Long-term follow-up of strictureplasty for Crohn's disease

Non-conventional Versus Conventional Strictureplasties for Crohn's Disease. A Systematic Review and Meta-analysis of Treatment Outcomes

BACKGROUND

Strictureplasties [SXP] represent an alternative to bowel resection in Crohn's disease [CD]. Over the years, there has been growing interest in the role of non-conventional SXP for the treatment of extensive CD. A systematic review was performed on complications and recurrence following conventional and non-conventional SXP.

METHODS

The available literature was screened according to the PRISMA statement, until June 2020. Results were categorised into three groups: studies reporting on conventional SXPs; studies with a mixed cohort of conventional and non-conventional SXPs [% non-conventional SXPs ≤15%]; and studies reporting on non-conventional SXPs. Considered endpoints were postoperative complications and overall and SXP site-specific surgical recurrence. Random-effect meta-analysis and meta-regression were used to obtain and compare combined estimates between groups.

RESULTS

A total of 26 studies for a total of 1839 patients with CD were included. The pooled postoperative complication rates were was 15.5% (95% confidence interval [CI] 11.2%-20.3%), 7.4% [95% CI 0.2%-22.9%], and 19.2% [95% CI 5-39.6%] for the three groups, respectively. The rates of septic complications were 4% [95% CI 2.2%-6.2%], 1.9% [95% CI 0.4%-4.3%], and 4.2% [95% CI 0.9%-9.8%], respectively. Cumulative overall surgical recurrence rates were 27.5% [95% CI 18.5%-37.6%], 13.2% [95% CI 8.6%-18.7%], and 18.1% [95% CI 6.8%-33.3%]; and SXP site-specific surgical recurrence rates were 13.2% [95% CI 6.9%-21.2%], 8.3% [95% CI 1.6-19.3%], and 8.8% [95% CI 2.2%-19%], respectively. Formal comparison between the groups revealed no differences.

CONCLUSIONS

Non-conventional SXP did not differ from conventional SXP with respect to safety and long-term recurrence. Consistent heterogeneity was observed and partially limits the conclusions of this study.

Role of Extended Mesenteric Excision in Postoperative Recurrence of Crohn's Colitis: A Single-Center Study

INTRODUCTION

The mesentery is involved in Crohn's disease. The impact of the extent of mesenteric resection on postoperative disease progression in Crohn's disease remains unconfirmed. This study aimed to determine the association between resection of the mesentery and postoperative outcomes in patients with Crohn's colitis (CC) undergoing colorectal surgery.

METHODS

Patients with CC who underwent colorectal resection between January 2000 and December 2018 were reviewed, and the data were gathered from a prospectively maintained database. Patients were divided into 2 groups according to the extent of mesenteric resection, the extensive mesenteric excision (EME) group and the limited mesenteric excision (LME) group. Outcomes including early postoperative morbidities and surgical recurrence were compared between the 2 groups.

RESULTS

Of the 126 patients included, 60 were in the LME group and 66 in the EME group. There was no significant difference between the 2 groups in early postsurgical outcomes except the intraoperative blood loss was increased in the LME group (P = 0.002). Patients in the EME group had a longer postoperative surgical recurrence-free survival time when compared with those in the LME group (P = 0.01). LME was an independent predictor of postoperative surgical recurrence (hazard ratio 2.67, 95% confidence interval 1.04-6.85, P = 0.04). This was further confirmed in the subgroup analysis of patients undergoing colorectal resection and anastomosis (hazard ratio 2.83, 95% confidence interval 1.01-7.96, P = 0.048).

DISCUSSION

In patients undergoing surgery for CC, inclusion of the mesentery is associated with similar short-term outcomes and improved long-term outcomes compared with those seen when the mesentery is retained.

Short- and long-term outcomes of strictureplasty for obstructive Crohn's disease

AIM

To evaluate the frequency and outcome of strictureplasty in the era of biologicals and to compare patients operated on by strictureplasty alone, resection alone or a combination of both.

METHOD

A retrospective review of all patients undergoing strictureplasty for obstructing jejunoileal Crohn's disease (CD) in Oxford between 2004 and 2016 was conducted. For comparison, a cohort of CD patients with resection only during 2009 and 2010 was included.

RESULTS

In all, 225 strictureplasties were performed during 85 operations, 37 of them in isolation and 48 with simultaneous resection. Another 82 procedures involved resection only; these patients had shorter disease duration, fewer previous operations and longer bowel preoperatively. The frequency of strictureplasty procedures did not alter during the study period and was similar to that in the preceding 25 years. There was no postoperative mortality. One patient required re-laparotomy for a leak after strictureplasty. None developed cancer. The 5-year reoperation rate for recurrent obstruction was 22% (95% CI 12-39) for resection alone, 30% (17-52) for strictureplasty alone and 42% (27-61) for strictureplasty and resection (log rank P = 0.038). Young age was a risk factor for surgical recurrence (log rank P = 0.006).

CONCLUSION

The use of strictureplasty in CD has not changed significantly since the widespread introduction of biologicals. Surgical morbidity remains low. The risk of recurrent strictures is high and young age is a risk factor. In this study, strictureplasty alone was associated with a lower rate of reoperation compared with strictureplasty with resection.

Strictureplasty versus bowel resection for the surgical management of fibrostenotic Crohn's disease: a systematic review and meta-analysis

BACKGROUND

Strictureplasty (SPX) conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease (CD). However, SPX may be associated with a higher risk of recurrence compared with bowel resection (BR).

AIM

We sought to compare morbidity and recurrence following SPX and BR in patients with fibrostenotic CD.

METHODS

A systematic review was performed according to PRISMA and MOOSE guidelines. Observational studies that compared outcomes of CD patients undergoing either SPX or BR were identified. Log hazard ratios (InHR) for recurrence-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots or Cox regression models and pooled using the inverse variance method. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Continuous variables were pooled as weighted mean differences.

RESULTS

Twelve studies of 1026 CD patients (SPX n = 444, 43.27%; BR with or without SPX n = 582, 56.72%) were eligible for inclusion. There was an increased likelihood of disease recurrence with SPX than with BR (OR 1.61; 95% CI, 1.03, 2.52; p = 0.04; I² = 0%). Patients who had a SPX alone had a significantly reduced RFS than those who underwent BR (HR 1.47; 95% CI, 1.08, 2.01; p = 0.02; I² = 0%). There was no difference in morbidity between the groups (OR 0.58; 95% CI, 0.26, 1.28; p = 0.18; I² = 0%).

CONCLUSION

SPX should only be performed in those patients with Crohn's strictures that are at high risk for short bowel syndrome and intestinal failure; otherwise, BR is the favored surgical technique for the management of fibrostenotic CD.

Strictureplasty in Complex Crohn's Disease: Beyond the Basics

The strictureplasty operation was originally adopted for use in selected patients with Crohn's disease to allow for bowel conservation. The procedure and its usage have evolved over time as experience and confidence with the technique has grown. The short- and long-term outcomes of strictureplasty compared with resection attest to its safety and durable efficacy.

Predictors of early recurrence after strictureplasty for Crohn's disease of the small bowel during the years of biologics

BACKGROUND

The identification of patients prone to early recurrence of Crohn's disease at the site of a strictureplasty is fundamental in the clinical practice.

AIMS

Aim of the study is to detect the risk factors for early reoperation for recurrence after primary strictureplasty.

METHODS

From 2000, patients undergoing a primary strictureplasty and a subsequent reoperation for recurrence of Crohn's disease at the site of a strictureplasty were included. Univariate and multivariable linear regression models were performed to analyse the relationship between the time to recurrence and independent variables.

RESULTS

Fifty-nine patients were included. Median time to recurrence was 4.5 years (0.7-12.6). At the multivariate linear regression, early relapse was significantly associated with use of biologics before primary surgery (-2.69, p < 0.0001) and location of disease in the ileum (-1.61, p 0.017). The use of biologics after surgery was similar between groups (40.7 vs 37.5%, p 0.79).

CONCLUSIONS

The location of Crohn's disease in the ileum and the use of biologics before surgery are strong predictors of early site-specific recurrence after strictureplasty. In this group of patients, a tailored follow-up and aggressive postoperative treatment should be considered.

Targeting anti-fibrotic pathways in Crohn's disease - The final frontier?

Intestinal fibrosis with stricture formation affects up to half of patients with Crohn's disease (CD), resulting in impaired quality of life, increased risk of surgical intervention, and associated patient morbidity. The underlying pathophysiologic mechansisms responsible for initiating and perpetuating intestinal fibrosis are complex, dynamic, and implicate both inflammation-dependent and independent pathways. Previously thought to be an irreversible complication of long-standing inflammation unresponsive to medical therapy, fibrostenotic CD has been traditionally managed with endoscopic or surgical approaches. However, recent advances in our understanding of the humoral, cellular, and environmental pathways driving intestinal fibrosis has the potential to fundamentally change these management paradigms for CD-related strictures. Furthermore, the promise of fibrosis treatments in other organ systems has encouraged hope that anti-fibrotic treatment approaches for CD may be within reach. Here, we summarize the key breakthroughs in our molecular understanding of intestinal fibrosis, review current medical, endoscopic, and surgical treatment approaches to CD-related strictures, propose future directions for anti-fibrotic therapy in CD, and identify crucial research questions in this field that require additional investigation.

Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease

Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.

Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence

BACKGROUND AND AIMS

Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease.

METHODS

Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells.

RESULTS

Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes.

CONCLUSIONS

Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

Long-Term Outcome of Endoscopic Balloon Dilatation for Strictures in Patients with Crohn's Disease

BACKGROUND/AIMS

Endoscopic balloon dilatation (EBD) is an alternative to surgery for strictures in patients with Crohn's disease (CD). The aim of the present study was to clarify the efficacy and safety of EBD for strictures in patients with CD.

METHODS

Twenty-six patients with CD who underwent EBD for strictures from August 2008 to November 2015 were followed up after dilatation. Short-term success was defined as the disappearance of obstructive symptoms after technically adequate dilatation was achieved. The short-term success rate of EBD, safety profile of EBD, and cumulative surgery-free and redilatation-free rates were analyzed.

RESULTS

Sixty-five EBDs were performed for CD patients in the follow-up period. The short-term success rate was 100% (26/26), and no complications were encountered during this study. Two (7.7%) patients underwent surgery during the observation period. The cumulative surgery-free rate after the initial EBD was 90.3% at both 2 and 3 years. The cumulative redilatation-free rate after the initial EBD was 52.1% at 2 years and 39.1% at 3 years.

CONCLUSION

EBD for strictures secondary to CD provides not only short-term success but also long-term efficacy. Although a high redilatation rate is one of the clinical problems of this procedure, EBD is an effective therapy for avoiding intestinal recession in CD -stricture.

European Crohn's and Colitis Organisation Topical Review on Prediction, Diagnosis and Management of Fibrostenosing Crohn's Disease

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focused on prediction, diagnosis, and management of fibrostenosing Crohn's disease [CD]. The objective was to achieve evidence-supported, expert consensus that provides guidance for clinical practice.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease

Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.

Triptolide ameliorates colonic fibrosis in an experimental rat model

Triptolide is known to exert anti-inflammatory and immunomodulatory activities; however, its impact on intestinal fibrosis has not been previously examined. Based on our previous studies of the suppressive activity of triptolide on human colonic subepithelial myofibroblasts and the therapeutic efficacy of triptolide in Crohn's disease, it was hypothesized that triptolide may have beneficial effects on intestinal fibrosis. In the present study, colonic fibrosis was induced in rats by 6 weekly repeated administration with a low-dose of 2,4,6-trinitrobenzene sulfonic acid (TNBS) and was then treated with triptolide or PBS daily (control) simultaneously. Extracellular matrix (ECM) deposition in the colon was examined with image analysis of Masson Trichrome staining. Total collagen levels in colonic homogenates were measured by a Sircol assay. Collagen Iα1 transcripts and collagen I protein were measured ex vivo in the isolated colonic subepithelial myofibroblasts by reverse transcription-quantitative polymerase chain reaction and immunoblot analysis, respectively. The results indicated that triptolide decreased ECM deposition and collagen production in the colon, and inhibited collagen Iα1 transcripts and collagen I protein expression in the isolated subepithelial myofibroblasts of the rats with colonic fibrosis. In conclusion, triptolide ameliorates colonic fibrosis in the experimental rat model, suggesting triptolide may be a promising compound for inflammatory bowel disease treatment.

Complications in surgery for Crohn's disease after preoperative antitumour necrosis factor therapy

BACKGROUND

The use of biological therapy (biologicals) is established in the treatment of Crohn's disease. This study aimed to determine whether preoperative treatment with biologicals is associated with an increased rate of complications following surgery for Crohn's disease with intestinal anastomosis.

METHODS

All patients receiving biologicals and undergoing abdominal surgery with anastomosis or strictureplasty were identified at six tertiary referral centres. Demographic data, and preoperative, operative and postoperative details were registered. Patients who were treated with biologicals within 2 months before surgery were compared with a control group who were not. Postoperative complications were classified according to anastomotic, infectious or other complications, and graded according to the Clavien-Dindo classification.

RESULTS

Some 111 patients treated with biologicals within 2 months before surgery were compared with 187 patients in the control group. The groups were well matched. There were no differences between the treatment and control groups in the rate of complications of any type (34·2 versus 28·9 per cent respectively; P = 0·402), anastomotic complications (7·2 versus 8·0 per cent; P = 0·976) and non-anastomotic infectious complications (16·2 versus 13·9 per cent; P = 0·586). In univariable regression analysis, biologicals were not associated with an increased risk of any complication (odds ratio (OR) 1·33, 95 per cent confidence interval 0·81 to 2·20), anastomotic complication (OR 0·89, 0·37 to 2·17) or infectious complication (OR 1·09, 0·62 to 1·91).

CONCLUSION

Treatment with biologicals within 2 months of surgery for Crohn's disease with intestinal anastomosis was not associated with an increased risk of complications.

Ciprofloxacin for the prevention of postoperative recurrence in patients with Crohn's disease: a randomized, double-blind, placebo-controlled pilot study

BACKGROUND

The commensal bacterial flora plays a critical role in the postoperative recurrence of Crohn's disease (CD). We conducted a randomized, double-blind, placebo-controlled 6-month pilot trial of ciprofloxacin for the prevention of endoscopic recurrence in patients with CD who underwent surgery.

METHODS

Thirty-three patients with CD, who had undergone surgery with ileocolonic anastomosis within the previous 2 weeks, were randomized to treatment with ciprofloxacin (500 mg twice daily) or placebo tablets for 6 months. Endpoints were endoscopic recurrence at 6 months and safety and tolerability of long-term ciprofloxacin therapy.

RESULTS

Thirty-three patients were randomized; 14 patients discontinued the study early. Significant endoscopic recurrence was observed in 3 of 9 patients (33%) in the ciprofloxacin group and 5 of 10 patients (50%) in the placebo group at 6 months after surgery (P < 0.578). The intention-to-treat analysis demonstrated endoscopic recurrence in 11 of 17 patients (65%) in the ciprofloxacin group and 11 of 16 patients (69%) in the placebo group at month 6 (P < 0.805). Thirty-six adverse events occurred in 19 of 33 patients (58%). Possible drug-associated adverse events occurred significantly more often in the ciprofloxacin group (P < 0.043), leading to study drug discontinuation in 24% (4 of 17) and 6% of patients (1 of 16) in the ciprofloxacin and placebo groups, respectively (P < 0.166).

CONCLUSIONS

In this pilot study, ciprofloxacin was not more effective than placebo for the prevention of postoperative recurrence in patients with CD. Long-term ciprofloxacin therapy is limited by drug-associated side effects. Future studies in postoperative prevention of CD should evaluate antibiotic approaches with a more favorable safety profile.

Is lymphatic status related to regression of inflammation in Crohn's disease?

AIM: To investigate the status of the lymphatic vessels in the small bowel affected by Crohn’s disease (CD) at the moment of surgery.

METHODS: During the period January 2011-June 2011, 25 consecutive patients affected by CD were operated on in our Institution. During surgery, Patent Blue V was injected subserosally and the way it spread along the subserosa of the intestinal wall, through the mesenterial layers towards the main lymphatic collectors and eventually to the lymph nodes was observed and recorded. Since some patients had been undergone strictureplasty at previous surgery, we also examined the status of intestinal lymph vessels after previous strictureplasties. The same procedure was performed in a control group of 5 patients affected by colorectal cancer. Length of lesions, caliber, maximal thickness of the diseased intestinal wall, thickness of the wall at injection site and thickness of the mesentery were evaluated at surgery.

RESULTS: We observed three features after the injection of Patent Blue V in the intestinal loops: (1) Macroscopically healthy terminal ileum of patients with CD or colon cancer showed thin lymphatic vessels linearly directed toward the mesentery; (2) In mild lesions in which the intestinal wall did not reach 8 mm of thickness, we observed short, wide and tortuous lymphatic vessels directed longitudinally along the intestinal axis toward disease-free areas and then transversally toward the mesentery; and (3) Injection in the severely affected lesions, that had a thickness of the intestinal wall over 10 mm, did not show any feature of lymphatic vessels at least on the subserosal surface. There was a correlation between the thickness of the parietal wall and the severity of the lymphatic alterations. Normal lymphatic vessels were observed at previous strictureplasties in the presence of complete regression of the inflammation.

CONCLUSION: Injection of Patent Blue V in the intestinal wall could help distinguish healthy tracts of the small bowel from those macroscopically borderline.

[Guidelines for the management of Crohn's disease]

Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) with uncertain etiopathogenesis. CD can involve any site of gastrointestinal tract from the mouth to anus and is associated with serious complications such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies are currently applied for diverse clinical situations of CD. However, a lot of decisions on the management of CD are made depending on the personal experiences and choices of physicians. To suggest preferable approaches to diverse problems of CD and to minimize the variations according to physicians, guidelines for the management of CD are needed. Therefore, IBD Study Group of the Korean Association for the Study of the Intestinal Diseases has set out to develop the guidelines for the management of CD in Korea. These guidelines were developed using the adaptation methods and encompass the treatment of inflammatory disease, stricturing disease, and penetrating disease. The guidelines also cover the indication of surgery, prevention of recurrence after surgery, and CD in pregnancy and lactation. These are the first Korean guidelines for the management of CD and the update with further scientific data and evidences is needed.

Comparison of conventional and nonconventional strictureplasties in Crohn's disease: a systematic review and meta-analysis

BACKGROUND

The Heineke-Mikulicz and Finney techniques are conventional strictureplasties that have been used to manage short (<10 cm) and medium-length (>10 cm and <20 cm) strictures from Crohn's disease. Nonconventional strictureplasty techniques have emerged to facilitate bowel conservation for atypical strictures. These techniques include the modified Finney, combined Heineke-Mikulicz and Finney, modified Heineke-Mikuliczs, Michelassi, and modifications of it and others.

OBJECTIVE

The aim of this study is to compare conventional vs nonconventional strictureplasties with respect to short-term complications and long-term results.

DATA SOURCES AND STUDY SELECTION

A MEDLINE search was performed using "Crohn's disease", "surgical therapy", "strictureplasty", "complications", "reoperation", and "recurrence" as medical subject headings. Studies conducted between 1975 and June 31, 2010 were found via PubMed, Ovid, Embase, and Cochrane databases and categorized into 3 groups. These groups consist of centers performing conventional strictureplasties, nonconventional strictureplasties, or both. Studies with at least 3 patients were reviewed.

INTERVENTIONS

A mixed-effects meta-analysis for each outcome was performed by use of Supermix software by SSI Scientific Software International.

MAIN OUTCOME MEASURES

We focused on immediate and long-term complication rates among the groups. The 6 immediate complications include small-bowel obstructions, sepsis, other infections, reoperations, early postoperative GI bleeds, and other early complications. The 5 long-term complications include recurrent strictures, small-bowel obstructions, reoperations, carcinoma, and deaths.

RESULTS

We reviewed 32 studies with 1616 patients who underwent 4538 strictureplasties. One thousand one hundred fifty-seven patients underwent conventional strictureplasties with an early complication rate of 15%; 459 patients underwent nonconventional strictureplasties with an early complication rate of 8%. A late complication rate of 29% for the conventional strictureplasty group and 17% for the nonconventional strictureplasty group was noted.

LIMITATIONS

We are limited by the data published with the inherent risk of finding and analyzing mostly articles with positive results.

CONCLUSION

The nonconventional strictureplasty techniques were noninferior to the conventional strictureplasty procedures with respect to all prespecified outcomes.

A comprehensive review of strictureplasty techniques in Crohn's disease: types, indications, comparisons, and safety

INTRODUCTION

Crohn's disease is one of the chronic inflammatory diseases of the gastrointestinal tract that is often complicated by stricture formation with resulting obstructive symptoms. The technical repertoire of strictureplasty procedures has increased over the years in an effort to manage the diverse presentations of this condition while limiting the need for bowel resection. In this comprehensive review, we describe, compare, categorize, and appraise the strengths and weaknesses of 15 unique strictureplasty techniques.

METHODS

To identify all unique strictureplasty procedures, a Medline search utilizing "Crohn's disease," "surgical therapy," "strictureplasty," "enteroenterostomy," "Heineke-Mikulicz," and "side-to-side isoperistaltic" strictureplasty as medical subject headings was completed. PubMed, Ovid, Embase, and Cochrane database searches were conducted. Relevant articles between 1980 to December 2010 were reviewed. We initially selected 58 articles, but only 18 introduced novel surgical procedures related to 15 types of strictureplasty in Crohn's disease.

RESULTS

We identified 15 types of strictureplasty techniques. These were categorized into three main groups. The revised nomenclature will facilitate the reader to understand the differences and utility of each technique. These groups include the Heineke-Mikulicz-like strictureplasties, the intermediate procedures, and the enteroenterostomies. Heineke-Mikulicz strictureplasty was the most frequently used technique.

CONCLUSION

Various techniques of strictureplasty have been reported in the published literature. Strictureplasty has been shown to be a safe and efficacious technique that is comparable to bowel resection for stricturing Crohn's disease. This technique spares bowel length and puts the Crohn's disease patient at a lower risk of developing short bowel syndrome with repeated resections.

Magnetic resonance enterography for Crohn's disease: what the surgeon can take home

BACKGROUND

Crohn's disease (CD) is a life-long, chronic, relapsing condition requiring often morphological assessment. MR enterography (MRE) offers advantages of not using ionizing radiation and yielding intraluminal and intra-abdominal informations. The aim of our study was to identify how MRE can be useful in planning surgical procedures.

PATIENTS AND METHODS

In this retrospective study, 35 patients who underwent MRE and then surgery for CD were enrolled from 2006 to 2010. MRE findings were compared to intraoperative findings. Histology of operative specimens, systemic inflammatory parameters, and fecal lactoferrin were also evaluated. Cohen's κ agreement test, sensitivity and sensibility, uni-/multivariate logistic regression, and non-parametric statistics were performed.

RESULTS

MRE identified bowel stenosis with a sensitivity of 0.95 (95% CI 0.76-0.99) and a specificity of 0.72 (95% CI 0.39-0.92). The concordance of MRE findings with intraoperative findings was high [Cohen's κ = 0.72 (0.16)]. Abscesses were detected at MRE with a sensitivity of 0.92 (95% CI 0.62-0.99) and a specificity of 0.90 (95% CI 0.69-0.98) with a Cohen's κ = 0.82 (0.16). The grade of proximal bowel dilatation resulted to be a significant predictor of the possibility of using strictureplasty instead of/associated to bowel resection either at univariate or at multivariate analysis.

CONCLUSION

Our study confirmed that MRE findings correlate significantly with disease activity. Detailed information about abscess could suggest percutaneous drainage that could ease the following surgery or avoid emergency laparotomy. Proximal bowel dilatation can suggest the possibility to perform bowel sparing surgery such as strictureplasty.

Intralesional steroid injection after endoscopic balloon dilation in pediatric Crohn's disease with stricture: a prospective, randomized, double-blind, controlled trial

BACKGROUND

Endoscopic balloon dilation (EBD) is an attractive conservative therapy for Crohn's disease (CD) with stricture; however, its long-term efficacy has been questioned because many patients require more dilations or postdilation surgery. Most reports are retrospective, and no pediatric data are available.

OBJECTIVE

To assess the effectiveness of corticosteroid intralesional injection after EBD in preventing stricture recurrence.

DESIGN

Single-center prospective, randomized, double-blind, controlled trial.

SETTING

Tertiary-referral university hospital.

PATIENTS

Between November 2005 and January 2009, 29 pediatric patients with stricturing CD were enrolled.

INTERVENTIONS

Enrolled patients were randomized to receive intrastricture injection of corticosteroid (CS) (n = 15) or placebo (n = 14) after EBD. Patients were followed clinically via small intestine contrast US and intestinal magnetic resonance imaging at 1, 3, 6, and 12 months; all underwent colonoscopy 12 months after dilation.

MAIN OUTCOME MEASUREMENTS

Time free of repeat dilation and time free of surgery in the 2 groups.

RESULTS

One of the 15 patients receiving CS required redilation, whereas the latter was needed in 5 of the 14 placebo patients; surgery was needed in 4 of the placebo patients, but in none of those receiving CS. The 2 groups statistically differed in the time free of redilation (P = .04) as well as for time free of surgery after EBD (P = .02), which were worse in the placebo group compared with the CS group. There were no significant differences in baseline demographics between the 2 groups.

LIMITATIONS

Sample size, participation bias, and short-term follow-up.

CONCLUSION

In pediatric CD with stricture, intralesional CS injection after EBD is an effective strategy for reducing the need both for redilation and surgery.

Surgical strategies for Crohn's disease

Crohn's disease (CD) is a chronic relapsing inflammatory disease of the intestine that may affect the entire digestive tract and present with various types of manifestations, including obstruction, internal or external fistula, abdominal abscess, bleeding, and perforation. Currently, neither medical therapy nor surgery can cure this chronic disease. Optimum management of CD patients requires an interactive partnership among gastroenterologist, surgeon and patient. It is estimated that approximately 80% of CD patients will require surgery at some point during their lifetime. This article reviews the surgical management strategies for CD, including indications for surgery and choice of procedures.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature

BACKGROUND

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence.

METHODS

We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP.

RESULTS

The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months.

CONCLUSION

Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Intestinal surgery for Crohn's disease: predictors of recovery, quality of life, and costs

INTRODUCTION

The aim of this prospective study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn's disease (CD) in terms of recovery, quality of life, and direct and indirect costs.

PATIENTS AND METHODS

Forty-seven consecutive patients admitted for intestinal surgery for CD were enrolled in this prospective study. Surgical procedures were evaluated as possible predictors of outcome in terms of disability status (Barthel's Index), quality of life (Cleveland Global Quality of Life score), body image, disease activity (Harvey-Bradshaw Activity Index), and costs (calculated in 2008 Euros). Univariate and multivariate analyses were performed.

RESULTS

Significant predictors of a long postoperative hospital stay were the creation of a stoma, postoperative complications, disability status on the third post-operative day, and surgical access (R (2) = 0.59, p < 0.01). Barthel's index at discharge was independently predicted by laparoscopic-assisted approach, ileal CD, and colonic CD (R (2) = 0.53, p < 0.01). The disability status at admission showed to be an independent predictor of quality of life score at follow-up. The overall cost for intestinal surgery for CD was 12,037 (10,117-15,795) euro per patient and stoma creation revealed to be its only predictor (p = 0.006).

CONCLUSIONS

Laparoscopy was associated with a shorter postoperative length of stay; stoma creation was associated with a long and expensive postoperative hospital stay, and stricturoplasty was associated with a slower recovery of bowel function.

Side-to-side-to-end strictureplasty for Crohn's disease

PURPOSE

Side-to-side strictureplasty is a useful procedure for preserving the bowel in patients with Crohn's disease. However, bowel resection is required in some patients, and diseased proximal bowel and disease-free distal bowel exist after resection. We performed a modified new technique called side-to-side-to-end strictureplasty.

METHODS

Four patients with Crohn's disease underwent this procedure. After resection of the diseased bowel that was not suitable for strictureplasty, side-to-side strictureplasty was performed with use of the proximal diseased loop. Thereafter, the distal end of the side-to-side stricture was anastomosed to the distal disease-free bowel in a side-to-side-to-end manner.

RESULTS

The length of the small intestine requiring surgical intervention was 69.8 +/- 26.4 (mean +/- standard deviation) cm, and the length of the small intestine necessitating resection was 31.8 +/- 12.6 cm. Side-to-side stricture was performed by use of 48.8 +/- 20.2 cm of the diseased proximal bowel, which was anastomosed to the disease-free distal bowel. Intra-abdominal abscess, which was not associated with this procedure, was observed in one patient, but was treated by drainage. The recoveries of all four patients were uneventful, without recurrence, after a follow-up of 21.5 +/- 16.2 months.

CONCLUSIONS

Side-to-side-to-end strictureplasty may be a useful procedure when diseased proximal bowel and disease-free distal bowel are present after bowel resection in patients with Crohn's disease.

Prospective study of long-term results and prognostic factors after conservative surgery for small bowel Crohn's disease

BACKGROUND & AIMS

Several bowel-sparing techniques have been proposed for treating patients with CD, but there have been no prospective studies analyzing risk factors and long-term outcome. We prospectively evaluated safety and long-term efficacy of conservative surgery for patients with complicated CD.

METHODS

From 1993-2007, 393 of 502 consecutive patients underwent surgery for complicated CD of the small bowel. Those with colonic involvement were excluded. The Student t test, chi(2) test, Kaplan-Meier estimates, and Cox proportional hazard model were used to analyze postoperative complications and long-term outcome.

RESULTS

A total of 865 jejunoileal segments underwent 318 small bowel resections and 367 strictureplasties (either classic or nonconventional). There were no deaths; the complication rate was 5.6%, and the cumulative 10-year recurrence rate was 35%. None of the prognostic factors were correlated with postoperative complications. Younger age, an upper jejunoileal location, stricturing behavior, and small-bowel wall thickening 12 months after surgery showed hazard ratios of 2.4 (95% confidence interval [CI], 1-5.4; P = .03), 2.5 (95% CI, 1.3-4.7; P = .004), 2.2 (95% CI, 1.1-4.1; P = .01), and 4.5 (95% CI, 2.3-8.6; P = .000), respectively. Immunomodulator therapy failed to reduce long-term surgical recurrence.

CONCLUSIONS

Young patients with extended and stricturing disease are at high risk for disease recurrence after surgery. Bowel wall thickening was a reliable prognostic factor for these patients. Conservative surgery is safe and effective in treating patients with jejunoileal CD and should be considered as the first-line surgical treatment, preventing the risk of short bowel syndrome caused by repeated resections.

Long-term follow-up of the endoscopic treatment of strictures in pediatric and adult patients with inflammatory bowel disease

BACKGROUND

Strictures are a common complication of inflammatory bowel disease (IBD) and are usually treated by surgical resection or strictureplasty. As an alternative to surgery, endoscopic balloon dilation and steroid injection have been used to relieve symptoms.

GOALS

To assess patient or stricture characteristics that may predict a better outcome and duration of response as endoscopic therapy is not without its risks.

STUDY

A retrospective review of patients with IBD strictures who underwent dilations between 1996 and 2005 was performed. The patients were followed in the adult and pediatric IBD clinics at a single center. Information was collected from medical records.

RESULTS

Strictures were identified in the small and large bowel of 24 patients (22 adult and 2 pediatric). The majority had Crohn's disease (22/24). In total, 71 dilations were performed on 29 strictures; 46 dilations for 17 strictures were augmented with triamcinolone. Mean duration of follow-up was 32 months. This study included 1 stomal, 12 anastomotic, and 16 de novo strictures. Of 12 anastomotic strictures, 6 were complex. Endoscopic dilation was uneventful in 22/24 patients. Bleeding and perforation occurred on separate occasions in 1/6 complex stricture patients and rupture of a paracolonic abscess in another patient with a de novo sigmoid stricture. Surgery was performed on 2 patients, 1 for refractory disease and 1 for noncompliance with therapy.

CONCLUSIONS

Endoscopic dilation can provide long-term effective palliation of symptoms with minimal risk in patients with simple strictures. Complex anastomotic strictures are technically more challenging compared with de novo strictures.

Surgery for inflammatory bowel disease

Despite the new and ever expanding array of medications for the treatment of inflammatory bowel disease (IBD), there are still clear indications for operative management of IBD and its complications. We present an overview of indications, procedures, considerations, and controversies in the surgical therapy of IBD.

Systematic review: Endoscopic dilatation in Crohn's disease

BACKGROUND

Endoscopic dilatation for Crohn's disease has been evaluated only in some small and heterogeneous studies.

AIM

To evaluate any association between the main clinical variables and endoscopic variables and the efficacy and safety of endoscopic dilatation in Crohn's disease.

METHODS

A Medline search regarding pneumatic dilatation in Crohn's disease was performed. Several technical and clinical variables were extracted from each study to build up a descriptive, pool-data analysis. Data on individual patients were extracted from suitable studies to create a simulated population upon which a multivariate statistical analysis was performed.

RESULTS

Thirteen studies enrolling 347 Crohn's disease patients were reviewed. Endoscopic dilatation was mainly applied to postsurgical strictures, being technically successful in 86% of the cases. Long-term clinical efficacy was achieved in 58% of the patients. Mean follow-up was as long as 33 months, corresponding to 800 patient years of follow-up. Major complication rate was 2%, being higher than 10% in two series. At multivariate analysis, a stricture length < or = 4 cm was associated with a surgery-free outcome (OR: 4.01; 95% CI: 1.16-13.8; P < 0.028).

CONCLUSIONS

Endoscopic dilatation is an effective and safe treatment for short strictures caused by Crohn's disease, impacting substantially on the natural history of these patients.

Strictureplasty

Strictureplasty in patients with Crohn's disease is an option in the colorectal surgeon's armamentarium for fibrostenotic obstructive disease. Common types include the Heineke-Mikulicz strictureplasty, Finney strictureplasty, and the side-to-side isoperistaltic strictureplasty. The procedure has potential for significant morbidity; therefore, it should be chosen for the patient carefully. Strictureplasty complements bowel resection in Crohn's disease; it is an excellent procedure to reduce the risk of developing short-bowel syndrome and its associated complications.

Strictureplasty vs resection in small bowel Crohn's disease: an evaluation of short-term outcomes and recurrence

AIM

To compare postoperative adverse events and recurrence following strictureplasty or bowel resection in patients with small bowel Crohn's disease (CD).

METHOD

A literature search was performed to identify studies published between 1980 and 2006 comparing outcomes of CD patients undergoing either strictureplasty or bowel resection. Hazard ratios were calculated from Kaplan-Meier plots of cumulative recurrence data. Quality assessment of the included studies was performed. Random-effect meta-analytical techniques were employed. Sensitivity analysis and assessment of heterogeneity were performed.

RESULTS

Seven studies comprising 688 CD patients (strictureplasty n = 311, 45%; resection with or without strictureplasty n = 377, 55%) were included. Patients undergoing strictureplasty alone had a lower risk of developing postoperative complications than those who underwent resection (OR = 0.60, 95% CI: 0.31-1.16) although this was not statistically significant (P = 0.13). Surgical recurrence after strictureplasty was more likely than after resection (OR = 1.36, 95% CI: 0.96-1.93, P = 0.09). Patients who had a resection had a significantly longer recurrence-free survival than those undergoing strictureplasty alone (HR = 1.08, 95% CI: 1.02-1.15, P = 0.01).

CONCLUSION

Patients with small bowel CD undergoing strictureplasty alone may have fewer postoperative complications than those undergoing a concomitant bowel resection. However, surgical recurrence maybe higher following strictureplasty alone than with a concomitant small bowel resection. Patients may require appropriate preoperative counselling regarding the pros and cons of each operative technique.

The use of Trichuris suis and other helminth therapies to treat Crohn’s disease

Infections with gastrointestinal (GI) nematodes are prevalent worldwide, despite the fact that anti-helminthic medications are regarded as safe, efficient, and widely available globally. In this review, we highlight the potential therapeutic benefits that may be realized through the clinical use of Trichuris suis and other helminths for Crohn's disease (CD). Long-lived helminthic parasites are remarkable in their ability to down-regulate host immunity, protecting themselves from elimination, and also minimize severe pathological host changes. This review summarizes what is known about the underlying mechanisms that may account for the observed patterns in humans treated with helminths for CD. The Th2 arm of the immune system is emphasized as a component of primary importance in the association between the host immune system and GI nematode infections. Although GI nematode infections in humans cause significant morbidity and mortality, the existence and nature of protective mechanisms these helminths may confer remain largely unclear.