Construction of an ileocolic neosphincter - Nipple valve anastomosis for prevention of postoperative recurrence of Crohn's disease in the neoterminal ileum after ileocecal or ileocolic resection. A long-term follow-up study

Surgical and non-surgical risk factors affecting the insufficiency of ileocolic anastomosis after first-time surgery in Crohn’s disease patients

BACKGROUND

Crohn's disease (CD) often necessitates surgical intervention, particularly when it manifests in the terminal ileum and ileocecal valve. Despite undergoing radical surgery, a subset of patients experiences recurrent inflammation at the anastomotic site, necessitating further medical attention.

AIM

To investigate the risk factors associated with anastomotic insufficiency following ileocecal resection in CD patients.

METHODS

This study enrolled 77 patients who underwent open ileocolic resection with primary stapled anastomosis. Patients were stratified into two groups: Group I comprised individuals without anastomotic insufficiency, while Group II included patients exhibiting advanced anastomotic destruction observed endoscopically or those requiring additional surgery during the follow-up period. Surgical and non-surgical factors potentially influencing anastomotic failure were evaluated in both cohorts.

RESULTS

Anastomotic insufficiency was detected in 12 patients (15.6%), with a mean time interval of 30 months between the initial surgery and recurrence. The predominant reasons for re-intervention included stenosis and excessive perianastomotic lesions. Factors associated with a heightened risk of anastomotic failure encompassed prolonged postoperative obstruction, anastomotic bleeding, and clinically confirmed micro-leakage. Additionally, patients in Group II exhibited preoperative malnutrition and early recurrence of symptoms related to CD.

CONCLUSION

Successful surgical outcomes hinge on the attainment of a fully functional anastomosis, optimal metabolic status, and clinical remission of the underlying disease. Vigilant endoscopic surveillance following primary resection facilitates the timely identification of anastomotic failure, thereby enabling noninvasive interventions.

Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

Post-surgical recurrence of Crohn's disease: Situational analysis and future prospects

Surgery retains a major role in the treatment of Crohn's disease, and the prevention of post-operative recurrence is an essential issue. In fact, despite the increasing use of biotherapies, almost all of the patients who undergo surgery will present with a recurrence, initially endoscopic and then clinical, eventually leading to a second intervention in 15 to 20% of cases. Certain risk factors for recurrence such as smoking, repeated and/or extensive resections, anoperineal involvement, myenteric plexitis, epithelioid granulomas, penetrating disease behaviour and lack of post-operative prophylactic treatment have been well established. Currently, measures to prevent post-operative recurrence are based mainly on smoking cessation in all patients and the prescription of anti-TNFα medications for patients with a high risk of recurrence (at least two risk factors for recurrence). However, new surgical techniques have recently been described which could modify post-operative prevention strategies. Kono's lateral anti-mesenteric anastomosis could significantly reduce clinical and endoscopic recurrence compared to conventional anastomosis techniques. Long latero-lateral isoperistaltic stricturoplasties have been shown to be feasible and are associated with a low rate of long-term symptomatic recurrence requiring surgery. In a preliminary series, intestinal resections with extensive mesenteric resection reduced the rate of recurrence in comparison with patients operated on conventionally (3% vs. 40% at five years). If the results of these new surgical techniques are confirmed, the indications for post-operative immunomodulatory treatments could be downgraded in patients currently considered to be at high risk of recurrence.

The feasibility of laparoscopic subtotal colectomy with cecorectal anastomosis in community practice for slow transit constipation

BACKGROUND

The objective of this paper is to demonstrate if slow transit constipation (STC) can be accurately diagnosed, selecting patients appropriate for surgery, and safely perform laparoscopic subtotal colectomy with cecorectal anastomosis (CRA) with acceptable short and long-term outcomes in the setting of medically complex patients in a community practice.

METHODS

A retrospective study was performed at a private community surgical practice. Cohort involved 10 patients with up to 10 years in follow-up care with a diverse range of ages, body mass index (BMI) and medical conditions. Pre-operative work-up followed a comprehensive algorithm designed to rule out organic conditions and dyssynergistic defecation. The Sitz Mark Colon Transit Study was used to confirm STC. Laparoscopic subtotal colectomy with CRA techniques were used in all cases. Frequency of BMs and patient satisfaction over the study period were tabulated.

RESULTS

Average post-operative length of stay (LOS) was five days. One early major post-operative complication occurred, however there were no perioperative deaths, anastomotic leaks or revisions of the original surgery after discharge from the hospital. Two patients died due to non-bowel related causes. An incisional hernia was the single long-term complication. Initial post-operative BMs averaged several per day. In the 1-5 year follow-up, BMs tapered down from 1 to 2/day with some laxative use. By the 5th to 10th year follow-up, constipation occurred with 2-3 BMs/week, all requiring an osmotic laxative. Most patients, however, were satisfied with their bowel pattern.

CONCLUSION

Surgical candidates with severe STC can be accurately diagnosed and treated with minimally invasive surgery in community practice with acceptable outcomes as compared to outcomes published in the literature.

Isoperistaltic versus antiperistaltic ileocolic anastomosis. Does it really matter? Results from a randomised clinical trial (ISOVANTI)

BACKGROUND

Right hemicolectomy is a very common surgery. Many studies compare different options for laparoscopic ileocolic anastomoses: intra- or extracorporeal; handsewn or stapled; side-to-side or end-to-side. However, there are no studies about the influence that peristalsis could have on this anastomosis. The aim of this study is to compare safety and feasibility of isoperistaltic and antiperistaltic anastomosis in terms of postoperative morbidity and mortality between both groups. The secondary endpoint is to compare long-term functional outcomes (chronic diarrhoea) and quality of life (GIQLI questionnaire) after a 1-year follow-up period.

METHODS

A double-blind, randomised, prospective trial in patients undergoing scheduled surgery for right colon cancer with laparoscopic right hemicolectomy and isoperistaltic (ISO) or antiperistaltic (ANTI) ileocolic anastomoses.

RESULTS

Hundred and eight patients were included in the study. Patients were randomised either to isoperistaltic or antiperistaltic configuration (54 ISO/ANTI). No significant differences in baseline variables were found. No differences in surgical time (130 [120-150] min ISO vs. 140 [127-160] ANTI, p = 0.481), nor in anastomotic time (19 [17-22] vs. 20 [16-25], p = 0.207) and nor in postoperative complications: 37.0% ISO versus 40.7% ANTI, (p = 0.693) were found. There were no differences in postoperative ileus (p = 0.112) nor in anastomotic leakage (3.7% vs. 5.56%, p = 1.00). Differences in "time to first flatus" and "time to first deposition" were found in favour of the antiperistaltic group (p = 0.004 and p = 0.017). Anastomotic configuration did not influence hospital stay (3 days [2-6] isoperistaltic vs. 3 [2-4] antiperistaltic, p = 0.236). During follow-up, there were no differences between the two groups at 1, 6 and 12 months (p = 0.154, p = 0.498 and p = 0.683), nor in chronic diarrhoea rates in GIQLI scores (24% ISO vs. 31.4% ANTI, p = 0.541).

CONCLUSIONS

The isoperistaltic and antiperistaltic ileocolic anastomosis present similar results in terms of performance, safety and functionality. However, further studies must be carried out in order to assess relationship between postoperative ileus and anastomosis configuration.

TRIAL REGISTRATION

Randomised Clinical trial (Identifier: NCT02309931).

Surgical Considerations in the Treatment of Small Bowel Crohn's Disease

Surgery remains a cornerstone of the management of Crohn's disease (CD). Despite the rise of biologic therapy, most CD patients require surgery for penetrating, obstructing, or malignant complications. Optimal surgical therapy requires sophisticated operative judgment and medical optimization. Intraoperatively, surgeons must balance treatment of CD complications against bowel preservation and functional outcome. This demands mastery of multiple techniques for anastomosis and strictureplasty, accurate assessment of bowel integrity for margin minimization, and a comprehensive skillset for navigating adhesions and altered anatomy, controlling thickened mesentery, and safely managing the hostile abdomen. Outside of the operating room, a multi-disciplinary team is critical for pre-operative optimization, patient support, and medical management. Postoperatively, prevention and surveillance of recurrence remain a matter of research and debate, and medical options include older drugs with limited efficacy and tolerability versus biologic agents with greater effect sizes and shorter track records. The evidence base for current management is limited by the inherent challenges of studying a chronic disease marked by heterogeneity and recurrence, but also by a lack of prospective trials incorporating both medical and surgical therapies.

The human ileocaecal junction: anatomical evidence of a sphincter

PURPOSE

The human ileocaecal junction (ICJ) is a major transition zone regulating intestinal transit. Historically, it has often been considered a valve rather than a sphincter. The microscopic anatomy of this junction was studied searching for evidence of an anatomical sphincter and neuromuscular specialisation.

METHODS

Ileocaecal specimens were obtained from ten cadavers and five surgical donors (7 male, mean age 81 years, age range 68-94) and examined by histology and immunohistochemistry. Quantitative analyses of muscle thickness and submucosal vascularity were performed together with immunohistochemical studies of innervation and the distribution of interstitial cells of Cajal.

RESULTS

The thickness of the muscular layer in both the ileum and the colon increased significantly over a distance of 1 cm leading up to the base of the ileal papilla where it reached a maximum (4.19 ± 2.0 mm) before gradually tapering towards the tip of the papilla. Submucosal vascularity in the ileal papilla was not increased compared to the adjacent ileum or caecum/colon. Neuronal density was less in the caecum and ileal papilla compared to the terminal ileum (P < 0.05). Interstitial cells of Cajal were identified within the myenteric plexus of the ICJ but their density was similar to the adjacent bowel.

CONCLUSIONS

A localised muscle thickening at the base of the ileal papilla is consistent with an intrinsic anatomical sphincter. There was no evidence that the ICJ has increased submucosal vascularity or a greater density of innervation compared to the adjacent bowel. The term ileocaecal valve is misleading and should be replaced by ileocaecal junction.