A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease

PURPOSE

The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection.

METHOD

The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures.

RESULTS

The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates.

CONCLUSION

Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.

Levels of Intestinal Inflammation and Fibrosis in Resection Specimens after Preoperative Anti-Tumor Necrosis Factor Alpha Treatment in Patients with Crohn's Disease: A Comparative Pilot Study

Background

Strictures are a common complication in Crohn's disease (CD), found in more than 50% of patients. They are characterized by the excessive deposition of extracellular proteins in the tissue as a result of the chronic inflammatory process. The effect of anti-tumor necrosis factor alpha (TNF-α) therapy on the development of fibrosis is not yet fully understood.

Aim

To investigate whether the degree of intestinal inflammation and fibrosis is correlated with preoperative anti-TNF-α) therapy on the development of fibrosis is not yet fully understood.

Methods

This unblinded, prospective, single tertiary center, pilot cohort study included all adult patients with CD who underwent elective, laparoscopic, or open intestinal resection. Preoperative investigations included measurement of blood TNF-α) therapy on the development of fibrosis is not yet fully understood.

Results

Histopathological specimens from 10 patients with CD who underwent ileocecal or ileocolic resections were retrieved. Four of those patients were on anti-TNF-α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. p=0.01). Anti-TNF-α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood.

Conclusions

Patients who underwent preoperative anti-TNF-α treatment had a higher fibrosis score than controls.α) therapy on the development of fibrosis is not yet fully understood.

An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME)

INTRODUCTION

Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short-term outcomes of TaTME, open, laparoscopic, and robotic TME internationally.

METHODS

A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.

RESULTS

Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02-2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10-7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non-transanal laparoscopic TME. However this association was lost in the mixed-effects model controlling for patient and disease factors (OR 1.23, 0.77-1.97, P = 0.39 and OR 2.11, 0.79-5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55-4.77, P < 0.001) and male gender (OR 2.29, 1.52-3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%.

CONCLUSION

This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.

The effect of pre-operative optimization on post-operative outcome in Crohn's disease resections

BACKGROUND

The timing of surgical intervention in Crohn's disease (CD) may depend on pre-operative optimization (PO) which includes different interventions to decrease the risk for unfavourable post-operative outcome. The objective of this study was to investigate the effect of multi-model PO on the post-operative outcome in CD.

METHOD

This is a multicentre retrospective cohort study. The primary outcome was 30-day post-operative complications. Secondary outcomes were intra-abdominal septic complications, surgical site infection (SSI), re-operation, length of post-operative stay in a hospital and re-admission. PO included nutritional support, discontinuation of medications, pre-operative antibiotic course and thrombosis prophylaxis.

RESULTS

Two hundred and thirty-seven CD elective bowel resections were included. Mean age was 39.9 years SD 14.25, 144 (60.8 %) were female and 129 (54.4 %) had one or more types of medical treatment pre-operatively. Seventy-seven patients (32.5 %) optimized by at least nutritional support or change in pre-operative medications. PO patients were more likely to have penetrating disease phenotype (p = 0.034), lower albumin (p = 0.015) and haemoglobin (p = 0.021) compared to the non-optimized. Multivariate analyses showed that treatment with anti-TNF alpha agents OR 2.058 CI [1.043-4.4.064] and low haemoglobin OR 0.741 CI [0.572-0.0.961] increased the risk of overall post-operative complications. Co-morbidity increased the risk of SSI OR 2.567 CI [1.182-5.576] while low haemoglobin was a risk factor for re-admission OR 0.613 CI [0.405-0.926]. Low pre-operative albumin correlated with longer stay in hospital.

CONCLUSIONS

PO did not change post-operative outcome most likely due to selection bias. Anti-TNF alpha agents, low haemoglobin, low albumin and co-morbidity were associated with unfavourable outcome.

Mechanical small bowel obstruction following a blunt abdominal trauma: A case report

INTRODUCTION

Intestinal obstruction following abdominal trauma has previously been described. However, in most reported cases pathological finding was intestinal stenosis.

PRESENTATION OF THE CASE

A 51-year-old male was admitted after a motor vehicle accident. Initial focused abdominal sonogram for trauma and enhanced computerized tomography were normal, however there was a fracture of the tibia. Three days later, he complained of abdominal pain, constipation, and vomiting. An exploratory laparotomy showed bleeding from the omentum and mechanical small bowel obstruction due to a fibrous band.

DISCUSSION

The patient had prior abdominal surgery, but clinical and radiological findings indicate that the impact of the motor vehicle accident initiated his condition either by causing rotation of a bowel segment around the fibrous band, or by formation of a fibrous band secondary to minimal bleeding from the omentum.

CONCLUSION

High index of suspicion of intestinal obstruction is mandatory in trauma patients presenting with complaints of abdominal pain, vomiting, and constipation despite uneventful CT scan.

Perforated diverticulitis sigmoidei after laparoscopic cholecystectomy

We present a case of 47-year-old healthy man who underwent an uneventful elective laparoscopic cholecystectomy. Despite the postoperative analgesia with non-steroidal anti-inflammatory drugs (NSAIDs), the patient developed diffuse abdominal pain culminating on the second postoperative day when the patient also had rebound tenderness. A diagnostic laparoscopy showed diverticular perforation, which was treated with laparoscopic lavage and drain. The patient's condition continued to deteriorate and the drain output resembled faecal material necessitating an emergency sigmoidium resection. The histopathological examination confirmed inflammation and perforation in the diverticulosis-bearing segment. The use of NSAID can be a reason for perforation, and may be for diverticulitis. NSAID should be used with caution in patients with a previous history or endoscopic-verified diverticulosis.

Increased risk of post-operative complications in patients with Crohn's disease treated with anti-tumour necrosis factor α agents - a systematic review

INTRODUCTION

Tumour necrosis factor α (TNF-α) plays a role in the immune defence, angiogenesis and collagen synthesis. Inhibition of these pathways may increase the risk of infections and impair wound healing in patients after surgery. Biologic treatments including anti-TNF-α agents are increasingly used in the treatment of inflammatory bowel disease. Taking into consideration the biologics' mechanism of action, fears have been expressed that they might increase the rate of post-operative complications. Results from 18 retrospective studies were conflicting, and meta-analyses based on these studies did not agree. The objective of this study was to review data from present reviews and meta-analyses in an attempt to come to conclusions for the use of anti-TNF-α in Crohn's disease patients in clinical practice.

METHODS

Literature search using both electronic and manual searches was conducted according to a pre-defined protocol. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied.

RESULTS

Two systematic reviews and six meta-analyses were found. Meta-analyses that included a large number of patients and applied quality assessment showed an increased risk of overall post-operative complications and an increased rate of infectious or anastomosis-related complications in patients receiving anti-TNF-α.

CONCLUSION

The use of anti-TNF-α agents in Crohn's disease patients is associated with an increased risk of post-operative complications after abdominal surgery.

The effect of anti-tumor necrosis factor alpha agents on postoperative anastomotic complications in Crohn's disease: a systematic review

BACKGROUND

Patients with Crohn's disease treated with anti-tumor necrosis factor alpha agents may have an increased risk of surgical complications.

OBJECTIVE

We assessed the effect of anti-tumor necrosis factor alpha on postoperative complications in patients with Crohn's disease undergoing abdominal surgery.

DATA SOURCES

Studies were identified through electronic and manual searches.

STUDY SELECTION

Observational studies on patients with Crohn's disease undergoing laparoscopic or open abdominal surgery were included.

INTERVENTIONS

Anti-tumor necrosis factor alpha agents were administered within 3 months before surgery.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic complications including overt dehiscence, intra-abdominal abscess, and enteric fistulas.

RESULTS

Fourteen studies on 679 patients in the intervention (anti-tumor necrosis factor alpha) group and 2363 controls were included. Random-effects meta-analysis found no difference in anastomotic complications between the 2 groups (7.6% versus 8.2%; risk ratio, 0.91; 95% CI, 0.56-1.48). There was clear heterogeneity between studies. In subgroup analyses, the anti-tumor necrosis factor alpha increased anastomotic complications in trials with a lower risk of bias, but not in the studies with a higher bias risk (risk ratio, 1.63; 95% CI, 1.03-2.60 and risk ratio, 0.17; 95% CI, 0.05-0.60). In the overall analysis and in studies with a lower bias risk, anti-tumor necrosis factor alpha agents increased the risk of nonanastomotic surgical complications, major medical complications, and minor medical complications.

LIMITATIONS

Limitations of observations studies.

CONCLUSIONS

In studies with a low risk of bias, anti-tumor necrosis factor alpha agents increased the risk of anastomotic complications. Inadequate bias control may lead to an underestimated risk of anastomotic complications.