1
|
Duan M, Coffey JC, Li Y. Mesenteric-based surgery for Crohn's disease: evidence and perspectives. Surgery 2024; 176:51-59. [PMID: 38594102 DOI: 10.1016/j.surg.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/20/2024] [Accepted: 02/26/2024] [Indexed: 04/11/2024]
Abstract
Postoperative anastomotic recurrence of Crohn's disease is challenging and can lead to symptom recurrence and further surgery. The mesenteric pole of the intestine is the initial site of macroscopic anastomotic recurrence, and the mesentery may play an important role in recurrence after surgical resection. Therefore, "mesenteric-based surgery" has gained increasing attention by clinicians. However, the role of mesentery in the postoperative recurrence remains controversial. This review will examine mesenteric changes in Crohn's disease, proposed roles for mesentery in disease progression, and the potential for mesenteric-based surgery in the surgical management of Crohn disease.
Collapse
Affiliation(s)
- Ming Duan
- Center for Inflammatory Bowel Diseases, Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, China
| | - J Calvin Coffey
- Department of Surgery, University of Limerick Hospital Group, and School of Medicine, University of Limerick, Limerick, Ireland.
| | - Yi Li
- Center for Inflammatory Bowel Diseases, Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, China
| |
Collapse
|
2
|
Campbell I, Glinka M, Shaban F, Kirkwood KJ, Nadalin F, Adams D, Papatheodorou I, Burger A, Baldock RA, Arends MJ, Din S. The Promise of Single-Cell RNA Sequencing to Redefine the Understanding of Crohn's Disease Fibrosis Mechanisms. J Clin Med 2023; 12:3884. [PMID: 37373578 PMCID: PMC10299644 DOI: 10.3390/jcm12123884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease with a high prevalence throughout the world. The development of Crohn's-related fibrosis, which leads to strictures in the gastrointestinal tract, presents a particular challenge and is associated with significant morbidity. There are currently no specific anti-fibrotic therapies available, and so treatment is aimed at managing the stricturing complications of fibrosis once it is established. This often requires invasive and repeated endoscopic or surgical intervention. The advent of single-cell sequencing has led to significant advances in our understanding of CD at a cellular level, and this has presented opportunities to develop new therapeutic agents with the aim of preventing or reversing fibrosis. In this paper, we discuss the current understanding of CD fibrosis pathogenesis, summarise current management strategies, and present the promise of single-cell sequencing as a tool for the development of effective anti-fibrotic therapies.
Collapse
Affiliation(s)
- Iona Campbell
- Edinburgh Inflammatory Bowel Disease Unit, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| | - Michael Glinka
- Edinburgh Pathology, Centre for Comparative Pathology, Cancer Research UK Scotland Centre, Institute of Cancer and Genetics, University of Edinburgh, Crewe Road, Edinburgh EH4 2XU, UK
| | - Fadlo Shaban
- Edinburgh Colorectal Unit, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| | - Kathryn J. Kirkwood
- Department of Pathology, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| | - Francesca Nadalin
- European Molecular Biology Laboratory, European Bioinformatics Institute, EMBL-EBI, Hinxton, Cambridge CB10 1SD, UK
| | - David Adams
- Experimental Cancer Genetics, Wellcome Sanger Institute, Hinxton, Cambridge CB10 1SA, UK
| | - Irene Papatheodorou
- European Molecular Biology Laboratory, European Bioinformatics Institute, EMBL-EBI, Hinxton, Cambridge CB10 1SD, UK
| | - Albert Burger
- Department of Computer Science, School of Mathematical and Computer Sciences, Heriot-Watt University, Edinburgh EH14 4AS, UK;
| | - Richard A. Baldock
- Edinburgh Pathology, Centre for Comparative Pathology, Cancer Research UK Scotland Centre, Institute of Cancer and Genetics, University of Edinburgh, Crewe Road, Edinburgh EH4 2XU, UK
| | - Mark J. Arends
- Edinburgh Pathology, Centre for Comparative Pathology, Cancer Research UK Scotland Centre, Institute of Cancer and Genetics, University of Edinburgh, Crewe Road, Edinburgh EH4 2XU, UK
| | - Shahida Din
- Edinburgh Inflammatory Bowel Disease Unit, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| |
Collapse
|
3
|
Giri S, Gopan A, Sundaram S, Kale A. Efficacy and Safety of Endoscopic Stenting for Crohn's Disease Related Strictures: A Systematic Review and Meta-analysis. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 80:177-185. [DOI: 10.4166/kjg.2022.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/08/2022] [Accepted: 07/20/2022] [Indexed: 02/16/2023]
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Amrit Gopan
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| |
Collapse
|
4
|
Chandrasinghe P. Surgical Management of Small Bowel Crohn's Disease. Front Surg 2022; 9:759668. [PMID: 35495760 PMCID: PMC9051431 DOI: 10.3389/fsurg.2022.759668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.
Collapse
|
5
|
Bislenghi G, Sucameli F, Fieuws S, Ferrante M, Sabino J, Wolthuis A, Vermeire S, D'Hoore A. Non-conventional Versus Conventional Strictureplasties for Crohn's Disease. A Systematic Review and Meta-analysis of Treatment Outcomes. J Crohns Colitis 2022; 16:319-330. [PMID: 34406378 DOI: 10.1093/ecco-jcc/jjab146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
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.
Collapse
Affiliation(s)
- G Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - F Sucameli
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - S Fieuws
- Interuniversity Center for Biostatistics and Statistical Bioinformatics, University of Leuven and University of Hasselt, Leuven, Belgium
| | - M Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuvaen, Leuven, Belgium
| | - J Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuvaen, Leuven, Belgium
| | - A Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - S Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuvaen, Leuven, Belgium
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| |
Collapse
|
6
|
Danilov MA, Leontiev AV, Abdulatipova ZM, Demidova AA. [Strictureplasty or resection? Optimal approach for fibrostenotic Crohn's disease]. Khirurgiia (Mosk) 2022:100-103. [PMID: 35147008 DOI: 10.17116/hirurgia2022021100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The indications for surgical intervention in patients with Crohn's disease (CD) are ineffective therapy and complications of this disease. In case of fibrostenotic CD, strictureplasty or bowel resection are indicated. The indications for organ-sparing surgeries are multiple small bowel lesions, previous surgery for CD and short bowel syndrome. Strictureplasty is not advisable in patients with fistulas, abscesses, bowel perforation and severe hypoalbuminemia due to extremely high risk of anastomotic leakage. Therefore, bowel resection is recommended if strict indications for various types of strictureplasty are absent. This approach is associated with effective maintenance of remission and longer recurrence-free period.
Collapse
Affiliation(s)
- M A Danilov
- Loginov Moscow Clinical Scientific Center, Russia, Moscow
| | - A V Leontiev
- Loginov Moscow Clinical Scientific Center, Russia, Moscow
| | | | - A A Demidova
- Loginov Moscow Clinical Scientific Center, Russia, Moscow
| |
Collapse
|
7
|
Sawayama H, Miyamoto Y, Yoshida N, Baba H. Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases. Ann Gastroenterol Surg 2022; 6:321-335. [PMID: 35634190 PMCID: PMC9130914 DOI: 10.1002/ags3.12548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/27/2021] [Indexed: 11/23/2022] Open
Abstract
The development of new drugs for inflammatory bowel disease (IBD) is remarkable, and treatment strategies using multiple agents and various techniques are required; however, the treatment strategy is likely to be complex. Therefore, appropriate evaluation of traditional surgical treatment strategies and accurate knowledge of the efficacy and limitations of novel treatments are required. Total infectious complications were found to be associated with the use of corticosteroids and anti‐tumor necrosis factor‐α agents, but not with immunomodulators, anti‐integrin agents, and 5‐aminosalicylic acid. Regarding surgical procedures for IBD, conceived anastomosis methods, including Kono‐S for Crohn's disease stenosis, are associated with better outcomes than conventional techniques. Autologous cell transplantation for Crohn's fistulae has been shown to have a favorable outcome. Diverticulitis is increasing and will be treated more frequently in the future. Risk factors for the incidence of diverticulitis and differences in pathogenesis according to right or left side diverticulitis have been reported. Antibiotic therapy may be omitted for uncomplicated diverticulitis. Moreover, regarding surgical procedures, both bowel resection and anastomosis are associated with favorable short‐term outcomes, higher stoma closure rate, and superior medical economy compared to Hartmann's procedure. Risk factors for recurrence after diverticulitis surgery may provide better postoperative follow‐up. In this review, we explore the current topics of colorectal benign diseases, focusing on IBD and diverticulitis, based on clinical trials and meta‐analyses from 2020‐2021. This review consolidates the available knowledge and improves the quality of surgical procedures and perioperative management for IBD and diverticulitis.
Collapse
Affiliation(s)
- Hiroshi Sawayama
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| |
Collapse
|
8
|
Ferrari L, Fichera A. Operative indications and options in intestinal Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
9
|
Kellil T, Chaouch MA, Guedich A, Touir W, Dziri C, Zouari K. Surgical features to reduce anastomotic recurrence of Crohn's disease that requires reoperation: a systematic review. Surg Today 2021; 52:542-549. [PMID: 34420112 DOI: 10.1007/s00595-021-02364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/19/2021] [Indexed: 10/20/2022]
Abstract
Anastomotic recurrence after intestinal resection is one of the main embarrassing problems encountered during Crohn's disease (CD) management. This complication is often associated with an expected consequence, mainly a multiple intestinal resection. This systematic review evaluates published evidence on surgical features to reduce surgical recurrence after bowel resection and provide surgeons with recommendations based on published evidence. We conducted bibliographic research on September 05, 2020, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis, randomized clinical trials, and controlled clinical trials. The strength of clinical data and subsequent recommendations were graded according to the Oxford Centre for Evidence-Based Medicine. Fourteen articles were retained. Early resection reduces surgical relapse and the need for additional medical treatment. There was no difference between conventional and laparoscopic bowel resection. Mesenteric excision seems to reduce surgical recurrence. Stapled side-to-side anastomosis reduces surgical recurrence. However, no difference was observed between Kono-S anastomosis ensure at least similar anastomotic recurrence rate compared to conventional anastomosis. Surgical recurrence was reduced after bowel resection when compared to stricturoplasty. There was no difference between the one and two steps resection. Several surgical features have been investigated. Some of them were unanimously found to be effective in lengthening the disease-free relapse. However, others are still controversial.
Collapse
Affiliation(s)
- Tarek Kellil
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia.
| | - Mohamed Ali Chaouch
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Arwa Guedich
- Department of Gastroenterology, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Wassim Touir
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Chadli Dziri
- Department B of Digestive Surgery, Charles Nicolle Hospital, University of Tunis, Tunis, Tunisia
| | - Khadija Zouari
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| |
Collapse
|
10
|
Lin XX, Qiu Y, Zhuang XJ, Liu F, Wu XM, Chen MH, Mao R. Intestinal stricture in Crohn's disease: A 2020 update. J Dig Dis 2021; 22:390-398. [PMID: 34014617 DOI: 10.1111/1751-2980.13022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is a chronic and relapsing-remitting inflammatory disorder of the gastrointestinal tract. Approximately 70% of patients inevitably develop fibrosis-associated intestinal stricture after 10 years of CD diagnosis, which seriously affects their quality of life. Current therapies play limited role in preventing or reversing the process of fibrosis and no specific anti-fibrotic therapy is yet available. Nearly half of patients thus have no alternative but to receive surgery. The potential mechanisms of intestinal fibrosis remain poorly understood; extracellular matrix remodeling, aberrant immune response, intestinal microbiome imbalance and creeping fat might exert fundamental influences on the multiple physiological and pathophysiological processes. Recently, the emerging new diagnostic techniques have markedly promoted an accurate assessment of intestinal stricture by distinguishing fibrosis from inflammation, which is crucial for guiding treatment and predicting prognosis. In this review, we concisely summarized the key studies published in the year 2020 covering pathogenesis, diagnostic modalities, and therapeutic strategy of intestinal stricture. A comprehensive and timely review of the updated researches in intestinal stricture could provide insight to further elucidate its pathogenesis and identify novel drug targets with anti-fibrotic potentiality.
Collapse
Affiliation(s)
- Xiao Xuan Lin
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao Jun Zhuang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Fen Liu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao Min Wu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Min Hu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| |
Collapse
|