patients with complex disease,” says Scott Steele, MD, MBA, Chair of the Department of Colorectal Surgery.

For example, laparoscopic transanal total mesorectal excision (TaTME) — originally a treatment for rectal cancer — is now an alternative for ileal pouch procedures in medically refractory IBD. Surgeons start upward through the anus to remove the colon and rectum rather than dissecting down through challenging areas of the abdomen. Cleveland Clinic and Cleveland Clinic Florida are leading centers for TaTME in the United States.

Even re-operative surgeries, which are relatively common in IBD patients, now have minimally invasive options.

“In the past, re-operations meant open surgery with a long recovery,” says Dr. Steele. “Today we can use transanal robotic and laparoscopic approaches to reduce complications such as ileus and wound infection, shorten hospital stays and optimize outcomes.”

Enhanced Recovery After Surgery (ERAS) protocols are helping speed IBD patients’ healing as well. Long-acting nerve blocks and nonopioid pain medications minimize patients’ pain from incision through recovery. Patients are encouraged to get out of bed sooner after surgery, accelerating their return to full function and helping prevent post-surgery complications such as blood clots and muscle atrophy.

Pioneering research

Cleveland Clinic physician-researchers are driving the next paradigm shift in IBD care.

“We recently began developing an ‘omics’ platform — a credit to one of our pioneers in IBD research Claudio Fiocchi, MD — using data and tissue samples that we’re collecting from our IBD patients,” says Dr. Regueiro. “Translational research studies will focus on unraveling why someone gets IBD and identifying opportunities for precision medicine.”

Other recent studies by Cleveland Clinic researchers have revealed:

• There is a potential link between mesenteric fat (creeping fat) and intestinal strictures in patients with Crohn’s disease. According to gastroenterologist Florian Rieder, MD, creeping fat may contribute to abnormal intestinal narrowing by inducing smooth muscle cell hyperplasia, possibly driven by alterations in free fatty acid metabolism. A research team is studying this connection in hopes of identifying therapeutic targets to prevent or treat intestinal stricture formation, as an alternative to surgery.
• Patients whose ileal pouch–anal anastomosis (IPAA) survives several years without a complication are likely to have excellent long-term outcomes. Stefan Holubar, MD, MS, Director of Research in the Department of Colorectal Surgery, led this first-ever study applying conditional survival methods to explore risk factors for pouch failure over time.
• One in four Crohn’s patients is at high risk for an anastomotic leak and thus may benefit from a temporary diverting ileostomy. This finding suggests a shift in surgical practice, notes Dr. Holubar. He led a team of researchers in creating a model and a score for predicting anastomotic leak risk in Crohn’s patients, guiding surgeons when to consider ileostomy.

“The care of patients with IBD is changing quickly, due in part to the rapid evolution of medical and surgical therapies available,” says Dr. Steele. “Cleveland Clinic will continue to explore innovative ideas and develop advanced treatments in our quest to give IBD patients the best outcomes.”

“The future of IBD care is filled with new opportunities and uncharted possibility,” adds Dr. Regueiro.