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

A Phase II Clinical Trial to Study the Safety of Triamcinolone after Endoscopic Radial Incision and Cutting Dilatation for Benign Stenosis of the Lower Gastrointestinal Tract: A Study Protocol

BACKGROUND

Lower gastrointestinal tract stenosis is commonly diagnosed and is typically treated with surgery or endoscopic balloon dilation (EBD). Radial incision and cutting (RIC) is a novel treatment approach that has several benefits compared with EBD and surgery. Although RIC has demonstrated a high technical success rate and has been shown to improve subjective symptoms, previous studies revealed that restenosis after RIC remain unsolved. Herein, we report the design of a prospective, multicenter, single-arm, interventional, phase II trial to evaluate the safety of local triamcinolone acetonide (TA) administration and its feasibility in preventing restenosis after RIC for lower gastrointestinal tract stenosis.

METHODS

The major inclusion criteria are age 20-80 years and the presence of benign stenosis in the lower gastrointestinal tract accessible by colonoscope. We will perform RIC followed by local administration of TA to 20 participants. The primary outcome is the safety of local TA administration, which will be assessed by determining the frequency of adverse events of special interest. The secondary outcomes are the technical success rate of RIC, duration of procedure, improvement in subjective symptoms, and duration of hospitalization. The outcomes, improvement in subjective symptoms, and long-term results will be evaluated using descriptive statistics, Student's t-test, and Kaplan-Meier curve, respectively.

DISCUSSION

This explorative study will provide useful information regarding the safety of TA administration after RIC, which may contribute to further investigations.

Surgical Emergencies in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) patients are at risk for undergoing emergency surgery for fulminant disease, toxic megacolon, bowel perforation, intestinal obstruction, or uncontrolled gastrointestinal hemorrhage. Unfortunately, medical advancements have failed to significantly decrease rates of emergency surgery for IBD. It is therefore important for all acute care and colorectal surgeons to understand the unique considerations owed to this often-challenging patient population.

First Mexican Consensus on Crohn's disease

INTRODUCTION

Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown.

OBJECTIVE

The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico.

MATERIAL AND METHODS

Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement.

RESULTS

The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established.

CONCLUSIONS

Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.

The Promise of Single-Cell RNA Sequencing to Redefine the Understanding of Crohn's Disease Fibrosis Mechanisms

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.

A pilot study investigating the safety and feasibility of endoscopic dilation using a radial incision and cutting technique for benign strictures of the small intestine: a study protocol

Background

Small benign intestinal stenosis is usually treated by endoscopic balloon dilation (EBD) or surgery. Although EBD and surgery are able to resolve the stenosis in most cases, they are associated with several problems such as insufficient dilation and surgical stress, respectively. On the contrary, a novel approach called radial incision and cutting (RIC) is reported to have several benefits when compared to EBD and surgery. We can currently adopt RIC only for the strictures in the colon or terminal ileum and not for those stenotic lesions present further in the small intestine where balloon-assisted endoscopy is utilized, because the long-type electric knife is currently not approved for use in Japan. We will herein conduct a pilot study to investigate the safety and feasibility of RIC for treating the benign stenoses of the small intestine using the long-type electric knife.

Methods

This will be a single-center, single-arm, interventional trial. The major criteria for inclusion will be age ranging from 20 to 80 years and the presence of benign stenosis in the small intestine. We will perform RIC on 10 participants. The primary outcome is the safety of this procedure, which will be assessed by measuring the frequency of adverse events of special interest. The secondary outcomes will be technical success rate, improvement in subjective symptoms, procedure time, and duration of hospitalization.

Discussion

This pilot study will provide useful information that will aid in adopting RIC for treating the benign strictures present in the small intestine.

Trial registration

jRCT Identifier, jRCTs022200040. Registered on 1 March 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01046-8.

Surgical Management of Small Bowel Crohn's Disease

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.

Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease

Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.

Prevalence and significance of mesentery thickening and lymph nodes enlargement in Crohn's disease

BACKGROUND

Mesentery thickening and enlarged lymphnodes are typical findings of Crohn's disease (CD), but their role is unknown. Aim of the present study was to evaluate their prevalence and significance on postoperative complications and long-term surgical recurrence after CD surgery.

METHODS

1272 consecutive, unselected patients were retrospectively reviewed, divided into 4 groups based on the presence or absence of a thickened mesentery and enlarged lymphnodes, and stratified for primary or recurrent surgical procedure. In all patients but those treated with strictureplasty the mesentery and lymphnodes were removed. Patients' characteristics, peri-operative findings, and long-term recurrence were compared by univariate and multivariate analysis.

RESULTS

Thickened mesentery and enlarged lymphnodes were not present in all cases, were typical of ileal location and penetrating behaviour, had a constant decrease over recurrences, were independent of either pre-operative medical therapy or surgical approach, did not increase the duration of surgery and complications, presented similar 20-years recurrence rate to normal mesentery and lymphnodes. Lymphopathy was associated to a worst nutritional status during disease recurrences. At multivariate analysis, age, location, and behaviour, but not mesenteric characteristics, were related to an increased risk of surgical recurrence.

CONCLUSIONS

This study provides new information on mesentery and lymphnodes in CD patients. Further studies are needed to clarify the appropriate surgical approach.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopy for Crohn's disease: A comprehensive exploration of minimally invasive surgical techniques

BACKGROUND

Along with the unceasing progress of medicine, Crohn's disease (CD), especially complex CD, is no longer a taboo for minimally invasive surgery. However, considering its special disease characteristics, more clinical trials are needed to confirm the safety and feasibility of laparoscopic surgery for CD.

AIM

To investigate the safety and feasibility of laparoscopic enterectomy for CD, assess the advantages of laparoscopy over laparotomy in patients with CD, and discuss comprehensive minimally invasive surgical techniques in complex CD.

METHODS

This study prospectively collected clinical data from patients with CD who underwent enterectomy from January 2017 to January 2020. It was registered in the Chinese clinical trial database with the registration number ChiCTR-INR-16009321. Patients were divided into a laparoscopy group and a traditional laparotomy group according to the surgical method. The baseline characteristics, operation time, intraoperative blood loss, temporary stoma, levels of abdominal adhesion, pathological characteristics, days to flatus and soft diet, postoperative complications, hospitalization time, readmission rate within 30 d, and hospitalization cost were compared between the two groups.

RESULTS

A total of 120 eligible patients were enrolled into the pre-standardized groups, including 100 in the laparoscopy group and 20 in the laparotomy group. Compared with the laparotomy group, the postoperative hospitalization time in the laparoscopy group was shorter (9.1 ± 3.9 d vs 11.0 ± 1.6 d, P < 0.05), the days to flatus were fewer (2.8 ± 0.8 d vs 3.5 ± 0.7 d, P < 0.05), the days to soft diet were fewer (4.2 ± 2.4 d vs 6.2 ± 2.0 d, P < 0.05) and the intraoperative blood loss was less (103.3 ± 80.42 mL vs 169.5 ± 100.42 mL, P < 0.05). There were no statistically significant differences between the two groups in preoperative clinical data, operation time (149.0 ± 43.8 min vs 159.2 ± 40.0 min), stoma rate, levels of abdominal adhesion, total cost of hospitalization, incidence of postoperative complications [8.0% (8/100) vs 15.0% (3/20)], or readmission rate within 30 days [1.0% (1/100) vs 0.00 (0/20)].

CONCLUSION

Compared with laparotomy, laparoscopic enterectomy promotes the recovery of gastrointestinal function, shortens the postoperative hospitalization time, and does not increase the incidence of postoperative complications. Laparoscopic enterectomy combined with varieties of minimally invasive surgical techniques is a safe and acceptable therapeutic method for CD patients with enteric fistulas.

Strictureplasties performed by laparoscopic approach for complicated Crohn's disease. A prospective, observational, cohort study

BACKGROUND

Laparoscopy is considered the best surgical approach for Crohn's Disease (CD), and strictureplasty a reliable alternative to intestinal resection. Nevertheless, their association has never been evaluated.

AIM

To investigate feasibility and safety of conventional (SP) and non-conventional (NCSP) strictureplasties, using laparoscopy, for complicated CD.

METHODS

Starting January 2008, a prospective cohort study was performed, in consecutive, unselected patients, undergoing primary surgery for CD (Group-A). The residential database (CD-CARD) was used for the retrospective extraction of control patients (Group-B). Univariate and multi-variate analysis of pre-operative characteristics, intra-operative findings, morbidity, and intra-abdominal septic complications (IASCs) was performed.

RESULTS

Between January 2008 and December 2019, 331 patients received 162 SPs, 138 NCSPs, and 373 resections (Group-A). From the CD-CARD, 227 control patients received 159 SPs, 117 NCSPs, and 271 resections (Group-B) (ns). Preoperatively, Group-A presented batter nutritional status and received more biological therapies, Group-B more steroids. Group-A presented less abdominal abscesses, planned ostomies, minor complications, shorter operating time and hospitalization than Group-B, but similar major complications, IASCs and anastomotic leaks. IASCs were related to older age, elevated inflammatory indices, and preoperative treatment with high-risk drugs.

CONCLUSIONS

SP and NCSP are feasible by laparoscopy, with low morbidity rate, confirming the advantages of both minimally invasive and conservative surgery.

Characterization of Crohn's disease patients in Egypt: Risk factors for postoperative recurrence (A cohort study)

BACKGROUND

The aim of study to identify the characterizations of Crohn's disease in Egyptian patients and to determine its predictors for postoperative recurrence.

METHODS

We conducted a retrospective observational cohort study on 15 patients diagnosed as Crohn's disease with surgical interventions. Different characteristics of studied patients were analyzed to determine the risk factors for postoperative recurrence such as age at diagnosis, gender, smoking, main presenting symptom, Montreal classification, perianal disease, laboratory findings and protocol of management including surgical characteristics like age at operation, surgical indication, preoperative medication, surgical approach, and operative findings.

RESULTS

Nine of the studied patients (60%) suffered from clinical postoperative recurrence with mean duration of 23.5 ± 40.6 months. In comparison the demographic, clinical, operative, and medical treatment data between patients with postoperative recurrence of Crohn's disease and those without recurrence, age at diagnosis (mean age 42.9 years) and age at operation (mean 44.7 years) were found statistically significant in postoperative recurrence group (p-value = 0.001). According to Montreal classification of Crohn's disease, patients >40 years were significantly found in postoperative recurrence group, while patients between 17 and 40 years were significantly found in postoperative non-recurrence group (p-value=0.007) and ileal location of Crohn's disease was found significantly in postoperative recurrent group (p-value=0.044). Postoperative biological therapy significantly decreased the incidence of postoperative recurrence in the current study (p-value= 0.041).

CONCLUSIONS

Age at diagnosis, age at operation, ileal location of Crohn's disease can significantly predict postoperative recurrence. Also, postoperative biological therapy can significantly decrease the incidence of postoperative recurrence.

Facing the unexpected: unusual causes of mechanical small bowel obstruction in adults

Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usually acute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through a systematic review and critical analysis of the available evidence, and summarises the essential intra-operative steps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.

Pathophysiology of Crohn's disease inflammation and recurrence

Chron’s Disease is a chronic inflammatory intestinal disease, first described at the beginning of the last century. The disease is characterized by the alternation of periods of flares and remissions influenced by a complex pathogenesis in which inflammation plays a key role. Crohn’s disease evolution is mediated by a complex alteration of the inflammatory response which is characterized by alterations of the innate immunity of the intestinal mucosa barrier together with a remodeling of the extracellular matrix through the expression of metalloproteins and increased adhesion molecules expression, such as MAcCAM-1. This reshaped microenvironment enhances leucocytes migration in the sites of inflammation, promoting a T_H1 response, through the production of cytokines such as IL-12 and TNF-α. IL-12 itself and IL-23 have been targeted for the medical treatment of CD. Giving the limited success of medical therapies, the treatment of the disease is invariably surgical. This review will highlight the role of inflammation in CD and describe the surgical approaches for the prevention of the almost inevitable recurrence.

Combined Endoscopic Stricturotomy and Balloon Dilation of Strictureplasty Site Stricture in Jejunal Crohn's Disease

Patients who undergo surgical strictureplasty for jejunal Crohn's disease-associated strictures may develop severe stenosis at the inlet and outlet sites of the strictureplasty. There is currently no consensus on the optimal management of these strictureplasty-associated strictures because immunosuppressive medications will be ineffective and surgical reintervention, most commonly with bowel resection, is invasive and may introduce new complications. Endoscopic therapy may sometimes be the only valid option. We present a case of severe strictureplasty inlet and outlet strictures that were successfully treated with combined endoscopic stricturotomy and balloon dilation.

Fibrostenotic strictures in Crohn's disease

The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.

Strictureplasty in Complex Crohn's Disease: Beyond the Basics

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

Ex vivo model for a new bilateral antimesenteric V-modified side-to-side isoperistaltic anastomosis to prevent recurrence in ileocolic Crohn's disease

INTRODUCTION

The high rate of recurrence following ileocaecal resection for Crohn's disease may lead to repeat surgery in 20-30% of patients at five years after surgery. Recurrence usually occurs at the anastomosis and the neoterminal ileum and the association of a strictureplasty to widen the bowel lumen in the regions immediately proximal ('anastomotic inlet') and distal ('anastomotic outlet') to the anastomosis may delay or reduce the risk of surgical recurrence.

MATERIALS AND METHODS

A side to side isoperistaltic anastomosis, with an associated V-modified strictureplasty on the anti-mesenteric border at the level of the anastomosis inlet and outlet has been designed. We produced a wet lab ex vivo model of the anastomosis and, to evaluate the different calibre of the anastomotic segments, we compared it with ex vivo models of three anastomotic configurations currently used in surgery for Crohn's disease: i) side to side isoperistaltic anastomosis; ii) modified side-to-side isoperistaltic anastomosis with double Heineke-Mikulicz procedure (Sasaki anastomosis); iii) anti-mesenteric functional end-to-end handsewn anastomosis (Kono-S anastomosis).

RESULTS

Differences were recorded at the level of the anastomosis inlet and outlet, with a larger volume estimated in the Sasaki anastomosis and in the V-modified anastomosis. The V-modified anastomosis had a larger volume compared with the Sasaki anastomosis for a longer segment of small bowel.

CONCLUSIONS

We have developed an experimental animal model for a new anastomotic technique which could be applied in surgery for Crohn's disease following small-bowel or ileocolic resection.

The current therapeutic options for Crohn's disease: from medical therapy to intestinal transplantation

Crohn's disease (CD) has an annual incidence per 100.000 person-year of 20.2 in North America and 12.7 in Europe, and the purpose of this review is to evaluate its medical management, from diagnosis to transplant. Pharmacologic manipulation with nutritional care aims to achieve and maintain remission, but more than half of patients will undergo an intestinal resection, very often repeated over time. They could experience short bowel syndrome (SBS) requiring total parenteral nutrition (TPN). Intestinal transplantation (ITx) represents an alternative in case of irreversible intestinal failure (IF) with life-threatening TPN complications. Patient survival after ITx is 79%, 53% and 43% at 1, 3 and 5 years respectively, with no differences among ITx for other disorders. Areas covered: The research discussed medical therapy with nutritional support, evaluating the role of endoscopy, surgery and transplant in CD. A systematic literature review was conducted using the PubMed search engine up to May 31^th, 2017 without restriction of the language. The decision on paper's eligibility was reached by consensus between the 3 screening authors. Expert commentary: CD treatment is mainly medical, leaving endoscopy and surgery for a complex course. ITx represents a therapeutic option if TPN complications with IF arise.

Endoscopic Balloon Dilation Size and Avoidance of Surgery in Stricturing Crohn's Disease

BACKGROUND

Endoscopic balloon dilation (EBD) is an effective method for treating stricture-related obstruction in Crohn's disease. We aimed to identify factors predictive of successful avoidance of surgery, including endoscopic features, in patients undergoing balloon dilation.

METHODS

We performed a retrospective review of patients with symptomatic Crohn's disease-related intestinal strictures undergoing EBD. Clinical, medication use, laboratory, and dilation data, including the minimum and maximum balloon sizes used, and number of balloons used per endoscopic session were collected. Multivariate analysis by Cox proportional hazard regression was used to model future surgical bowel resection.

RESULTS

In a total of 135 subjects undergoing 292 dilations, multivariate modeling demonstrated that failure to achieve a maximum dilation of 14 mm or more increased the risk of surgery (hazard ratio [HR] 2.88, 95% confidence limit [CL], 1.10-7.53). Although there was no difference in the risk of future surgery between maximum EBD sizes of 14 to 15 mm and 16 to 18 mm, those reaching 16 to 18 mm exhibited a longer interval between subsequent dilations (mean 240 ± 136.7 versus 456 ± 357.3 d, respectively, P = 0.023). Endoscope passage at index dilation was not predictive of future surgery (HR 0.63, 95% CL, 0.31-1.26). Adjusting for covariates of EBD size, stricture location and type, a C-reactive protein >1.5 mg/dL (HR 2.60, 95% CL, 1.12-5.94), and anti-tumor necrosis factor initiation after index EBD (HR 2.39, 95% CL, 1.09-5.25) increased the risk of future surgery.

CONCLUSIONS

Although dilation calibers larger than 14 to 15 mm were not more protective against future surgery, those reaching 16 to 18 mm underwent maintenance dilation less frequently. The risk of surgery associated with post-EBD anti-tumor necrosis factor initiation suggests that effective therapy is often used too late in the disease course.

Risk factors for postoperative recurrence of Crohn's disease with emphasis on surgical predictors

Intestinal resection for Crohn’s disease is not curative and postoperative recurrence rates remain high. Early detection of indices associated with recurrence and risk stratification are fundamental for the postoperative management of patients. Early endoscopy at 6-12 months is the “gold standard” procedure, whereas other modalities such as fecal calprotectin and imaging techniques can contribute to the diagnosis of recurrence. The purpose of this review is to summarize current data regarding risk factors correlated with postoperative relapse. Smoking is a well-established, modifiable risk factor. There are sufficient data that correlate penetrating disease, perianal involvement, extensive resections, prior surgery, histological features (plexitis and granulomas), and improper management after resection with high rates for recurrence. The literature provides conflicting data for other possible predictors, such as age, sex, family history of inflammatory bowel disease, location of disease, strictureplasties, blood transfusions, and postoperative complications, necessitating further evidence. On the other hand, surgical factors such as anastomotic configuration, open or laparoscopic approach, and microscopic disease at specimen margins when macroscopic disease is resected, seem not to be related with an increased risk of recurrence. Further recognition of histological features as well as gene-related factors are promising fields for research.

Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN

The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.

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

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

Current challenges in the surgical management of Crohn's disease: a systematic review

BACKGROUND

Crohn's disease is a chronic inflammatory disorder, and the broad variability in phenotypic presentations makes the treatment of this disease a true multidisciplinary approach. We sought to review the current recommendations regarding the surgical management of Crohn's disease.

DATA SOURCE

A Systematic literature review of surgical techniques was performed from 1979 through 2015. We evaluated 30 articles focusing on findings over the past 5 years.

CONCLUSIONS

Crohn's is a complex disease with no surgical cure. Invasive techniques vary from strictureplasty to resection and percutaneous drainage of penetrating disease when indicated. There is a paucity of well-controlled randomized studies evaluating these surgical techniques, and therefore, we continue to rely on smaller studies and historical data. The surgical goals are to minimize postoperative complications while preserving intestinal length and slowing the progression to clinical recurrence. The evidence discussed is one strategy against this complex pathology.

Medical Therapy of Fibrostenotic Crohn's Disease

Introduction

The present review serves to provide a concise overview of the current knowledge on therapeutic strategies with regard to fibrostenotic lesions in Crohn's disease.

Methods

A literature search was performed focusing on the last 5 years, and current concepts of pathophysiology, epidemiology, and treatment have been summarized.

Results

Fibrostenotic lesions in Crohn's disease are currently considered to be a consequence of the chronic inflammatory nature of the disease. Hence, therapeutic strategies are limited to the concept that early treatment of the inflammatory lesions can prevent structural changes, and to various endoscopic and surgical approaches. Direct targeting of the fibrostenotic lesion itself has not been the focus until now. This review will provide an overview of the pathophysiology and epidemiology of fibrostenotic lesions including current therapeutic approaches. Since research with regard to other organ systems and fibrosis is far more advanced, current strategies from available studies in these areas will be discussed. The results and the potential impact for Crohn's disease will be considered.

Conclusion

The vision of these approaches is to reverse structural changes and restore normal function.

Surgical strategies in paediatric inflammatory bowel disease

Inflammatory bowel disease (IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid (distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum (pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.

Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease

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

Surgical treatment of complex small bowel Crohn disease

INTRODUCTION

The clinical presentations of Crohn disease of the small bowel vary from low to high complexity. Understanding the complexity of Crohn disease of the small bowel is important for the surgeon and the gastroenterologist caring for the patient and may be relevant for clinical research as a way to compare outcomes. Here, we present a categorization of complex small bowel Crohn disease and review its surgical treatment as a potential initial step toward the establishment of a definition of complex disease.

RESULTS

The complexity of small bowel Crohn disease can be sorted into several categories: technical challenges, namely, fistulae, abscesses, bowel or ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive disease; the presence of short gut; a history of prolonged use of medications, particularly steroids, immunomodulators, and biological agents; and a high risk of recurrence.

CONCLUSIONS

Although the principles of modern surgical treatment of Crohn disease have evolved to bowel conservation such as strictureplasty techniques and limited resection margins, such practices by themselves are often not sufficient for the management of complex small bowel Crohn disease. This manuscript reviews each category of complex small bowel Crohn disease, with special emphasis on appropriate surgical strategy.

Small bowel Crohn's disease: an emerging disease phenotype?

An increasing understanding of the pathogenesis of Crohn's disease (CD), coupled with improvements in therapeutic options, has promoted the concept of stratifying patients with CD into distinct disease phenotypes according to risk. Small bowel CD, due to the numerous non-specific potential symptoms and the anatomical location of the disease, is a particularly difficult phenotype to identify. The fact that the majority of de novo strictures occur in the ileum/ileo-colonic region ensures that recognition of small bowel involvement is essential. Certainly, it is becoming increasingly recognised due to improvements in imaging and endoscopic techniques. Both CT and MR enterography appear capable of accurately diagnosing small bowel CD. Furthermore, the development of capsule endoscopy and balloon-assisted enteroscopy allow direct visualisation of the small bowel. Limited data to date would suggest that small bowel CD is a difficult entity to treat even in the current era of the ever-expanding field of biological therapies. Further long-term follow-up studies are necessary using both small bowel capsule endoscopy and cross-sectional imaging to truly assess, firstly, whether small bowel CD is more resistant to treatment and, secondly, whether it has an effect over time in terms of complications. In the future, serological and genetic tests, coupled with the aforementioned investigations, will permit early diagnosis and early treatment of small bowel CD.

Medical therapy of stricturing Crohn's disease: what the gut can learn from other organs - a systematic review

Crohn’s disease (CD) is a chronic remitting and relapsing disease. Fibrostenosing complications such as intestinal strictures, stenosis and ultimately obstruction are some of its most common long-term complications. Despite recent advances in the pathophysiological understanding of CD and a significant improvement of anti-inflammatory therapeutics, medical therapy for stricturing CD is still inadequate. No specific anti-fibrotic therapy exists and the incidence rate of strictures has essentially remained unchanged. Therefore, the current therapy of established fibrotic strictures comprises mainly endoscopic dilation as well as surgical approaches. However, these treatment options are associated with major complications as well as high recurrence rates. Thus, a specific anti-fibrotic therapy for CD is urgently needed. Importantly, there is now a growing body of evidence for prevention as well as effective medical treatment of fibrotic diseases of other organs such as the skin, lung, kidney and liver. In face of the similarity of molecular mechanisms of fibrogenesis across these organs, translation of therapeutic approaches from other fibrotic diseases to the intestine appears to be a promising treatment strategy. In particular transforming growth factor beta (TGF-β) neutralization, selective tyrosine kinase inhibitors, blockade of components of the renin-angiotensin system, IL-13 inhibitors and mammalian target of rapamycin (mTOR) inhibitors have emerged as potential drug candidates for anti-fibrotic therapy and may retard progression or even reverse established intestinal fibrosis. However, major challenges have to be overcome in the translation of novel anti-fibrotics into intestinal fibrosis therapy, such as the development of appropriate biomarkers that predict the development and accurately monitor therapeutic responses. Future clinical studies are a prerequisite to evaluate the optimal timing for anti-fibrotic treatment approaches, to elucidate the best routes of application, and to evaluate the potential of drug candidates to reach the ultimate goal: the prevention or reversal of established fibrosis and strictures in CD patients.

Laparoscopy in Crohn's disease

In Crohn's disease (CD) surgical management, laparoscopic approach offers several theoretical advantages over the open approach. However, the importance of inflammatory lesions associated with CD, and the frequent presence of adhesions from previous surgery have initially questioned its feasibility and safety. In the present review article we will discuss the role of laparoscopic approach for Crohn's disease surgical management, along with its potential benefits as compared to the open approach.

Surgery for luminal Crohn’s disease

Many patients with Crohn’s disease (CD) require surgery. Indications for surgery include failure of medical treatment, bowel obstruction, fistula or abscess formation. The most common surgical procedure is resection. In jejunoileal CD, strictureplasty is an accepted surgical technique that relieves the obstructive symptoms, while preserving intestinal length and avoiding the development of short bowel syndrome. However, the role of strictureplasty in duodenal and colonic diseases remains controversial. In extensive colitis, after total colectomy with ileorectal anastomosis (IRA), the recurrence rates and functional outcomes are reasonable. For patients with extensive colitis and rectal involvement, total colectomy and end-ileostomy is safe and effective; however, a few patients can have subsequent IRA, and half of the patients will require proctectomy later. Proctocolectomy is associated with a high incidence of delayed perineal wound healing, but it carries a low recurrence rate. Patients undergoing proctocolectomy with ileal pouch-anal anastomosis had poor functional outcomes and high failure rates. Laparoscopic surgery has been introduced as a minimal invasive procedure. Patients who undergo laparoscopic surgery have a more rapid recovery of bowel function and a shorter hospital stay. The morbidity also is lower, and the rate of disease recurrence is similar compared with open procedures.

Surgical stricturoplasty in the treatment of ileal pouch strictures

OBJECTIVE

The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures.

METHOD

Consecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses.

RESULTS

A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (p = 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (p < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups.

CONCLUSION

Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.

Crohn's disease complicated by strictures: a systematic review

The occurrence of strictures as a complication of Crohn's disease is a significant clinical problem. No specific antifibrotic therapies are available. This systematic review comprehensively addresses the pathogenesis, epidemiology, prediction, diagnosis and therapy of this disease complication. We also provide specific recommendations for clinical practice and summarise areas that require future investigation.

Surgical management of IBD--from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Endoscopic management of inflammatory bowel disease strictures

Stricture formation is a common complication of Crohn’s disease, occurring in approximately one third of all patients with this condition. While the traditional management of such strictures has been largely surgical, there have been case series going back three decades highlighting the potential role of endoscopic balloon dilation in this clinical setting. This review article summarizes the stricture pathogenesis, focusing on known clinical and genetic risk factors. It then highlights the endoscopic balloon dilation research to date, with particular emphasis on three large recent case series. It concludes by describing the literature consensus regarding specific methodology and presenting avenues for future investigations.

How I do it: Side-to-side isoperistaltic strictureplasty for extensive Crohn's disease

INTRODUCTION

Bowel-sparing surgical techniques, such as the Heineke-Mikulicz and the Finney strictureplasty, have been proposed as an alternative to lengthy intestinal resection in the treatment of small bowel strictures in Crohn's disease. However, these conventional strictureplasty techniques lend themselves poorly to cases of multiple short strictures closely clustered over a lengthy small bowel segment.

DISCUSSION

In this article, we present the surgical technique of the side-to-side isoperistaltic strictureplasty, which is optimal in addressing these specific situations.