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Jenkin A, Edmundson A, Clark D. Surgical outcomes in ileal Crohn's disease complicated by ileosigmoid fistula. ANZ J Surg 2024. [PMID: 39039806 DOI: 10.1111/ans.19176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND The management of Crohn's disease (CD) complicated by ileosigmoid fistula (ISF) remains a challenge, and Australian outcomes have not previously been reported. METHODS A retrospective review of a tertiary colorectal inflammatory bowel disease unit, across public and private sites, from 2005 to 2023 to identify adult patients having undergone operative management of ISF. RESULTS Twenty-nine patients underwent surgery for ISF in the study period. Seventeen were male and the median age was 40 years. The pre-operative diagnosis of ISF was made in 76%, and patients were more likely to undergo resectional surgery if the pre-operative diagnosis was made endoscopically. Sixty-nine percent of cases were performed electively, with 76% completed laparoscopically with an 18.5% conversion rate to an open approach. The ISF was oversewn in three patients, repaired primarily in 14 patients, managed with segmental wedge resection in eight patients and resected via an anterior resection in four patients. The rate of stoma formation at the index procedure was 20.7% overall and 22% in patients being acutely managed with steroids. Emergent cases were more likely to be defunctioned with a stoma. Morbidity was 17.2% with a single anastomotic leak. CONCLUSION ISF in CD remains difficult to diagnose pre-operatively, but can be safely managed laparoscopically without formal resection, and with limited use of diverting stoma formation. The specific surgical approach to the sigmoid in ISF is difficult to pre-determine and often requires decisions to be made intra-operatively.
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Affiliation(s)
- Ashley Jenkin
- Colorectal Unit, The Royal Brisbane Hospital, Herston, Queens Land, Australia
- School of Medicine, General Surgery, University of Queensland, St Lucia, Queensland, Australia
| | | | - David Clark
- Colorectal Unit, The Royal Brisbane Hospital, Herston, Queens Land, Australia
- School of Medicine, General Surgery, University of Queensland, St Lucia, Queensland, Australia
- St Vincent's Private Hospital Northside, Chermside, Queensland, Australia
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Lotakis DM, Rubalcava NS, Lopyan NM, Heider A, Rabah R, Elizabeth Speck K, Jarboe MD, Ehrlich PF, Ralls MW. Clinical relevance of inflammation on rectal biopsy for Hirschsprung disease: An outcomes analysis. J Pediatr Gastroenterol Nutr 2024; 78:36-42. [PMID: 38291694 DOI: 10.1002/jpn3.12047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/15/2023] [Accepted: 09/15/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Inflammation on diagnostic rectal biopsy for children with suspected Hirschsprung disease (HSCR) is reported on pathology, and its significance is unknown. We describe the management and outcomes of a cohort with inflammation on rectal biopsy compared to those without. Specifically, to address the hypothesis that inflammation on diagnostic biopsy is associated with increased complication rates irrespective of intervention type and timing. METHODS A single institution retrospective review of children with HSCR who underwent biopsy and endorectal pull-through (ERPT) from 2010 to 2020 was performed. The primary outcome was overall complications at 30-days following ERPT. Secondary outcomes included timing and type of operative intervention as well as postoperative enterocolitis diagnosed within 6-months of ERPT. RESULTS Forty-nine children were identified; inflammation was present on diagnostic biopsy for 17 children. Those with inflammation were more likely to have clinical evidence of enterocolitis at the time of biopsy (p = 0.001) and were more likely to undergo leveling colostomy before ERPT (p = 0.01). Children with inflammation had a higher anastomotic leak rate (p = 0.04). Subgroup analysis of patients with inflammation undergoing primary ERPT versus leveling colostomy demonstrated no significant difference in outcomes following definitive ERPT. CONCLUSIONS Our study suggests inflammation on diagnostic rectal biopsy for HSCR is associated with increased anastomotic leak rates. While additional prospective studies are indicated, attention to methods of mitigating inflammation and confirming its resolution before definitive pull-through may be of benefit for improving clinical outcomes in patients found with inflammation on diagnostic rectal biopsy.
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Affiliation(s)
- Dimitra M Lotakis
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan S Rubalcava
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, Creighton University Arizona Health Education Alliance, Phoenix, Arizona, USA
| | - Natalie M Lopyan
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Amer Heider
- Division of Pediatric and Perinatal Pathology, Department of Pathology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Raja Rabah
- Division of Pediatric and Perinatal Pathology, Department of Pathology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - K Elizabeth Speck
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Marcus D Jarboe
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter F Ehrlich
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew W Ralls
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
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Avellaneda N, Rodrigues Coy CS, Sarubbi Fillmann H, Saad-Hossne R, Muñoz JP, García-Duperly R, Bellolio F, Rotholtz N, Rossi G, Marquez V JR, Cillo M, Lacerda-Filho A, Carrie A, Yuki Maruyama B, Sarubbi Fillmann L, Silvino Craveiro MM, Ferro E, Londoño-Schimmer E, Iglesias A, Bras Harriott C, Campana JP, Londoño Estrada D, Balachandran R, Kotze PG. Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicentric Latin American experience. Cir Esp 2023; 101:824-832. [PMID: 37244420 DOI: 10.1016/j.cireng.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures. MATERIALS AND METHODS We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo > II), the "postoperative complication" (POC) group; and those who did not, the "no postoperative complication" (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC. RESULTS In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs. 17.83; P = .026), who presented more preoperative anemia (33.33 vs. 17.48%; P = .009), required more urgent care (37.25 vs. 22.38; P = .023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs. 143.86 min; P = .005), more intraoperative complications (17.65 vs. 4.55%; P < .001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications. CONCLUSION This study shows that risk factors for complications after primary ileocecal resections for Crohn's disease in Latin America are similar to those reported elsewhere. Future efforts in the region should be aimed at improving these outcomes by controlling some of the identified factors.
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Affiliation(s)
- Nicolás Avellaneda
- General Surgery Department, Hospital Universitario CEMIC, Argentina; Colorectal Surgery Department, Aarhus University Hospital, Denmark.
| | | | | | | | | | | | - Felipe Bellolio
- Coloproctology Unit, Digestive Surgery Department, Pontíficia Universidad Católica de Chile, Chile
| | - Nicolás Rotholtz
- Colorectal Surgery Service, General Surgery Department, Hospital Aleman de Buenos Aires, Argentina
| | - Gustavo Rossi
- Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Mariano Cillo
- Colorectal Surgery Department, Hospital Británico de Buenos Aires, Argentina
| | | | - Augusto Carrie
- General Surgery Department, Hospital Universitario CEMIC, Argentina
| | - Beatriz Yuki Maruyama
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | | | | | - Ezequiel Ferro
- Colorectal Surgery Department, Nueva Proctología, Argentina
| | | | - Andrés Iglesias
- Coloproctology Unit, Digestive Surgery Department, Pontíficia Universidad Católica de Chile, Chile
| | - Camila Bras Harriott
- Colorectal Surgery Service, General Surgery Department, Hospital Aleman de Buenos Aires, Argentina
| | - Juan Pablo Campana
- Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
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Schweer JT, Neumann PA, Doebler P, Doebler A, Pascher A, Mennigen R, Rijcken E. Crohn's Disease as a Possible Risk Factor for Failed Healing in Ileocolic Anastomoses. J Clin Med 2023; 12:jcm12082805. [PMID: 37109142 PMCID: PMC10141622 DOI: 10.3390/jcm12082805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
Anastomotic leakage (AL) after colorectal resections is a serious complication in abdominal surgery. Especially in patients with Crohn's disease (CD), devastating courses are observed. Various risk factors for the failure of anastomotic healing have been identified; however, whether CD itself is independently associated with anastomotic complications still remains to be validated. A retrospective analysis of a single-institution inflammatory bowel disease (IBD) database was conducted. Only patients with elective surgery and ileocolic anastomoses were included. Patients with emergency surgery, more than one anastomosis, or protective ileostomies were excluded. For the investigation of the effect of CD on AL 141, patients with CD-type L1, B1-3 were compared to 141 patients with ileocolic anastomoses for other indications. Univariate statistics and multivariate analysis with logistic regression and backward stepwise elimination were performed. CD patients had a non-significant higher percentage of AL compared to non-IBD patients (12% vs. 5%, p = 0.053); although, the two samples differed in terms of age, body mass index (BMI), Charlson comorbidity index (CCI), and other clinical variables. However, Akaike information criterion (AIC)-based stepwise logistic regression identified CD as a factor for impaired anastomotic healing (final model: p = 0.027, OR: 17.043, CI: 1.703-257.992). Additionally, a CCI ≥ 2 (p = 0.010) and abscesses (p = 0.038) increased the disease risk. The alternative point estimate for CD as a risk factor for AL based on propensity score weighting also resulted in an increased risk, albeit lower (p = 0.005, OR 7.36, CI 1.82-29.71). CD might bear a disease-specific risk for the impaired healing of ileocolic anastomoses. CD patients are prone to postoperative complications, even in absence of other risk factors, and might benefit from treatment in dedicated centers.
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Affiliation(s)
- Julian Thomas Schweer
- Department of General, Visceral, and Transplantation Surgery, Muenster University Hospital, 48149 Muenster, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich School of Medicine, 81675 Munich, Germany
| | - Philipp Doebler
- Department of Statistics, Chair of Statistical Methods in Social Sciences, Technical University of Dortmund, 44227 Dortmund, Germany
| | - Anna Doebler
- Psychological Assessment and Methods Group, Institute of Psychology, Faculty of Educational Sciences, University of Duisburg-Essen, 45141 Essen, Germany
| | - Andreas Pascher
- Department of General, Visceral, and Transplantation Surgery, Muenster University Hospital, 48149 Muenster, Germany
| | - Rudolf Mennigen
- Medizinisches Versorgungszentrum Portal 10, 48155 Muenster, Germany
| | - Emile Rijcken
- Department of General, Visceral, and Transplantation Surgery, Muenster University Hospital, 48149 Muenster, Germany
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Abstract
A number of factors should be considered when performing an intestinal anastomosis in the setting of surgery for Crohn's disease. Preoperative risk factors, such as malnutrition, abdominal sepsis, and immunosuppressive medications, may increase the risk of postoperative anastomotic complications and alter surgical decision-making. The anatomical configuration and technique of constructing the anastomosis may have an impact on postoperative function and risk of recurrence, particularly in the setting of ileocolic resection, where the Kono-S anastomosis has gained popularity in recent years. There may be circumstances in which it may be more appropriate to perform an ostomy either without an anastomosis or to temporarily divert an anastomosis when the risk of anastomotic complications is felt to be high. In the setting of total abdominal colectomy or proctocolectomy for Crohn's colitis, restorative procedures may appropriate in lieu of a permanent stoma in certain scenarios.
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Affiliation(s)
- Brian R. Kann
- Department of Colon & Rectal Surgery, Ochsner Health, New Orleans, Louisiana,Address for correspondence Brian R. Kann, MD, FACS, FASCRS Department of Colon & Rectal Surgery, Ochsner Health1514 Jefferson Highway, New Orleans, LA 70121
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Wickramasinghe D, Carvello M, Di Candido F, Maroli A, Adegbola S, Sahnan K, Morar P, Spinelli A, Warusavitarne J. Factors associated with stoma formation in ileocolic resection for Crohn's disease and the development of a predictive scoring system. Langenbecks Arch Surg 2022; 407:2997-3003. [PMID: 35906298 DOI: 10.1007/s00423-022-02626-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE The likelihood of a stoma following ileocolic resection (ICR) for Crohn's disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS). METHODS Patient data were collected from St. Marks Hospital, London, UK and Humanitas Clinical and Research Center, Milan, Italy, on all patients who underwent an ICR for CD from 2005 to 2017. A logistic regression analysis was used for multivariate analysis. The SS was developed from the logistic regression model. The performance of the SS was evaluated using receiver operating characteristics area under the curve (AUROC). RESULTS A total of 628 surgeries were included in the analysis. Sixty-nine surgeries were excluded due to missing data. The remaining 559 were divided into two cohorts for the scoring system's development (n = 434) and validation (n = 125). The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included sex, preoperative albumin and haemoglobin levels, surgical access and simultaneous colonic resection. The AUROC for the development and validation cohorts were 0.803 and 0.905, respectively (p < 0.0001). Youden's index suggested the cut-off score of - 95.9, with a sensitivity of 87.6% and a specificity of 62.9%. CONCLUSIONS Male sex, low preoperative albumin, anaemia, laparoscopic conversion and simultaneous colonic resection were associated with an increased likelihood of requiring a stoma and were used to develop an SS. The calculator is available online at https://rebrand.ly/CrohnsStoma .
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Affiliation(s)
- Dakshitha Wickramasinghe
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
- St. Mark's Hospital, London, UK.
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7
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Lavorini E, Allaix ME, Ammirati CA, Astegiano M, Morino M, Resegotti A. Late is too late? Surgical timing and postoperative complications after primary ileocolic resection for Crohn's disease. Int J Colorectal Dis 2022; 37:843-848. [PMID: 35274184 PMCID: PMC8976788 DOI: 10.1007/s00384-022-04125-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the recent advances in medical therapy, the majority of patients with Crohn's disease (CD) still require surgery during the course of their life. While a correlation between early primary surgery and lower recurrence rates has been shown, the impact of surgical timing on postoperative complications is unclear. The aim of this study is to assess the impact of surgical timing on 30-day postoperative morbidity. METHODS This is a retrospective analysis of a prospectively collected database of 307 consecutive patients submitted to elective primary ileocolic resection for CD at our institution between July 1994 and July 2018. The following variables were considered: age, gender, year of treatment, smoking habits, preoperative steroid therapy, presence of fistula or abscess, type of anastomosis, and time interval between diagnosis of CD and surgery. Univariate and multivariate logistic regressions were performed to examine the association between risk factors and complications. RESULTS Major complications occurred in 29 patients, while anastomotic leak was observed in 16 patients. Multivariate logistic regression analysis showed that surgical timing in years (OR 1.10 p = 0.002 for a unit change), along with preoperative use of steroids (OR 5.45 p < 0.001) were independent risk factors for major complications. Moreover, preoperative treatment with steroids (6.59 p = 0.003) and surgical timing (OR 1.10 p = 0.023 for a unit change) were independently associated with anastomotic leak, while handsewn anastomosis (OR 2.84 p = 0.100) showed a trend. CONCLUSIONS Our results suggest that the longer is the time interval between diagnosis of CD and surgery, the greater is the risk of major surgical complications and of anastomotic leak.
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Affiliation(s)
- E. Lavorini
- Department of Surgical Sciences, University of Torino, C.so Dogliotti 14, 10126 Turin, Italy
| | - M. E. Allaix
- Department of Surgical Sciences, University of Torino, C.so Dogliotti 14, 10126 Turin, Italy
| | - C. A. Ammirati
- Department of Surgical Sciences, University of Torino, C.so Dogliotti 14, 10126 Turin, Italy
| | - M. Astegiano
- SC Gastroenterology U, AOU Città Della Salute E Della Scienza, Turin, Italy
| | - M. Morino
- Department of Surgical Sciences, University of Torino, C.so Dogliotti 14, 10126 Turin, Italy
| | - A. Resegotti
- Department of Surgical Sciences, University of Torino, C.so Dogliotti 14, 10126 Turin, Italy
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Lahes S, Fischer C, Spiliotis AE, Schulz A, Gäbelein G, Igna D, Glanemann M. Effect of immunosuppressive medication on postoperative complications following abdominal surgery in Crohn's disease patients. Int J Colorectal Dis 2022; 37:2535-2542. [PMID: 36441196 PMCID: PMC9741563 DOI: 10.1007/s00384-022-04287-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Immunosuppressants represent an effective pharmacological treatment for the remission and management of Crohn's disease (CD); however, it has not been well-defined if these medications are associated with an increased incidence of postoperative complications after intestinal surgery. This retrospective study evaluated the association between immunosuppressive treatment and complications following bowel resection in patients with CD. METHODS A total of 426 patients with CD who underwent abdominal surgery between 2001 and 2018 were included in the study. The participants were divided into two groups. In the first group, patients were under immunosuppressive treatment at the time of surgical resection, while in the second group, patients had never received pharmacological therapy for CD before surgery. RESULTS No statistically significant difference was found in the incidence of postoperative complications between the two groups. Double or triple immunosuppressive therapy was not associated with increased complications compared to monotherapy or no pharmacological treatment. Preoperative risk factors such as hypoalbuminemia, abscess, fistula, intestinal perforation, long duration of symptoms, and the intraoperative performance of more than one anastomosis were related to increased rates of postoperative complications. Factors affecting the occurrence of postoperative complications in the univariate analysis were included in the multivariate analysis using a stepwise logistic regression model, and these factors were also related to increased rates of postoperative surgical complications. CONCLUSION Immunosuppressive therapy was not associated with increased rates of postoperative complications following bowel resection in patients with CD.
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Affiliation(s)
- Saleh Lahes
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany.
| | - Celine Fischer
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany
| | - Antonios E Spiliotis
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany
| | - Antje Schulz
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany
| | - Gereon Gäbelein
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany
| | - Dorian Igna
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany
| | - Matthias Glanemann
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Kirrberger Straße, 66421, Homburg, Saarland, Germany
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Zemel M, Solo E, Tulchinsky H. Does microscopic involvement of the surgical margins after ileocecectomy in Crohn's patients predict early recurrence? Int J Colorectal Dis 2021; 36:2427-2435. [PMID: 33928416 DOI: 10.1007/s00384-021-03941-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The primary aim of this study was to determine whether the microscopic presence of Crohn's disease (CD) in the resected specimen margins in patients undergoing ileocecectomy predicts disease recurrence. The secondary aim was to identify other risk factors which can predict recurrence. METHODS All CD patients who underwent ileocecectomy in a single colorectal unit between 2000 and 2015 were retrospectively evaluated. The diagnosis of CD and margin involvement status were retrieved from pathology reports. Recurrence was determined according to medical records or via a telephone questionnaire. Demographic, clinical, and surgical parameters were compared between patients with and without histopathologic evidence of CD in the resected margins. RESULTS A total of 202 CD patients were included, 49 with and 153 without evidence of microscopic involvement in the resected margins. The main demographic characteristics, surgical approach and procedure, and postoperative course, including medical treatment, clinical or endoscopic recurrence, and reoperation rates, were similar for both groups. Patients who were operated laparoscopically (n=58, p 0.016), conversion from laparoscopic to open (n=25, p 0.016), stapled anastomosis (n=150, p 0.004), when stricturoplasty was required (n=12, p 0.046), and those with perianal disease (n=32, p 0.045) had shorter time to recurrence. Male gender had increased hazard ratio (n=106, HR 1.38) for reoperation, but not significantly (p=0.058). CONCLUSIONS The presence of microscopic CD at the resected specimen margins was not associated with the risk of disease recurrence. Other demographic, clinical, and technical features that did correlate with early recurrence were identified. These results support a conservative approach to the extent of resection in CD patients undergoing ileocecectomy. TRIAL REGISTRATION Not relevant.
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Affiliation(s)
- Meir Zemel
- The Colorectal Unit, Surgical Division, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel Aviv, Israel
| | - Elian Solo
- The Colorectal Unit, Surgical Division, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel Aviv, Israel
| | - Hagit Tulchinsky
- The Colorectal Unit, Surgical Division, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel Aviv, Israel.
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Reischl S, Lee JH, Miltschitzky JRE, Vieregge V, Walter RL, Twardy V, Kasajima A, Friess H, Kamaly N, Neumann PA. Ac2-26-Nanoparticles Induce Resolution of Intestinal Inflammation and Anastomotic Healing via Inhibition of NF-κB Signaling in a Model of Perioperative Colitis. Inflamm Bowel Dis 2021; 27:1379-1393. [PMID: 33512505 DOI: 10.1093/ibd/izab008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although in most patients with inflammatory bowel diseases, conservative therapy is successful, a significant proportion of patients still require surgery once in their lifetime. Development of a safe perioperative treatment to dampen colitis activity without disturbance of anastomotic healing is an urgent and unmet medical need. Annexin A1 (ANXA1) has been shown to be effective in reducing colitis activity. Herein, a nanoparticle-based perioperative treatment approach was used for analysis of the effects of ANXA1 on the resolution of inflammation after surgery for colitis. METHODS Anxa1-knockout mice were used to delineate the effects of ANXA1 on anastomotic healing. A murine model of preoperative dextran sodium sulfate colitis was performed. Collagen-IV-targeted polymeric nanoparticles, loaded with the ANXA1 biomimetic peptide Ac2-26 (Ac2-26-NPs), were synthesized and administered perioperatively during colitis induction. The effects of the Ac2-26-NPs on postoperative recovery and anastomotic healing were evaluated using the disease activity index, histological healing scores, and weight monitoring. Ultimately, whole-genome RNA sequencing of the anastomotic tissue was performed to unravel underlying molecular mechanisms. RESULTS Anxa1-knockout exacerbated the inflammatory response in the healing anastomosis. Treatment with Ac2-26-NPs improved preoperative colitis activity (P < 0.045), postoperative healing scores (P < 0.018), and weight recovery (P < 0.015). Whole-genome RNA sequencing revealed that the suppression of proinflammatory cytokine and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signaling was associated with the treatment effects and a phenotypic switch toward anti-inflammatory M2 macrophages. CONCLUSIONS Proresolving therapy with Ac2-26-NPs promises to be a potent perioperative therapy because it improves colitis activity and even intestinal anastomotic healing by the suppression of proinflammatory signaling.
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Affiliation(s)
- Stefan Reischl
- Technical University of Munich, School of Medicine, Department of Surgery, Munich, Germany
| | - Jong Hyun Lee
- Technical University of Denmark, Department of Health Technology, Copenhagen, Denmark
| | | | - Vincent Vieregge
- Technical University of Munich, School of Medicine, Department of Surgery, Munich, Germany
| | - Robert Leon Walter
- Technical University of Munich, School of Medicine, Department of Surgery, Munich, Germany
| | - Vanessa Twardy
- University of Muenster, School of Medicine, Department of Surgery, Muenster, Germany
| | - Atsuko Kasajima
- Technical Technical University of Munich, School of Medicine, Institute of Pathology, Munich, Germany
| | - Helmut Friess
- Technical University of Munich, School of Medicine, Department of Surgery, Munich, Germany
| | - Nazila Kamaly
- Technical University of Denmark, Department of Health Technology, Copenhagen, Denmark.,Imperial College London, Department of Chemistry, Molecular Sciences Research Hub, London, United Kingdom
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Adamina M, Feakins R, Iacucci M, Spinelli A, Cannatelli R, D'Hoore A, Driessen A, Katsanos K, Mookhoek A, Myrelid P, Pellino G, Peros G, Tontini GE, Tripathi M, Yanai H, Svrcek M. ECCO Topical Review Optimising Reporting in Surgery, Endoscopy, and Histopathology. J Crohns Colitis 2021; 15:1089-1105. [PMID: 33428711 DOI: 10.1093/ecco-jcc/jjab011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Diagnosis and management of inflammatory bowel diseases [IBD] requires a lifelong multidisciplinary approach. The quality of medical reporting is crucial in this context. The present topical review addresses the need for optimised reporting in endoscopy, surgery, and histopathology. METHODS A consensus expert panel consisting of gastroenterologists, surgeons, and pathologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. The following topics were covered: in endoscopy: [i] general IBD endoscopy; [ii] disease activity and surveillance; [iii] endoscopy treatment in IBD; in surgery: [iv] medical history with surgical relevance, surgical indication, and strategy; [v] operative approach; [vi] intraoperative disease description; [vii] operative steps; in pathology: [viii] macroscopic assessment and interpretation of resection specimens; [ix] IBD histology, including biopsies, surgical resections, and neoplasia; [x] IBD histology conclusion and report. Statements were developed using a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥ 80% of participants agreed on a recommendation. RESULTS Thirty practice positions established a standard terminology for optimal reporting in endoscopy, surgery, and histopathology. Assessment of disease activity, surveillance recommendations, advice to surgeons for operative indication and strategies, including margins and extent of resection, and diagnostic criteria of IBD, as well as guidance for the interpretation of dysplasia and cancer, were handled. A standardised report including a core set of items to include in each specialty report, was defined. CONCLUSIONS Interdisciplinary high-quality care requires thorough and standardised reporting across specialties. This topical review offers an actionable framework and practice recommendations to optimise reporting in endoscopy, surgery, and histopathology.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Roger Feakins
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham, UK.,Division of Gastroenterology, University Hospitals Birmingham NHS Trust, UK
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano,Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Rosanna Cannatelli
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK.,Gastroenterology Unit, Spedali Civili di Brescia, Brescia, Italy
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Ann Driessen
- Department of Pathology, University Hospital Antwerp, University Antwerp, Edegem, Belgium
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy.,Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Georgios Peros
- Department of Surgery, Cantonal Hospital of Winterthur, Winterthur, Switerland; Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Henit Yanai
- Division of Gastroenterology, IBD Center, Rabin Medical Center, Petah Tikva, Israel
| | - Magali Svrcek
- Department of Pathology, Sorbonne Université, AP-HP, Saint-Antoine hospital, Paris, France
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12
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Schineis C, Ullrich A, Lehmann KS, Holmer C, Lauscher JC, Weixler B, Kreis ME, Seifarth C. Microscopic inflammation in ileocecal specimen does not correspond to a higher anastomotic leakage rate after ileocecal resection in Crohn's disease. PLoS One 2021; 16:e0247796. [PMID: 33661983 PMCID: PMC7932166 DOI: 10.1371/journal.pone.0247796] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/12/2021] [Indexed: 12/15/2022] Open
Abstract
Background Patients with Crohn’s disease suffer from a higher rate of anastomotic leakages after ileocecal resection than patients without Crohn’s disease. Our hypothesis was that microscopic inflammation at the resection margins of ileocecal resections in Crohn’s disease increases the rate of anastomotic leakages. Patients and methods In a retrospective cohort study, 130 patients with Crohn’s disease that underwent ileocecal resection between 2015 and 2019, were analyzed. Anastomotic leakage was the primary outcome parameter. Inflammation at the resection margin was characterized as “inflammation at proximal resection margin”, “inflammation at distal resection margin” or “inflammation at both ends”. Results 46 patients (35.4%) showed microscopic inflammation at the resection margins. 17 patients (13.1%) developed anastomotic leakage. No difference in the rate of anastomotic leakages was found for proximally affected resection margins (no anastomotic leakage vs. anastomotic leakage: 20.3 vs. 35.3%, p = 0.17), distally affected resection margins (2.7 vs. 5.9%, p = 0.47) or inflammation at both ends (9.7 vs. 11.8%, p = 0.80). No effect on the anastomotic leakage rate was found for preoperative hemoglobin concentration (no anastomotic leakage vs. anastomotic leakage: 12.3 vs. 13.5 g/dl, p = 0.26), perioperative immunosuppressive medication (62.8 vs. 52.9%, p = 0.30), BMI (21.8 vs. 22.4 m2/kg, p = 0.82), emergency operation (21.2 vs. 11.8%, p = 0.29), laparoscopic vs. open procedure (p = 0.58), diverting ileostomy (31.9 vs. 57.1%, p = 0.35) or the level of surgical training (staff surgeon: 80.5 vs. 76.5%, p = 0.45). Conclusion Microscopic inflammation at the resection margins after ileocecal resection in Crohn’s disease is common. Histologically inflamed resection margins do not appear to affect the rate of anastomotic leakages. Our data suggest that there is no need for extensive resections or frozen section to achieve microscopically inflammation-free resection margins.
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Affiliation(s)
- Christian Schineis
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andrea Ullrich
- Department of Pathology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kai S. Lehmann
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Johannes C. Lauscher
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Benjamin Weixler
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin E. Kreis
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Seifarth
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- * E-mail:
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13
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A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease. Int J Colorectal Dis 2021; 36:253-263. [PMID: 33048241 DOI: 10.1007/s00384-020-03786-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection. METHOD The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures. RESULTS The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates. CONCLUSION Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.
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14
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Larson DW, Abd El Aziz MA, Perry W, Behm KT, Shawki S, Mandrekar J, Mathis KL, Grass F. Surgical Resection for Crohn's and Cancer: A Comparison of Disease-Specific Risk Factors and Outcomes. Dig Surg 2021; 38:120-127. [PMID: 33503622 DOI: 10.1159/000511909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment. RESULTS The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001). CONCLUSIONS Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.
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Affiliation(s)
- David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Perry
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sherief Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jay Mandrekar
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,
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15
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Sakurai Kimura CM, Scanavini Neto A, Queiroz NSF, Horvat N, Camargo MGM, Borba MR, Sobrado CW, Cecconello I, Nahas SC. Abdominal Surgery in Crohn's Disease: Risk Factors for Complications. Inflamm Intest Dis 2020; 6:18-24. [PMID: 33850835 DOI: 10.1159/000510999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/17/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD. Methods A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018. Results Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively). Conclusion Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.
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Affiliation(s)
- Cintia Mayumi Sakurai Kimura
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Arceu Scanavini Neto
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Natally Horvat
- Department of Radiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Marcelo Rodrigues Borba
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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16
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Lowenfeld L, Cologne KG. Postoperative Considerations in Inflammatory Bowel Disease. Surg Clin North Am 2019; 99:1095-1109. [PMID: 31676050 DOI: 10.1016/j.suc.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of inflammatory bowel disease (IBD) is often multidimensional, requiring both medical and surgical therapies at different times throughout the course of the disease. Both medical and surgical treatments may be used in the acute setting, during a flare, or in a more elective maintenance role. These treatments should be planned as complementary and synergistic. Gastroenterologists and colorectal surgeons should collaborate to create a cohesive treatment plan, arranging the sequence and timing of various treatments. This article reviews the anticipated postoperative recovery after surgical treatment of IBD, possible postoperative complications, and considerations of timing surgery with medical therapy.
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Affiliation(s)
- Lea Lowenfeld
- Surgery, Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA
| | - Kyle G Cologne
- Surgery, Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA.
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17
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Nguyen GC, Du L, Chong RY, Jackson TD. Hypoalbuminaemia and Postoperative Outcomes in Inflammatory Bowel Disease: the NSQIP Surgical Cohort. J Crohns Colitis 2019; 13:1433-1438. [PMID: 31253985 PMCID: PMC6821313 DOI: 10.1093/ecco-jcc/jjz083] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The inflammatory bowel diseases [IBD], including Crohn's disease [CD] and ulcerative colitis [UC], frequently lead to bowel surgery. Hypoalbuminaemia has been shown to be a prognostic factor for outcomes following surgery for other indications, and we sought to determine its role in predicting IBD-related postoperative outcomes. METHODS We included patients who underwent IBD-related major abdominal surgery in the American College of Surgeons' National Surgical Quality Improvement Program [ACS-NSQIP] between 2005 and 2012. We assessed the impact of indicators of protein-energy malnutrition [PEM] including hypoalbuminaemia, weight loss, and body mass index on postoperative outcomes. RESULTS We identified 10 913 IBD patients [6082 Crohn's disease and 4831 ulcerative colitis] who underwent bowel surgery. The prevalence of modest and severe hypoalbuminaemia was 17% and 24%, respectively; 30-day mortality was higher in Crohn's patients with modest and severe hypoalbuminaemia compared with those with normal albumin levels preoperatively [0.7% vs 0.2%, p <0.05; 2.4% vs 0.2%, p <0.01]. The same was true for patients with UC with modest and severe hypoalbuminaemia [0.9% vs 0.1%, p <0.01; 5.6% vs 0.1%, p <0.01]. Overall infectious complications were more common in the presence of severe hypoalbuminaemia for CD [20% vs 13%, p <0.01]. and UC [28% vs 15%, p <0.01] patients. Last, there were higher rates of extra-intestinal, non-septic complications in both CD and UC patients with hypoalbuminaemia compared with those with normal albumin levels. CONCLUSIONS This study suggests that moderate-severe hypoalbuminaemia is associated with worse IBD-related postoperative outcomes and may have a role in preoperative risk stratification.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada,Corresponding author: Geoffrey C. Nguyen, MD, PhD, FRCPC, 600 University Ave, Suite 437, Toronto, Ontario, M5G 1X5, Canada. Tel.: 416-586-4800 ext. 2819; Fax: 416-586-5971;
| | - Lillian Du
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada
| | - Rachel Y Chong
- Lakeridge Health, Department of Medicine, Queen’s University, Oshawa, ON, Canada
| | - Timothy D Jackson
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada,University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada
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18
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Intra-abdominal Sepsis After Ileocolic Resection in Crohn's Disease: The Role of Combination Immunosuppression. Dis Colon Rectum 2018; 61:1393-1402. [PMID: 30303885 DOI: 10.1097/dcr.0000000000001153] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intra-abdominal sepsis complicates <10% of ileocolic resections for Crohn's disease, but the impact of combination immunosuppression and repeat resection on its development remains unknown. OBJECTIVE The purpose of this study was to determine risk factors for intra-abdominal sepsis after ileocolic resection, specifically examining the role of combination immunosuppression and repeat intestinal resection. DESIGN This was a retrospective review of patient records from 2007 to 2017. SETTINGS The study was conducted at a single-institution IBD tertiary referral center. PATIENTS Patients with a diagnosis of Crohn's disease who were undergoing ileocolic resection with primary anastomosis were included. Diverted patients were excluded. MAIN OUTCOME MEASURES Preoperative and intraoperative variables, including preoperative immunosuppressive regimens and previous intestinal resection, were evaluated as potential risk factors for intra-abdominal sepsis. RESULTS A total of 621 patients (55% women) underwent ileocolic resection for Crohn's disease; 393 (63%) were first-time resections. The rate of 30-day intra-abdominal sepsis was 8% (n = 50). On univariate analysis, triple immunosuppression (combination of a corticosteroid, immunomodulator, and biological) and previous intestinal resection were significantly associated with intra-abdominal sepsis. Both risk factors remained significant on multivariable analysis (OR for triple immunosuppression (vs none) = 3.53 (95% CI, 1.27-9.84); previous intestinal resection OR = 2.27 (95% CI, 1.25-4.13)). A significant trend was seen between an increasing number of these risk factors (triple immunosuppression and previous intestinal resection) and rate of intra-abdominal sepsis (5%, 12%, and 22% for 0, 1, and 2 risk factors; p < 0.01). A trend was observed between increasing number of previous intestinal resections and the rate of intra-abdominal sepsis (p < 0.01). LIMITATIONS This study is limited by its single-institution tertiary referral center scope. CONCLUSIONS Combination immunosuppression and previous intestinal resection were both associated with the development of intra-abdominal sepsis. In light of these results, surgeons should consider the effects of combination immunosuppression and a history of previous intestinal resection, in addition to other risk factors, when deciding which patients warrant temporary intestinal diversion. See Video Abstract at http://links.lww.com/DCR/A664.
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19
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Setoodeh S, Liu L, Boukhar SA, Singal AG, Westerhoff M, Waljee AK, Ahmed T, Gopal P. The Clinical Significance of Crohn Disease Activity at Resection Margins. Arch Pathol Lab Med 2018; 143:505-509. [DOI: 10.5858/arpa.2018-0011-oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Conflicting data about the clinical significance of microscopic Crohn disease (CD) activity at resection margins have led to varying practice patterns for routine reporting by pathologists.
Objective.—
To characterize the association between active disease at resection margins with postoperative CD recurrence and time-to-recurrence in the era of anti–tumor necrosis factor therapy.
Design.—
We performed a multicenter retrospective cohort study of 101 consecutive CD bowel resections during 10 years. Margin slides were reviewed, and CD activity at the margins was graded as none, mild, moderate, or severe. The association between microscopic CD activity at the margin with postoperative recurrence and time-to-recurrence were evaluated with logistic regression and Cox regression analyses, respectively.
Results.—
Crohn disease activity at resection margins was reported in 43% of pathology reports. Resection margins had CD involvement in 39.6% of cases, 20 of which were classified as mild, 6 as moderate, and 12 with severe CD activity. Although patients with mild (odds ratio, 1.14; 95% CI, 0.40–3.20) and moderate to severe (odds ratio, 1.97; 95% CI, 0.62–6.35) activity were at increased risk of disease recurrence, the differences were not statistically significant. Patients with mild (hazard ratio, 0.97; 95% CI, 0.50–1.91) and moderate to severe (hazard ratio, 1.29; 95% CI, 0.65–2.55) disease activity at margins did not have significantly different time-to-recurrence compared with those without disease activity.
Conclusions.—
Our study suggests CD activity at resection margins is not significantly associated with postoperative CD recurrence.
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Affiliation(s)
- Sasan Setoodeh
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Li Liu
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Sarag A. Boukhar
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Amit G. Singal
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Maria Westerhoff
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Akbar K. Waljee
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Tasneem Ahmed
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
| | - Purva Gopal
- From the Department of Pathology (Drs Setoodeh and Gopal) and the Division of Digestive and Liver Diseases (Drs Singal and Ahmed), UT Southwestern Medical Center, Dallas, Texas; the Department of Pathology, Mercy Medical Center, Baltimore, Maryland (Dr Liu); the Department of Pathology, University of Iowa Healthcare, Iowa City (Dr Boukhar); the Department of Pathology (Dr Westerhoff) and the Divi
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20
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Aaltonen G, Ristimäki A, Keränen I, Carpelan-Holmström M, Lepistö A. Does a histologically inflamed resection margin increase postoperative complications in patients with Crohn's disease? Scand J Gastroenterol 2018; 53:279-283. [PMID: 29431516 DOI: 10.1080/00365521.2018.1435717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Our study assessed whether the presence of histologically inflamed resection margins increased postoperative anastomotic complications in Crohn's disease (CD) patients. We also examined the influence of other risk factors for postoperative complications. MATERIALS AND METHODS Presence of chronic inflammation and activity of inflammation was scored from the resection margin specimens of 70 patients undergoing surgery due to CD. Anastomotic complications were recorded with a one-month follow-up. We also analysed other risk factors for postoperative complications, such as patient age, previous surgeries, preoperative C-reactive protein, faecal calprotectin, albumin and haemoglobin levels, American Society of Anesthesiologists (ASA) classification, preoperative immunosuppressive medication, surgical approach and the presence of intraoperative fistula or abscess. RESULTS In total, 46 patients (65.7%) had active inflammation in the bowel resection margin - 12 patients (17.1%) with mild, five patients (7.1%) with moderate and 29 patients (41.4%) with strong activity. We found 14 (20.0%) postoperative complications, of which three (4.6%) were anastomotic. The presence of active inflammation at the resection margin did not significantly influence the occurrence of postoperative anastomotic complications. None of the other risk factors examined significantly increased postoperative complications among our sample. CONCLUSIONS After bowel-sparing surgery for CD, the frequency of histologically inflamed resection margins is high. However, postoperative complication rate remains low. The current practice with resection of only the most affected bowel segments for CD seems to be a safe choice. We still need further research concerning risk factors for postoperative complications in Crohn's patients.
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Affiliation(s)
- Gisele Aaltonen
- a Department of Colorectal Surgery , Helsinki University Hospital , Helsinki , Finland
| | - Ari Ristimäki
- b Department of Pathology , Research Programs Unit and HUSLAB University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Ilona Keränen
- a Department of Colorectal Surgery , Helsinki University Hospital , Helsinki , Finland
| | | | - Anna Lepistö
- a Department of Colorectal Surgery , Helsinki University Hospital , Helsinki , Finland
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21
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Liu X, Wu X, Zhou C, Hu T, Ke J, Chen Y, He X, Zheng X, He X, Hu J, Zhi M, Gao X, Hu P, Wu X, Lan P. Preoperative hypoalbuminemia is associated with an increased risk for intra-abdominal septic complications after primary anastomosis for Crohn's disease. Gastroenterol Rep (Oxf) 2017; 5:298-304. [PMID: 29230300 PMCID: PMC5691863 DOI: 10.1093/gastro/gox002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/11/2016] [Accepted: 12/21/2016] [Indexed: 12/18/2022] Open
Abstract
Objective The aim of this study was to evaluate the impact of preoperative hypoalbuminemia on the development of intra-abdominal septic complications (IASCs) after primary anastomosis for patients with Crohn’s disease (CD). Methods All CD patients undergoing bowel resection with a primary anastomosis during the study period from 2007 to 2015 were enrolled. The association of preoperative hypoalbuminemia (<30 g/L) with the risk for IASCs were assessed using both univariate and multivariate analyses. Results A total of 124 eligible patients were included, 117 (94.4%) of whom had available preoperative albumin level. Preoperative hypoalbuminemia occurred in 13 (11.7%) patients. The duration from diagnosis to surgery was longer for patients with preoperative hypoalbuminemia than those without (p = 0.012). Patients with preoperative hypoalbuminemia were more likely to have a history of preoperative use of 5-aminosalicylic acid (p = 0.013) and have an intraoperative finding of small bowel obstruction (p = 0.015). Of all patients, 24 (19.4%) developed postoperative IASCs. Univariate analysis showed that patients with preoperative hypoalbuminemia had an increased risk for IASCs (p = 0.012). Multivariate analysis confirmed the association between preoperative hypoalbuminemia and IASCs (odds ratio 4.67, 95% confidence interval: 1.28–17.04, p = 0.02). Similar findings were also obtained when preoperative albumin level was analysed as a continuous variable (p = 0.019). Conclusions Preoperative hypoalbuminemia is a significant predictor for the development of postoperative IASCs in CD patients after bowel resection with a primary anastomosis. Favorable preoperative nutrition status might lessen the risk for IASCs.
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Affiliation(s)
- Xuanhui Liu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xianrui Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chi Zhou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Tuo Hu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yufeng Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaosheng He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaobin Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Min Zhi
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiang Gao
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Pinjin Hu
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaojian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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22
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Complications and Disease Recurrence After Primary Ileocecal Resection in Pediatric Crohn's Disease: A Multicenter Cohort Analysis. Inflamm Bowel Dis 2017; 23:272-282. [PMID: 28079626 DOI: 10.1097/mib.0000000000000999] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies on the outcome of ileocecal resection in pediatric Crohn's disease (CD) have a limited follow-up and fail to assign predictors of adverse outcomes. Therefore, we aimed to investigate (I) the complication and disease recurrence rates and (II) identify risk factors for these adverse outcomes after ileocecal resection for pediatric CD. METHODS This is a retrospective cohort analysis of all children (<18 years) that underwent ileocecal resection as first intestinal resection for CD derived from 7 tertiary hospitals in the Netherlands (1990-2015). Risk factors were identified using multivariable analysis. RESULTS In total, 122 children were included (52% male; median age 15.5 years [interquartile range 14.0-16.0]). Severe postoperative complications rate was 10%. Colonic disease (odds ratio: 5.6 [95% confidence interval {CI}: 1.3-26.3], P = 0.024), microscopically positive resection margins (odds ratio: 10.4 [95% CI: 1.1-100.8] P = 0.043), and emergency surgery (odds ratio: 6.8 [95% CI: 1.1-42.2], P = 0.038) were risk factors for severe complications. Clinical and surgical recurrence rates after 1, 5 and 10 years were 19%, 49%, 71% and 2%, 12%, 22%, respectively. Female sex (hazard ratio [HR]: 2.1 [95% CI: 1.1-3.8], P = 0.023) was a risk factor for clinical recurrence, whereas ileocecal disease (HR: 3.9 [95% CI: 1.2-12.5], P = 0.024) and microscopically positive resection margins (HR: 9.6 [95% CI: 1.2-74.5], P = 0.031) were risk factors for surgical recurrence. Immediate postoperative therapy reduced the risk of both clinical (HR: 0.3 [95% CI: 0.1-0.6], P = 0.001) and surgical (HR: 0.5 [95% CI: 0.1-0.9], P = 0.035) recurrence. CONCLUSIONS Ileocecal resection is an effective and durable treatment of pediatric CD, although postoperative complications occur frequently. Postoperative therapy may be started immediately to prevent disease recurrence.
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Abstract
The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.
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24
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Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
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25
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Morar PS, Faiz O, Warusavitarne J, Brown S, Cohen R, Hind D, Abercrombie J, Ragunath K, Sanders DS, Arnott I, Wilson G, Bloom S, Arebi N. Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures. Aliment Pharmacol Ther 2015; 42:1137-48. [PMID: 26358739 DOI: 10.1111/apt.13388] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/16/2015] [Accepted: 08/11/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. AIM To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. METHODS A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. RESULTS Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. CONCLUSIONS Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.
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Affiliation(s)
- P S Morar
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
| | - J Warusavitarne
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
| | - S Brown
- Sheffield Teaching Hospitals, Sheffield, UK
| | - R Cohen
- University College Hospital, London, UK
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - J Abercrombie
- NIHR Nottingham Digestive Disease Biomedical Research Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Ragunath
- NIHR Nottingham Digestive Disease Biomedical Research Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - I Arnott
- Departments of Gastroenterology and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - G Wilson
- Departments of Gastroenterology and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - S Bloom
- University College Hospital, London, UK
| | - N Arebi
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
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Crowell KT, Messaris E. Risk factors and implications of anastomotic complications after surgery for Crohn’s disease. World J Gastrointest Surg 2015; 7:237-242. [PMID: 26523211 PMCID: PMC4621473 DOI: 10.4240/wjgs.v7.i10.237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/15/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
Anastomotic complications occur more frequently in patients with Crohn’s disease leading to postoperative intra-abdominal septic complications (IASC). Patients with IASC often require re-operation or drainage to control the sepsis and have an increased frequency of disease recurrence. The aim of this article was to examine the factors affecting postoperative IASC in Crohn’s disease after anastomoses, since some risk factors remain controversial. Studies investigating IASC in Crohn’s operations were included, and all risk factors associated with IASC were evaluated: nutritional status, presence of abdominal sepsis, medication use, Crohn’s disease type, duration of disease, prior operations for Crohn’s, anastomotic technique, extent of resection, operative timing, operative length, and perioperative bleeding. In this review, the factors associated with an increased risk of IASC are preoperative weight loss, abdominal abscess present at time of surgery, prior operation, and steroid use. To prevent IASC in Crohn’s patients, preoperative optimization with nutritional supplementation or drainage of abscess should be performed, or a diverting stoma should be considered for patients with multiple risk factors.
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27
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Li Y, Stocchi L, Shen B, Liu X, Remzi FH. Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease. Br J Surg 2015; 102:1418-25; discussion 1425. [PMID: 26313750 DOI: 10.1002/bjs.9906] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/03/2015] [Accepted: 06/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear. METHODS An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013. RESULTS Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028). CONCLUSION Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.
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Affiliation(s)
- Y Li
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - L Stocchi
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - B Shen
- Departments of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - X Liu
- Departments of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - F H Remzi
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Cayci M, Bostanci EB, Turhan N, Karaman K, Dalgic T, Ozer I, Ercan M, Ulas M, Akoglu M. The analysis of clinico-pathologic characteristics in patients who underwent surgery due to stricturing and non-perineal fistulizing forms of Crohn's disease: a retrospective cohort study. Int J Surg 2015; 15:49-54. [PMID: 25647540 DOI: 10.1016/j.ijsu.2015.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 01/25/2015] [Accepted: 01/29/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND The diagnosis of Crohn's disease is based mainly on the patient's history and clinical examination and supported by serologic, radiologic, endoscopic, and histologic findings. AIMS The main purpose of the present study was to evaluate in a retrospective manner the clinico-pathological characteristics of patients who underwent surgery due to stricturing or non perineal fistulizing Crohn's disease. MATERIAL AND METHODS Between January 2007 and June 2012, 75 patients who were operated on for stricturing and non-perineal fistulizing forms of Crohn's disease were analyzed according to their clinico-pathological characteristics. RESULTS The L3 localization (Montreal Classification) was detected significantly more often in the non-perineal fistulizing group than in the stricturing group (P < 0.03). Wound infection (18 patient, 24%) was the most commonly observed postoperative complication, followed by postoperative ileus (5 patients, 6.7%) and intraabdominal abscess (4 patients, 5.2%). The distribution of postoperative complications according to the two groups was not significantly different (P = 0.772). Submucosal fibrosis, ulcers and transmural inflammation were the three most common histopathological signs in resected specimens from both groups. Pseudopolyps, microabscess, granuloma, mononuclear inflammation and deep fissures were significantly far more frequent in the non perineal fistulizing group when compared to the stricturing group (P < 0.05). On the other hand, superficial ulcers were significantly more frequent in the stricturing group (P = 0.007). CONCLUSION No specific clinical feature was found to differentiate patients with the stricturing form of Crohn's disease from the fistulizing form. However, histopathological analysis of the resected specimens revealed significant differences in some parameters between the two disease forms.
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Affiliation(s)
- Murat Cayci
- Sevket Yilmaz Teaching and Research Hospital, Department of Gastroenterological Surgery, Bursa, Turkey.
| | - Erdal Birol Bostanci
- Sakarya University, Faculty of Medicine, Department of General Surgery, Sakarya, Turkey
| | - Nesrin Turhan
- Turkiye Yuksek Ihtisas Teaching and Research Hospital, Department of Pathology, Ankara, Turkey
| | - Kerem Karaman
- Sakarya University, Faculty of Medicine, Department of General Surgery, Sakarya, Turkey
| | - Tahsin Dalgic
- Turkiye Yuksek Ihtisas Teaching and Research Hospital, Department of Gastroenterological Surgery, Ankara, Turkey
| | - Ilter Ozer
- Turkiye Yuksek Ihtisas Teaching and Research Hospital, Department of Gastroenterological Surgery, Ankara, Turkey
| | - Metin Ercan
- Sakarya University, Faculty of Medicine, Department of General Surgery, Sakarya, Turkey
| | - Murat Ulas
- Turkiye Yuksek Ihtisas Teaching and Research Hospital, Department of Gastroenterological Surgery, Ankara, Turkey
| | - Musa Akoglu
- Sakarya University, Faculty of Medicine, Department of General Surgery, Sakarya, Turkey
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Huang W, Tang Y, Nong L, Sun Y. Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn's disease: A meta-analysis of observational studies. J Crohns Colitis 2015; 9:293-301. [PMID: 25572276 DOI: 10.1093/ecco-jcc/jju028] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Postoperative intra-abdominal septic complications [IASCs] are the most feared risks of surgery for Crohn's disease[CD]. The risk factors for IASCs still remain controversial. The aim of this study was to assess the risk factors for IASCs in CD patients undergoing abdominal surgery. METHODS MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for IASCs in CD patients. A meta-analysis was conducted to investigate the impact of various risk factors on IASCs in CD. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels. RESULTS This review included 15 studies evaluating 3807 patients undergoing 4189 operations. The meta-analyses found that low albumin levels (odds ratio [OR]: 1.93; 95% confidence interval [CI]: 1.362.75), preoperative steroids use [OR: 1.99; 95% CI: 1.54-2.57], a preoperative abscess [OR: 1.94; 95% CI: 1.263.0], previous surgery history [OR: 1.50; 95% CI: 1.151.97] may be risk factors for IASCs. There were no associations between anastomosis methods [OR: 0.94; 95% CI: 0.58-1.53], biologics therapy [OR: 1.29; 95% CI: 0.792.11], and immunomodulator use [OR: 1.07; 95% CI: 0.661.73] with the risk of IASCs. Due to observational design, the quality of evidence was regarded low or moderate for these risk factors by the GRADE approach. CONCLUSIONS This meta-analysis provides some evidence that steroids use, previous surgical history, a preoperative abscess, and low albumin levels may be associated with higher rates of IASCs in CD. Knowledge about those risk factors may influence treatment and procedure-related decisions, and possibly reduce the ss rate.
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Affiliation(s)
- Wenpeng Huang
- Department of General Surgery, Third Affiliated Hospital of Guangxi Traditional Chinese Medicinal University, Liuzhou, Guangxi, China
| | - Yanbo Tang
- Department of Gastroenterology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Legen Nong
- Department of Laboratory, Youjiang Medical College For Nationalities, Youjiang, Guanxi, China
| | - Yifan Sun
- Department of Laboratory, Third Affiliated Hospital of Guangxi Traditional Chinese Medicinal University, Liuzhou, Guangxi, China
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30
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Moran GW, Dubeau MF, Kaplan GG, Yang H, Seow CH, Fedorak RN, Dieleman LA, Barkema HW, Ghosh S, Panaccione R. Phenotypic features of Crohn's disease associated with failure of medical treatment. Clin Gastroenterol Hepatol 2014; 12:434-42.e1. [PMID: 23978351 DOI: 10.1016/j.cgh.2013.08.026] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 08/08/2013] [Accepted: 08/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is conflicting evidence on the effects of thiopurines (azathioprine or mercaptopurine) and anti-tumor necrosis factor (TNF) therapies on rates of surgery among patients with Crohn's disease (CD). We aimed to identify factors that identify patients who are unlikely to respond to medical therapy and will therefore require surgery. METHODS We performed a retrospective study using the Alberta Inflammatory Bowel Disease Consortium registry to identify 425 patients diagnosed with CD who received a prescription of a thiopurine and/or an anti-TNF agent from a referral center, from July 1, 1975, through September 13, 2012. We collected data on CD-related abdominal surgery after therapy and disease features when therapy was instituted. Cox proportional regression models were used to associate disease features with outcomes after adjusting for potential confounders. Risk estimates were presented as hazard rate ratios (HRRs) with 95% confidence intervals (CIs). RESULTS Among patients given thiopurines, stricturing disease (adjusted HR, 4.63; 95% CI, 2.00-10.71), ileal location (adjusted HR, 6.20; 95% CI, 1.64-23.42), and ileocolonic location (adjusted HR, 3.71; 95% CI, 1.08-12.74) at the time of prescription were associated significantly with the need for surgery. Prescription of an anti-TNF agent after prescription of a thiopurine reduced the risk for surgery, compared with patients prescribed only a thiopurine (adjusted HR, 0.41; 95% CI, 0.22-0.75). Among patients given anti-TNF agents, stricturing (adjusted HR, 6.17; 95% CI, 2.81-13.54) and penetrating disease (adjusted HR, 3.39; 95% CI, 1.45-7.92) at the time of prescription were associated significantly with surgery. Older age at diagnosis (17-40 y) reduced the risk for abdominal surgery (adjusted HR, 0.41; 95% CI, 0.21-0.80) compared with a younger age group (≤16 y). Surgery before drug prescription reduced the risk for further surgeries among patients who received thiopurines (adjusted HR, 0.33; 95% CI, 0.13-0.68) or anti-TNF agents (adjusted HR, 0.49; 95% CI, 0.25-0.96). Terminal ileal disease location was not associated with a stricturing phenotype. CONCLUSIONS Based on a retrospective database analysis, patients prescribed thiopurine or anti-TNF therapy when they have a complicated stage of CD are more likely to require surgery. Better patient outcomes are achieved by treating CD at early inflammation stages; delayed treatment increases rates of treatment failure.
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Affiliation(s)
- Gordon W Moran
- Inflammatory Bowel Disease Clinic, University of Calgary, Alberta, Canada; Division of Gastroenterology, University of Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Alberta, Canada; Nottingham Digestive Diseases Centre, Biomedical Research Unit, University of Nottingham, Nottingham, United Kingdom
| | - Marie-France Dubeau
- Inflammatory Bowel Disease Clinic, University of Calgary, Alberta, Canada; Division of Gastroenterology, University of Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Inflammatory Bowel Disease Clinic, University of Calgary, Alberta, Canada; Division of Gastroenterology, University of Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Hong Yang
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Cynthia H Seow
- Inflammatory Bowel Disease Clinic, University of Calgary, Alberta, Canada; Division of Gastroenterology, University of Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Alberta, Canada
| | - Richard N Fedorak
- Division of Gastroenterology, Department of Medicine University of Alberta, Edmonton, Alberta, Canada
| | - Levinus A Dieleman
- Division of Gastroenterology, Department of Medicine University of Alberta, Edmonton, Alberta, Canada
| | - Herman W Barkema
- Department of Community Health Sciences, University of Calgary, Alberta, Canada; Department of Production Animal Health, University of Calgary, Alberta, Canada
| | - Subrata Ghosh
- Inflammatory Bowel Disease Clinic, University of Calgary, Alberta, Canada; Division of Gastroenterology, University of Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Alberta, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, University of Calgary, Alberta, Canada; Division of Gastroenterology, University of Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Alberta, Canada.
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Positive histological margins are risk factors for intra-abdominal septic complications after ileocolic resection for Crohn's disease? Dis Colon Rectum 2013; 56:e50. [PMID: 23478622 DOI: 10.1097/dcr.0b013e3182821daa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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The author replies. Dis Colon Rectum 2013; 56:e50. [PMID: 23478623 DOI: 10.1097/dcr.0b013e3182821dc1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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