Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn's disease using "bowel-sparing" techniques

Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.

Modified Primary Anastomosis Using an Intestinal Internal Drainage Tube for Crohn's Disease: A Pilot Study

PURPOSE

Surgical treatment is an important part of the management of Crohn's disease (CD). However, the current recommended staged procedures require two operations, with long hospital stays and high costs, while traditional primary anastomosis has a high risk of complications. Therefore, the aim of this study was to compare the clinical efficacy and safety of modified primary anastomosis using intestinal internal drainage tubes for CD.

METHODS

In this study, emergency and nonemergency CD patients were included separately. Then, the patients were divided into three subgroups: patients with intestinal internal drainage tubes (modified primary anastomosis), staged procedures, and traditional primary anastomosis. The main outcomes were the number of hospitalizations, length and cost of the first hospital stay, length and cost of total hospital stays, and complications.

RESULTS

The outcomes of the three subgroups of emergency CD patients were not significantly different. For nonemergency CD patients, patients with intestinal internal drainage tubes had shorter total hospital stays and fewer hospitalizations compared with the staged procedures subgroup, while no significant differences in any outcomes were observed between the modified and traditional primary anastomosis subgroups.

CONCLUSIONS

For emergency CD patients, no significant advantage in terms of the main outcomes was observed for modified primary anastomosis. For nonemergency CD patients, modified primary anastomosis reduced the length of total hospital stays and hospitalizations compared with staged procedures. The placement of intestinal internal drainage tubes allows some patients who cannot undergo primary anastomosis to undergo it, which is a modification of traditional primary anastomosis.

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.

Repeated surgery for recurrent Crohn's disease: does the outcome keep worsening operation after operation? A comparative study of 1224 consecutive procedures

Complicated Crohn’s disease (CD) will require surgical treatment during patients’ lifetime, with a considerable recurrence rate requiring additional surgery. The present study is a retrospective analysis of a prospectively maintained database in an IBD Tertiary Centre that included all the consecutive, unselected patients undergoing surgery for CD between 1993 and 2019. Patients treated with small bowel resections, colonic resections, conventional and non-conventional strictureplasties were considered. The aim was to evaluate morbidity and long-term recurrence of repeated surgery. Among the population included, the following procedures were performed: 713 (58.2%) primary surgery (group S1), 325 (26.5%) first recurrence (group S2), and 186 (15.3%) multiple recurrences (group S3). Patients undergoing repeat surgery were older (p < 0.0001) and had a longer disease duration (p < 0.0001), extended disease (p = 0.0001), shorter time frame to first surgery (p < 0.0001), nutritional impairment (p < 0.0001), and a history of aggressive medical therapy (p = 0.04). Patients undergoing surgery for recurrences required higher complexity level surgery, with more conservative approaches (p = 0.0004) and a higher ostomy number (p = 0.06). Recurrent patients had higher short bowel syndrome rate (p < 0.0001), higher minor (p = 0.04) but not major (p = 0.2) postoperative complications rate. The 10-year surgical recurrence rate was 18% for group S1, 27% for S2, and 48% for S3, with significant differences at the log-rank test. Repeated surgery for complicated CD was associated with an increased rate of minor, but not major complications, requiring high-risk surgery, with a major ostomy rate and short bowel syndrome, and is associated with an increased long-term surgical recurrence, even on strictureplasty sites.

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.

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.

The Presence of Postoperative Infectious Complications is Associated with the Risk of Early Postoperative Clinical Recurrence of Crohn's Disease

BACKGROUND

The purpose of the study was to identify risk factors for early clinical and surgical recurrence in Crohn's disease (CD) patients who underwent intestinal resection.

METHOD

This was a retrospective study. Consecutive patients who underwent intestinal resection with a primary anastomosis from January 2011-December 2014 were enrolled. Gender, age at surgery, clinical phenotypes of CD, serum albumin and C-reactive protein level the day before surgery, smoking status at surgery, anastomosis technique, number of anastomoses, details of postoperative complications, the postoperative prophylactic treatment were assessed to figure out risk factors for postoperative clinical and surgical recurrence within 1 year after the initial resection by univariate and then multivariate analysis.

RESULTS

Two hundred and thirty-seven patients were analyzed. The risk of early postoperative clinical recurrence was 2.99 times higher in patients suffered postoperative infectious complications [odds ratio (OR) 2.99; 95% CIs, 1.42-6.32; p = 0.004], while never-smoking was found to be a protective factor for early clinical recurrence (OR 0.326; 95% CIs, 0.18-0.59; p < 0.0001). For surgical recurrence within 1 year after resection, the presence of postoperative intra-abdominal septic complications might be a risk factor (OR 6.77; 95% CIs, 1.61-28.5; p = 0.009). Smoker at surgery was also a risk factor for early surgical recurrence (OR 5.41; 95% CIs, 1.36-21.5; p = 0.017).

CONCLUSION

The presence of postoperative infectious complications was identified as a possible risk factor for early postoperative clinical recurrence after resection in CD patients.

Inhibition of Fibroblast Activation Protein Restores a Balanced Extracellular Matrix and Reduces Fibrosis in Crohn's Disease Strictures Ex Vivo

BACKGROUND

Crohn's disease (CD) is a chronic bowel inflammation that ultimately leads to fibrosis, for which medical therapy is currently unavailable. Fibrotic strictures in CD are characterized by excessive extracellular matrix (ECM) deposition, altered balance between matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs), and overexpression of fibroblast activation protein (FAP), a marker of active fibroblasts. Here we investigated the role of FAP-targeted therapy in ECM remodeling in CD strictures ex vivo.

METHODS

Bowel specimens were obtained from stenotic and nonstenotic ileal segments from 30 patients with fibrostenotic CD undergoing surgery. FAP expression was evaluated in isolated mucosal myofibroblasts by immunoblotting and flow cytometry. Bowel tissue cultures were treated with anti-FAP antibody, and soluble collagen, TIMP-1, and MMPs were measured in tissue culture supernatants by immunoblotting. Anti-FAP-treated myofibroblasts were analyzed for TIMP-1 expression by immunoblotting, for migratory potential by wound healing assay, and for apoptosis by Annexin V staining.

RESULTS

Myofibroblasts from stenotic CD mucosa showed upregulation of FAP expression when compared with nonstenotic mucosa. Treatment of stenotic tissues with anti-FAP antibody induced a dose-dependent decrease in collagen production, particularly affecting type I collagen. The treatment also reduced TIMP-1 production in CD strictures, without altering MMP-3 and MMP-12 secretion. Accordingly, anti-FAP treatment inhibited TIMP-1 expression in stenotic CD myofibroblasts and enhanced myofibroblast migration without affecting survival.

CONCLUSIONS

FAP inhibition reduced type I collagen and TIMP-1 production by CD strictures ex vivo without compromising uninvolved bowel areas. These results suggest that targeting FAP could reconstitute ECM homeostasis in fibrostenotic CD.

Bariatric surgery in patients with inflammatory bowel disease: an accessible path? Report of a case series and review of the literature

BACKGROUND AND AIMS

Morbid obesity is an emerging problem in the inflammatory bowel disease [IBD] population. Bariatric and IBD surgeries share technical difficulties and elevated morbidity. However, nothing is known about the possibility of performing bariatric surgery in patients with a definite diagnosis of IBD. The aim of this study was to evaluate safety and efficacy of restrictive bariatric surgical procedures in IBD patients.

METHODS

Six patients with morbid obesity and IBD were operated on with restrictive bariatric surgery and concomitant or deferred IBD surgery. We compared BMI, excess weight loss, and perioperative complications of restrictive bariatric surgery in IBD with a control group of 95 bariatric patients. We also evaluated clinical, biochemical, pharmacological, and endoscopic characteristics before and after surgery in IBD patients.

RESULTS

Perioperative results, in terms of BMI, excess weight loss, and complications after restrictive bariatric surgery, were comparable between obese IBD and control patients. IBD patients experienced a significant postoperative reduction in BMI, CRP levels, WCC, and systolic blood pressure and a significant increment in hemoglobin levels. None of the patients reported signs of malabsorption. All the patients except one were able to discontinue steroids, were in endoscopic remission at 1 year, and were in clinical remission at the latest follow-up visit. Two patients halved azathioprine dosage. One patient had a postoperative clinical recurrence treated with adalimumab.

CONCLUSIONS

Bariatric surgery seems to be safe and effective in IBD patients. Concomitant ileocolic resection does not increase perioperative complications. Relationship between IBD and obesity remains unclear, but weight loss could be useful in the pharmacological control of IBD.

Indian Society of Gastroenterology consensus statements on Crohn's disease in India

In 2012, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on Crohn's disease (CD). This consensus, produced through a modified Delphi process, reflects our current recommendations for the diagnosis and management of CD in India. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.

Perianal disease is associated with psychiatric co-morbidity in Crohn's disease in remission

BACKGROUND AND AIM

Crohn's disease is a life-long inflammatory disease which can impair quality of life, in particular in patients with psychiatric co-morbidities such as depression and anxiety. The aim of this prospective cohort study was to assess the prevalence of depression and anxiety and related risk factors in patients with quiescent Crohn's disease.

METHODS

A consecutive series of adult patients with confirmed diagnosis of Crohn's disease, in clinical remission, were included and investigated during ambulatory visits using a standard questionnaire assessing demographic and clinical features of the disease. Within 1 month after the ambulatory visit, all patients were interviewed by phone to assess the presence of psychiatric disorders using standardized questionnaires. The questionnaire assessed the development of psychiatric disorders after the diagnosis of Crohn's disease, the use of antidepressant or antianxiety therapy and current anxiety or depression by means of the Hospital Anxiety and Depression Scale.

RESULTS

One hundred and ninety-five patients were included. Seventy-two (36.9 %) patients showed anxiety and/or depression symptoms, 46 (23.6 %) patients showed anxiety symptoms, 6 (3.1 %) patients showed depression symptoms and 20 (10.3 %) patients showed both symptoms. Forty-eight of these patients (58 %) were without any antidepressive or antianxiety treatment. Anxiety with or without depression was significantly correlated with female sex (p = 0.017), history of perianal disease (p = 0.003) and perianal surgery (p = 0.042).

CONCLUSION

Anxiety is a frequent, often untreated, condition in patient affected by Crohn's disease in clinical remission. Female sex, history of perianal disease and perianal surgery are major risk factors for anxiety.

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.

Perforating Crohn's disease: conservative and surgical treatment

Surgery is a part of the clinical history of patients with Crohn's disease (CD) since nearly all the patients receive at least one surgical procedure. The main indication for surgery is obstruction, but 50-60% of patients present a concomitant perforating disease at surgery, and 10% of patients have a primary indication for abscess or fistula. Generally, fistulas are classified on an anatomical basis, indicating the site of origin followed by the target (i.e. ileocolic, ileovesical, etc.). Enteroenteric fistulas are frequently asymptomatic and are not always considered an indication for surgery. However, in case of bypass with severe malnutrition or bacterial overgrowth (i.e. duodenal involvement), surgery is the only option. Enterovesical, enteroureteral and enterobiliary fistulas, due to their potential for septic complications, are a definite indication for surgery. Enterogenital fistulas have an indication mainly for their impact on the quality of life. Enterocutaneous fistulas are, in most cases, a late surgical complication, and the indication and timing for treatment are due to their output volume. Abscesses may be present alone or in association with enteric fistulas. The initial approach is conservative, and a percutaneous drainage should be a good treatment or a bridge to elective surgery. Since a modern surgical approach to CD has to be minimally invasive and highly conservative whenever possible, the presence of perforating disease should be well characterized in order to plan a laparoscopic approach and to reduce the amount of resected bowel, in case combining resection and strictureplasty. Perforating CD necessitates a multidisciplinary approach involving, behind the gastroenterologist and the surgeon, the radiologist, the urologist, the gynecologist and the nutritionist in order to obtain the best tailored treatment.

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.

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.

Epidemiology and natural history of inflammatory bowel diseases

In the West, the incidence and prevalence of inflammatory bowel diseases has increased in the past 50 years, up to 8-14/100,000 and 120-200/100,000 persons, respectively, for ulcerative colitis (UC) and 6-15/100,000 and 50-200/100,000 persons, respectively, for Crohn's disease (CD). Studies of migrant populations and populations of developing countries demonstrated a recent, slow increase in the incidence of UC, whereas that of CD remained low, but CD incidence eventually increased to the level of UC. CD and UC are incurable; they begin in young adulthood and continue throughout life. The anatomic evolution of CD has been determined from studies of postoperative recurrence; CD begins with aphthous ulcers that develop into strictures or fistulas. Lesions usually arise in a single digestive segment; this site tends to be stable over time. Strictures and fistulas are more frequent in patients with ileal disease, whereas Crohn's colitis remains uncomplicated for many years. Among patients with CD, intestinal surgery is required for as many as 80% and a permanent stoma required in more than 10%. In patients with UC, the lesions usually remain superficial and extend proximally; colectomy is required for 10%-30% of patients. Prognosis is difficult to determine. The mortality of patients with UC is not greater than that of the population, but patients with CD have greater mortality than the population. It has been proposed that only aggressive therapeutic approaches, based on treatment of early recurrent lesions in asymptomatic individuals, have a significant impact on progression of these chronic diseases.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature

BACKGROUND

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence.

METHODS

We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP.

RESULTS

The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months.

CONCLUSION

Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Side-to-side-to-end strictureplasty for Crohn's disease

PURPOSE

Side-to-side strictureplasty is a useful procedure for preserving the bowel in patients with Crohn's disease. However, bowel resection is required in some patients, and diseased proximal bowel and disease-free distal bowel exist after resection. We performed a modified new technique called side-to-side-to-end strictureplasty.

METHODS

Four patients with Crohn's disease underwent this procedure. After resection of the diseased bowel that was not suitable for strictureplasty, side-to-side strictureplasty was performed with use of the proximal diseased loop. Thereafter, the distal end of the side-to-side stricture was anastomosed to the distal disease-free bowel in a side-to-side-to-end manner.

RESULTS

The length of the small intestine requiring surgical intervention was 69.8 +/- 26.4 (mean +/- standard deviation) cm, and the length of the small intestine necessitating resection was 31.8 +/- 12.6 cm. Side-to-side stricture was performed by use of 48.8 +/- 20.2 cm of the diseased proximal bowel, which was anastomosed to the disease-free distal bowel. Intra-abdominal abscess, which was not associated with this procedure, was observed in one patient, but was treated by drainage. The recoveries of all four patients were uneventful, without recurrence, after a follow-up of 21.5 +/- 16.2 months.

CONCLUSIONS

Side-to-side-to-end strictureplasty may be a useful procedure when diseased proximal bowel and disease-free distal bowel are present after bowel resection in patients with Crohn's disease.

CARD15 gene variants and risk of reoperation in Crohn's disease patients

OBJECTIVES

Several studies have investigated, with conflicting results, the risk factors for reoperation in Crohn's disease (CD) patients. CARD15 gene variants have been identified as a major genetic risk factor for CD patients and associated with ileal disease, stenosis, and risk of surgery. However, data regarding the association between these variants and the need for reoperation are very few and conflicting. This study evaluated the risk factors of reoperation, including CARD15 gene variants.

METHODS

A total of 253 consecutive CD patients, recruited in four Italian tertiary-care inflammatory bowel disease (IBD) referral centers, who had submitted to surgery for CD, were included in the study. Clinical characteristics of CD patients, time and main indications for surgery, type of operation, postoperative therapy, and time to second surgery were recorded. CARD15 gene variants were determined by DNA sequencing analysis in each center. Factors related to surgical recurrence, including CARD15 variants, were estimated by Cox proportional hazard regression.

RESULTS

In all, 89 patients (35.1%) showed at least one surgical recurrence. Reoperation was significantly correlated with stenosis as indications at initial surgery only. CARD15 variants were found in 36.0% of patients, but did not correlate significantly with the demographic and clinical characteristics of the patients, rate of first surgical recurrence, and time to second operation. CARD15 variants did not significantly affect the reoperation rate, irrespective of indications for surgery.

CONCLUSIONS

Reoperation for CD is correlated with stenosis at initial surgery, but not with CARD15 gene variants. This finding does not justify more aggressive prophylactic therapy on the basis of CARD15 genotype.

Prospective study of long-term results and prognostic factors after conservative surgery for small bowel Crohn's disease

BACKGROUND & AIMS

Several bowel-sparing techniques have been proposed for treating patients with CD, but there have been no prospective studies analyzing risk factors and long-term outcome. We prospectively evaluated safety and long-term efficacy of conservative surgery for patients with complicated CD.

METHODS

From 1993-2007, 393 of 502 consecutive patients underwent surgery for complicated CD of the small bowel. Those with colonic involvement were excluded. The Student t test, chi(2) test, Kaplan-Meier estimates, and Cox proportional hazard model were used to analyze postoperative complications and long-term outcome.

RESULTS

A total of 865 jejunoileal segments underwent 318 small bowel resections and 367 strictureplasties (either classic or nonconventional). There were no deaths; the complication rate was 5.6%, and the cumulative 10-year recurrence rate was 35%. None of the prognostic factors were correlated with postoperative complications. Younger age, an upper jejunoileal location, stricturing behavior, and small-bowel wall thickening 12 months after surgery showed hazard ratios of 2.4 (95% confidence interval [CI], 1-5.4; P = .03), 2.5 (95% CI, 1.3-4.7; P = .004), 2.2 (95% CI, 1.1-4.1; P = .01), and 4.5 (95% CI, 2.3-8.6; P = .000), respectively. Immunomodulator therapy failed to reduce long-term surgical recurrence.

CONCLUSIONS

Young patients with extended and stricturing disease are at high risk for disease recurrence after surgery. Bowel wall thickening was a reliable prognostic factor for these patients. Conservative surgery is safe and effective in treating patients with jejunoileal CD and should be considered as the first-line surgical treatment, preventing the risk of short bowel syndrome caused by repeated resections.

Bowel ultrasound in Crohn's disease: surgical perspective

BACKGROUND

Bowel ultrasound has been proven to be a useful tool in the management of Crohn's disease, particularly in the assessment of intra-abdominal complications, most of which require surgery.

MATERIALS AND METHODS

The National Library of Medicine has been searched for articles on the use of bowel ultrasound in Crohn's disease focusing on aspects of interest to the surgeon.

RESULTS AND CONCLUSIONS

Several studies have demonstrated that bowel ultrasound may be useful to reduce the risk of unnecessary laparotomy in patients presenting acute abdomen with suspected chronic inflammatory bowel disease. Bowel ultrasound has been proven to be of value in the follow-up of Crohn's disease patients since allowing early diagnosis of intra-abdominal complications and, therefore, optimising the diagnostic and surgical approach. At followup, bowel ultrasound may accurately diagnose early postoperative complications and long-term disease recurrence. In patients submitted to conservative surgery, ultrasonography reveals changes in diseased bowel walls that may be predictive of recurrence of the disease, and hence determinant in the choice of medical treatment.

Doença de Crohn: fatores de risco para recidiva no pós-operatório

Apesar dos avanços na compreensão da doença de Crohn, os fatores determinantes da recidiva no pós-operatório permanecem especulativos. O objetivo deste estudo foi analisar retrospectivamente os fatores preditivos da recidiva na doença de Crohn no pós-operatório. Métodos: foram analisados 45 pacientes com diagnóstico de doença de Crohn, submetidos ao tratamento cirúrgico, avaliando recidiva da doença e fatores como idade, sexo, raça, tabagismo, localização, padrão anatomo-clínico, indicação cirúrgica, tipo de anastomose. Resultados: em 67,7% dos pacientes houve recidiva da doença sendo a causa mais freqüente a forma fistulizante; 64,6% foram operados três vezes ou mais (p=0,002). Doentes com quadro de perfuração apresentaram maior número de reoperações, três ou mais operações, em 63,6% (p=0,003). Conclusões: Quadro de perfuração e forma fistulizante da doença determinaram maior número de recidiva nos pacientes estudados.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis

PURPOSE

This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.

METHODS

A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.

RESULTS

A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.

CONCLUSIONS

Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Strictureplasty vs resection in small bowel Crohn's disease: an evaluation of short-term outcomes and recurrence

AIM

To compare postoperative adverse events and recurrence following strictureplasty or bowel resection in patients with small bowel Crohn's disease (CD).

METHOD

A literature search was performed to identify studies published between 1980 and 2006 comparing outcomes of CD patients undergoing either strictureplasty or bowel resection. Hazard ratios were calculated from Kaplan-Meier plots of cumulative recurrence data. Quality assessment of the included studies was performed. Random-effect meta-analytical techniques were employed. Sensitivity analysis and assessment of heterogeneity were performed.

RESULTS

Seven studies comprising 688 CD patients (strictureplasty n = 311, 45%; resection with or without strictureplasty n = 377, 55%) were included. Patients undergoing strictureplasty alone had a lower risk of developing postoperative complications than those who underwent resection (OR = 0.60, 95% CI: 0.31-1.16) although this was not statistically significant (P = 0.13). Surgical recurrence after strictureplasty was more likely than after resection (OR = 1.36, 95% CI: 0.96-1.93, P = 0.09). Patients who had a resection had a significantly longer recurrence-free survival than those undergoing strictureplasty alone (HR = 1.08, 95% CI: 1.02-1.15, P = 0.01).

CONCLUSION

Patients with small bowel CD undergoing strictureplasty alone may have fewer postoperative complications than those undergoing a concomitant bowel resection. However, surgical recurrence maybe higher following strictureplasty alone than with a concomitant small bowel resection. Patients may require appropriate preoperative counselling regarding the pros and cons of each operative technique.

An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn's disease

PURPOSE

The side-to-side strictureplasty is a bowel-sparing alternative to resection in the treatment of stricturing Crohn's disease. This study was initiated to review the adoption of the side-to-side strictureplasty as a new surgical technique and the relative outcomes a decade after its description.

METHODS

A total of 184 unique patients from six centers in the United States, Italy, and Japan served as the basis for this study. A questionnaire instrument was used to assemble prospectively acquired preoperative, intraoperative, perioperative, and postoperative data from each center into a computer-generated database.

RESULTS

Average age at surgery for patients selected for a side-to-side strictureplasty varied significantly between centers (minimum, 31.0 years; maximum, 39.5 years, P < 0.006). Use of the side-to-side strictureplasty technique for primary Crohn's disease vs. surgically recurrent disease also varied significantly by center (primary minimum, 16.7 percent; maximum, 68.6 percent, P < 0.03). Furthermore, length of diseased bowel selected for construction of a side-to-side strictureplasty was significantly different among centers (minimum, 20.8 +/- 9.9 cm; maximum, 64.3 +/- 29.3 cm, P < 0.001). Use of synchronous bowel resection away from the site of the side-to-side strictureplasty was relatively common (minimum, 21.1 percent; maximum, 66.7 percent) as it was with the use of additional synchronous strictureplasties (minimum, 41.9 percent; maximum, 83.3 percent). The six centers experienced a low number of complications (minimum, 5.7 percent; maximum, 20.8 percent). Forty-one of 184 total patients required surgery for recurrent disease, with an average time to recurrence of 35 months. The difference of reoperation-free five-year survival experienced by the patients in the six centers was not statistically significant, with a cumulative reoperation-free five-year survival of 77 percent across all centers.

CONCLUSIONS

Worldwide implementation of the side-to-side strictureplasty technique and its variations has occurred. This procedure carries a very low mortality and morbidity rate, with acceptable recurrence rates.

Strictureplasty for active Crohn's disease

BACKGROUND AND AIMS

Several studies over the last 20 years have confirmed the safety and efficacy of strictureplasty in the treatment of obstructive Crohn's disease. However, almost all of these studies use strictureplasty to treat fibrotic strictures: limited resection being preferred to treat active disease strictures. One study dating from 1986 used strictureplasty to treat purely active disease strictures, with disappointing results. No other similar studies have been published. We investigate the complication and recrudescence rates together with the intervention-free intervals in patients undergoing strictureplasty for active disease strictures.

METHODS

A retrospective review of 14 patients who underwent strictureplasty either in isolation or in combination with limited resection for active small bowel Crohn's disease between 1996 and 2004 was undertaken.

RESULTS

A total of 73 strictureplasties were carried out. There was no operative mortality; however, one patient subsequently died from metastatic small bowel adenocarcinoma arising from existing Crohn's disease. One patient subsequently developed complications directly attributed to strictureplasty and required further surgery. Three patients developed recrudescent disease and required further surgery in the form of either strictureplasty, limited resection or both. All patients undergoing strictureplasty with resection and over 70% of patients undergoing strictureplasty alone were intervention-free at 41 months. With extended follow-up, the same proportion of patients would remain intervention-free at 70 months or longer.

CONCLUSIONS

The use of strictureplasty in active disease strictures is well tolerated and has similar, if not better, recurrence and complication rates when compared with limited resection in patients with similar disease profiles.

Intervention-free Interval following Strictureplasty for Crohn’s Disease

INTRODUCTION

Strictureplasty is now well established as a bowel-sparing alternative for surgical treatment of complicated Crohn's disease. Limited resection is still preferred in patients with uncomplicated disease, as subsequent reoperation rates are low.

METHODS

A retrospective review of 26 patients who underwent surgery for small bowel Crohn's disease between 1996 and 2004 was undertaken. A total of 96 small bowel strictureplasties had been performed; 19 patients had strictureplasties performed in isolation, and the remaining 7 patients underwent strictureplasty with concomitant limited resection.

RESULTS

There was no operative mortality. The median follow-up was 41 months. Four patients developed complications that required further surgery. At 41 months, 73.3% of patients undergoing strictureplasty alone and 79.7% undergoing strictureplasty with concomitant resection were intervention-free. If followed up to 70 months or more, the same proportion of patients would remain intervention-free. Four patients developed further recrudescent disease and required surgery: strictureplasty, limited resection, or both. Of these patients, 25% were intervention-free at 41 months.

CONCLUSIONS

Our results show that strictureplasty alone or with concomitant resection can confer intervention-free periods of 41 months or more in 73.3% of patients, suggesting that strictureplasty can be utilized as an alternative to limited resection in uncomplicated Crohn's disease.

Long-term follow-up of strictureplasty for Crohn's disease

BACKGROUND

Strictureplasty is an effective means of alleviating obstructive Crohn's disease while conserving bowel length. The aim of this study was to establish long-term outcomes of strictureplasty.

METHODS

Between 1978 and 2003, 479 strictureplasties were performed in 100 patients during 159 operations. Information on Crohn's disease, medical therapy, laboratory indices, surgical details, complication rates and outcomes was recorded. The primary endpoint was abdominal reoperation.

RESULTS

Mean follow-up was 85.1 (range 0.2-240.9) months. The overall morbidity rate was 22.6 per cent, with septic complications in 11.3 per cent, obstruction in 4.4 per cent and gastrointestinal haemorrhage in 3.8 per cent. The 30-day mortality rate was 0.6 per cent and the procedure-related series mortality rate 3.0 per cent. Perioperative parenteral nutrition was the only marker for morbidity (P < 0.001). Reoperation rates were 52 per cent at a mean of 40.2 (range 0.2-205.8) months after a first, 56 per cent at 26.1 (range 3.5-63.5) months after a second, 86 per cent at 27.4 (range 1.4-74.5) months after a third, and 62.5 per cent at 25.9 (range 7.3-70.5) months following a fourth strictureplasty procedure. The major risk factor for reoperation was young age (P < 0.001).

CONCLUSION

Long-term follow-up has confirmed the safety of strictureplasty in Crohn's disease. Morbidity is appreciable, although the surgical mortality rate is low. Reoperation rates are comparable following first and repeat strictureplasty procedures.

Bowel ultrasound in Crohn's disease

Most published studies have found bowel ultrasound to be a useful tool in the management of Crohn's disease. Indeed, it has been successfully used as the imaging technique of choice in screening patients with clinically suspected Crohn's disease. In these patients, bowel ultrasound, which is well accepted by patients, non-invasive and of low cost, may be the first diagnostic tool employed for young patients and can be used in the preliminary diagnostic work-up prior to further invasive tests. The most important application of bowel ultrasound is, however, in the follow-up of patients already diagnosed with Crohn's disease, in whom it may be useful to assess the site and extent of the lesions and to ensure the early detection of intra-abdominal complications, particularly abscesses and strictures. In this regard, improving the ultrasound assessment of intramural blood flow by means of colour power-Doppler ultrasonography and intravenous contrast agents may help to differentiate fibrotic and inflammatory strictures, and to discriminate inflammatory masses from intra-abdominal abscesses. Despite several attempts to correlate ultrasound findings with clinical and biochemical activity, there are as yet no convincing data on the usefulness of ultrasound in assessing the activity of Crohn's disease. In contrast, preliminary results are in agreement regarding the usefulness of ultrasound in the assessment of postoperative recurrence and in monitoring the outcome of the disease following surgery. In fact, the persistence of a thickened bowel wall or increased high bowel wall thickening at ultrasound following surgery has been identified as an index of early surgical recurrence. How these data may be usefully employed in the management of individuals with Crohn's disease needs to be investigated in further studies.

Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease

OBJECTIVE

Crohn's disease is a chronic inflammatory, panintestinal disease of uncertain aetiology. The recurrence rate of Crohn's disease, often taken as the time when further surgical procedure is undertaken, has been reported to be as high as 76% in 10 years. The site of the disease has not yet been associated with the recurrence rate of Crohn's disease. The aim of the study was to compare the outcome of patients who were surgically treated for jejunal Crohn's disease to those whose diseases was confined to the ileocaecal region.

METHOD

The information was tracked from our database of 724 surgically treated Crohn's disease patients between 1943 and 2002. Twenty-eight patients with jejunal Crohn's disease at their first operation (12 jejunum alone, 16 also involving other sites) were identified. For each of these patients, 3 patients with ileocaecal Crohn's, matched for age, sex, and smoking habits (n = 84) were identified as controls.

RESULTS

The median age in both groups was 21 years (range 16-52 years) with a median follow-up period of 19 years. The 3, 5 and 10 years re-operation rate for the groups with jejunal disease were 43%, 50% and 61% compared to 22%, 30% and 51% with ileocaecal disease, respectively.

CONCLUSIONS

The presence of jejunal Crohn's disease is associated with a higher rate of early disease recurrence compared to ileocaecal disease but long-term recurrences rate do not differ significantly.

Strictureplasty

BACKGROUND

Advances in the use of bowel-sparing surgery for Crohn's disease have led to the development of strictureplasty as an important technique to conserve small bowel length and reduce morbidity associated with malabsorption.

METHODS

A literature review of long-term studies on strictureplasty was undertaken, and evidence of its safety and efficacy was evaluated.

RESULTS

The safety and efficacy of strictureplasty is confirmed in retrospective studies carried out over a period of 5-10 years, particularly when employed in patients at risk of short bowel syndrome, but certain questions regarding bowel function and disease activity after surgery remain unanswered. There is also concern that diseased tissue is left in situ after strictureplasty; this tissue has the potential for malignant transformation in the long term.

CONCLUSION

Strictureplasty has been used in surgery for Crohn's disease for the past 25 years. Studies have proven its efficacy in the treatment of carefully selected patients at risk of malabsorption owing to short bowel syndrome.

Behaviour of the bowel wall during the first year after surgery is a strong predictor of symptomatic recurrence of Crohn's disease: a prospective study

BACKGROUND

Recurrences after surgery for Crohn's disease are frequent and unpredictable. To date, there is little agreement as to which factors increase a patient risk of early recurrence.

AIM

To assess whether the post-operative behaviour of diseased bowel walls, as determined by ultrasound, may be a useful predictor of relapse.

METHODS

A total of 127 Crohn's disease patients were monitored after surgery by means of bowel ultrasound as well as by clinical and laboratory evaluations for a median follow-up of 41.0 months. Bowel wall thickness of diseased loops measured at ultrasound during follow-up was compared with the presurgery values. Multivariable survival analysis was performed to elucidate predictors of early post-operative recurrence. Receiver operating characteristic curves were also constructed taking into account bowel wall thickness for selecting Crohn's disease patients with high risk of clinical/surgical recurrence.

RESULTS

The estimated 5 years survival probability of symptomatic Crohn's disease recurrence were 90% and 33%, respectively for unchanged/worsened bowel wall thickness vs. improved bowel wall thickness at 12 months from surgery. The hazard ratio for unchanged/worsened bowel wall thickness at 12 months was 8.9 (95% CI: 3.4-23.2). Receiver operating characteristic curve identified a bowel wall thickness > 6.0 mm at 12 months from surgery as directly associated with the risk of having a Crohn's disease recurrence (hazard ratio was 6.5, 95% CI: 2.8-15.4).

CONCLUSIONS

Systematic ultrasound follow-up of diseased bowel walls after conservative surgery allows the early identification of patients at high risk of clinical/surgical recurrence.

Azathioprine and mesalamine for prevention of relapse after conservative surgery for Crohn's disease

BACKGROUND & AIMS

Because the reoperation rate for Crohn's disease is high after resective surgery, use of conservative surgery has increased. Mesalamine was investigated for the prevention of postoperative relapse, with disappointing results. The role of azathioprine in the postoperative setting is unknown. We aimed to compare the efficacy and safety of azathioprine and mesalamine in the prevention of clinical and surgical relapse in patients who have undergone conservative surgery for Crohn's disease.

METHODS

In a prospective, open-label, randomized study, 142 patients received azathioprine (2 mg. kg -1. day -1 ) or mesalamine (3 g/day) for 24 months. Clinical relapse was defined as the presence of symptoms with a Crohn's Disease Activity Index score >200 and surgical relapse as the presence of symptoms refractory to medical treatment or complications requiring surgery.

RESULTS

After 24 months, the risk of clinical relapse was comparable in the azathioprine and mesalamine groups, both on intention-to-treat (odds ratio [OR], 2.04; 95% confidence interval [CI], 0.89-4.67) and per-protocol analyses (OR, 1.79; 95% CI, 0.80-3.97). No difference was observed with respect to surgical relapse at 24 months between the 2 groups. In a subgroup analysis, azathioprine was more effective than mesalamine in preventing clinical relapse in patients with previous intestinal resections (OR, 4.83; 95% CI, 1.47-15.8). More patients receiving azathioprine withdrew from treatment due to adverse events than those receiving mesalamine (22% vs. 8%; P = 0.04).

CONCLUSIONS

While no difference was observed in the efficacy of azathioprine and mesalamine in preventing clinical and surgical relapses after conservative surgery, azathioprine is more effective in those patients who have undergone previous intestinal resection.

A prospective, longitudinal study of nonconventional strictureplasty in Crohn’s disease1 1No competing interests declared

BACKGROUND

Bowel-sparing techniques have been proposed to avoid extended or repeated resections in patients with Crohn'rsquo;s disease (CD), but without precise indications, prospective evaluation, and with a technically limited repertoire.

STUDY DESIGN

A prospective longitudinal study of new nonconventional strictureplasties (NCSP) in order to evaluate the safety, type and site of recurrence, and longterm clinical and surgical efficacy.

RESULTS

Between January 1993 and December 2002, 102 among 305 consecutive patients underwent at least one NCSP for complicated CD. Patients were treated following precise indications and then included in a prospective database with scheduled followup. Factors claimed to influence postoperative and longterm outcomes and type and site of recurrence were analyzed. We performed 48 ileoileal side-to-side isoperistaltic strictureplasty (SP), 41 widening ileocolic SP, 32 ileocolic side-to-side isoperistaltic SP, associated with Heineke-Mikulicz SP (in 80 procedures) or with minimal bowel resections or both (in 47 procedures). Postoperative mortality was nil; complication rate was 5.7%. Ten years clinical and surgical recurrence rates were 43% and 27%, respectively. Recurrence rate on an NCSP site was 0.8%. No specific factor was identified as related to postoperative or longterm outcomes.

CONCLUSIONS

Perioperative and longterm results of NCSP are comparable to or even better than both conservative and resective surgery as reported in the literature, with a low recurrence rate on the NCSP site. Considering the unpredictability of the clinical course of CD and the lifetime need for surgical procedures, NCSP, together with minimal resection and classic SP repertoire, should be considered first-line treatment in complicated CD.

Side-to-side isoperistaltic strictureplasty in the treatment of extensive Crohn's disease

BACKGROUND

First performed in 1992, the side-to-side isoperistaltic strictureplasty (SSIS) is a bowel-sparing surgical option for Crohn's patients presenting with sequentially occurring stenoses over long intestinal segments (>15 cm). This investigation was designed to study the outcomes and patterns of recurrence after a SSIS.

MATERIALS AND METHODS

Between 1992 and 2003, 30 patients underwent SSIS at the University of Chicago. Their data were gathered prospectively in an Institutional Review Board-approved database.

RESULTS

A total of 31 SSISs were constructed in 30 patients. As an indication of the severity of disease in these patients, 25 of 30 (83%) required a concomitant bowel resection, and 13 (43%) underwent at least one additional strictureplasty. The average length of diseased bowel used to construct the SSIS was 51 cm. The average length of residual small bowel after performance of SSIS was 275 cm, and the SSIS represented an average 19% of the remaining small bowel that would have otherwise been sacrificed with resection. Three patients experienced perioperative complications (10%) and one died (3%). Seven patients (23%) required reoperation to treat recurrence of symptoms within the first 5 years. In four of these patients, recurrence was found at or near the previous SSIS.

CONCLUSIONS

A side-to-side isoperistaltic strictureplasty (SSIS) is a safe and effective surgical option for sequentially occurring Crohn's strictures over long intestinal segments.

Small bowel stenosis in Crohn's disease: clinical, biochemical and ultrasonographic evaluation of histological features

AIM

To establish whether intestinal ultrasound, clinical or biochemical indices of activity can assess histological features of ileal stenosis in Crohn's disease.

METHODS

In 43 patients undergoing surgery for a single ileal stenosis, clinical and biochemical parameters, as well as intestinal ultrasound, were assessed prior to surgery. The echo pattern of thickened bowel segments at the site of stenosis was classified as hypoechoic, stratified or mixed (segments with/without stratification). During surgery, stenoses were identified, resected and then histologically examined using standardized criteria.

RESULTS

Clinical and biochemical indices of activity showed an overall weak positive correlation with histological inflammatory parameters and a negative correlation with fibrosis. The intestinal ultrasound echo pattern at the stenosis site was stratified in 25 patients, hypoechoic in 14 and mixed in four. Stenoses characterized by a stratified echo pattern showed a significantly higher degree of fibrosis, those characterized by hypoechoic echo pattern showed a higher degree of inflammation, while stenoses with a mixed echo pattern showed high degrees of both fibrosis and inflammation.

CONCLUSION

Ultrasound and, to a lesser degree, clinical and laboratory indices discriminate between inflammatory and fibrotic ileal stenoses complicating Crohn's disease, thus allowing appropriate medical and/or surgical treatment to be defined.

Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn's disease: a prospective comparative study

OBJECTIVE

Accurate assessment of intestinal complications of Crohn's disease (CD) is extremely important, both in clinical practice and in trials. The accuracy of radiographic and ultrasonographic diagnosis of internal fistulae and abscesses complicating CD is still debated and requires further investigation. We compared ultrasonography (US) and contrast radiography in detecting intestinal fistulae and abscesses complicating CD.

METHODS

A prospective study was carried out on 625 consecutive CD patients who underwent complete evaluation of the intestinal tract by means of colonoscopy and double contrast barium enema, small bowel enteroclysis, and abdominal ultrasound (US). Computed tomography (CT) was also carried out in cases of severe CD with clinical suspicion of septic complications. The accuracy of US, barium radiology, and CT in detecting internal fistulae and abscesses was assessed by comparing results with intraoperative findings in 128 consecutive patients who underwent operation immediately after diagnostic workup.

RESULTS

Internal fistulae and intra-abdominal abscesses were identified intraoperatively in 56 (43.7%) and 26 (20.3%) patients, respectively. Diagnostic accuracy of US and x-ray studies in detecting internal fistulae was comparable (85.2% vs 84.8%), with sensitivity of 71.4% for US and 69.6% for x-ray studies, and specificity of 95.8% for both. Combination of radiographic techniques and US significantly improved diagnostic accuracy in detection of internal fistulae. In severe cases of CD with clinical suspicion of septic complications such as abdominal mass or fever, the accuracy of US, barium studies, and CT was 88.5%, 80.3%, and 77%, respectively (p = ns). The presence of abscesses was correctly detected in 90.9% of cases by means of US and in 86.4% by CT (p = ns), although accuracy was higher for CT (91.8%) than for US (86.9%) because of false positive results in US studies.

CONCLUSIONS

Despite the fact that barium radiology is widely considered the method of choice in detection of internal fistulae, accuracy is not entirely satisfactory. Comparable accuracy was found for US and CT. The combination of barium and US studies, or the sole use of US in more CD patients with more severe disease, can reliably detect most internal fistulae and abscesses.

Oxidative stress, vitamin A and vitamin E behaviour in patients submitted to conservative surgery for complicated Crohn's disease

AIMS

To assess whether plasma peroxidation and plasma levels of antioxidant compounds are correlated with clinical and biochemical activity in complicated Crohn's disease patients, and to evaluate whether the relief of obstructive complication by conservative surgery has any effect on the oxidative stress.

PATIENTS AND METHODS

From May 1998 to May 2000, 20 Crohn's disease patients were studied. Basal peroxidative state (basal thiobarbituric acid reactive substances), peroxidative state after stimulation with copper sulfate (stimulated thiobarbituric acid reactive substances], lag time of plasma peroxidation susceptibility, plasma levels of vitamin E and A, C reactive protein, erythrocyte sedimentation rate and Crohn's disease activity index, were determined, before surgery, then 2 months and 1 year after surgery. A group of 134 healthy volunteers were used as controls. All patients were treated by conservative surgical procedures (i.e., strictureplasty and/or minimal resections). Student t test for paired and unpaired data and Spearman R correlation coefficient were calculated.

RESULTS

Peroxidative plasma levels, as well as inflammatory indices, are significantly reduced 2 months and 1 year after surgery (p < 0.005), but basal levels of peroxidation and antioxidant scavengers seem to be disregulated in Crohn's disease patients compared to those in controls (p < 0.005). A correlation was found between basal thiobarbituric acid reactive substances, lag-time and erythrocyte sedimentation rate (R:0.51; p < 0.05. R:0.56; p < 0.05) and C reactive protein (R:0. 6; p < 0.005. R:0. 65; p < 0.005).

CONCLUSIONS

An imbalance between pro- and antioxidant mechanisms, due to chronic gut inflammation, is present in complicated Crohn's disease, and an excess of lipid peroxidation is probably an important pathogenetic factor Conservative surgery can reduce the oxidative stress avoiding repeated or extended resections that could lead to intestinal malabsorption and short bowel syndrome.

Review article: indication and type of surgery in Crohn's disease

The large majority of patients affected by Crohn's disease require surgery during their clinical history. Radical resection originally advocated for Crohn's disease does not decrease the recurrence rate, and repeated resections predispose patients to the development of short-bowel syndrome. Over the last few years, conservative surgery has become accepted by many authors as a safe means of treating obstructive Crohn's disease. In this review article we analyse the efficacy and safety of conservative techniques, in comparison with resective surgery. Indications, advantages and technical aspects of resective and conservative surgery are reported. The experience with 489 patients treated for complicated or treatment refractory Crohn's disease in our Institution suggests that strictureplasty is a safe and effective procedure in many cases, as reported by other authors. The risk of cancer in areas of active disease as in stenosis treated with strictureplasty seems to be negligible. Resective surgery still represents the 'gold standard' in patients with perforating Crohn's disease; however, conservative surgery, usually contraindicated in perforating Crohn's disease, can be advocated in patients with localized perforating disease presenting an actual risk of short bowel syndrome.

Preoperative characteristics and postoperative behavior of bowel wall on risk of recurrence after conservative surgery in Crohn's disease: a prospective study

OBJECTIVE

To evaluate in patients with Crohn's disease, using transabdominal ultrasound, the morphologic characteristics of the diseased bowel wall before and after conservative surgery and to assess whether these characteristics and their behavior in the postoperative follow-up are useful and reliable prognostic factors of clinical and surgical recurrence.

SUMMARY BACKGROUND DATA

Ultrasound is effective for evaluating the thickness of bowel wall, the most typical and constant finding of Crohn's disease. No data are currently available concerning the behavior of the diseased intestinal wall after conservative surgery and whether the preoperative characteristics of bowel wall or its behavior after conservative surgery may predict recurrence.

METHODS

In 85 consecutive patients treated with strictureplasty and miniresections for Crohn's disease, clinical and ultrasonographic evaluations were performed before and 6 months after surgery. Assessed before surgery were the maximum bowel wall thickness, the length of bowel wall thickening, the bowel wall echo pattern (homogeneous, stratified, and mixed), and the postoperative bowel wall behavior, classified as normalized, improved, unchanged, or worsened.

RESULTS

A significant correlation was found between a long preoperative bowel wall thickening and surgical recurrence. Bowel wall thickness after surgery was unchanged or worsened in 43.3% of patients; in these patients, there was a high frequency of previous surgery. Patients with unchanged or worsened bowel wall thickness had a higher risk of clinical and surgical recurrence compared with those with normalized or improved bowel wall thickness.

CONCLUSION

With the use of abdominal ultrasound, the authors found that the thickening of diseased bowel wall may unexpectedly improve after conservative surgery, and this is associated with a favorable outcome in terms of clinical and surgical recurrence. In addition to its diagnostic usefulness, ultrasound also provides reliable prognostic information concerning clinical and surgical recurrence in patients with Crohn's disease in the postoperative follow-up.