Ileocolic Resection for Crohn Disease: The Influence of Different Surgical Techniques on Perioperative Outcomes, Recurrence Rates, and Endoscopic Surveillance

Safety and effectivity of Kono-S anastomosis in Crohn's patients: a systematic review and Meta-analysis

PURPOSE

Kono-S anastomosis, an antimesenteric, functional, end-to-end handsewn anastomosis, was introduced in 2011. The aim of this meta-analysis is to evaluate the safety and effectivity of the Kono-S technique.

METHODS

A comprehensive search of MEDLINE (PubMed), Embase (Elsevier), Scopus (Elsevier), and Cochrane Central (Ovid) from inception to August 24th, 2023, was conducted. Studies reporting outcomes of adults with Crohn's disease undergoing ileocolic resection with subsequent Kono-S anastomosis were included. PRISMA and Cochrane guidelines were used to screen, extract and synthesize data. Primary outcomes assessed were endoscopic, surgical and clinical recurrence rates, as well as complication rates. Data were pooled using random-effects models, and heterogeneity was assessed with I² statistics. ROBINS-I and ROB2 tools were used for quality assessment.

RESULTS

12 studies involving 820 patients met the eligibility criteria. A pooled mean follow-up time of 22.8 months (95% CI: 15.8, 29.9; I2 = 99.8%) was completed in 98.3% of patients. Pooled endoscopic recurrence was reported in 24.1% of patients (95% CI: 9.4, 49.3; I2 = 93.43%), pooled surgical recurrence in 3.9% of patients (95% CI: 2.2, 6.9; I2 = 25.97%), and pooled clinical recurrence in 26.8% of patients (95% CI: 14, 45.1; I2 = 84.87%). The pooled complication rate was 33.7%. The most common complications were infection (11.5%) and ileus (10.9%). Pooled anastomosis leakage rate was 2.9%.

CONCLUSIONS

Despite limited and heterogenous data, patients undergoing Kono-S anastomosis had low rates of surgical recurrence and anastomotic leakage with moderate rates of endoscopic recurrence, clinical recurrence and complications rate.

Surgical treatment of inflammatory bowel disease: From the gastroenterologist's stand-point

Treatment of ulcerative colitis (UC) and Crohn's disease (CD) represents, in the majority of cases, a real challenge to the gastroenterologist's abilities and skills as well as a clinical test concerning his/her levels of medical knowledge and experience. During the last two decades, our pharmaceutical arsenal was significantly strengthened, especially after the introduction of the so-called biological agents, drugs which to a large extent not only improved the results of conservative treatment but also changed the natural history of the disease. However, colectomy is still necessary for some patients with severe UC although smaller compared to the past, precisely because of the improvements achieved in the available conservative treatment. Nevertheless, surgeries to treat colon dysplasia and cancer are increasing to some extent. At the same time, satisfactory improvements in surgical techniques, the pre-and post-operative care of patients, as well as the selection of the appropriate time for performing the surgery have been noticed. Regarding patients with CD, the improvement of conservative treatment did not significantly change the need for surgical treatment since two-thirds of patients need to undergo surgery at some point in the course of their disease. On the other hand, the outcome of the operation has improved through good preoperative care as well as the wide application of more conservative surgical techniques aimed at keeping as much of the bowel in situ as possible. This article discusses the indications for surgical management of UC patients from the gastroenterologist's point of view, the results of the emerging new techniques such as transanal surgery and robotics, as well as alternative operations to the classic ileo-anal-pouch anastomosis. The author also discusses the basic principles of surgical management of patients with CD based on the results of the relevant literature. The self-evident is emphasized, that is, to achieve an excellent therapeutic result in patients with severe inflammatory bowel disease in today's era; the close cooperation of gastroenterologists with surgeons, pathologists, imaging, and nutritionists is of paramount importance.

Kono-S anastomosis in Crohn's disease: initial experience in pediatric patients

PURPOSE

Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications.

METHODS

We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification.

RESULTS

Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months.

CONCLUSION

According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.

Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study

Objective

Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis.

Background

The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique.

Methods

In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied.

Results

In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery.

Conclusion

The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.

Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease

INTRODUCTION

The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD.

METHODS

Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes.

RESULTS

Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence.

DISCUSSION

The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.

Clinical Update on the Prevention and Management of Postoperative Crohn's Disease Recurrence

PURPOSE OF REVIEW

Despite advances in therapeutics, a significant portion of patients with Crohn's disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn's disease recurrence.

RECENT FINDINGS

Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and "-omic" risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy. Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn's disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.

Balloon-assisted enteroscopy-based endoscopic stricturotomy for deep small bowel strictures from Crohn's disease: First cohort study of a novel approach

BACKGROUND

There is little data on the role of endoscopic stricturotomy (ES) in treating deep small bowel strictures. We aimed to investigate the efficacy and safety of balloon-assisted enteroscopy-based ES (BAE-based ES) for deep small bowel strictures associated with Crohn's disease (CD).

METHODS

This multicentre retrospective cohort study included consecutive patients with CD-associated deep small bowel strictures treated with BAE-based ES between 2017 and 2023. The outcomes included technical success, clinical improvement, surgery-free rate, reintervention-free rate, and adverse events.

RESULTS

Twenty-eight patients with CD underwent 58 BAE-based ES procedures for non-passable deep small bowel strictures, with a median follow-up time of 519.5 days (interquartile range, 306-728 days). Fifty-six (96.0%) procedures were technically successful in 26 (92.9%) patients. Twenty patients (71.4%) showed clinical improvement at week 8. The cumulative surgery-free rate at 1 year was 74.8% (95% confidence interval [CI], 60.3-92.9%). A higher body mass index was associated with a decreased need for surgery (hazard ratio = 0.084, 95% CI, 0.016-0.45, P = 0.0036). Postprocedural adverse events (bleeding and perforation) requiring reintervention occurred in 3.4% of the procedures.

CONCLUSIONS

The novel BAE-based ES provides high technical success, favorable efficacy, and safety in CD-associated deep small bowel strictures, which may provide an alternative for endoscopic balloon dilation and surgery.

Postoperative Crohn's Disease

Although surgery rates in Crohn's disease are declining in the past twenty years, bowel resection remains an important and still commonly used therapeutic option in Crohn's disease. Preoperatively, patients clinical status must be optimized including preparation for perioperative recovery including with nutrition optimization and preparation for postoperative pharmacotherapy. Postoperatively a medical therapy is often required and in recent years it has often been a biological therapy. One randomized controlled study suggested that infliximab is more likely to prevent endoscopic recurrence than placebo. But other biologicals have been used as well. Ileocolonoscopy should be undertaken by 6 months after an ileal or ileocecal resection especially. Adjunctive imaging such as transabdominal ultrasound, capsule endoscopy or cross sectional imaging may be required. Biomarker measurement with fecal calprotectin especially, or C-reactive protein, serum ferritin, serum albumin and serum hemoglobin will also be helpful.

Kono-S Anastomosis in Crohn's Disease: A Retrospective Study on Postoperative Morbidity and Disease Recurrence in Comparison to the Conventional Side-To-Side Anastomosis

INTRODUCTION

The rates of postoperative recurrence following ileocecal resection due to Crohn's disease remain highly relevant. Despite this fact, while the Kono-S anastomosis technique initially demonstrated promising results, robust evidence is still lacking. This study aimed to analyze the short- and long-term outcomes of the Kono-S versus side-to-side anastomosis.

METHODS

A retrospective single-center study was performed including all patients who received an ileocecal resection between 1 January 2019 and 31 December 2021 at the Department of Surgery at the University Hospital of Wuerzburg. Patients who underwent conventional a side-to-side anastomosis were compared to those who received a Kono-S anastomosis. The short- and long-term outcomes were analyzed for all patients.

RESULTS

Here, 29 patients who underwent a conventional side-to-side anastomosis and 22 patients who underwent a Kono-S anastomosis were included. No differences were observed regarding short-term postoperative outcomes. The disease recurrence rate postoperatively was numerically lower following the Kono-S anastomosis (median Rutgeert score of 1.7 versus 2.5), with a relevantly increased rate of patients in remission (17.2% versus 31.8%); however, neither of these results reached statistical significance.

CONCLUSION

The Kono-S anastomosis method is safe and feasible and potentially decreases the severity of postoperative disease remission.

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.