When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn’s disease?

New anti-mesenteric delta-shaped stapled anastomosis: Technical report with short-term postoperative outcomes in patients with Crohn's disease

BACKGROUND

Medical treatment for Crohn's disease (CD) has continuously improved, which has led to a decrease in surgical recurrence rates. Despite these advancements, 25% of patients will undergo repeat intestinal surgery. Recurrence of CD commonly occurs on the mesentery side of the anastomosis site.

AIM

To compare the new anti-mesenteric side-to-side delta-shaped stapled anastomosis (DSA) with the conventional stapled functional end-to-end anastomosis (CSA).

METHODS

This retrospective study included CD patients who underwent ileo-ileal or ileo-colic anastomosis between January 2020 and December 2023. The DSA technique employed a stapler to maintain the concept of anti-mesentery side-to-side anastomosis by performing a 90° vertical closure of the open window compared with the CSA technique. At the corner where the open window is closed, the DSA avoids forming a pouch and creates an anastomosis resembling a delta shape within the intestinal lumen. We compared demographics, preoperative condition, operative findings, and operative outcomes for the two techniques.

RESULTS

The study included 175 patients, including 92 in the DSA group and 83 in the CSA group. The two groups were similar in baseline characteristics, preoperative medical treatment, and operative findings except for the Montreal classification location. The 30-days postoperative complication rate was significantly lower in the DSA group compared with the CSA group (16.3% vs 32.5%, P = 0.009). Ileus incidence was significantly lower in the DSA group than in the CSA group (4.3% vs 14.5%, P = 0.033), and the hospital stay was shorter in the DSA group than in the CSA group (5.67 ± 1.53 days vs 7.39 ± 3.68 days, P = 0.001).

CONCLUSION

The DSA technique was feasible and showed comparable postoperative outcomes with lower short-term complications compared with the CSA technique. Further studies on CD recurrence and long-term complications are warranted.

Stoma associated complications after diverting loop ileostomy, end ileostomy or split stoma formation after right sided colectomy-a retrospective cohort study (StoComSplit Analysis)

BACKGROUND

For high-risk patients receiving right-sided colectomy, stoma formation is a safety strategy. Options are anastomosis with loop ileostomy, end ileostomy, or split stoma. The aim is to compare the outcome of these three options.

METHODS

This retrospective cohort study included all patients who underwent right sided colectomy and stoma formation between January 2008 and December 2021 at two tertial referral centers in Switzerland. The primary outcome was the stoma associated complication rate within one year.

RESULTS

A total of 116 patients were included. A total of 20 patients (17%) underwent primary anastomosis with loop ileostomy (PA group), 29 (25%) received an end ileostomy (ES group) and 67 (58%) received a split stoma (SS group). Stoma associated complication rate was 43% (n = 21) in PA and in ES group and 50% (n = 34) in SS group (n.s.). A total of 30% (n = 6) of patients in PA group needed reoperations, whereas 59% (n = 17) in ES and 58% (n = 39) in SS group had reoperations (P = 0.07). Wound infections occurred in 15% (n = 3) in PA, in 10% (n = 3) in ES, and in 30% (n = 20) in SS group (P = 0.08). A total of 13 patients (65%) in PA, 7 (24%) in ES, and 29 (43%) in SS group achieved stoma closure (P = 0.02). A total of 5 patients (38%) in PA group, 2 (15%) in ES, and 22 patients (67%) in SS group had a stoma-associated rehospitalization (P < 0.01).

CONCLUSION

Primary anastomosis and loop ileostomy may be an option for selected patients. Patients with end ileostomies have fewer stoma-related readmissions than those with a split stoma, but they have a lower rate of stoma closure.

CLINICAL TRIAL REGISTRATION

Trial not registered.

Safety & feasibility of targeted mesenteric approaches with Kono-S anastomosis and extended mesenteric excision in ileocolic resection and anastomosis in Crohn's disease

BACKGROUND

The mesentery has recently been implicated in the pathophysiology of Crohn's disease (CD), and several techniques have been developed to target the mesentery to reduce its influence on recurrence. We aimed to describe short-term safety and feasibility after these approaches.

METHODS

This is a comparative, retrospective, single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection from 2015 to 2022 with Kono-S anastomosis (KSA), extended mesenteric excision (EME) only, or both: mesenteric excision and exclusion (MEE).

RESULTS

186 patients underwent KSA (n ​= ​74), EME (n ​= ​66), or MEE (n ​= ​46). The groups had comparable baseline characteristics. The MEE group operative time was longer (median: 187 vs. KSA 170, EME 152 ​min, p ​< ​0.01). Postoperatively, the groups had similar lengths of stay (median 4 days), readmissions (9.1 ​%), major postoperative complications (6.5 ​%), and anastomotic leaks (1.1 ​%).

CONCLUSION

Targeting the mesentery with novel surgical approaches for ileocolic Crohn's disease was safe and feasible for short-term follow-up.

Anastomotic Considerations in Crohn's Disease

A number of factors should be considered when performing an intestinal anastomosis in the setting of surgery for Crohn's disease. Preoperative risk factors, such as malnutrition, abdominal sepsis, and immunosuppressive medications, may increase the risk of postoperative anastomotic complications and alter surgical decision-making. The anatomical configuration and technique of constructing the anastomosis may have an impact on postoperative function and risk of recurrence, particularly in the setting of ileocolic resection, where the Kono-S anastomosis has gained popularity in recent years. There may be circumstances in which it may be more appropriate to perform an ostomy either without an anastomosis or to temporarily divert an anastomosis when the risk of anastomotic complications is felt to be high. In the setting of total abdominal colectomy or proctocolectomy for Crohn's colitis, restorative procedures may appropriate in lieu of a permanent stoma in certain scenarios.

Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort

BACKGROUND

Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease.

METHODS

A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group).

RESULTS

Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188).

CONCLUSION

Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.

Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy

OBJECTIVE

This study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy.

METHODS

Patients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared.

RESULTS

This study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques.

CONCLUSION

Surgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.

Abdominal Surgery in Crohn's Disease: Risk Factors for Complications

Introduction

Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD.

Methods

A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018.

Results

Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively).

Conclusion

Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.