A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis

The Clinical Relevance of an Inflamed Appendix in Crohn's Disease

BACKGROUND AND AIMS

An appendectomy for appendiceal inflammation has been suggested to ameliorate the clinical course of patients with ulcerative colitis [UC]. In contrast, for Crohn's disease [CD] an inverse association has been suggested with a higher incidence of CD and worse prognosis after appendectomy. The aim of this study was to analyse the clinical relevance of an inflamed appendix in CD patients undergoing ileocaecal resection [ICR].

METHODS

All consecutive patients undergoing primary ICR between 2007 and 2018 were considered for inclusion. Microscopic data of available appendiceal resection specimens [n = 99] were revised by a dedicated inflammatory bowel disease [IBD] pathologist and scored as inflamed or not inflamed. Eighteen patients had a previous appendectomy. Pathological findings were correlated with disease characteristics and recurrence rates [clinical, endoscopic, and intervention-related].

RESULTS

In total 117 patients were included, 77 [65.8%] females, with a median age of 30 years (interquartile range [IQR] 24-43), and a median follow up of 102 months [IQR 76-114]. Of patients without previous appendectomy [n = 99], 39% had an inflamed appendix. No significant differences in disease characteristics [eg, disease location, behaviour, time to surgery] or prognosis could be demonstrated between the two groups. In contrast, previous appendectomy [n = 18] was associated with penetrating disease and numerically shorter disease duration at the time of resection. Furthermore, a trend was seen towards a stronger association with postoperative recurrence.

CONCLUSION

The current study could not confirm a different prognosis for CD patients with and without an inflamed appendix. In contrast, in patients with a previous appendectomy, a trend was seen towards increased postoperative recurrence, which might be related to the higher incidence of penetrating disease.

First Mexican Consensus on Crohn's disease

INTRODUCTION

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of Colonic Emergencies

The etiology of colonic emergencies includes a wide-ranging and diverse set of pathologic conditions. Fortunately, for the surgeon treating a patient with one of these emergencies, the surgical management of these various causes is limited to choosing among proximal diversion, segmental colectomy with or without proximal diversion, or a total abdominal colectomy with end ileostomy (or rarely, an ileorectal anastomosis). The nuanced complexity in these situations usually revolves around the nonsurgical and/or endoscopic options and deciding when to proceed to the operating room.

The Role of Adipose Tissue Mesenchymal Stem Cells in Colonic Anastomosis Healing in Inflammatory Bowel Disease: Experimental Study in Rats

(1) Background: A surgical operation on an inflamed bowel is, diachronically, a challenge for the surgeon, especially for patients with inflammatory bowel disease. Adipose tissue-derived mesenchymal stromal cells are already in use in clinical settings for their anti-inflammatory properties. The rationale of the current study was to use AdMSCs in high-risk anastomoses to monitor if they attenuate inflammation and prevent anastomotic leak. (2) Methods: a total of 4 groups of rats were subjected to a surgical transection of the large intestine and primary anastomosis. In two groups, DSS 5% was administered for 7 days prior to the procedure, to induce acute intestinal inflammation. After the anastomosis, 5 × 106 autologous AdMSCs or an acellular solution was injected locally. Macroscopic evaluation, bursting pressure, hydroxyproline, and inflammatory cytokine expression were the parameters measured on the 8th post-operative day. (3) Results: Significantly less intra-abdominal complications, higher bursting pressures, and a decrease in pro-inflammatory markers were found in the groups that received AdMSCs. No difference in VEGF expression was observed on the 8th post-operative day. (4) Conclusions: AdMSCs attenuate inflammation in cases of acutely inflamed anastomosis.

Long-term Outcomes and Factors Predicting Outcome of IPAA When Used Intentionally for Well-Defined Crohn's Disease

BACKGROUND

Crohn's disease is considered a contraindication for IPAA. In our prior study, when IPAA was used intentionally for well-defined Crohn's disease, we found a high incidence of recurrent disease with a low incidence of pouch failure.

OBJECTIVE

This study aimed to replicate these findings in a larger cohort over a longer period.

DESIGN

Retrospective review of a prospective IBD registry.

SETTINGS

Large IBD referral center.

PATIENTS

Patients with preoperative colorectal Crohn's disease requiring surgery were included in the study.

INTERVENTION

IPAA.

MAIN OUTCOME MEASURES

Long-term Crohn's disease recurrence, pouch failure, and pouch function.

RESULTS

Forty-six patients were identified. Crohn's disease was diagnosed on the basis of perianal disease (n = 18; 39%), small-bowel disease (n = 16; 35%), noncaseating granuloma (n = 10; 22%), and discontinuous inflammation (colorectal skip lesions) (n = 11; 24%). After a median follow-up of 93 (7-291) months, 22 patients (48%) developed recurrent Crohn's disease based on afferent limb disease (n = 14; 30%) or pouch fistulizing disease (n = 8; 18%). Only 4 patients (9%) developed pouch failure. No clinical factor was associated with Crohn's disease recurrence. Young age at the time of surgery and short duration of disease before IPAA were associated with pouch fistula recurrence ( p = 0.003 and p = 0.03, respectively). Most patients (86%) reported excellent continence, with no urgency (67%) and median stool frequency of 6 (range, 3-9) per day.

LIMITATION

Retrospective nature and relatively small sample size.

CONCLUSION

This largest reported series examining the intentional use of IPAA in Crohn's disease showed a high (48%) incidence of postoperative Crohn's disease with a low (9%) incidence of pouch failure. Young age and short disease course before surgery were risk factors for poor outcomes. Highly motivated patients with colorectal Crohn's disease may consider IPAA and avoid a definitive ileostomy. See Video Abstract at http://links.lww.com/DCR/C171 .

RESULTADOS A LARGO PLAZO Y FACTORES PREDICTORES DE RESULTADOS DE LA ANASTOMOSIS ILEOANAL CON RESERVORIO CUANDO SE USA INTENCIONALMENTE PARA LA ENFERMEDAD DE CROHN BIEN DEFINIDA

ANTECEDENTES: La enfermedad de Crohn (EC) se considera una contraindicación para la anastomosis ileoanal con reservorio (IPAA). Nuestro estudio previo de IPAA cuando fue usada intencionalmente para EC bien definida mostró una alta incidencia de enfermedad recurrente con una baja incidencia de falla del reservorio.OBJETIVO: Replicar estos hallazgos en una cohorte más grande durante un período más largo.DISEÑO: Revisión retrospectiva de una base de datos prospectiva de enfermedad inflamatoria intestinal.ESCENARIO: Un centro grande de referencia de EII.PACIENTES: EC colorrectal preoperatoria con necesidad de tratamiento quirúrgico.INTERVENCIÓN: Anastomosis ileoanal con reservorio.RESULTADOS PRINCIPALES: Recurrencia de EC a largo plazo, falla del reservorio y función del reservorio.RESULTADOS: Cuarenta y seis pacientes fueron identificados. El diagnóstico de EC se basó en enfermedad perianal (n = 18; 39%), enfermedad del intestino delgado (n = 16; 35%), granuloma no caseificante (n = 10; 22%) e inflamación discontinua (lesiones salteadas colorrectales) (n = 11; 24%). Después de una mediana de seguimiento de 93 (7-291) meses, 22 (48 %) pacientes desarrollaron EC recurrente debido a enfermedad del asa aferente (n = 14; 30%) o enfermedad fistulizante del reservorio (n = 8; 18%). Solo 4 (9%) pacientes desarrollaron falla del reservorio. Ningún factor clínico se asoció con la recurrencia de EC. La edad joven en el momento de la cirugía y la corta duración de la enfermedad antes de IPAA se asociaron con la recurrencia de la fístula del reservorio ( p = 0.003 y p = 0.03, respectivamente). El recuento de plaquetas preoperatorio más alto fue la única característica clínica significativamente asociada con el fracaso del reservorio ( p = 0.02). La mayoría de los pacientes (86%) reportaron una continencia excelente, sin urgencia (67%) y una mediana de frecuencia evacuatoria de 6 (rango, 3-9) por día.LIMITACIONES: Naturaleza retrospectiva y tamaño de muestra relativamente pequeño.CONCLUSIÓN: Esta serie, la más grande reportada que examina el uso intencional de IPAA en la EC mostró una incidencia alta (48Rectal Cancer: Clinical and Molecular Predictors of a Complete Response to Total Neoadjuvant Therapy%) de EC posoperatoria con una incidencia baja (9%) de falla del reservorio. La edad joven y el curso corto de la enfermedad antes de la cirugía fueron factores de riesgo para pobres resultados. Pacientes altamente motivados con EC colorrectal pueden considerar una IPAA y evitar una ileostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/C171 . (Traducción-Dr. Jorge Silva Velazco ).

Segmental Versus Total Colectomy for Crohn's Disease in the Biologic Era: Results From The SCOTCH International, Multicentric Study

BACKGROUND

The extent of resection in colonic Crohn's disease [cCD] is still a topic of debate, depending on the number of locations, the risk of recurrence and permanent stoma, and the role of medical therapy.

METHODS

The Segmental COlecTomy for CroHn's disease [SCOTCH] international study is a retrospective analysis on six tertiary centre prospective databases, comprising all consecutive, unselected patients operated on between 2000 and 2019 with segmental colectomy [SC] or total colectomy [TC] for cCD. The primary aim was long-term surgical recurrence. Secondary aims were perioperative complications, stoma formation and predictors of recurrence.

RESULTS

Among 687 patients, SC was performed in 285 [41.5%] and TC in 402 [58.5%]. Mean age at diagnosis and surgery, disease duration, and follow-up were 30 ± 15.8, 40.4 ± 15.4, 10.4 ± 8.6 and 7.1 ± 5.2 years respectively. Isolated cCD, inflammatory pattern, perianal CD, younger age, longer disease duration and preoperative maximal therapy were more frequent in TC, while SC presented more small bowel locations and perforating disease, required fewer 90-day re-admissions, and fewer temporary and definitive stomas. Morbidity and mortality were similar. The 15-year surgical recurrence was 44% in TC and 27% in SC [p = 0.006]. In patients with one to three diseased segments, recurrence risk was related to the omission of biological therapy (hazard ratio [HR] 5.6), the number of segments [HR 2.5], perianal disease [HR 1.9] and paediatric diagnosis [HR 2.8].

CONCLUSION

When technically feasible, SC is safe and reduces temporary and permanent stoma. Young age, number of locations and perianal disease adversely affect, but postoperative biological therapy significantly reduces, the long-term surgical recurrence.

[Ileal pouch after restorative coloproctectomy]

The continuous development of pouch surgery has enabled continence-preserving treatment after coloproctectomy. The ileoanal J‑pouch is nowadays the standard reconstruction after restorative coloproctectomy with excellent functional long-term results. Taking the relative contraindications and a suitable patient selection into consideration, pouch placement can be indicated not only for ulcerative colitis and familial adenomatous polyposis, but also for patients with nonfistular Crohn's disease. Due to a high treatment density with immunosuppressants, the surgical treatment regimen should be subdivided into a multistage procedure, whereby according to current data a modified two-stage procedure should be favored.

Quality of Life in Inflammatory Bowel Diseases (IBDs) Patients after Surgery

Inflammatory Bowel Diseases (IBDs) are chronic, relapsing and disabling diseases that affect the gastrointestinal tract. This relapsing course is often unpredictable with severe flares and the need for intensive medical treatment, hospitalization, or emergent/urgent surgery, all of which significantly impact patients' quality of life (QoL). QoL in IBD patients is significantly lower than in the general population, and depression and anxiety have been shown to have a higher prevalence than in healthy individuals, especially during disease flares. Complications requiring hospitalization and repeated surgeries are not uncommon during the disease course and significantly affect QoL in IBD patients. Patient-reported outcome measures (PROMs) can be used to measure the impact of chronic disease on QoL from the patient's perspective. The use of PROMs in IBD patients undergoing surgery could help to investigate the impact of the surgical procedure on QoL and determine whether there is any improvement or worsening. This review summarizes the use of PROMs to assess QoL after various surgical procedures required for IBD treatment.

Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn's Disease: Results from an International Multicentre Study

BACKGROUND AND AIMS

Crohn's disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn's disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach.

METHODS

This was a retrospective database analysis of Crohn's disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications.

RESULTS

Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older [p = 0.0429], had less extensive colitis [p = 0.0002] and no preoperatively identified synchronous lesions [p = 0.0109].Median follow-up was 43 [31-62] months. There was no difference in unadjusted progression-free survival [p = 0.2570] or in overall survival [p = 0.4191] between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio [HR] 1.00, p = 0.9993) or overall survival [HR 0.77, p = 0.6654]. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable [7.58% vs 6.06%, p = 0.9998].

CONCLUSIONS

Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

State-of-the-art surgery for Crohn's disease: Part II-colonic Crohn's disease and associated neoplasms

Despite advances in medical therapy, surgery continues to play a vital role in the management of Crohn's disease and its complications. Continuing from Part I of this series (small intestine/ileal disease), we focus next on colonic Crohn's disease and associated neoplasms. We will first review the surgical management of medical-refractory Crohn's colitis and its complications and then examine cancer risk, surveillance, and surgical management of Crohn's-associated colorectal dysplasia and malignancy. We conclude with a discussion of restoration of gastrointestinal continuity following colonic surgery for Crohn's disease.

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

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

Endoscopic balloon dilation of colorectal strictures complicating Crohn's disease: a multicenter study

INTRODUCTION

While endoscopic balloon dilation (EBD) is widely used to manage ileal strictures, EBD of colorectal strictures remains poorly investigated in Crohn's disease (CD).

METHODS

We performed a retrospective study that included all consecutive CD patients who underwent EBD for native or anastomotic colorectal strictures in 9 tertiary centers between 1999 and 2018. Factors associated with EBD failure were also investigated by logistic regression.

RESULTS

Fifty-seven patients (25 women, median age: 36 years (InterQuartile Range, 31-48) were included. Among the 60 strictures, 52 (87%) were native, 39 (65%) measured < 5 cm and the most frequent location was the left colon (27%). Fifty-seven (95%) were non-passable by the scope and 35 (58%) were ulcerated. Among the 161 EBDs performed (median number of dilations per stricture: 2, IQR 1-3), technical and clinical success were achieved for 79% (n = 116/147) and 77% (n = 88/115), respectively. One perforation occurred (0.6% per EDB and 2% per patient). After a median follow-up of 4.3 years (IQR 2.0-8.4), 24 patients (42%) underwent colonic resection and 24 (42%) were asymptomatic without surgery. One colon lymphoma and one colorectal cancer were diagnosed (3.5% of patients) from endoscopic biopsies and at the time of surgery, respectively. No factor was associated with technical or clinical success.

CONCLUSION

EDB of CD-associated colorectal strictures is feasible, efficient and safe, with more than 40% becoming asymptomatic without surgery.

Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn's disease

AIM

In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon.

METHODS

A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates.

RESULTS

A total of 63 patients were included; mean age was 47 years (SD 15 years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n = 56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n = 54; 85.7%) versus neoplasia (n = 9; 14.3%). The median length of long-term follow-up was 17.7 months (IQR: 4.72, 38.7 months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon.

CONCLUSION

Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.

Decreasing Trends in Intestinal Resection and Re-Resection in Crohn's Disease: A Nationwide Cohort Study

OBJECTIVE

To assess time trends in intestinal resection and re-resection in Crohn's disease (CD) patients.

SUMMARY OF BACKGROUND DATA

CD treatment has changed considerably over the past decades. The effect of these advances on the necessity of intestinal resections and the risk of re-resection is unclear.

METHODS

In this nationwide cohort study, adult CD patients with ileocolonic, small bowel, colon, or rectum resections between 1991 and 2015 were included. Data were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology (PALGA). Time trends were analyzed with a broken stick model and Cox proportional hazard model with smoothing splines.

RESULTS

The identified cohort comprised 8172 CD patients (3293/4879 male/female) in whom 10,315 intestinal resections were performed. The annual intestinal resection rate decreased nonlinearly from 1.9/100,000 (1991) to 0.2/100,000 (2015). A significantly steeper-decrease was observed before 1999 (slope –0.13) as compared to subsequent years (slope –0.03) (p<0.001). Analogous trends were observed for ileocolonic, small bowel, and colon resections. Overall cumulative risk of re-resection was 10.9% at 5 years, 18.6% at 10 years, and 28.3% at 20 years after intestinal resection. The hazard for intestinal re-resection showed a nonlinear decreasing trend, with hazard ratio 0.39 (95% confidence interval 0.36-0.44) in 2000 and hazard ratio 0.25 (95% confidence interval 0.18-0.34) in 2015 as compared to 1991.

CONCLUSION

Over the past 25 years, intestinal resection rate has decreased significantly for ileocolonic, small bowel, and colonic CD. In addition, current postoperative CD patients are at 75% lower risk of intestinal re-resection.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review

BACKGROUND

Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure.

OBJECTIVE

This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease.

DATA SOURCES

A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews.

STUDY SELECTION

The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected.

INTERVENTION

Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology.

MAIN OUTCOMES MEASURES

The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate.

RESULTS

Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified.

LIMITATIONS

This investigation was limited by the small number of studies with significant study heterogeneity.

CONCLUSION

In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

Colonic Crohn’s disease – decision is more important than incision: A surgical dilemma

The most common localization for intestinal Crohn’s disease (CD) is the terminal ileum and ileocecal area. It is estimated that patients with CD have one in four chance of undergoing surgery during their life. As surgery in ulcerative colitis ultimately cures the disease, in CD, regardless of the extent of bowel removed, the risk of disease recurrence is as high as 40%. In elective surgery, management of isolated Crohn’s colitis continues to evolve. Depending on the type of surgery performed, colonic CD patients often require further medical or surgical therapy to prevent or treat recurrence. The elective surgical treatment of colonic CD is strictly dependent on the localization of disease, and the choice of the procedure is dependent of the extent of colonic involvement and previous resection. The most common surgical options in colonic CD are total proctocolectomy (TPC) with permanent ileostomy, segmental bowel resection, subtotal colectomy. TPC completely removes all colonic and rectal disease and avoids the use of a potentially diseased anus. We will review current options for the elective surgical treatment of colonic CD, based on the current literature and our own personal experience.

Surgical management of Crohn's disease: a state of the art review

PURPOSE

The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions.

METHODS

A literature search of MEDLINE (PubMed) was conducted using the following search terms: 'Surgery' and 'Crohn'. Different current surgical treatment strategies are discussed based on disease location.

RESULTS

Several surgical options are possible in medically refractory or complex Crohn's disease as a last resort therapy. Recent evidence indicated that surgery could also be a good alternative in terms of effectiveness, quality of life and costs as first-line therapy if biologicals are considered, e.g. ileocolic resection for limited disease, or as part of combination therapy with biologicals, e.g. surgery aiming at closure of select perianal fistula in combination with biologicals. The role of the mesentery in ileocolic disease and Crohn's proctitis is an important surgical dilemma. In proctectomy, evidence is directing at removing the mesentery, and in ileocolic disease, it is still under investigation. Other surgical dilemmas are the role of the Kono-S anastomosis as a preventive measure for recurrent Crohn's disease and the importance of (non)conventional stricturoplasties.

CONCLUSION

Surgical management of Crohn's disease remains challenging and is dependent on disease location and severity. Indication and timing of surgery should always be discussed in a multidisciplinary team. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease rather than being a last resort therapy.

Ileostomy reversal after subtotal colectomy in Crohn's disease: a single institutional experience at a high-volume center

PURPOSE

Our aim was to evaluate factors leading to ostomy reversal among a group of 44 patients with Crohn's disease (CD) who underwent subtotal colectomy (STC) between June 2011 and September 2018.

METHODS

Our study design was a retrospective chart review. Patients with CD who underwent STC were included. Logistic regression analysis was used to evaluate several risk factors for non-reversal including medications received prior to surgery and indication for STC.

RESULTS

Of 44 STCs performed, 31 (70.5%) were completed laparoscopically and 13 required an open approach (29.5%). Nine patients (20.4%) underwent ostomy reversal, and the mean time to reversal was 8.4 months. Preoperative therapy with an immunomodulator or biologic was associated with ostomy reversal (OR and CI: 0.43, 0.09-0.93; 0.47, 0.10-0.96), as was a diagnosis of intraabdominal abscess (0.43, 0.09-0.93).

CONCLUSION

Ileostomy reversal after STC in Crohn's disease is uncommon. Certain treatment regimens and diagnostic factors may impact the likelihood of ostomy reversal. Based on the available data, patients with CD whose disease is severe enough to require STC should be counseled that their ostomy will most likely be permanent. However, due to the low incidence of this procedure for CD, more data is needed.

The Predictive Value of Inflammation at Ileocecal Resection Margins for Postoperative Crohn's Recurrence: A Cohort Study

BACKGROUND

Resections for Crohn's disease should be limited and only resect macroscopically affected bowel. However, recent studies suggest microscopic inflammation at resection margins as a predictor for postoperative recurrence. The clinical impact remains unclear, as non-uniform pathological criteria have been used. The aim of this study was to assess the predictive value of pathological characteristics at ileocecal resection margins for recurrence.

METHODS

Both resection margins of 106 consecutive patients undergoing ileocecal resection for Crohn's disease between 2002 and 2009 were revised and scored for active inflammation, myenteric plexitis, and granulomas. Pathological findings were correlated to recurrence, defined as recurrent disease activity demonstrated by endoscopy (modified Rutgeerts score ≥i2) requiring upscaling medical treatment, using multivariate analysis.

RESULTS

Active inflammation was found at the proximal and distal resection margin in 27% and 15% of patients, respectively, myenteric plexitis in 37% and 32%, respectively, and granulomas in 4% and 6%, respectively. In total, 47 out of 106 patients developed recurrence. Only active inflammation at the distal colonic resection margin was an independent significant predictor for recurrence (88% vs 43% vs 51% for distal, proximal, and no involved margins, respectively; P < 0.01).

CONCLUSION

Active inflammation at the distal colonic resection margin after ileocecal resection identifies a patient group at high risk for postoperative recurrence both at the anastomotic site and the colon because it identifies undiagnosed L3 disease. These patients have a different and more aggressive natural history and require more intense medical treatment. Therefore, pathological evaluation of the distal resection margin should be implemented in daily practice.

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

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

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

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

Is There a Role for Ileal Pouch Anal Anastomosis in Crohn's Disease?

Traditionally, surgical interventions for colonic Crohn's disease (CD) have been limited to total abdominal colectomy and ileorectal anastomosis, or total proctocolectomy with end ileostomy if there is rectal involvement. However, improved understandings of the biology of CD, as well as the development of biologic therapies, have enabled more limited resections. Here, we review the indications for, and limitations of, specific procedures aiming to preserve intestinal continuity in colonic CD.

Current Status of Segmental Colectomy in Select Crohn's Disease Patients

Crohn's disease is a complex disease with a varying clinical and anatomical spectrum. One-third of patients with Crohn's will have disease confined to the colon. In this article, the authors review the surgical treatment options for colonic Crohn's disease including the current status of performing segmental colectomy in colonic Crohn's, the pros and cons of segmental versus subtotal colectomy, and the influence of biologics on recurrence rates following segmental colectomy.

Predictive parameters of early postoperative complications in Crohn's disease: Single team experience

BACKGROUND/AIMS

Most of the patients with Crohn's disease (CD) may require at least one surgical procedure over their lifetime. However, these patients tend to have a high incidence of postoperative complications. The aim of this retrospective study was to investigate the predictive parameters of postoperative complications in CD.

MATERIALS AND METHODS

All consecutive patients with CD between March 2001 and March 2016 who underwent bowel resection were included to this study. Postoperative complications were divided as; major complications including anastomotic leakage, ostomy complications, acute mechanical intestinal obstruction and hemorrhage, and minor complications including wound infection.

RESULTS

A total of 147 patients (74 females, 73 males) with a mean age of 36±11.9 years met the inclusion criteria. Behaviors of CD were stricturing in 90 (62%), fistulizing in 45 (30%) and inflammatory in 12 (8%) patients. Minimally invasive approach was applied in 35% (n=51) of the patients. Twentysix (17%) patients had early (≤30 days) postoperative surgical complications including anastomotic leak (n=10), intra-abdominal bleeding (n=2), complications related to ostomy (n=2), acute mechanical intestinal obstruction (n=1) and wound infection (n=11). Only fistulizing disease behavior was associated with early postoperative complications (p=0.014).

CONCLUSION

This study suggests that postoperative complications are still more common in fistulizing CD. Surgical approach did not affect the complication rate. The decision should be individualized according to the prominent risk factors and surgeons' preference.

Surgery for Intestinal Crohn's Disease: Results of a multidisciplinary approach

OBJECTIVES

Crohn's disease is a chronic inflammatory bowel disease that requires lifelong multidisciplinary management. Seventy percent of patients affected by Crohn's disease will require at least one surgical procedure over their lifetime. The aim of this retrospective study was to present our series of patients suffering from Crohn's disease who were scheduled for surgery by a multidisciplinary team.

MATERIAL AND METHODS

The data were retrieved from a review of 950 patients with Crohn's disease treated at our institution between March 2000 and March 2016. Only patients with intestinal Crohn's disease were included into the study. A multidisciplinary team assessed the decision to perform surgery.

RESULTS

There were 203 patients who underwent surgery included in this study. One hundred and sixty-six were intestinal and 37 were perianal Crohn's disease. The mean age was 36±11.5 (range, 12-75) years. Ninety-two were stricturing, 45 were fistulizing, and 12 were inflammatory. The most commonly affected site was the ileocecal region (n=109, 65.7%), and the most common surgical procedure was the ileocecal resection (n=109, 65.6%). Laparoscopic approach was the procedure of choice in 56 (33.7%) patients. Of the patients enrolled, the most common early (<30 days) complications observed were the wound infection as the first (n=11) and anastomotic leak as the second (n=10). The mortality rate was 2.4% (n=4).

CONCLUSION

Multidisciplinary approach to Crohn's disease may decrease the surgical complications and recurrence rates leading to a better treatment.

New perspectives on the long-term outcome of segmental colectomy for Crohn's colitis: an observational study on 200 patients

BACKGROUND AND AIMS

Surgical management of Crohn's colitis represents one of the most complex situations in colorectal surgery. Segmental colectomy (SC) and total abdominal colectomy with ileorectal anastomosis (TAC-IRA) are the most common procedures, but there are few available data on their long-term outcome. The aim of the present study was to analyze the long-term outcome of patients who underwent segmental colectomy for Crohn's colitis, with regard to the risk for total abdominal colectomy.

METHODS

In this observational, monocentric, retrospective analysis, we analyzed patients who received a segmental colectomy for Crohn's colitis at our institution. The database was updated by asking patients to complete a questionnaire by telephone or at the outpatient clinic. Only patients followed up at our Hospital were included. Patients were followed up by a specialized multidisciplinary team (IBD Unit). The primary endpoint was the interval between segmental colectomy and, when performed, total abdominal colectomy.

RESULTS

Between 1973 and 2014, 200 patients underwent segmental colectomy for Crohn's colitis. The median follow-up was 13.5 years (interquartile range [IQR] 7.8-21.5). Overall, 62 patients (31%) had a surgical recurrence, of these, 42 (21%) received total abdominal colectomy. At multivariate analysis, the presence of ≥ 3 sites (HR = 2.47; 95% CI 1.22-5.00; p = 0.018) and perianal disease (HR = 3.23; 95% CI 1.29-8.07; p = 0.006) proved to be risk factors for total abdominal colectomy.

CONCLUSIONS

The risk for surgical recurrence after SC for Crohn's colitis is acceptable. We recommend a bowel-sparing policy for the treatment of Crohn's colitis in any case in which the extent of the disease at the moment of surgery makes the conservative approach achievable.

Colectomy in refractory Crohn's colitis improves nutrition and reduces steroid use

BACKGROUND

Pediatric patients with severe refractory Crohn's colitis (CC) may require total colectomy (TC) or diverting loop ileostomy (DLI). Our understanding of outcomes (postoperative complications, nutrition and restoration of intestinal continuity) is currently limited.

METHODS

Pediatric patients with severe CC who underwent TC or DLI were identified. Demographics, pre and postoperative anthropometric and biochemical data, surgical complications and medication requirements were recorded.

RESULTS

Twenty-seven patients (TC=22, DLI=5) with a median age of 15.0years (range 3-18) were identified, 64% male with a median follow-up of 45months (range 3-120). Mean weight and BMI improved for TC patients by 1year postoperatively - weight z-score from -1.08 to -0.54 (p=0.02), BMI z-score from -0.83 to -0.38 (p=0.04), with a non-significant height change from - 0.79 to -0.65 (p=0.07). Mean hemoglobin and albumin both also improved - 9.88g/dl to 11.76g/dl (p=0.003) and 3.44g/dl to 4.03g/dl (p=0.004) respectively. These measures did not significantly improve after DLI. Most TC patients (59%) had attempted restoration of intestinal continuity with 45% in continuity at end of follow-up. One DLI patient underwent ileostomy takedown but subsequently needed re-diversion.

CONCLUSIONS

In severe CC, TC offers an opportunity to improve nutrition and growth, with a reasonable likelihood of restoring intestinal continuity.

LEVEL OF EVIDENCE

Level IV - Case series.

A systematic review of segmental vs subtotal colectomy and subtotal colectomy vs total proctocolectomy for colonic Crohn's disease

AIM

Surgical management of colonic Crohn's disease (CD) is still unclear because different procedures can be adopted. The choice of operation is dependent on the involvement of colonic disease but the advantages and disadvantages of the extent of resection are still debated.

METHOD

The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileorectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). Studies published between 1984 and 2012 including comparisons of STC vs SC and of STC vs TPC were selected. The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma. Fixed effect models were used to evaluate the study outcomes.

RESULTS

Eleven studies, consisting of a total of 1436 patients (510 STC, 500 SC and 426 TPC), were included. Analysis of the data showed no significant difference between STC and SC in terms of overall and surgical recurrence of CD. In contrast, STC showed a higher risk of overall and surgical recurrence of CD than TPC (OR 3.53, 95% CI 2.45-5.10, P < 0.0001; OR 3.52, 95% CI 2.27-5.44, P < 0.0001, respectively). SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC (OR 2.84, 95% CI 1.16-6.96, P < 0.02; OR 0.19, 95% CI 0.09-0.38, P < 0.0001, respectively). SC resulted in a lower risk of permanent stoma than STC (OR 0.52, 95% CI 0.35-0.77).

CONCLUSION

All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. However, patients in the TPC group showed a lower recurrence risk than those in the STC group. Moreover, SC had a higher risk of postoperative complications but a lower risk of permanent stoma. These data should be taken into account when deciding surgical strategies and when informing patients about postoperative risks.

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

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

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

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.

[Surgery in Crohn's disease]

Surgical treatment is primarily used to treat complications of Crohn's disease but also to improve the quality of life. An adequate preoperative preparation including improvement of the nutritional status, weaning off or stopping immunosuppressive medication and preoperative drainage of abscesses can decrease the complication rate. With the exception of when neoplasia is present, bowel-sparing techniques (e. g. strictureplasty and limited resection) are now standard, which has resulted in a low risk of short bowel syndrome. The laparoscopic approach is possible for most indications even in the case of recurrent disease, in primary ileocecal resection the laparoscopic approach has been shown to be superior to the open approach. None of the available techniques for anastomotic reconstruction of the bowels has been shown to be superior. A drainage seton is a good option to retain the quality of life in complex fistulas and reconstructive repair should only be considered when the rectum is free from inflammation.

Current management of intestinal bowel disease: the role of surgery

Inflammatory bowel disease (IBD) is a chronic affection, in which the two main phenotypical components are Crohn's disease and ulcerative colitis. In both diseases, medical treatment has the main role; in some phases of the natural history of IBD, surgery becomes an important therapeutic tool. The IBD represents a model of multidisciplinary management. Timing represents the key issue for proper management of IBD patients. For acute and severe IBD, the surgery can be a salvage procedure. Today, the laparoscopic approach plays an important role in armamentarium of the surgeon. Several articles compared the short- and long-term results between laparoscopic and open approaches in IBD. The aim of this review is to focus the role of surgery in IBD as well as the role of laparoscopic approach, and principally, the "state of the art" for surgical treatment, sometimes very challenging for surgeon, in all clinical features of IBD by a review of literature highlighted by the most recent international guidelines.

Laparoscopic 3D high-definition Deloyers procedure: when, how, why?

After extensive mobilization and resection of the left colon, colorectal anastomosis may result impossible due to the distance between the remaining colon and the rectal stump. The Deloyers procedure represents an interesting alternative to total colectomy with ileorectal anastomosis. In this manuscript, we describe when and how to perform this technique with a mini-invasive approach. We also report the case of a patient who underwent Deloyers procedure, due to early ischemia of the descending colon after left colectomy.

Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study

BACKGROUND

The aim of the present study was to document long-term clinical recurrence and re-resection rates of segmental and extended colectomy in patients with Crohn's colitis and to identify risk factors causing recurrence.

METHODS

Records of patients with isolated colonic Crohn's disease who underwent colectomy between 1995 and 2013 and were followed at our medical center were identified. Data on age at diagnosis, gender, smoking, disease location at diagnosis, perianal and rectal disease, indication for surgery, preoperative disease duration, type of operation, primary anastomosis at first operation, length of resected specimen, recurrence of symptoms, postoperative medication, reoperation, and total follow-up time were retrieved.

RESULTS

Thirty-five suitable patients (18 segmental colectomy, 17 extensive colectomy; 17 males; mean age at operation 36.6 years) were identified. Mean age at primary operation was 36 years. The mean preoperative disease duration was 121 months. Postoperative medical treatment was needed in 10 (56 %) patients undergoing segmental colectomy and in 16 (94 %) of those undergoing extensive colectomy (p = 0.01). There was longer reoperation-free survival in the segmental colectomy patient group (p = 0.02) and also a trend toward longer symptom-free survival compared to the extensive colectomy patient group (p = 0.105). There was no correlation between the length of resected bowel and recurrence. Patients operated on at a younger age did not have a higher rate of recurrence of symptoms. Shorter disease duration, smoking, and male gender were risk factors for clinical recurrence.

CONCLUSIONS

Segmental resection with primary anastomosis can be safely performed in patients with limited Crohn's colitis with reasonable clinical recurrence rates.

Crohn's Disease of the Colon, Rectum, and Anus

There is no cure for Crohn disease. Newer treatments, such as biological therapy, have led to an improved quality of life. This article focuses on the surgical management of Crohn disease of the colon, rectum, and anus. Restorative and nonrestorative surgical options for colonic Crohn disease are discussed. Treatment options for perianal Crohn disease are also reviewed.

A think tank of the Italian society of colorectal surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: Crohn's disease

The management of Crohn's disease (CD) requires extensive expertise. Many treatment options are available, and surgery still plays a crucial role. In recent years, many medical societies have provided surgeons and gastroenterologists dealing with CD with authoritative guidelines. However, a certain degree of variation can be observed in these papers, and application of guidelines in clinical practice should be improved. The Italian society of colorectal surgery (SICCR) promoted the project reported here, which consists of a think tank of Italian colorectal surgeons to address the surgical aspects of CD management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of CD. The management of CD is, by necessity, patient-tailored, and it is based on clinical data and surgeon's preference, but the committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Inflammatory bowel disease meta-evidence and its challenges: is it time to restructure surgical research?

AIM

The aim of this study was to compare the methodological quality and input paper characteristics of systematic reviews and meta-analyses reported in the medical and surgical literature by performing a systematic 'overview of reviews'. Ulcerative colitis (UC) and Crohn's disease (CD) were used as the framework for this comparison as they are relatively common serious conditions, with both medical and surgical options for therapy.

METHOD

Medline, Embase, CINHAL and the Cochrane Database were searched to November 2013. Eligible papers were systematic reviews or meta-analyses that considered a question of therapy in CD or UC. Two independent reviewers selected the papers, extracted the data and scored their methodology using the AMSTAR scoring system. The papers were categorized into medical therapy (M), surgical therapy (S) or medical and surgical therapy (MS) groups. Following retrieval of the sample of meta-evidence papers, the original input studies used in their creation were identified and a search of Medline, Embase, CINHAL and the Cochrane Database was performed. A team of researchers then examined the collection of papers for bibliographic and financial information.

RESULTS

Five hundred papers were identified in the meta-evidence search, of which 118 were deemed eligible. There was a difference in the AMSTAR-rated average quality of the papers between the S and M group (S 7.36 vs M 8.75, P = 0.01). On average S papers were published in journals with a lower impact factor (S 3.26, M 5.04, MS 5.30, P < 0.001). S papers also showed more heterogeneity (I(2) ; S 37%, M 24%, MS 10%, P < 0.001). Some 25% of S meta-analyses used data-sets with significant heterogeneity (I(2) > 75%), compared with 8% of M meta-analyses and 3% of the MS meta-analyses. Some 5% of S papers were done on data sets that had I(2) values > 90%. There was no difference in the average number of papers assessed in each group, the average number of patients per meta-paper, the average time covered by the reviews, the average number of papers considered within each meta-analysis, or the average number of patients considered within each meta-analysis. Considering the conclusions of each meta-analysis, S meta-evidence was 50% more likely than M meta-evidence to be unable to make recommendations for practice. A total of 1499 original input papers were identified, of which 283 were used in more than one review. Within the non-repeated papers (n = 1023) the average impact factor within the S group was lower than that of the M and the MS groups (3.720 vs 11.230 vs 7.563, respectively; ANOVAP < 0.001). M papers had higher rates of pharmaceutical sponsorship than S papers (M 56% vs S 1%) and twice the level of government support (M 16% vs S 8%). Of note, 21% of M papers had corporate sponsorship but did not list any conflict of interest.

CONCLUSION

Compared with M meta-analyses, S meta-analyses in the UC and CD domain are more likely to be of poorer methodological quality, are of a greater degree of heterogeneity and less often offer a positive conclusion. The papers used to generate meta-evidence in M papers have a greater degree of corporate and government sponsorship, and are more likely to come from journals with higher impact factors.

Surgical strategies in paediatric inflammatory bowel disease

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

National trends in intestinal resection for Crohn's disease in the post-biologic era

INTRODUCTION

Prior international datasets have demonstrated equivocal results in the rate of surgical procedures for the treatment of Crohn's disease (CD) following the introduction of biologic medications. The first biologic medication licensed for use in the Republic of Ireland (ROI) was infliximab in 1999. The current study examined national trends in intestinal resection for CD in the ROI following the introduction of biologic medications.

METHODS

The Irish Hospital In-Patient Enquiry database was examined for the period 2000-2010. Cases of CD and relevant surgical interventions were identified using International Classification of Diseases, ninth and tenth editions. Using Irish census data to establish population denominators, trends in population-based procedure rates were examined. Trends were tested for significance with Spearman rank tests.

RESULTS

From 2000 to 2010, there were 11,796 patient admissions with a principal diagnosis of CD. The rates of admission for CD overall (r(2) = -0.191, P = 0.574) and for emergencies (r(2) = 0.055, P = 0.873) did not change; however, elective admissions reduced (r(2) = -0.636, P = 0.035). The mean length of stay reduced (r(2) = -0.783, P = 0.004). The rates of small bowel/right colon procedures (r(2) = 0.282, P = 0.401) and proctectomy (r(2) = -0.209, P = 0.537) did not change. Left colon procedures reduced (r(2) = -0.800, P = 0.003) while the rate of total colectomy increased (r(2) = 0.718, P = 0.013).

CONCLUSIONS

During the decade following the introduction of biologic medications in the ROI, the rate of elective hospitalization and length of stay reduced. However, there has not been a dramatic reduction in the rate of intestinal resection for Crohn's disease at a population level.

Intersphincteric proctectomy with end-colostomy for anorectal Crohn's disease results in early and severe proximal colonic recurrence

BACKGROUND

Perianal Crohn's disease (CD) represents a more aggressive phenotype of inflammatory bowel disease and often coincides with proctocolitis. This study aims to assess the outcome of patients undergoing proctectomy with end-colostomy.

METHODS

A retrospective outcome analysis of 10 consecutive patients who underwent intersphincteric proctectomy with end-colostomy between February 2007 and May 2011 was performed. All patients suffered from refractory distal and perianal CD. The proximal colon was normal at endoscopy. All data were extracted from a prospectively maintained database. The main outcome parameter was disease recurrence and need for completion colectomy.

RESULTS

Severe and early endoscopic recurrence in the proximal colon occurred in 9/10 patients at a median time interval of 9.5 months (range: 1.9-23.6 months). Despite protracted medical treatment, completion colectomy was necessary in 5 patients. One patient, who underwent a second segmental colectomy with a new end-colostomy, showed again endoscopic recurrence and is currently treated with anti-TNF agents.

CONCLUSIONS

Intersphincteric proctectomy with colostomy seems to be an ineffective surgery for perianal CD with coexisting proctitis and results in a high risk of recurrence of the disease in the remaining colon. Therefore, despite a normal appearance of the proximal colon, a proctocolectomy with end-ileostomy seems to be the surgical approach of choice in these patients.

Restorative procedures in colonic crohn disease

Surgical management for refractory Crohn colitis often involves creation of a temporary or permanent stoma. Traditionally, the procedure of choice has been a total proctocolectomy with permanent ileostomy. However, restorative procedures that help to avoid a permanent stoma are being used with more frequency. In this article, the authors will address these procedures, including colocolonic anastomosis, ileorectal anastomosis, ileal pouch rectal anastomosis, and ileal pouch anal anastomosis. Factors that may influence one's decision to perform these procedures, such as patient age and nutritional status, medical comorbidities, sphincter function, desire to avoid a permanent ostomy, and prior medical therapy, will be discussed. Functional outcomes regarding these procedures will also be described. One should keep in mind that surgery does not cure Crohn disease and that postoperative long-term management is essential in preventing progression or recurrence of disease.