Long-term outcome of surgically treated Crohn's colitis: a prospective study

Global geoepidemiology of gastrointestinal surgery rates in Crohn's disease

BACKGROUND

Data regarding the worldwide gastrointestinal surgery rates in patients with Crohn's disease (CD) remains limited.

AIM

To systematically review the global variation in the rates of surgery in CD.

METHODS

A comprehensive search analysis was performed using multiple electronic databases from inception through July 1, 2020, to identify all full text, randomized controlled trials and cohort studies pertaining to gastrointestinal surgery rates in adult patients with CD. Outcomes included continent based demographic data, CD surgery rates over time, as well as the geoepidemiologic variation in CD surgery rates. Statistical analyses were conducted using R.

RESULTS

Twenty-three studies spanning four continents were included. The median proportion of persons with CD who underwent gastrointestinal surgery in studies from North America, Europe, Asia, and Oceania were 30% (range: 1.7%-62.0%), 40% (range: 0.6%-74.0%), 17% (range: 16.0%-43.0%), and 38% respectively. No clear association was found regarding the proportion of patients undergoing gastrointestinal surgery over time in North America (R 2 = 0.035) and Europe (R 2 = 0.100). A moderate, negative association was seen regarding the proportion of patients undergoing gastrointestinal surgery over time (R 2 = 0.520) in Asia.

CONCLUSION

There appears to be significant inter-continental variation regarding surgery rates in CD. Homogenous evidence-based guidelines accounting for the geographic differences in managing patients with CD is prudent. Moreover, as a paucity of data on surgery rates in CD exists outside the North American and European continents, future studies, particularly in less studied locales, are warranted.

Segmental Versus Total Colectomy for Crohn's Disease in the Biologic Era: Results From The SCOTCH International, Multicentric Study

BACKGROUND

The extent of resection in colonic Crohn's disease [cCD] is still a topic of debate, depending on the number of locations, the risk of recurrence and permanent stoma, and the role of medical therapy.

METHODS

The Segmental COlecTomy for CroHn's disease [SCOTCH] international study is a retrospective analysis on six tertiary centre prospective databases, comprising all consecutive, unselected patients operated on between 2000 and 2019 with segmental colectomy [SC] or total colectomy [TC] for cCD. The primary aim was long-term surgical recurrence. Secondary aims were perioperative complications, stoma formation and predictors of recurrence.

RESULTS

Among 687 patients, SC was performed in 285 [41.5%] and TC in 402 [58.5%]. Mean age at diagnosis and surgery, disease duration, and follow-up were 30 ± 15.8, 40.4 ± 15.4, 10.4 ± 8.6 and 7.1 ± 5.2 years respectively. Isolated cCD, inflammatory pattern, perianal CD, younger age, longer disease duration and preoperative maximal therapy were more frequent in TC, while SC presented more small bowel locations and perforating disease, required fewer 90-day re-admissions, and fewer temporary and definitive stomas. Morbidity and mortality were similar. The 15-year surgical recurrence was 44% in TC and 27% in SC [p = 0.006]. In patients with one to three diseased segments, recurrence risk was related to the omission of biological therapy (hazard ratio [HR] 5.6), the number of segments [HR 2.5], perianal disease [HR 1.9] and paediatric diagnosis [HR 2.8].

CONCLUSION

When technically feasible, SC is safe and reduces temporary and permanent stoma. Young age, number of locations and perianal disease adversely affect, but postoperative biological therapy significantly reduces, the long-term surgical recurrence.

Small Bowel Crohn's Disease Recurrence is Common After Total Proctocolectomy for Crohn's Colitis

BACKGROUND

Surgical intervention for Crohn's disease involving the colon is often a total proctocolectomy with end ileostomy. There are limited data regarding postoperative small bowel recurrence rates in the recent era.

OBJECTIVE

The purpose of this study was to determine the rate of small bowel Crohn's disease recurrence following total proctocolectomy and secondarily define risk factors for disease recurrence.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at four hospitals within a single healthcare system.

PATIENTS

Patients were those with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2009-2019.

MAIN OUTCOME MEASURES

Main outcome measures were clinical, endoscopic, radiographic, and/or surgical Crohn's disease recurrence.

RESULTS

In total, 193 patients were included with a median follow-up of 1.8 years (IQR 0.4-4.6). Overall, 74.6% (n = 144) of patients had been previously exposed to biologic therapy, and 51.3% (n = 99) had a history of small bowel Crohn's disease. Postoperatively, 14.5% (n = 28) of patients received biologic therapy. Crohn's disease recurrence occurred in 23.3% (n = 45) of patients with an estimated median 5-year recurrence rate of 40.8% (95% CI' 30.2-51.4). Surgical recurrence occurred in 8.8% (n = 17) of patients with an estimated median 5-year recurrence rate of 16.9% (95% CI' 8.5-25.3). On multivariable analysis, prior small bowel surgery for Crohn's disease (HR 2.61; 95% CI' 1.42-4.81) and Crohn's diagnosis at age <18 years (HR 2.56; 95% CI' 1.40-4.71) were associated with Crohn's recurrence. In patients without prior small bowel Crohn's disease, 14.9% (n = 14) had Crohn's recurrence with an estimated 5-year overall recurrence rate of 31.1% (95% CI' 13.3-45.3) and 5-year surgical recurrence rate of 5.7% (95% CI' 0.0-12.0).

LIMITATIONS

The study was limited by its retrospective design and lack of consistent follow-up on all patients.

CONCLUSIONS

Greater than one third of patients who underwent total proctocolectomy for Crohn's disease were estimated to have small bowel Crohn's recurrence at 5 years after surgery. Patients with a history of small bowel surgery for Crohn's and diagnosis at any early age may benefit from more intensive postoperative surveillance and consideration for early medical prophylaxis. See Video Abstract at http://links.lww.com/DCR/B762.

RECURRENCIA FRECUENTE DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUS DE LA PROCTOCOLECTOMA TOTAL POR COLITIS DE CROHN

ANTECEDENTES:La cirugia para la enfermedad de Crohn que involucra el colon es a menudo una proctocolectomía total con ileostomía terminal. Hay datos limitados con respecto a las tasas de recurrencia posoperatoria de la enfermedad de Crohn del intestino delgado en la actualidad.OBJETIVO:Buscamos determinar la tasa de recurrencia de la enfermedad de Crohn del intestino delgado después de la proctocolectomía total y, en segundo lugar, definir los factores de riesgo de recurrencia de la enfermedad.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Cuatro hospitales de un mismo sistema sanitario.PACIENTES:Pacientes con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2009-2019.PRINCIPALES MEDIDAS DE VALORACIÓN:Recurrencia clínica, endoscópica, radiográfica y / o quirúrgica de la enfermedad de Crohn.RESULTADOS:Se incluyeron 193 pacientes con un seguimiento promedio de 1,8 años (IQR 0,4-4,6). El 74,6% (n = 144) de los pacientes habían recibido previamente terapia biológica y el 51,3% (n = 99) tenían antecedentes de enfermedad de Crohn del intestino delgado. Después de la operación, el 14,5% (n = 28) de los pacientes recibieron terapia biológica. La recurrencia de la enfermedad de Crohn ocurrió en el 23,3% (n = 45) de los pacientes con una tasa de recurrencia media estimada a los 5 años del 40,8% (IC del 95%: 30,2-51,4). La recidiva quirúrgica se produjo en el 8,8% (n = 17) de los pacientes con una tasa de recidiva media estimada a los 5 años del 16,9% (IC del 95%: 8,5-25,3). En el análisis multivariable, la cirugía previa del intestino delgado para la enfermedad de Crohn (HR 2,61, IC del 95%: 1,42-4,81) y el diagnóstico de Crohn a la edad <18 (HR 2,56, IC del 95%: 1,40-4,71) se asociaron con la recurrencia de Crohn. En pacientes sin enfermedad previa de Crohn del intestino delgado, el 14,9% (n = 14) tuvo recurrencia de Crohn con una tasa de recurrencia general estimada a 5 años del 31,1% (IC del 95%: 13,3-45,3) y una tasa de recurrencia quirúrgica a 5 años del 5,7% (IC del 95%: 0,0-12,0).LIMITACIONES:Diseño retrospectivo, falta de seguimiento constante de todos los pacientes.CONCLUSIONES:Se estimó que más de un tercio de los pacientes que se sometieron a proctocolectomía total tenían recurrencia de Crohn del intestino delgado a los 5 años después de la cirugía. Los pacientes con antecedentes de cirugía por enfermedad de Crohn del intestino delgado y diagnóstico a una edad temprana pueden beneficiarse de una vigilancia posoperatoria más intensiva y la consideración de una profilaxis médica temprana. Consulte Video Resumen en http://links.lww.com/DCR/B762. (Traducción- Dr. Ingrid Melo).

Anorectal Strictures in Complex Perianal CD: How to Approach?

Anorectal strictures are a notoriously difficult to treat phenotype of perianal Crohn's disease. Quality of life is diminished due to ongoing pain, incontinence, difficulty with stool evacuation, and recurrent medical and surgical treatments. Medical therapy is aimed at treating luminal disease and mucosal ulceration to prevent worsening of fibrosis. Clinical examination and endoscopic intervention can be used for serial dilations of strictures. Unfortunately, despite optimal medical therapy and endoscopic intervention with serial anal dilations, surgery with intestinal diversion or proctocolectomy may be required as part of the treatment algorithm in a significant proportion of patients.

Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn's disease

AIM

In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon.

METHODS

A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates.

RESULTS

A total of 63 patients were included; mean age was 47 years (SD 15 years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n = 56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n = 54; 85.7%) versus neoplasia (n = 9; 14.3%). The median length of long-term follow-up was 17.7 months (IQR: 4.72, 38.7 months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon.

CONCLUSION

Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.

Decreasing Trends in Intestinal Resection and Re-Resection in Crohn's Disease: A Nationwide Cohort Study

OBJECTIVE

To assess time trends in intestinal resection and re-resection in Crohn's disease (CD) patients.

SUMMARY OF BACKGROUND DATA

CD treatment has changed considerably over the past decades. The effect of these advances on the necessity of intestinal resections and the risk of re-resection is unclear.

METHODS

In this nationwide cohort study, adult CD patients with ileocolonic, small bowel, colon, or rectum resections between 1991 and 2015 were included. Data were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology (PALGA). Time trends were analyzed with a broken stick model and Cox proportional hazard model with smoothing splines.

RESULTS

The identified cohort comprised 8172 CD patients (3293/4879 male/female) in whom 10,315 intestinal resections were performed. The annual intestinal resection rate decreased nonlinearly from 1.9/100,000 (1991) to 0.2/100,000 (2015). A significantly steeper-decrease was observed before 1999 (slope –0.13) as compared to subsequent years (slope –0.03) (p<0.001). Analogous trends were observed for ileocolonic, small bowel, and colon resections. Overall cumulative risk of re-resection was 10.9% at 5 years, 18.6% at 10 years, and 28.3% at 20 years after intestinal resection. The hazard for intestinal re-resection showed a nonlinear decreasing trend, with hazard ratio 0.39 (95% confidence interval 0.36-0.44) in 2000 and hazard ratio 0.25 (95% confidence interval 0.18-0.34) in 2015 as compared to 1991.

CONCLUSION

Over the past 25 years, intestinal resection rate has decreased significantly for ileocolonic, small bowel, and colonic CD. In addition, current postoperative CD patients are at 75% lower risk of intestinal re-resection.

Colonic Crohn’s disease – decision is more important than incision: A surgical dilemma

The most common localization for intestinal Crohn’s disease (CD) is the terminal ileum and ileocecal area. It is estimated that patients with CD have one in four chance of undergoing surgery during their life. As surgery in ulcerative colitis ultimately cures the disease, in CD, regardless of the extent of bowel removed, the risk of disease recurrence is as high as 40%. In elective surgery, management of isolated Crohn’s colitis continues to evolve. Depending on the type of surgery performed, colonic CD patients often require further medical or surgical therapy to prevent or treat recurrence. The elective surgical treatment of colonic CD is strictly dependent on the localization of disease, and the choice of the procedure is dependent of the extent of colonic involvement and previous resection. The most common surgical options in colonic CD are total proctocolectomy (TPC) with permanent ileostomy, segmental bowel resection, subtotal colectomy. TPC completely removes all colonic and rectal disease and avoids the use of a potentially diseased anus. We will review current options for the elective surgical treatment of colonic CD, based on the current literature and our own personal experience.

Management of Isolated Anal Strictures in Crohn's Disease

BACKGROUND

Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions.

OBJECTIVE

To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing.

DATA SOURCES

An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020.

STUDY SELECTION

Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease.

INTERVENTION(S)

Medical and surgical management.

MAIN OUTCOME MEASURES

Symptomatic relief, need for proctocolectomy.

RESULTS

Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy.

LIMITATIONS

Limited literature published, all retrospective in nature.

CONCLUSIONS

Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.

Restoration of intestinal continuity after stoma formation for Crohn’s disease in the era of biological therapy

Background

The rate of restoration of intestinal continuity after colonic resection and stoma creation in patients with Crohn’s disease has not been well-documented in the era of biologics. Thus, the incidence of restoration of intestinal continuity since the introduction of biological drugs was assessed.

Methods

Consecutive patients (n = 43) who underwent colonic resection with ileostomy or colostomy formation for Crohn’s disease at a single tertiary referral center between 2002 and 2014 were identified. Data from individual chart review were analyzed retrospectively. Patients were personally contacted for follow-up.

Results

Of the 43 patients 8 (18.4%) had a proctectomy leaving 35 patients (81.4%) with the rectum preserved. Of the 30 patients qualifying for final analysis restoration of bowel continuity was finally achieved in 10 patients (33.3%). Permanent stoma rates were comparable in the group of patients with and without biological therapy after surgery (64.3% vs. 60%). The median follow-up period was 7 years (range 3–15 years). Of the patients 20 suffered from perianal disease involvement (66.7%), which was associated with a higher rate of permanent stoma (n = 16/20, 80%) in contrast to patients without perianal disease (n = 4/10, 40%, p = 0.045).

Conclusion

The overall incidence of stoma formation was low for patients with Crohn’s disease; however, once a stoma is created the chance of ending up with a permanent stoma is high even in the era of biologics. Despite the use of new therapeutic agents perianal disease increases the risk of a permanent stoma.

Role of intestinal flora characteristics in traditional Chinese medicine-based diagnosis and treatment of spleen and stomach diseases

Abnormal rise and fall of spleen and stomach Qi will lead to a series of spleen and stomach diseases. Spleen-deficiency syndrome and damp-heat syndrome are important traditional Chinese medicine (TCM) syndromes of spleen-stomach diseases, and they also correlate with imbalance of intestinal flora. Given the correlation between spleen and stomach diseases and intestinal flora, this paper discusses the changes of intestinal flora in common spleen and stomach diseases by reviewing the relevant literature, in order to demonstrate the role of intestinal flora in the diagnosis and treatment of TCM syndromes and promote the objectification of TCM syndromes.

Risk of postoperative morbidity in patients having bowel resection for colonic Crohn's disease

BACKGROUND

The aim of the present multicenter study was to analyze the incidence and risk factors associated with postoperative morbidity in patients who had colorectal resection for colonic Crohn's disease.

METHODS

Consecutive patients undergoing colorectal resection for colonic Crohn's disease at seven surgical units in 1992-2017 were included. Exclusion criteria were: proctectomy for perianal disease, surgery for cancer, previous colectomies, surgery before 1998. Abdominal colectomy and proctocolectomy were defined as extended resections; all other operations were classified as segmental resections. Postoperative intraabdominal septic complications (IASC) were: anastomotic leaks, peritonitis and abscess.

RESULTS

One hundred ninety-nine patients met the inclusion criteria: 116 patients had segmental resections and extended resections were performed in 83 patients. An anastomosis was constructed in 122 patients and an additional stoma was formed in 15 of those cases. Segmental resections were performed significantly more frequently in stricturing or penetrating disease (93% vs. 61%, p < 0.001) and were completed by an anastomosis more often than extended resections (78% vs. 37%, p < 0.001). The overall IASC rate was 17%. On multivariate analysis, formation of an anastomosis (Hazard ratio 2.9; 95% CI 1.1-7.7; p = 0.036) and preoperative hemoglobin level of < 10 g/dl (Hazard ratio 3.1; 95% CI 1.1-9.1; p = 0.034) were associated with an increase of postoperative IASC rate. Preoperative medication did not influence postoperative outcome.

CONCLUSIONS

Severe preoperative anemia is associated with an increased postoperative morbidity. Resections completed by an anastomosis pose an increased postoperative complication risk in patients with colonic Crohn's disease as compared to resections without an anastomosis.

Management of Crohn's Disease and Complications in Patients With Ostomies

Fecal diversion with ostomy construction can be a temporary or definitive surgical measure for the treatment of refractory inflammatory bowel disease (IBD). However, the fecal diversion surgery is associated with various stoma, peristomal complications, and recurrence or occurrence of de novo small bowel Crohn's disease (CD). Stoma complications often need enterostomal therapy or surgical revision. Peristomal cutaneous lesions, such as pyoderma gangrenosum, usually require immunomodulator or biological therapy. Routine monitoring for occurrence or recurrence of CD with endoscopy or imaging should be performed, and prophylaxis with mesalamines, antibiotics, immunomodulators, or anti-TNFα or anti-integrin agents is needed for patients at risk. Those agents, along with corticosteroids, may also be used for the treatment of CD of the neo-small intestine, particularly inflammatory and fistulizing phenotypes. Endoscopic balloon dilation or endoscopic stricturotomy via stoma is safe and feasible to treat short (<4-5 cm), straight strictures in the neo-small intestine. Medically or endoscopically refractory fibrostenotic disease usually requires surgical intervention, with bowel-sparing stricturoplasty being the surgical treatment of choice.

New perspectives on the long-term outcome of segmental colectomy for Crohn's colitis: an observational study on 200 patients

BACKGROUND AND AIMS

Surgical management of Crohn's colitis represents one of the most complex situations in colorectal surgery. Segmental colectomy (SC) and total abdominal colectomy with ileorectal anastomosis (TAC-IRA) are the most common procedures, but there are few available data on their long-term outcome. The aim of the present study was to analyze the long-term outcome of patients who underwent segmental colectomy for Crohn's colitis, with regard to the risk for total abdominal colectomy.

METHODS

In this observational, monocentric, retrospective analysis, we analyzed patients who received a segmental colectomy for Crohn's colitis at our institution. The database was updated by asking patients to complete a questionnaire by telephone or at the outpatient clinic. Only patients followed up at our Hospital were included. Patients were followed up by a specialized multidisciplinary team (IBD Unit). The primary endpoint was the interval between segmental colectomy and, when performed, total abdominal colectomy.

RESULTS

Between 1973 and 2014, 200 patients underwent segmental colectomy for Crohn's colitis. The median follow-up was 13.5 years (interquartile range [IQR] 7.8-21.5). Overall, 62 patients (31%) had a surgical recurrence, of these, 42 (21%) received total abdominal colectomy. At multivariate analysis, the presence of ≥ 3 sites (HR = 2.47; 95% CI 1.22-5.00; p = 0.018) and perianal disease (HR = 3.23; 95% CI 1.29-8.07; p = 0.006) proved to be risk factors for total abdominal colectomy.

CONCLUSIONS

The risk for surgical recurrence after SC for Crohn's colitis is acceptable. We recommend a bowel-sparing policy for the treatment of Crohn's colitis in any case in which the extent of the disease at the moment of surgery makes the conservative approach achievable.

Segmental Resection versus Total Proctocolectomy for Crohn's Colitis: What is the Best Operation in the Setting of Medically Refractory Disease or Dysplasia?

Crohn's disease (CD) may affect any part of the gastrointestinal tract. When isolated to the colon, and patients become medically refractory, there are several surgical options - segmental resection, subtotal colectomy with ileorectal anastomosis, or a total proctocolectomy and end ileostomy. Unfortunately, surgery does not cure CD, and, regardless of the extent of bowel removed, recurrence may be seen in the small bowel. This may lead to need for further immunosuppression or surgery. Therefore, when appropriate, a segmental colectomy or subtotal colectomy may prevent a permanent ostomy required with a total proctocolectomy. In the setting of dysplasia identified on colonoscopy, low quality evidence guides our treatment paradigms. Even though identification of dysplasia has greatly improved with chromoendoscopy, rates of synchronous or metachronous neoplasm remain high. Thus, a total proctocolectomy and end ileostomy, whereas a larger operation, may be best for the patient to remove all at risk tissue. Further research with prospective or randomized control trials is needed to improve our practice guidelines of both scenarios.

Dietary Therapies in Pediatric Inflammatory Bowel Disease: An Evolving Inflammatory Bowel Disease Paradigm

Nutrition has long been recognized as a critical component in the treatment of pediatric inflammatory bowel disease (IBD). Formerly, nutritional interventions have focused on targeting improved weight gain and linear growth, as well as correction of micronutrient deficiencies. Recently, there has been growing interest and study of dietary interventions for induction and maintenance of remission. In addition to exclusive enteral nutrition, successes have been achieved with specific exclusion diets. This article evaluates current literature regarding the role of diet and nutrition in pathogenesis of disease, as well as the role of diet as primary therapy for pediatric IBD.

Impact of Preoperative Exclusive Enteral Nutrition on Postoperative Complications and Recurrence After Bowel Resection in Patients with Active Crohn's Disease

BACKGROUND

The impact of preoperative enteral nutrition (EN) on postoperative complications and recurrence in Crohn's disease (CD) has not been investigated to date. The purpose of the present study was to determine the effect of preoperative exclusive EN on postoperative complications and recurrence after bowel resection in patients with active CD.

METHODS

Patient data were obtained from a prospectively maintained database. 81 patients who received bowel resection for ileal or ileocolonic CD were studied. Before operation, 42 CD patients received exclusive EN for 4 weeks, and the other patients had no nutritional therapy. All patients were followed up regularly for 2 years after surgery, and ileocolonoscopy was performed every 6 months after bowel resection.

RESULTS

Patients receiving exclusive EN had a dramatic improvement of nutritional (BMI, albumin, pre-albumin, and Hb) and inflammatory (CRP and CDAI) status compared with baseline after the EN therapy for 4 weeks (P < 0.05). Furthermore, significantly lower incidence of both infectious and non-infectious complications was observed in patients receiving exclusive EN compared with those received no nutritional therapy (P < 0.05). Exclusive EN therapy for 4 weeks significantly reduced endoscopic recurrence rates after resection for CD 6 months after operation. However, during the 2-year follow-up, incidence of clinical recurrence was similar in both groups (P > 0.05).

CONCLUSIONS

Preoperative exclusive EN therapy for 4 weeks reduced postoperative complications, which may be associated with improvement of nutritional and inflammatory status in patients with active CD.

Colectomy in refractory Crohn's colitis improves nutrition and reduces steroid use

BACKGROUND

Pediatric patients with severe refractory Crohn's colitis (CC) may require total colectomy (TC) or diverting loop ileostomy (DLI). Our understanding of outcomes (postoperative complications, nutrition and restoration of intestinal continuity) is currently limited.

METHODS

Pediatric patients with severe CC who underwent TC or DLI were identified. Demographics, pre and postoperative anthropometric and biochemical data, surgical complications and medication requirements were recorded.

RESULTS

Twenty-seven patients (TC=22, DLI=5) with a median age of 15.0years (range 3-18) were identified, 64% male with a median follow-up of 45months (range 3-120). Mean weight and BMI improved for TC patients by 1year postoperatively - weight z-score from -1.08 to -0.54 (p=0.02), BMI z-score from -0.83 to -0.38 (p=0.04), with a non-significant height change from - 0.79 to -0.65 (p=0.07). Mean hemoglobin and albumin both also improved - 9.88g/dl to 11.76g/dl (p=0.003) and 3.44g/dl to 4.03g/dl (p=0.004) respectively. These measures did not significantly improve after DLI. Most TC patients (59%) had attempted restoration of intestinal continuity with 45% in continuity at end of follow-up. One DLI patient underwent ileostomy takedown but subsequently needed re-diversion.

CONCLUSIONS

In severe CC, TC offers an opportunity to improve nutrition and growth, with a reasonable likelihood of restoring intestinal continuity.

LEVEL OF EVIDENCE

Level IV - Case series.

A systematic review of segmental vs subtotal colectomy and subtotal colectomy vs total proctocolectomy for colonic Crohn's disease

AIM

Surgical management of colonic Crohn's disease (CD) is still unclear because different procedures can be adopted. The choice of operation is dependent on the involvement of colonic disease but the advantages and disadvantages of the extent of resection are still debated.

METHOD

The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileorectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). Studies published between 1984 and 2012 including comparisons of STC vs SC and of STC vs TPC were selected. The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma. Fixed effect models were used to evaluate the study outcomes.

RESULTS

Eleven studies, consisting of a total of 1436 patients (510 STC, 500 SC and 426 TPC), were included. Analysis of the data showed no significant difference between STC and SC in terms of overall and surgical recurrence of CD. In contrast, STC showed a higher risk of overall and surgical recurrence of CD than TPC (OR 3.53, 95% CI 2.45-5.10, P < 0.0001; OR 3.52, 95% CI 2.27-5.44, P < 0.0001, respectively). SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC (OR 2.84, 95% CI 1.16-6.96, P < 0.02; OR 0.19, 95% CI 0.09-0.38, P < 0.0001, respectively). SC resulted in a lower risk of permanent stoma than STC (OR 0.52, 95% CI 0.35-0.77).

CONCLUSION

All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. However, patients in the TPC group showed a lower recurrence risk than those in the STC group. Moreover, SC had a higher risk of postoperative complications but a lower risk of permanent stoma. These data should be taken into account when deciding surgical strategies and when informing patients about postoperative risks.

Completion Proctectomy for Crohn's Colitis: Lessons Learned

Surgical management of Crohn's disease is reserved for patients refractory to medical therapy and those who develop complications alleviated by surgery. Surgical resection may be the most efficient way to restore health in patients with stricturing and or fistulizing disease of the terminal ileum / small bowel. However, decision-making in patients with Crohn's colitis is more difficult. The merits of segmental resection versus subtotal/total colectomy versus total proctocolectomy with end ileostomy are affected by a myriad of factors, including extent of colon involvement, the patient's age, and the patient's degree of desire to avoid an ileostomy. In patients undergoing a total proctocolectomy for Crohn's colitis, the anal canal should be removed. The following case highlights the potential difficulty that may arise when the anal canal is left in situ.

The microbiota in inflammatory bowel disease: current and therapeutic insights

Inflammatory bowel disease is a heterogeneous group of chronic disorders that result from the interaction of the intestinal immune system with the gut microbiome. Until recently, most investigative efforts and therapeutic breakthroughs were centered on understanding and manipulating the altered mucosal immune response that characterizes these diseases. However, more recent studies have highlighted the important role of environmental factors, and in particular the microbiota, in disease onset and disease exacerbation. Advances in genomic sequencing technology and bioinformatics have facilitated an explosion of investigative inquiries into the composition and function of the intestinal microbiome in health and disease and have advanced our understanding of the interplay between the gut microbiota and the host immune system. The gut microbiome is dynamic and changes with age and in response to diet, antibiotics and other environmental factors, and these alterations in the microbiome contribute to disease onset and exacerbation. Strategies to manipulate the microbiome through diet, probiotics, antibiotics or fecal microbiota transplantation may potentially be used therapeutically to influence modulate disease activity. This review will characterize the factors involved in the development of the intestinal microbiome and will describe the typical alterations in the microbiota that are characteristic of inflammatory bowel disease. Additionally, this manuscript will summarize the early but promising literature on the role of the gut microbiota in the pathogenesis of inflammatory bowel disease with implications for utilizing this data for diagnostic or therapeutic application in the clinical management of patients with these diseases.

Post-operative recurrence of Crohn's disease after definitive stoma: an underestimated risk

INTRODUCTION

Crohn's disease (CD) is a progressive inflammatory disease affecting the entire gastrointestinal tract. The need for a definitive stoma (DS) is considered as the ultimate phase of damage. It is often believed that the risk of further disease progression is small when a DS has been performed.

AIMS

The goals of the study were to establish the rate of CD recurrence above the DS and to identify predictive factors of CD recurrence at the time of DS.

METHODS

We retrospectively reviewed all medical records of consecutive CD patients having undergone DS between 1973 and 2010. We collected clinical data at diagnosis, CD phenotype, treatment, and surgery after DS and mortality. Stoma was considered as definitive when restoration of continuity was not possible due to proctectomy, rectitis, anoperineal lesions (APL), or fecal incontinence. Clinical recurrence (CR) was defined as the need for re-introduction or intensification of medical therapy, and surgical recurrence (SR) was defined as a need for a new intestinal resection.

RESULTS

Eighty-three patients (20 males, 63 females) with a median age of 34 years at CD diagnosis were included. The median time between diagnosis and DS was 9 years. The median follow-up after DS was 10 years. Thirty-five patients (42%) presented a CR after a median time of 28 months (2-211) and 32 patients (38%) presented a SR after a median time of 29 months (4-212). In a multivariate analysis, APL (HR = 5.1 (1.2-21.1), p = 0.03) and colostomy at time of DS (HR = 3.8 (1.9-7.3), p = 0.0001) were associated factors with the CR.

CONCLUSION

After DS for CD, the risk of clinical recurrence was high and synonymous with surgical recurrence, especially for patients with APL and colostomy.

Systematic review with meta-analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy

BACKGROUND

Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC-PI) may be a treatment option for medically refractory colonic Crohn's disease (CD).

AIM

To perform a systematic review and meta-analysis to evaluate the rate, risk factors and outcomes of CD recurrence after TC-PI.

METHODS

In a systematic review ending 31 March 2016, we identified 18 cohort studies (1438 adults) who underwent TC-PI for colonic CD (median follow-up, 7.4 years; interquartile range, 5.3-9.0). We estimated pooled rates [with 95% confidence interval (CI)] of clinical and surgical recurrence, and risk factors for disease recurrence.

RESULTS

On meta-analysis, the risk of clinical recurrence after TC-PI was 28.0% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients), with a 5 and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60) respectively. The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients), with a 5 and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34) respectively. The risk of clinical and surgical recurrence in patients without ileal disease at baseline was 11.5% (95% CI, 7.7-16.8) and 10.4% (95% CI, 4.5-22.5) respectively. History of ileal disease was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6). Other inconsistent risk factors for disease recurrence were penetrating disease and young age at disease onset.

CONCLUSIONS

Small bowel clinical recurrence occurs in about 28% of patients after total colectomy with permanent ileostomy for colonic Crohn's disease. Disease recurrence risk is 3.2 times higher in patients with history of ileal disease, and continued medical therapy may be advisable in this population. In patients without ileal inflammation at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy.

Predicting Outcomes to Optimize Disease Management in Inflammatory Bowel Diseases

BACKGROUND AND AIMS

Efforts to slow or prevent the progressive course of inflammatory bowel diseases [IBD] include early and intensive monitoring and treatment of patients at higher risk for complications. It is therefore essential to identify high-risk patients - both at diagnosis and throughout disease course.

METHODS

As a part of an IBD Ahead initiative, we conducted a comprehensive literature review to identify predictors of long-term IBD prognosis and generate draft expert summary statements. Statements were refined at national meetings of IBD experts in 32 countries and were finalized at an international meeting in November 2014.

RESULTS

Patients with Crohn's disease presenting at a young age or with extensive anatomical involvement, deep ulcerations, ileal/ileocolonic involvement, perianal and/or severe rectal disease or penetrating/stenosing behaviour should be regarded as high risk for complications. Patients with ulcerative colitis presenting at young age, with extensive colitis and frequent flare-ups needing steroids or hospitalization present increased risk for colectomy or future hospitalization. Smoking status, concurrent primary sclerosing cholangitis and concurrent infections may impact the course of disease. Current genetic and serological markers lack accuracy for clinical use.

CONCLUSIONS

Simple demographic and clinical features can guide the clinician in identifying patients at higher risk for disease complications at diagnosis and throughout disease course. However, many of these risk factors have been identified retrospectively and lack validation. Appropriately powered prospective studies are required to inform algorithms that can truly predict the risk for disease progression in the individual patient.

Crohn's Disease: Evolution, Epigenetics, and the Emerging Role of Microbiome-Targeted Therapies

Crohn's disease (CD) is a chronic, systemic, immune-mediated inflammation of the gastrointestinal tract. Originally described in 1932 as non-caseating granulomatous inflammation limited to the terminal ileum, it is now recognized as an expanding group of heterogeneous diseases defined by intestinal location, extent, behavior, and systemic extraintestinal manifestations. Joint diseases, including inflammatory spondyloarthritis and ankylosing spondylitis, are the most common extraintestinal manifestations of CD and share more genetic susceptibility loci than any other inflammatory bowel disease (IBD) trait. The high frequency and overlap with genes associated with infectious diseases, specifically Mendelian susceptibility to mycobacterial diseases (MSMD), suggest that CD may represent an evolutionary adaptation to environmental microbes. Elucidating the diversity of the enteric microbiota and the protean mucosal immune responses in individuals may personalize microbiome-targeted therapies and molecular classifications of CD. This review will focus on CD's natural history and therapies in the context of epigenetics, immunogenetics, and the microbiome.

Surgical Treatment of Crohn Colitis Involving More Than 2 Colonic Segments: Long-Term Outcomes From a Single Institution

The incidence of primary Crohn colitis is uncommon and surgical treatment has remained controversial, although most patients with Crohn colitis eventually require surgical intervention. This study aims to compare the operative outcomes of patients who underwent segmental versus either total colectomy or total proctocolectomy for Crohn colitis and to assess potential risk factors associated with clinical and surgical recurrence-free survivals.This is a retrospective study of 116 patients who underwent primary surgery for Crohn colitis between August 1997 and July 2011. Patients were classified based on the type of surgery: segmental colectomy (SC group; n = 71) or either total colectomy or total proctocolectomy (TC group; n = 45).There were no significant differences in postoperative complications or the nutritional state between the SC and TC groups. Patients in TC group had a significantly higher clinical recurrence-free survival (CRFS). Among the 54 patients with multisegmental Crohn colitis, the TC group had a significantly increased CRFS and surgical recurrence-free survival (SRFS), compared with patients in the SC group (5-year CRFS: 82.0% ± 5.8% vs 22.2% ± 13.9%, P = 0.001; 5-year SRFS: 88.1% ± 5.0% vs 44.4% ± 16.6%, P = 0.001). By multivariate analysis of patients with multisegments involved, SC was a risk factor for SRFS and CRFS (hazard ratio [HR] = 4.637, 95% confidence interval [CI] = 1.387-15.509, P = 0.013 and HR = 32.407, 95% CI = 2.873-365.583, P = 0.005).TC patients have significantly increased CRFS and TC in patients with multisegment involvement may affect improved SRFS and CRFS. Among patients with multisegmental Crohn colitis, SC is an independent risk factor for CRFS and SRFS.

Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study

BACKGROUND

The aim of the present study was to document long-term clinical recurrence and re-resection rates of segmental and extended colectomy in patients with Crohn's colitis and to identify risk factors causing recurrence.

METHODS

Records of patients with isolated colonic Crohn's disease who underwent colectomy between 1995 and 2013 and were followed at our medical center were identified. Data on age at diagnosis, gender, smoking, disease location at diagnosis, perianal and rectal disease, indication for surgery, preoperative disease duration, type of operation, primary anastomosis at first operation, length of resected specimen, recurrence of symptoms, postoperative medication, reoperation, and total follow-up time were retrieved.

RESULTS

Thirty-five suitable patients (18 segmental colectomy, 17 extensive colectomy; 17 males; mean age at operation 36.6 years) were identified. Mean age at primary operation was 36 years. The mean preoperative disease duration was 121 months. Postoperative medical treatment was needed in 10 (56 %) patients undergoing segmental colectomy and in 16 (94 %) of those undergoing extensive colectomy (p = 0.01). There was longer reoperation-free survival in the segmental colectomy patient group (p = 0.02) and also a trend toward longer symptom-free survival compared to the extensive colectomy patient group (p = 0.105). There was no correlation between the length of resected bowel and recurrence. Patients operated on at a younger age did not have a higher rate of recurrence of symptoms. Shorter disease duration, smoking, and male gender were risk factors for clinical recurrence.

CONCLUSIONS

Segmental resection with primary anastomosis can be safely performed in patients with limited Crohn's colitis with reasonable clinical recurrence rates.

Colonic disease site and perioperative complications predict need for later intestinal interventions following intestinal resection in pediatric Crohn's disease

INTRODUCTION

We studied variables associated with outcomes following intestinal resection for Crohn's disease.

METHODS

A retrospective review of a prospectively maintained single surgeon database was performed. Outcomes evaluated included disease recurrence, need for further resection/dilatation, and complications. Explanatory variables included: anatomical region of resection, open or laparoscopic approach, surgical procedure, technique of anastomosis, number of anastomoses, use of biological therapy, resection margin disease, age at resection, and period (quartile) in series.

RESULTS

81 children had 100 resections at a median age 14.5years with a median follow-up of 7.7years. Overall complication rate was 22%. Of the 77 children with no prior resection, 40 (52%) had disease recurrence, and 24 (31%) underwent further resection or dilatation. None of the explanatory variables predicted complications. Disease recurrence was significantly associated with younger age at first resection but not duration of follow-up. The probability of further intestinal intervention was strongly associated with disease site and complications. Odds ratio for further surgery for colonic disease site compared to ileocecal disease site was 7 (95% CI 1.8-26; P=0.004). Odds ratio for further intestinal resection following surgery where a complication had occurred compared to no complication was 3.4 (95% CI 1.1-10.3; P=0.02. Both disease site and complication status also significantly affected the interval to further surgery.

CONCLUSIONS

The probability of requiring a second intestinal intervention for pediatric Crohn's disease is related to the disease site and the complication status.

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis

BACKGROUND

Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients.

AIMS

We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD.

METHODS

We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness.

RESULTS

IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy.

CONCLUSIONS

In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.

Surgical aspects of inflammatory bowel diseases in pediatric and adolescent age groups

BACKGROUND

Inflammatory bowel disease (IBD) is increasingly encountered in children. Early disease is associated with higher complication rate with increased incidence of surgical intervention.

PATIENTS AND METHODS

From January 2010 to June 2015, 25 patients in the pediatric and adolescent age groups with IBD underwent surgical intervention in our center. They were classified into two groups. Group I included 15 patients with ulcerative colitis where 5 cases had left colon disease underwent left colectomy, while 10 cases had pancolonic disease underwent total colectomy and anal mucosectomy with ileo-anal or ileal pouch-anal anastomosis with covering ileostomy. Group II included 10 cases with Crohn's disease where the indications for surgery were intestinal obstruction in seven cases, fulminant perianal infection with septic shock in one, perianal fistula and ulcers in one, and growth failure due to resistant intestinal fistula in one.

RESULTS

Group I included eight males and seven females; mean age at surgery was 10.6 years. There were postoperative complications in seven cases in the form of pelvic abscess and wound infection in one, wound infection in two, and recurrent pouchitis in four cases. Group II contained eight males and two females; mean age at surgery was 6.6 years. Two cases had recurrent symptoms after stricturoplasty. The mean length of time from diagnosis to surgery was 2.4 years (ranging from 6 to 36 months).

CONCLUSION

A multidisciplinary team is mandatory for proper management of IBD cases. The risk of the disease and the expected surgical complications determine the timing of surgical interference.

Crohn's Disease of the Colon, Rectum, and Anus

There is no cure for Crohn disease. Newer treatments, such as biological therapy, have led to an improved quality of life. This article focuses on the surgical management of Crohn disease of the colon, rectum, and anus. Restorative and nonrestorative surgical options for colonic Crohn disease are discussed. Treatment options for perianal Crohn disease are also reviewed.

Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease

BACKGROUND

Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success.

AIMS

To perform a systematic review with meta-analysis to evaluate the effectiveness, long-term outcomes and factors associated with success of temporary faecal diversion for perianal CD.

METHODS

Through a systematic literature review through 15 July 2015, we identified 16 cohort studies (556 patients) reporting outcomes after temporary faecal diversion. We estimated pooled rates [with 95% confidence interval (CI)] of early clinical response, attempted and successful restoration of bowel continuity after temporary faecal diversion (without symptomatic relapse), and rates of re-diversion (in patients with attempted restoration) and proctectomy (with or without colectomy and end-ileostomy). We identified factors associated with successful restoration of bowel continuity.

RESULTS

On meta-analysis, 63.8% (95% CI: 54.1-72.5) of patients had early clinical response after faecal diversion for refractory perianal CD. Restoration of bowel continuity was attempted in 34.5% (95% CI: 27.0-42.8) of patients, and was successful in only 16.6% (95% CI: 11.8-22.9). Of those in whom restoration was attempted, 26.5% (95% CI: 14.1-44.2) required re-diversion because of severe relapse. Overall, 41.6% (95% CI: 32.6-51.2) of patients required proctectomy after failure of temporary faecal diversion. There was no difference in the successful restoration of bowel continuity after temporary faecal diversion in the pre-biological or biological era (13.7% vs. 17.6%, P = 0.60), in part due to selection bias. Absence of rectal involvement was the most consistent factor associated with restoration of bowel continuity.

CONCLUSIONS

Temporary faecal diversion may improve symptoms in approximately two-thirds of patients with refractory perianal Crohn's disease, but bowel restoration is successful in only 17% of patients.

Patterns and Predictors of Long-term Nonuse of Medical Therapy Among Persons with Inflammatory Bowel Disease

BACKGROUND

To evaluate patterns and predictors of long-term nonuse of inflammatory bowel disease (IBD)-specific medications among patients with IBD.

METHODS

All incident cases of IBD diagnosed between 1987 and 2012 were identified from the population-based University of Manitoba IBD Epidemiology Database. Point prevalence of long-term medication nonuse (defined as no receipt of IBD-specific medications for a year or longer) was determined over calendar time and the course of disease. Cox proportional hazard regression analysis was performed to identify factors associated with delayed initiation and with becoming a long-term nonuser.

RESULTS

Among 6451 persons with IBD followed since 1987 (46.8% male, 47.8% with Crohn's disease), 11.7% were not dispensed an IBD-specific medication within the first year and 6.2% within 5 years after diagnosis. Factors associated with delayed initiation included having Crohn's disease (hazard ratio [HR] = 0.78, 95% confidence interval [CI], 0.73-0.83), lower socioeconomic status (HR = 0.91, 95% CI, 0.84-0.98), age more than 65 years (HR = 0.76, 95% CI, 0.67-0.86), and having any medical comorbidity. The prevalence of long-term nonuse consistently remained between 40% and 50% of persons with IBD across the study years. Patients with Crohn's disease (HR = 1.14, 95% CI, 1.04-1.25), lower socioeconomic status (HR = 1.14, 95% CI, 1.02-1.27), patients with IBD-associated surgery (HR = 1.72, 95% CI, 1.51-1.96), or delayed initiation of first IBD medication were more likely to become long-term nonusers after initiation.

CONCLUSIONS

At any given time, roughly half of all patients with IBD have not used IBD-specific medications in the previous year. Further work is required to evaluate the clinical implications of long-term medication nonuse in IBD.

Intestinal microbiota pathogenesis and fecal microbiota transplantation for inflammatory bowel disease

The intestinal microbiota plays an important role in inflammatory bowel disease (IBD). The pathogenesis of IBD involves inappropriate ongoing activation of the mucosal immune system driven by abnormal intestinal microbiota in genetically predisposed individuals. However, there are still no definitive microbial pathogens linked to the onset of IBD. The composition and function of the intestinal microbiota and their metabolites are indeed disturbed in IBD patients. The special alterations of gut microbiota associated with IBD remain to be evaluated. The microbial interactions and host-microbe immune interactions are still not clarified. Limitations of present probiotic products in IBD are mainly due to modest clinical efficacy, few available strains and no standardized administration. Fecal microbiota transplantation (FMT) may restore intestinal microbial homeostasis, and preliminary data have shown the clinical efficacy of FMT on refractory IBD or IBD combined with Clostridium difficile infection. Additionally, synthetic microbiota transplantation with the defined composition of fecal microbiota is also a promising therapeutic approach for IBD. However, FMT-related barriers, including the mechanism of restoring gut microbiota, standardized donor screening, fecal material preparation and administration, and long-term safety should be resolved. The role of intestinal microbiota and FMT in IBD should be further investigated by metagenomic and metatranscriptomic analyses combined with germ-free/human flora-associated animals and chemostat gut models.

Exclusive enteral nutritional therapy can relieve inflammatory bowel stricture in Crohn's disease

GOALS

To examine the efficiency of exclusive enteral nutrition (EEN) in relieving inflammatory bowel stricture in patients with Crohn's disease (CD).

BACKGROUND

Patients with CD usually develop bowel strictures due to transmural edema of intestinal wall, which can potentially be managed with conservative medical treatment. Previous studies showed that EEN therapy could induce clinical remission through its anti-inflammation effect.

METHODS

We achieved a prospective observational study. CD patients with inflammatory bowel stricture were preliminarily differentiated from a fibrous one, and further treated with EEN therapy for 12 weeks. Demographics and clinical variables were recorded. Nutritional (body mass index, albumin, pre-albumin, transferrin, etc.), inflammatory (C-reactive protein, erythrocyte sedimentation rate, white blood cell, etc.), and radiologic parameters (bowel wall thickness, luminal diameter, and luminal cross-sectional area) were evaluated at baseline, week 4, and week 12, respectively.

RESULTS

Between May 2012 and January 2013, 65 patients with CD were preliminarily diagnosed with inflammatory bowel stricture and 6 patients were further excluded. Among the remaining 59 cases, 50 patients (84.7%) finished the whole EEN treatment, whereas the other 9 patients (15.3%) gained progressive bowel obstruction resulting in surgery. Intention-to-treat analyses showed that 48 patients (81.4%) achieved symptomatic remission, 35 patients (53.8%) achieved radiologic remission, and 42 patients (64.6%) achieved clinical remission. Among those patients who complete the whole EEN therapy, inflammatory, nutritional, and radiologic parameters improved significantly compared with baseline. Of note, the average luminal cross-sectional area at the site of stricture increased approximately 331% at week 12 (195.7 ± 18.79 vs. 59.09 ± 10.64 mm, P<0.001).

CONCLUSIONS

EEN therapy can effectively relieve inflammatory bowel stricture in CD, which replenishes roles of enteral nutrition in the treatment of CD. Further studies are expected to investigate the underlying mechanisms of this effect in the future.

Advances in minimally invasive surgery in pediatric patients

Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.

Surgical management of nonpolypoid colorectal lesions and strictures in colonic inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) and dysplasia have pathologic characteristics and risks different from those of patients with sporadic carcinomas. Therefore, surgical interventions need to be more aggressive than in sporadic cases. This article reviews the surgical management of nonpolypoid lesions, dysplasia, and strictures found in patients with IBD.

Natural history of Crohn's disease following total colectomy and end ileostomy

BACKGROUND

Crohn's disease (CD) requires surgical management in up to two-thirds of patients. Few studies have addressed the issue of ileal recurrence after colectomy and permanent ileostomy. The aims of our study were to assess the rate and predictors of postoperative recurrence of CD in patients with permanent ileostomy.

METHODS

In a retrospective study from a tertiary referral center, we analyzed the natural history of patients with CD who underwent total colectomy and permanent ileostomy. Our primary outcomes were (1) overall disease recurrence including luminal recurrence, perianal disease or peristomal lesions requiring therapy, and (2) luminal recurrence alone defined as endoscopic and clinical recurrence within the terminal ileum. We examined if patient characteristics predicted recurrence using multivariate Cox proportional hazard models.

RESULTS

Our study included 73 patients with CD followed for a mean of 28 months (range, 0-168 mo) after total colectomy and permanent ileostomy. Twenty patients had overall disease recurrence within 10 years after surgery, at rates of 15% and 50% at 1 and 5 years, respectively. Rate of luminal recurrence was 8% and 35% at 1 and 5 years, respectively. Diagnosis at age less than 18 years (hazard ratio, 2.94; 95% confidence interval, 1.14-7.62) and anti-tumor necrosis factor therapy before surgery (hazard ratio, 4.75; 95% confidence interval, 1.25-18.13) were the only independent predictive factors for overall disease recurrence.

CONCLUSIONS

Up to one-third of patients with CD have overall recurrence of disease after treatment with total colectomy and permanent ileostomy. There is need to develop algorithms for surveillance and management of this select subgroup of patients.

Colonic crohn disease

Colonic Crohn disease is a complicated disease entity that requires a multidisciplinary effort on the part of the surgeon, gastroenterologist, and pathologist. Crohn disease affects ∼500,000 people in North America with nearly 300,000 people suffering from colonic manifestations. This represents a significant portion of the patient population in the typical colorectal surgeon's practice. As such, an intimate understanding of the disease process, presentation, and treatment options is imperative. In this article, the authors review the clinical manifestations, diagnosis, and medical and surgical treatment options with a focus on current strategies for surgical management.

Heat-killed VSL#3 ameliorates dextran sulfate sodium (DSS)-induced acute experimental colitis in rats

To determine the effects of heat-killed VSL#3 (B. breve, B. longum and B. infantis; L. plantarum, L. bulgaricus, L. casei and L. acidophilus; S. salivarius subsp. thermophilus) therapy in the dextran sulfate sodium (DSS)-induced acute experimental colitis in rats. Acute experimental colitis was induced in rats by 5% DSS and freely drink for seven days. Beginning on Day 8, rats underwent gavage once daily for seven days with heat-killed probiotic VSL#3 (0.6 g/kg/day), colonic damage was evaluated histologically and biochemically seven days after gavage. Expression of inflammatory related mediators (STAT3, P-STAT3) and cytokines (IL-6, IL-23, TGFβ) in colonic tissue were detected. The results revealed that heat-killed and live VSL#3 have identical anti-inflammatory properties by the assessed DAI (disease activity index), colon length, histological tissue and MPO activity. Heat-killed and live VSL#3 results in reduced IL-6, IL-23, TGFβ, STAT3 and P-STAT3 expression in colonic tissue. Heat-killed and live VSL#3 have showed the similar anti-inflammatory activity by inhibiting IL-6/STAT3 pathway in the DSS-induced acute experimental colitis in rats.

Surgery and diagnostic imaging in abdominal Crohn's disease

Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.

State-of-the-art medical prevention of postoperative recurrence of Crohn's disease

Postoperative recurrence of Crohn's disease is a frequent and often severe sequela of the disease. Until a few years ago it was deemed inescapable, as all the conventional medications used to treat the disease have been proven of little benefit in preventing recurrence after surgical treatment. In the past few years, anti-TNF agents given immediately after surgery have shown a remarkable efficacy in the prevention of disease recurrence. Large, randomized, controlled trials are currently underway to confirm these findings. Anti-TNF treatment of endoscopic lesions that occur after surgery seems to be less effective than using TNF antagonists to prevent recurrence. However, although the data are limited, this treatment strategy seems to be still superior to all the other prevention strategies that are not based on anti-TNF agents. Limited data are available on long-term outcomes of patients treated with anti-TNF agents after surgery. They suggest that these medications are safe and effective after many years of treatment. In addition, these agents might prevent recurrence even at doses lower than those used in patients with Crohn's disease who have not had surgery.

Complications of peristomal recurrence of Crohn's disease: a case report and a review of literature

Patients with Crohn's disease and colonic inflammation that proves refractory to medical therapy often require a proctocolectomy and end ileostomy. Disease recurrence can occur despite creation of an end ileostomy and may lead to peristomal complications such as fistula formation, abscesses, stoma retraction, or strictures. We present the case of a 51-year-old man with medically refractory ileocolonic Crohn's disease who underwent a proctocolectomy with end ileostomy. The disease course was complicated by recurrence of ileal Crohn's disease despite biological therapy. The patient presented with peristomal complications including an enterocutaneous fistula, stoma retraction, and an ileal stricture necessitating surgical revision of the ileostomy. Review of literature confirms an approximately 30% risk of recurrence of Crohn's disease after an end ileostomy. A penetrating phenotype and preexisting ileal disease are risk factors for disease recurrence. A thorough evaluation of the stoma/peristomal area and evaluation of the small bowel by ileoscopy and small bowel imaging are required to assess the extent of disease and extraluminal complications such as stomal retraction and fistulas that require further surgical intervention. While postoperative medical treatment with immunosuppression or biological therapy is often employed, these therapies are unproven to prevent postoperative recurrence in the setting of a stoma.

Frequency and risk factors of postoperative recurrence of Crohn's disease after intestinal resection in the Chinese population

BACKGROUND

Data on risk factors of postoperative recurrence in patients with Crohn's disease (CD) have shown conflicting results. The aim of this retrospective study is to identify predictors of early symptomatic recurrence of CD after surgical intestinal resection in the Chinese population.

MATERIALS AND METHODS

Patients diagnosed as CD who underwent intestinal resection in Jinling Hospital between May 2004 and December 2010 were included in our study. Clinical data of these patients were reviewed. Multivariable survival analysis was performed to elucidate risk factors of early postoperative symptomatic recurrence.

RESULTS

There were a total of 141 CD patients who had at least one previous curative resection for CD under regular follow-up in our unit. Our data indicated disease behavior (95 % CI 1.01-1.70, P = 0.044), smoking habits (95 % CI 1.32-2.84, P = 0.001), indication of perforation (95 % CI 1.09-4.02, P = 0.026), and location of anastomosis (95 % CI 1.09-3.39, P = 0.023) which are, as a result, strong independent predictors of symptomatic recurrence, while the anastomosis type as side-to-side anastomosis (SSA) was significantly associated with a decreased risk of symptomatic recurrence when compared with other anastomosis type (95 % CI 0.26-0.94, P = 0.038). Medical prophylaxes also played a role in the prevention of postoperative symptomatic recurrence.

CONCLUSIONS

A smoking habits and perforation indication for surgery at the time of resection are associated with an increased risk of symptomatic recurrence. Anastomosis type with SSA is associated with a reduced risk of symptomatic recurrence. This population-based study supports the concept that environmental factors, disease character, and surgical technique influence the risk of postoperative symptomatic recurrence of CD.

Surgical management of Crohn's disease

INTRODUCTION

Crohn's disease is an inflammatory bowel disease that can affect the entire gastrointestinal tract. It is chronic and incurable, and the mainstay of therapy is medical management with surgical intervention as complications arise. Surgery is required in approximately 70% of patients with Crohn's disease. Because repeat interventions are often needed, these patients may benefit from bowel-sparing techniques and minimally invasive approaches. Various bowel-sparing techniques, including strictureplasty, can be applied to reduce the risk of short-bowel syndrome.

METHODS

A review of the available literature using the PubMed search engine was undertaken to compile data on the surgical treatment of Crohn's disease.

RESULTS AND CONCLUSION

Data support the use of laparoscopy in treating Crohn's disease, although the potential technical challenges in these settings mandate appropriate prerequisite surgical expertise.

Inulin and fructo-oligosaccharides have divergent effects on colitis and commensal microbiota in HLA-B27 transgenic rats

Modulation of intestinal microbiota by non-digestible carbohydrates may reduce inflammation in inflammatory bowel disease (IBD). The aim of the present study was to assess the effects of inulin and fructo-oligosaccharides (FOS) on intestinal microbiota and colitis in HLA-B27 transgenic rats, a well-validated rodent model for IBD. In this study, 4-week-old rats were fed 8 g/kg body weight inulin or FOS for 12 weeks, or not. Faeces were collected at 4 and 16 weeks of age; and caecal samples were collected at necropsy. The effects of inulin and FOS on chronic intestinal inflammation were assessed using a gross gut score, histology score and levels of mucosal IL-1β. Intestinal microbiota were characterised by quantitative PCR and denaturing gradient gel electrophoresis. Colitis was significantly reduced in all FOS-fed rats compared to the control diet, whereas inulin decreased chronic intestinal inflammation in only half the number of animals. Quantitative analysis of caecal microbiota demonstrated that inulin increased the numbers of total bacteria and the Bacteroides-Prevotella-Porphyromonas group, FOS increased bifidobacteria, and both fructans decreased Clostridium cluster XI. In the faecal samples, both inulin and FOS decreased total bacteria, Bacteroides-Prevotella-Porphyromonas group, and Clostridium clusters XI and XIVa. FOS increased Bifidobacterium spp., and mediated a decrease of gene copies of Enterobacteriaceae and Clostridium difficile toxin B in faeces. SCFA concentrations in the faecal and caecal samples were unaffected by the diets. In conclusion, FOS increased the abundance of Bifidobacterium spp., whereas both fructans reduced Clostridium cluster XI and C. difficile toxin gene expression, correlating with a reduction of chronic intestinal inflammation.