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Wang S, Du K, Duan M, Xu Y, Guo Z, Gong J, Zhu W, Li Y. Reversal Surgery for Split Stoma with Peristomal Incision is Associated with Improved Postoperative Outcome in Patients with Crohn's Disease. J INVEST SURG 2024; 37:2363179. [PMID: 38862416 DOI: 10.1080/08941939.2024.2363179] [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: 10/27/2023] [Accepted: 05/29/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Temporary stoma formation is common in Crohn's disease (CD), while stoma reversal is associated with postoperative morbidity. This study aimed to evaluate the postoperative outcomes of split stoma reversal, SSR (i.e., exteriorization of proximal and distal ends of the stoma through a small common opening) and end stoma closure, ESC (i.e., the proximal stump externalized, and distal end localized abdominally. METHODS Patients with CD who underwent stoma reversal surgeries between January 2017 and December 2021 were included. Demographic, clinical, and postoperative data were collected and analyzed to evaluate outcomes of reversal surgery. RESULTS A total of 255 patients who underwent stoma reversal surgeries met the inclusion criteria. SSR was superior to ESC in terms of operative time (80.0 vs. 120.0, p = 0.0004), intraoperative blood loss volume (20.0 vs. 100.0, p = 0.0002), incision length (3.0 vs. 15.0, p < 0.0001), surgical wound classification (0 vs. 8.3%, p = 0.04), postoperative hospital stay (7.0 vs. 9.0, p = 0.0007), hospital expense (45.6 vs. 54.2, p = 0.0003), and postoperative complications (23.8% vs. 44.3%, p = 0.0040). Although patients in the ESC group experienced more surgical recurrence than those in the SSR group (8.3% vs. 3.2%) during the follow-up, the Kaplan-Meier curve analysis revealed no statistical difference (p = 0.29). CONCLUSIONS The split stoma can be recommended when stoma construction is indicated in patients with Crohn's disease.
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Affiliation(s)
- Shixian Wang
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
| | - Kangling Du
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
| | - Ming Duan
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yihan Xu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Doğru V, Akova U, Esen E, Wong DJ, da Luz Moreira A, Erkan A, Kirat J, Grieco MJ, Remzi FH. Temporary diverting loop ileostomy in Crohn's disease surgery; indications and outcome. Langenbecks Arch Surg 2024; 409:247. [PMID: 39120756 DOI: 10.1007/s00423-024-03404-x] [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: 03/27/2024] [Accepted: 07/03/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION Crohn's disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks. METHODS In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn's surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation. RESULTS In total, 168 patients were included. The median age of the patients was 38 years (IQR 27-51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41-61] vs. 37 [IQR 27-50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006). CONCLUSION Selectively staging the Crohn's disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.
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Affiliation(s)
- Volkan Doğru
- Akdeniz University Hospital, Antalya, Türkiye
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Umut Akova
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Eren Esen
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Daniel J Wong
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Arman Erkan
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
- Center for Advanced Inflammatory Bowel Disease Care, Northwell Health, 125 Community Drive, Manhasset, NY, 11030, USA
| | - John Kirat
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Michael J Grieco
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Feza H Remzi
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA.
- Center for Advanced Inflammatory Bowel Disease Care, Northwell Health, 125 Community Drive, Manhasset, NY, 11030, USA.
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Sun Z, Cao L, Chen Y, Song T, Guo Z, Zhu W, Li Y. The impact of delayed closure of ileostomy on postoperative complications in patients with Crohn's disease: a case-matched study. Updates Surg 2024; 76:1339-1345. [PMID: 38238543 DOI: 10.1007/s13304-023-01722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/29/2023] [Indexed: 08/24/2024]
Abstract
Ileostomy creation is a common procedure to mitigate postoperative complications in Crohn's disease (CD) patients. However, the optimal timing for ileostomy closure remains controversial. This study aims to investigate whether delayed ileostomy closure (> 6 months post formation) affects postoperative complications compared to early closure (≤ 6 months post formation). Consecutive CD patients who underwent ileostomy reversal at a tertiary care center between January 1, 2013, and December 1, 2021, were included. The study compared patients who underwent early ileostomy closure to matched patients undergoing delayed ileostomy closure. The 90-day postoperative complications were compared between the two groups. The study included 352 eligible patients for ileostomy reversion. Our data showed that patients undergoing delayed ileostomy closure had higher incidence of ileostomy-related infectious complications (12% vs. 4%, p = 0.008), a longer postoperative hospital stay (10 days with an IQR of 7-12 days versus 8 days with an IQR of 7-11 days, p = 0.024), and increased rate of ileus (28% versus 15%, p = 0.003). There were 256 patients included after 1:1 propensity score matching. The results revealed no significant differences in postoperative hospital stay, infectious or non-infectious complications except for a statistically significant increase in the incidence of ileus in the delayed closure group (p = 0.01). Patients undergoing delayed ileostomy closure has similar outcomes to early closure in terms of postoperative complications, except for a higher incidence of ileus.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Lei Cao
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Yusheng Chen
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Tianrun Song
- Department of General Surgery, Jinling Clinical School of Medicine (Eastern Theater General Hospital), Nanjing Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Zhen Guo
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Weiming Zhu
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China.
| | - Yi Li
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China.
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Adamina M, Minozzi S, Warusavitarne J, Buskens C, Chaparro M, Verstockt B, Kopylov U, Agrawal M, Allocca M, Atreya R, Battat R, Bettenworth D, Bislenghi G, Brown SR, Burisch J, Casanova MJ, Czuber-Dochan W, de Groof J, El-Hussuna A, Ellul P, Fidalgo C, Fiorino G, Gisbert JP, Sabino JG, Hanzel J, Holubar S, Iacucci M, Iqbal N, Kapizioni C, Karmiris K, Kobayashi T, Kotze PG, Luglio G, Maaser C, Moran G, Noor N, Papamichael K, Peros G, Reenaers C, Sica G, Sigall-Boneh R, Vavricka SR, Yanai H, Raine T, Gordon H, Myrelid P. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2024:jjae089. [PMID: 38878002 DOI: 10.1093/ecco-jcc/jjae089] [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: 05/21/2024] [Indexed: 07/28/2024]
Abstract
This article is the second in a series of two publications on 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 prior ECCO guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital of Fribourg & Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Visceral and Thoracic Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Christianne Buskens
- Department of Surgery, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Maria Chaparro
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid; Spain
| | - Bram Verstockt
- Department Gastroenterology & Hepatology, University Hospitals Leuven, KU Leuven and Dpt. Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Manasi Agrawal
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva; Faculty of Medicine, Tel Aviv University, Tel Aviv; Israel
| | - Mariangela Allocca
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Raja Atreya
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert Battat
- Department of Surgery, Università Tor Vergata, Roma, Italy
| | | | - Gabriele Bislenghi
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Steven Ross Brown
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Johan Burisch
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - María José Casanova
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham
- Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham. NG7 2UH. United Kingdom
| | | | - Joline de Groof
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Alaa El-Hussuna
- Health Sciences Postgraduate Program, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Pierre Ellul
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Catarina Fidalgo
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - Gionata Fiorino
- Department of Gastroenterology, Attikon University Hospital, Athens, Greece
| | - Javier P Gisbert
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - João Guedelha Sabino
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Jurij Hanzel
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana; Chair of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marietta Iacucci
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Nusrat Iqbal
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Konstantinos Karmiris
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal
| | | | | | - Gaetano Luglio
- Colorectal Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Christian Maaser
- Florence Nightingale Faculty of Nursing- Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Gordon Moran
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid. Spain
| | - Nurulamin Noor
- Gastrounit, Medical Division, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | | | - Georgios Peros
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
| | - Catherine Reenaers
- CED Schwerpunktpraxis, Münster and Medical Faculty of the University of Münster, Münster, NRW, Germany
| | - Giuseppe Sica
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Rotem Sigall-Boneh
- First Department of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan R Vavricka
- IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Gastroenterology and Endoscopy, Milan, Italy
| | - Henit Yanai
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Hannah Gordon
- Translational Gastroenterology and Liver Unit, University of Oxford, Oxford, UK
| | - Pär Myrelid
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Modified Primary Anastomosis Using an Intestinal Internal Drainage Tube for Crohn's Disease: A Pilot Study. J Clin Med 2023; 12:jcm12010364. [PMID: 36615164 PMCID: PMC9821564 DOI: 10.3390/jcm12010364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/24/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Surgical treatment is an important part of the management of Crohn's disease (CD). However, the current recommended staged procedures require two operations, with long hospital stays and high costs, while traditional primary anastomosis has a high risk of complications. Therefore, the aim of this study was to compare the clinical efficacy and safety of modified primary anastomosis using intestinal internal drainage tubes for CD. METHODS In this study, emergency and nonemergency CD patients were included separately. Then, the patients were divided into three subgroups: patients with intestinal internal drainage tubes (modified primary anastomosis), staged procedures, and traditional primary anastomosis. The main outcomes were the number of hospitalizations, length and cost of the first hospital stay, length and cost of total hospital stays, and complications. RESULTS The outcomes of the three subgroups of emergency CD patients were not significantly different. For nonemergency CD patients, patients with intestinal internal drainage tubes had shorter total hospital stays and fewer hospitalizations compared with the staged procedures subgroup, while no significant differences in any outcomes were observed between the modified and traditional primary anastomosis subgroups. CONCLUSIONS For emergency CD patients, no significant advantage in terms of the main outcomes was observed for modified primary anastomosis. For nonemergency CD patients, modified primary anastomosis reduced the length of total hospital stays and hospitalizations compared with staged procedures. The placement of intestinal internal drainage tubes allows some patients who cannot undergo primary anastomosis to undergo it, which is a modification of traditional primary anastomosis.
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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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Cira K, Weber MC, Wilhelm D, Friess H, Reischl S, Neumann PA. The Effect of Anti-Tumor Necrosis Factor-Alpha Therapy within 12 Weeks Prior to Surgery on Postoperative Complications in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:6884. [PMID: 36498459 PMCID: PMC9738467 DOI: 10.3390/jcm11236884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 11/24/2022] Open
Abstract
The rate of abdominal surgical interventions and associated postoperative complications in inflammatory bowel disease (IBD) patients is still substantially high. There is an ongoing debate as to whether or not patients who undergo treatment with anti-tumor necrosis factor-alpha (TNF-α) agents may have an increased risk for general and surgical postoperative complications. Therefore, a systematic review and meta-analysis was conducted in order to assess the effect of anti-TNF-α treatment within 12 weeks (washout period) prior to abdominal surgery on 30-day postoperative complications in patients with IBD. The results of previously published meta-analyses examining the effect of preoperative anti-TNF-α treatment on postoperative complications reported conflicting findings which is why we specifically focus on the effect of anti-TNF-α treatment within 12 weeks prior to surgery. PubMed, Cochrane, Scopus, Web of Science, World Health Organization Trial Registry, ClinicalTrials.gov and reference lists were searched (June 1995−February 2022) to identify studies, investigating effects of anti-TNF-α treatment prior to abdominal surgery on postoperative complications in IBD patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated and subgroup analyses were performed. In this case, 55 cohort studies (22,714 patients) were included. Overall, postoperative complications (OR, 1.23; 95% CI, 1.04−1.45; p = 0.02), readmission (OR, 1.39; 95% CI, 1.11−1.73; p = 0.004), and intra-abdominal septic complications (OR, 1.89; 95% CI, 1.44−2.49; p < 0.00001) were significantly higher for anti-TNF-α-treated patients. Significantly higher intra-abdominal abscesses and readmission were found for anti-TNF-α-treated CD patients (p = 0.05; p = 0.002). Concomitant treatment with immunosuppressives in <50% of anti-TNF-α-treated patients was associated with significantly lower mortality rates (OR, 0.32; 95% CI, 0.12−0.83; p = 0.02). Anti-TNF-α treatment within 12 weeks prior to surgery is associated with higher short-term postoperative complication rates (general and surgical) for patients with IBD, especially CD.
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Affiliation(s)
- Kamacay Cira
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Marie-Christin Weber
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Stefan Reischl
- Institute of Diagnostic and Interventional Radiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
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Yang ML, Brar MS, Boughn A, Saini J, Kennedy E, MacRae H, de Buck Van Overstraten A. Does Oversewing Stapled Ileocolic Anastomoses for Crohn's Disease Reduce Anastomotic Complications? An Inverse-Probability Weighting Analysis of a Single Centre Cohort. J Gastrointest Surg 2022; 26:1951-1953. [PMID: 35178650 DOI: 10.1007/s11605-022-05247-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/07/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Mei Lucy Yang
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Amelia Boughn
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Jessica Saini
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Helen MacRae
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Anthony de Buck Van Overstraten
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada.
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Tadesse R, Ewnte B, Tesfaye K. Perforated ileum as the initial presentation of Crohn's disease, a case report. Int J Surg Case Rep 2022; 97:107305. [PMID: 35907295 PMCID: PMC9403019 DOI: 10.1016/j.ijscr.2022.107305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The perforation of the bowel as the first presentation of inflammatory bowel disease is a rare occurrence reported in about 0.15-3 % of the literature and is especially unusual in young patients <30 years of age. It is a serious event with most of the perforations occurring on the ileum. This article describes a unique case of a 20-year-old female patient who presented with perforated ileum due to Crohn's disease as an initial presentation operated at a private surgical center. CASE PRESENTATION We present a case of a previously asymptomatic 21-year-old female presenting with intestinal perforation secondary to Crohn's disease for the first time. The patient presented with crampy abdominal pain and frequent bilious vomiting of 3 days duration. She also had a high-grade fever and abdominal distension. WBC was 24,000 and an abdominal CT scan showed perforation of the bowel consistent with Crohn's Disease. Ruling out other etiologies perforated viscous secondary to query Crohn's Disease was entertained and laparotomy revealed 2 × 2 cm perforation on the anti-mesenteric border of the terminal ileum. The perforated segment was resected primary anastomosis was performed. Following surgery, the patient was discharged symptom-free and linked to the Gastroenterology unit after a biopsy confirmed Crohn's disease. She was started on Prednisolone and Azathioprine exactly a month after her surgery. Her 6-month follow-up is smooth. CONCLUSION Presentation of bowel perforation as an initial feature of Crohn's Disease is a rare phenomenon. Adequate resuscitation followed by emergency laparotomy with primary resection and anastomosis could be life-saving for a hemodynamically stable patient.
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Myrelid P, Soop M, George BD. Surgical Planning in Penetrating Abdominal Crohn's Disease. Front Surg 2022; 9:867830. [PMID: 35592128 PMCID: PMC9110798 DOI: 10.3389/fsurg.2022.867830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mattias Soop
- Department of Surgery, Ersta Hospital, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Bruce D. George
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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11
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Zhang Z, He X, Hu J, Zheng Z, Chen Y, Tang J, Li S, Ke J, Lian L, Lan P, Wu X. Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease. Surgery 2021; 171:1486-1493. [PMID: 34863524 DOI: 10.1016/j.surg.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease. METHODS A retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach. RESULTS A total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) CONCLUSION: Split stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.
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Affiliation(s)
- Zongjin Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zheyu Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongle Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian Tang
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Senmao Li
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiaojian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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12
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Patients with Crohn's Disease Undergoing Abdominal Surgery: Clinical and Prognostic Evaluation Based on a Single-Center Cohort in China. World J Surg 2021; 46:450-460. [PMID: 34718840 DOI: 10.1007/s00268-021-06366-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence and prevalence of Crohn's disease (CD) are increasing in China, but there are few reports on the characteristics of patients requiring abdominal surgery. This study aimed to evaluate the clinical characteristics of these patients and the potential risk factors for postoperative complications and surgical recurrence. METHODS In this observational, retrospective single-center cohort analysis, patients with CD who had undergone at least one abdominal surgery at our center from 2007 to 2020 were included. Data were collected from a prospectively maintained database. Clinical factors were assessed by logistic regression models, Kaplan-Meier methods, and Cox proportional hazards regression models. The predictive accuracy of the nomogram was determined by a concordance index (C-index) and calibration curve and was validated using bootstrap resampling. RESULTS In the 1639 patients, clinical characteristics were evaluated. In a multivariable logistic regression model, penetrating behavior (P = 0.002), emergency surgery (P = 0.010), and smoking status (P = 0.015) were significantly associated with an increased risk of postoperative septic complications. In contrast, staged surgery (P = 0.009) was inversely associated with postoperative complications. Upper gastrointestinal disease (P = 0.042), penetrating behavior (P = 0.027), emergency at initial surgery (P < 0.001) were significantly associated with an increased risk of surgical recurrence after the index surgery in our Cox regression model, whereas staged surgery (P = 0.036) was significantly associated with a decreased risk. The C-index of the nomogram for predicting recurrence was 0.744 (P = 0.015), and calibration curves showed good agreement between predictions of 3, 5, and 10 years of recurrence and actual observations. CONCLUSIONS There are several disease- and surgery-associated risk factors of postoperative adverse outcomes in patients with CD undergoing abdominal surgery. This is important in optimizing the management of CD which has evolved into a global disease with rising prevalence in newly industrialized countries including China.
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Iesalnieks I, Bittermann T, Schlitt HJ, Hackl C. Reversal of end-ileostomy in patients with Crohn's disease. Int J Colorectal Dis 2021; 36:2119-2125. [PMID: 33929586 DOI: 10.1007/s00384-020-03823-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE End-ileostomy after two-staged ileocolic resection is frequently performed in Crohn's disease patients at high risk for postoperative complications. However, there is paucity on data regarding the morbidity after the stoma reversal. METHODS One hundred thirty patients undergoing closure of end-ileostomy between 1994 and 2016 were included. Data collection was retrospective in 11 first, and it was prospective in 119 last patients. Anastomotic complications were defined as anastomotic leak, perianastomotic abscess, and perianastomotic peritonitis. RESULTS The median interval between ileostomy construction and reversal was 4.0 months. Ninety-seven of 121 patients with available data (80%) gained weight between both surgeries. Hemoglobin level increased between surgeries in 107 patients (85%). Fifteen patients (11.5%) received parenteral fluid substitution or parenteral nutrition between both surgeries. There were 37 hospital readmissions during the time between stoma construction and reversal (29%). After ileostomy reversal, 14 patients developed anastomotic complications (11%). By multivariate regression analysis, preoperative steroid intake (hazard ratio 4.5, 95% CI: 1.11-18.0, p = 0.035) and hospital readmission for infectious complications (HR 4.5, 95% CI: 1.11-18.0, p = 0.035) were statistically significantly associated with an increased risk to develop postoperative anastomotic complications. There were no postoperative deaths. CONCLUSION Closure of end-ileostomy could be complicated by some serious morbidity. These risks should be taken into consideration weighing carefully between the one- and two-stage ileocolic resection in Crohn's disease patients.
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Affiliation(s)
- I Iesalnieks
- Department of Surgery, University of Regensburg, Regensburg, Germany. .,Department of Surgery, Klinik München Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany.
| | - T Bittermann
- Department of Surgery, University of Regensburg, Regensburg, Germany
| | - H J Schlitt
- Department of Surgery, University of Regensburg, Regensburg, Germany
| | - C Hackl
- Department of Surgery, University of Regensburg, Regensburg, Germany
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14
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Predictive Value of CT Enterography Index for Postoperative Intra-abdominal Septic Complications in Patients With Crohn's Disease: Implications for Surgical Decision-Making. Dis Colon Rectum 2021; 64:964-976. [PMID: 33951684 DOI: 10.1097/dcr.0000000000001796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative intra-abdominal septic complications in patients with Crohn's disease undergoing intestinal resection and anastomosis are frequent and difficult to manage. OBJECTIVE This study sought to explore the value of preoperative CT enterography to predict intra-abdominal septic complications. DESIGN This was a retrospective and prospective observational study. SETTINGS This study was conducted in a tertiary referral hospital. PATIENTS Patients with Crohn's disease undergoing primary intestinal resection were enrolled in our study. MAIN OUTCOME MEASURES The CT enterography severity index was calculated and its ability to predict intra-abdominal septic complications evaluated by multivariate analyses. A prospective study was then performed to assess the reliability of this CT enterography index. RESULTS The incidence of postoperative intra-abdominal septic complications in patients undergoing a 1-stage procedure was significantly higher than those undergoing a 2-stage procedure (3/103 vs 24/241; 2.9% vs 10.0%; p = 0.026). A multivariate analysis identified 5 CT enterography parameters, including mesenteric fibrofatty proliferation, intra-abdominal abscess or phlegmon, intestinal fistula, peritoneal effusion, and intestinal dilatation with stricture to be independent predictors of intra-abdominal septic complications (p < 0.001). A nomogram model based on these 5 parameters was constructed. A receiver operating characteristic analysis identified a CT enterography nomogram score cutoff of 175 as a predictor of intra-abdominal septic complications with a sensitivity of 83.3% and a specificity of 85.3%. In the prospective study, those patients with a CT enterography nomogram score >175 were assigned to the 2-stage group, which resulted in a similar intra-abdominal septic complication incidence in those undergoing intestinal resection with or without anastomosis (2/82 vs 2/34; p = 0.355). LIMITATIONS This study was limited by its single-center scope. CONCLUSIONS Preoperative CT enterography findings may predict postoperative outcomes and help determine surgical approach in Crohn's disease. Patients with worse intra-abdominal findings confirmed by CT enterography may benefit from stoma creation after intestinal resection. See Video Abstract at http://links.lww.com/DCR/B588. EL VALOR PREDICTIVO DEL NDICE ENTEROGRFICO POR TOMOGRAFA COMPUTADA PARA LAS COMPLICACIONES SPTICAS INTRAABDOMINALES POSTOPERATORIAS EN PACIENTES CON ENFERMEDAD DE CROHN IMPLICACIONES PARA LA TOMA DE DECISIONES QUIRRGICAS ANTECEDENTES:Las complicaciones sépticas intra-abdominales postoperatorias en pacientes con enfermedad de Crohn sometidos a resección intestinal y anastomosis son frecuentes y difíciles de manejar.OBJETIVO:Este estudio buscó explorar el valor del índice enterográfico por tomografía computada en el pré-operatorio y así poder predecir futuras complicaciones sépticas intra-abdominales.DISEÑO:Estudio observacional retro-prospectivo.AJUSTE:Investigación realizada en un hospital de referencia terciaria.PACIENTES:Se incluyeron en nuestro estudio pacientes con enfermedad de Crohn sometidos a una resección intestinal primaria.PRINCIPALES MEDIDAS DE RESULTADO:Se calculó el índice de gravedad de la enterografía por tomografía axial computada y se evaluó su capacidad para predecir las complicaciones sépticas intra-abdominales mediante un análisis multivariado. Luego se realizó un estudio prospectivo para evaluar la confiabilidad del índice enterográfico por tomografía axial computada.RESULTADOS:La incidencia de complicaciones sépticas intra-abdominales postoperatorias en pacientes sometidos a un procedimiento de un solo tiempo fue significativamente mayor que aquellos sometidos a un procedimiento de dos tiempos (3/103 frente a 24/241; 2,9% frente a 10,0%; p = 0,026). El análisis multivariado identificó cinco parámetros enterográficos por tomografía axial computada, incluidos la proliferación fibrograsa mesentérica, el absceso o flegmón intra-abdominal, la fístula entérica, el derrame peritoneal y la dilatación intestinal debido a estenosis como predictores independientes de complicaciones sépticas intra-abdominales (p <0,001). Se construyó un modelo de Nomograma basado en estos cinco parámetros. Un análisis de las características operatorias del receptor identificó una puntuación de cohortes del nomograma de la enterografía por tomografía axial computada de 175 como predictor de complicaciones sépticas intra-abdominales con una sensibilidad del 83,3% y una especificidad del 85,3%. En el estudio prospectivo, los pacientes con puntuación de nomograma enterográfico por tomografía axial computada superior a 175 fueron asignados al grupo en dos tiempos, lo que resultó en una incidencia similar de complicaciones sépticas intra-abdominales en aquellos sometidos a resección intestinal con o sin anastomosis (2/82 vs. 2/34; p = 0,355).LIMITACIONES:Este estudio estuvo limitado por su alcance unicéntrico.CONCLUSIÓN:Los hallazgos enterográficos por tomografía axial computada pré-operatoria pueden predecir ciertos resultados postoperatorios y ayudar a determinar el abordaje quirúrgico en la enfermedad de Crohn. Los pacientes con peores hallazgos intra-abdominales confirmados por enterografía en la tomografía axial computada podrían beneficiarse de la creación de un estoma después de la resección intestinal. Consulte Video Resumen en http://links.lww.com/DCR/B588. (Traducción-Dr Xavier Delgadillo).
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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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16
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Abdalla S, Benoist S, Maggiori L, Zerbib P, Lefevre JH, Denost Q, Germain A, Cotte E, Beyer-Berjot L, Corte H, Desfourneaux V, Rahili A, Duffas JP, Pautrat K, Denet C, Bridoux V, Meurette G, Faucheron JL, Loriau J, Guillon F, Vicaut E, Panis Y, Brouquet A. Impact of preoperative enteral nutritional support on postoperative outcome in patients with Crohn's disease complicated by malnutrition: Results of a subgroup analysis of the nationwide cohort registry from the GETAID Chirurgie group. Colorectal Dis 2021; 23:1451-1462. [PMID: 33624371 DOI: 10.1111/codi.15600] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/27/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022]
Abstract
AIM Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort. METHOD Malnutrition was defined as body mass index <18 kg/m2 and/or albuminaemia <30 g/L and/or weight loss >10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma. RESULTS Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016). CONCLUSION Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.
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Affiliation(s)
- Solafah Abdalla
- Department of Digestive Surgery and Surgical Oncology, Hôpital Bicêtre, Université Paris Saclay, APHP, Le Kremlin Bicêtre, France.,UMR 1195, Institut National de la Santé et de la Recherche Médicale, Hôpital de Bicêtre, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Stéphane Benoist
- Department of Digestive Surgery and Surgical Oncology, Hôpital Bicêtre, Université Paris Saclay, APHP, Le Kremlin Bicêtre, France
| | - Léon Maggiori
- Department of Digestive Surgery, Hôpital Saint-Louis, Université Paris VII, APHP, Paris, France
| | | | - Jérémie H Lefevre
- Department of Digestive Surgery, Hôpital Saint Antoine, Université Paris Sorbonne, APHP, Paris, France
| | - Quentin Denost
- Department of Digestive Surgery, CHU Bordeaux, Bordeaux, France
| | | | - Eddy Cotte
- Department of Digestive Surgery, CHU Lyon-Sud, Pierre-Bénite, France
| | | | - Hélène Corte
- Department of Digestive Surgery, Hôpital Saint-Louis, Université Paris VII, APHP, Paris, France
| | | | - Amine Rahili
- Department of Digestive Surgery, CHU Nice, Nice, France
| | - Jean-Pierre Duffas
- Department of Digestive Surgery, CHU Toulouse-Rangueil, Toulouse, France
| | - Karine Pautrat
- Department of Digestive Surgery, Hôpital Lariboisière, Université Paris VII, APHP, Paris, France
| | - Christine Denet
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | | | | | | | - Jérôme Loriau
- Department of Digestive Surgery, Hôpital Saint Joseph, Paris, France
| | - Françoise Guillon
- Department of Digestive Surgery, CHU Montpellier, Montpellier, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Hôpital Fernand Widal, Université Paris VII, AP-HP, Paris, France
| | - Yves Panis
- Department of Colorectal Surgery, Hôpital Beaujon, Université Paris VII, APHP, Clichy, France
| | - Antoine Brouquet
- Department of Digestive Surgery and Surgical Oncology, Hôpital Bicêtre, Université Paris Saclay, APHP, Le Kremlin Bicêtre, France.,UMR 1195, Institut National de la Santé et de la Recherche Médicale, Hôpital de Bicêtre, Université Paris Saclay, Le Kremlin Bicêtre, France
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17
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Soop M. Challenges in Crohn's disease: Intestinal failure and short bowel syndrome in Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Levin A, Risto A, Myrelid P. The changing landscape of surgery for Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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19
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Yoon YS, Stocchi L, Holubar S, Aiello A, Shawki S, Gorgun E, Steele SR, Delaney CP, Hull T. When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn’s disease? Surg Endosc 2020; 35:2543-2557. [DOI: 10.1007/s00464-020-07670-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/21/2020] [Indexed: 12/14/2022]
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20
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Bolckmans R, Singh S, Ratnatunga K, Wickramasinghe D, Sahnan K, Adegbola S, Kalman D, Jones H, Travis S, Warusavitarne J, Myrelid P, George B. Temporary faecal diversion in ileocolic resection for Crohn's disease: is there an impact on long-term surgical recurrence? Colorectal Dis 2020; 22:430-438. [PMID: 31715062 DOI: 10.1111/codi.14895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022]
Abstract
AIM Temporary faecal diversion after ileocolic resection (ICR) for Crohn's disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. METHOD This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence. RESULTS Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P < 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12). CONCLUSION Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.
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Affiliation(s)
- R Bolckmans
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Singh
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K Ratnatunga
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D Wickramasinghe
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - K Sahnan
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - S Adegbola
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - D Kalman
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - H Jones
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - J Warusavitarne
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - P Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - B George
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Soop M, Khan H, Nixon E, Teubner A, Abraham A, Carlson G, Lal S. Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre. J Crohns Colitis 2020; 14:1558-1564. [PMID: 32215559 PMCID: PMC7648168 DOI: 10.1093/ecco-jcc/jjaa060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported. METHODS Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records. RESULTS A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2. CONCLUSIONS IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.
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Affiliation(s)
- Mattias Soop
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK,Corresponding author: Mattias Soop, MD PhD, Department of Surgery, Ersta Hospital, Box 4619, SE 116 91 Stockholm, Sweden. Tel.: +4867146100;
| | - Haroon Khan
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Emma Nixon
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Antje Teubner
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Arun Abraham
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Gordon Carlson
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Simon Lal
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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22
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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23
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Immunosuppressed Patients with Crohn's Disease Are at Increased Risk of Postoperative Complications: Results from the ACS-NSQIP Database. J Gastrointest Surg 2019; 23:1188-1197. [PMID: 30887300 DOI: 10.1007/s11605-019-04186-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of immunosuppressants on postoperative complications following colon resections for Crohn's disease remains controversial. This study aimed to compare postoperative outcomes between immunosuppressed and immunocompetent patients with Crohn's disease undergoing elective colon resection. METHODS Analysis of 30-day outcomes using a cohort from the American College of Surgeons National Surgical Quality Improvement Program colectomy-specific database was performed. The database is populated by trained clinical reviewers who collect 30-day postoperative outcomes for patients treated at participating North-American institutions. Adult patients who underwent an elective colectomy between 2011 and 2015 were included. Immunosuppression for Crohn's disease was predefined as use of regular corticosteroids or immunosuppressants within 30 days of the operation. Patients who received chemotherapy within 90 days of surgery, and patients who had disseminated cancer, preoperative shock, or emergency surgery were excluded. Primary outcome was infectious complications. RESULTS Three thousand eight hundred sixty patients with Crohn's disease required elective colon resection and met the inclusion criteria. Of these, 2483 were immunosuppressed and 1377 were immunocompetent. On multivariate analysis, the odds of infectious complications [OR 1.25; 95% CI (1.033-1.523)], overall surgical site infection [1.40; (1.128-1.742)], organ space surgical site infection [1.47; (1.094-1.984)], and anastomotic leak [1.51; (1.018-2.250)] were significantly higher for immunosuppressed compared to immunocompetent patients with Crohn's disease. CONCLUSIONS Patients with Crohn's disease who were on immunosuppressant medications within 30 days of elective colectomy had significantly increased rates of infectious complications, overall surgical site infection, organ space surgical site infection, and anastomotic leak compared to patients who were not on immunosuppressive agents.
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24
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Zhou J, Li Y, Gong J, Zhu W. No Association between staging operation and the 5-Year Risk of Reoperation in Patients with Crohn's Disease. Sci Rep 2019; 9:275. [PMID: 30670721 PMCID: PMC6342980 DOI: 10.1038/s41598-018-34867-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/25/2018] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to investigate the impact of staging operation on the risk of reoperation in patients with CD who underwent primary bowel resection. This was a retrospective study of 980 patients with CD who were hospitalized in Jinling Hospital Affiliated to Nanjing Medical University between January 1, 2001, and October 1, 2016. The patients were grouped according to staging operation (n = 64) and one-stage operation (n = 148). Postoperative intestinal function recovery time, postoperative short-term complications, and reoperation rates were compared between the two groups. There was significant difference in disease behavior between the staging operation group and the one-stage operation group. There was no significant difference in postoperative tolerance of enteral nutrition among groups (P > 0.05). Obvious differences were found in the comparison of the first time of exhaustion, defecation after operation, postoperative length of stay and postoperative complications among groups (all P < 0.05). There was no difference in the 5-year cumulative reoperation-free rates between the two groups (P > 0.05). In conclusion, surgical intervention at proper time and appropriate operation during operation are essential for patients with CD. It is believed that staging operation with ostomy followed by intestinal anastomosis is feasible when there are more than two risk factors for postoperative intra-abdominal infectious complications.
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Affiliation(s)
- Jiajie Zhou
- Department of General Surgery, Jinling Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, 210002, China.,Department of General Surgery, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, 223300, China
| | - Yi Li
- Department of General Surgery, Jinling Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, 210002, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, 210002, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, 210002, China.
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25
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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26
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Feng JS, Li JY, Yang Z, Chen XY, Mo JJ, Li SH. Stapled side-to-side anastomosis might be benefit in intestinal resection for Crohn's disease: A systematic review and network meta-analysis. Medicine (Baltimore) 2018; 97:e0315. [PMID: 29642162 PMCID: PMC5908623 DOI: 10.1097/md.0000000000010315] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIM Intestinal anastomosis is an essential step in the intestinal resection in patients with Crohn's disease (CD). Anastomotic configuration such as handsewn end-to-end anastomosis (HEEA), stapled side-to-side anastomosis (SSSA) and so on may be a predictor of prognosis for postoperative CD patients. However, the association between anastomotic types and surgical outcomes are controversial. The aim of this review is to identify the optimal anastomosis for intestinal resection in patients with CD. METHODS Clinical trials comparing anastomosis after intestinal resection in patients with CD were searched in the database of MEDLINE, EMBASE, and the Cochrane Library. Outcomes such as postoperative hospital stay, complications, mortality, recurrence, and reoperation were evaluated. Pairwise treatment effects were estimated through a random-effects network meta-analysis based on the frequency framework by using the STATA software and reported as the estimated summary effect for each comparison between the 2 treatments in the network with a 95% credible interval. RESULTS A total of 1113 patients in 11 trials were included. In pair-wise comparisons between groups, for overall postoperative complications, SSSA showed a more probability of superiority to HEEA; for complications other than anastomotic leak, anastomotic leak, wound infection, postoperative hospital stay and mortality, there were no significant difference between groups; for clinical recurrence, SSSA showed a more probability of superiority to HEEA; for reoperation, SSSA showed a more probability of superiority to HEEA. The number of eligible randomized controlled trails (RCTs) was small, and more than half of the included trials were retrospective studies; selection bias may lead to a less power in this assessment; follow-up time between different groups was different, which may possibly have affected the interpretation of the analysis of long-term outcome. CONCLUSION By comprehensive analyzing all the postoperative outcomes, SSSA appeared to be the optimal anastomotic strategy after intestinal resection for patients with CD.
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Affiliation(s)
- Jin-shan Feng
- Scientific Research Center (Campus Zhanjiang), Guangdong Medical University, Zhanjiang
| | - Jin-yu Li
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha
| | - Zheng Yang
- Department of Psychology, Affiliated Hospital of Guangdong Medical University
| | - Xiu-yan Chen
- The First Clinical Medical College, Guangdong Medical University, Zhanjiang
| | - Jia-jie Mo
- Department of Functional Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Shang-hai Li
- Department of Cardiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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27
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Iesalnieks I, Hoene M, Bittermann T, Schlitt HJ, Hackl C. Mechanical Bowel Preparation (MBP) Prior to Elective Colorectal Resections in Crohn's Disease Patients. Inflamm Bowel Dis 2018. [PMID: 29529206 DOI: 10.1093/ibd/izx088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies addressing the role of mechanical bowel preparation (MBP) in Crohn's disease (CD) patients are lacking. METHODS Consecutive elective colorectal resections for CD have been included in the present analysis. Exclusion criteria were small bowel resections not including colon, urgent surgeries, surgeries for cancer, and abdominoperineal resections for perianal disease. MBP was performed routinely between 1992 and 2004, omitted between 2005 and 2015, and reintroduced in 2016.Intraabdominal septic complications (IASC) were anastomotic leakage, intraabdominal abscess, intestinal fistula, and peritonitis. RESULTS Overall, 680 bowel resections for CD have been performed between 1992 and 2017. After exclusion of the abovementioned patients, 549 patients were included in the present analysis. The IASC rate was 12% in patients undergoing surgery after MPB as opposed to 24% when MBP was omitted (P < 0.001). By the multivariate analysis, preoperative MBP significantly reduced the risk of IASC (Hazard ratio 0.45; 95% CI, 0.23 - 0.86; P = 0.016). Preoperative weight loss (HR 2.0; 95% CI, 1.1 - 3.6; P = 0.024), penetrating disease (HR 2.6; 95% CI, 1.3 - 5.4; P = 0.01), and stapled as opposed to hand-sewn ileocolic anastomosis (HR 3.3; 95% CI, 1.4 - 7.7; P = 0.006) were associated with an increased risk of IASC. The positive impact of MBP was strongest on anastomotic complication rate in patients undergoing ileocolic resections for penetrating disease (11% vs 36%, P < 0.001). CONCLUSION Preoperative MPB should be strongly considered before colorectal surgery in patients with CD, especially in patients undergoing ileocolic resections for penetrating disease.
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Affiliation(s)
- Igors Iesalnieks
- Department of Surgery, University of Regensburg, Germany.,Department of Surgery, Marienhospital Gelsenkirchen, Germany
| | - Melanie Hoene
- Department of Surgery, University of Regensburg, Germany
| | | | - Hans J Schlitt
- Department of Surgery, University of Regensburg, Germany
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Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection An international audit by ESCP and S-ECCO. Colorectal Dis 2017; 20:219-227. [PMID: 28913968 DOI: 10.1111/codi.13889] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/30/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patient and disease-related factors, as well as operation technique all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. AIM To investigate the effect of pre- and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease. METHOD International prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. This study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien-Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, re-operation, surgical site infection and length of stay at hospital. Multivariable binary logistic regression analyses were used to produce odds ratios (OR) and 95% confidence intervals (CI). RESULTS Three hundred and seventy five resections in 375 patients were included. The median age was 37 and 57.1% were female. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36 95% CI 1.10-4.97)], urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13-3.55) and unplanned intraoperative adverse events (OR 2.30, 95% CI 1.20-4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, CI [1.08-1.61]) and those who had urgent/expedited operations (OR 1.21, CI [1.07-1.37]). CONCLUSION Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intraoperative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients. This article is protected by copyright. All rights reserved.
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29
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Dirrenberger B, Clerc-Urmès I, Germain A, Bresler L, Olivera P, Martelli L, Danese S, Baumann C, Laurent V, Peyrin-Biroulet L. Value of cross-sectional imaging in assessing active Crohn's disease before stoma reversal. Dig Liver Dis 2017; 49:864-871. [PMID: 28454853 DOI: 10.1016/j.dld.2017.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/28/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are currently no guidelines on the need to assess disease activity before stoma reversal in Crohn's disease (CD). We sought to determine the value of cross-sectional imaging for detecting active CD before stoma reversal. METHODS 38 CD patients underwent cross-sectional imaging before stoma reversal. CD activity was blindly evaluated by an independent radiologist. Postoperative outcomes were recorded. RESULTS Before stoma reversal, cross-sectional imaging identified active CD in 20 of the 38 study participants (52.6%). In 9 out of 10 tested patients, radiologic and endoscopic assessments gave concordant findings with regard to CD recurrence before stoma reversal. Stoma reversal was delayed in half of the patients with active CD and in none of the patients without active CD. Before stoma reversal, tumor necrosis factor alpha antagonists or immunosuppressants were initiated in 45% of the patients with active CD and 5.6% of the patients without active CD. In the year following stoma reversal, the recurrence rate (in a radiologic assessment) was higher in patients with active CD than in patients without active CD (75.0% vs. 30.8%, respectively; p=0.04). CONCLUSION Cross-sectional imaging revealed postoperative recurrence in about a quarter of patients before stoma reversal; this finding may influence the postoperative treatment strategy and outcomes.
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Affiliation(s)
- Bastien Dirrenberger
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | - Isabelle Clerc-Urmès
- ESPRI-BioBase Unit, PARC Clinical Research Support Facility, Nancy University Medical Center, Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, Nancy University Medical Center, Nancy, France
| | - Laurent Bresler
- Department of Digestive Surgery, Nancy University Medical Center, Nancy, France
| | - Pablo Olivera
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | - Laura Martelli
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | | | - Cédric Baumann
- ESPRI-BioBase Unit, PARC Clinical Research Support Facility, Nancy University Medical Center, Nancy, France
| | - Valérie Laurent
- Department of Radiology, Nancy University Medical Center, Nancy, France
| | - Laurent Peyrin-Biroulet
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France.
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30
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Grott M, Horisberger K, Weiß C, Kienle P, Hardt J. Resection enterostomy versus Hartmann's procedure for emergency colonic resections. Int J Colorectal Dis 2017; 32:1171-1177. [PMID: 28389778 DOI: 10.1007/s00384-017-2808-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND If a primary anastomosis is considered too risky after emergency colon resection either a resection enterostomy or an end stoma with closure of the distal bowel (Hartmann's procedure) is possible. This study analyzes the rate of restoration of intestinal continuity and other surgical outcomes after resection enterostomy placement versus Hartmann's procedure for emergency colon resections. METHODS All patients who underwent emergency colorectal resections between August 2009 and June 2014 at the University Medical Center Mannheim were reviewed in regard to therapeutic approach, rate of restoration of bowel continuity, and surgical morbidity after the primary operation and after reversal surgery. RESULTS Fifty-five patients in whom both studied interventions would have been technically feasible were further analyzed. The rate of revisional surgery was significantly higher in the resection enterostomy cohort after the primary operation. There were no significant differences regarding morbidity, mortality, and the rate of restoration of intestinal continuity. Overall, bowel continuity could be restored in 63% (29/46) of the surviving patients. The median time of surgery of the initial as well as of the reversal surgery was significantly longer in the Hartmann's group. Five of 13 patients underwent protective ileostomy placement in the Hartmann's group at the time of the reversal (vs. none in the resection enterostomy group). CONCLUSIONS The bowel continuity can be restored in the majority of patients after emergency colonic resection. Conclusive evidence which surgical option should be preferred when a primary anastomosis is considered too risky-Hartmann's procedure or resection enterostomy-is still lacking.
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Affiliation(s)
- M Grott
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - K Horisberger
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - C Weiß
- Department of Medical Statistics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - P Kienle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany.
| | - J Hardt
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
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Preoperative Nutritional Therapy Reduces the Risk of Anastomotic Leakage in Patients with Crohn's Disease Requiring Resections. Gastroenterol Res Pract 2015; 2016:5017856. [PMID: 26858749 PMCID: PMC4706910 DOI: 10.1155/2016/5017856] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/24/2015] [Accepted: 08/30/2015] [Indexed: 01/04/2023] Open
Abstract
Background. The rate of anastomotic leakage is high in surgeries for Crohn's disease, and therefore a temporary diverting stoma is often needed. We conducted this study to investigate whether preoperative nutritional therapy could reduce the risk of anastomotic leakage while decreasing the frequency of temporary stoma formation. Methods. This was a retrospective study. Patients requiring bowel resections due to Crohn's disease were reviewed. The rate of anastomotic leakage and temporary diverting stoma was compared between patients who received preoperative nutritional therapy and those on a normal diet before surgery. Possible predictive factors for anastomotic leakage were also analyzed. Results. One hundred and fourteen patients undergoing 123 surgeries were included. Patients in nutritional therapy (NT) group had a significantly lower level of C-reactive protein on the day before surgery. Patients in NT group suffered less anastomotic leakage (2.3% versus 17.9%, P = 0.023) and less temporary diverting stoma (22.8% versus 40.9%, P = 0.036). Serum albumin of the day before surgery ≤35 g/L and preoperative nutritional therapy were identified as factors which independently affected the rate of anastomotic leakage. Conclusion. Preoperative nutritional therapy reduced the risk of anastomotic leakage and the frequency of temporary diverting stoma formation in patients with Crohn's disease requiring resections.
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Myrelid P, Salim SY, Darby T, Almer S, Melgar S, Andersson P, Söderholm JD. Effects of anti-inflammatory therapy on bursting pressure of colonic anastomosis in murine dextran sulfate sodium induced colitis. Scand J Gastroenterol 2015; 50:991-1001. [PMID: 25861827 DOI: 10.3109/00365521.2014.964760] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to examine the effect of colitis and anti-inflammatory therapies on the healing of colonic anastomoses in mice. METHODS Female C57BL/6 mice were randomized into eight groups; four groups receiving plain tap-water and four groups receiving dextran sulfate sodium. Intra-peritoneal treatment was given therapeutically for 14 days with placebo, prednisolone, azathioprine, or infliximab (IFX). Colonic anastomoses were performed and bursting pressure (BP) measurements were recorded and the inflammation evaluated with histology and zymography. RESULTS The mice with colitis had a more active inflammation based on histology and bowel weight compared with the tap water group, 8.3 (7.6-9.5) mg/mm and 5.5 (4.8-6.2) mg/mm respectively (p < 0.0001). Similarly mice with colitis receiving placebo had a more active inflammation, 12.8 (10.6-15.0) mg/mm, which differed significantly from all the other therapy arms among the colitic mice; prednisolone 8.1 (7.5-9.1) mg/mm (p = 0.014), azathioprine 8.2 (7.0-8.5) mg/mm (p = 0.0046), IFX 6.7 (6.4-7.9) mg/mm (p = 0.0055). BP for the placebo group was 90.0 (71.5-102.8) mmHg and did not differ from azathioprine or IFX groups, 84.4 (70.5-112.5) and 92.3 (75.8-122.3) mmHg respectively. In contrast BP for the prednisolone group was significantly decreased compared to placebo, 55.5 (42.8-73.0) mmHg (p = 0.0004). CONCLUSIONS All therapies had a beneficial effect on the colitis. An impaired BP of colonic anastomoses was noted after preoperative steroids but not after azathioprine or IFX in this model.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University , Linköping , Sweden
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Mege D, Bege T, Beyer-Berjot L, Loundou A, Grimaud JC, Brunet C, Berdah S. Does faecal diversion prevent morbidity after ileocecal resection for Crohn's disease? Retrospective series of 80 cases. ANZ J Surg 2015; 87:E74-E79. [PMID: 25780907 DOI: 10.1111/ans.13034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND After ileocecal resection for Crohn's disease, a temporary faecal diversion is indicated in high-risk patients. The impact of a temporary stoma on post-operative morbidity has been poorly assessed so far. The aim was to analyse post-operative morbidity of temporary faecal diversion after ileocecal resection for Crohn's disease. METHODS Patients undergoing temporary faecal diversion combined with ileocecal resection were retrospectively included. Patients presenting with complications were compared with patients with an uneventful post-operative course, to identify any predictive factor for morbidity. RESULTS Eighty faecal diversions were performed (43 males, 33.5 (18-75) years), including 63 split stoma (79%) and 17 covering loop ileostomies (21%). Fifty-two patients (65%) presented with a perforating disease. Post-operative complications occurred in 15 patients (19%), 15 days after surgery (1-30). The main complications were intra-abdominal abscess (n = 6), functional renal failure (n = 6), fistula (n = 2) and stomal prolapse (n = 2). Two patients required surgery. Previous bowel resections (60% versus 28%, P = 0.01) were significantly associated with post-operative morbidity. CONCLUSIONS Temporary faecal diversion is useful in high-risk patients after ileocecal resection for Crohn's disease. Patients' information about post-operative risks remains an important issue. Risk factors for post-operative morbidity despite faecal diversion are previous bowel resections.
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Affiliation(s)
- Diane Mege
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - Thierry Bege
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France.,Laboratory of Biomechanics and Applications UMRT24, Marseille, France
| | - Laura Beyer-Berjot
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - Anderson Loundou
- Department of Public Health, Medicine University, Marseille, France
| | - Jean-Charles Grimaud
- Department of Gastroenterology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - Christian Brunet
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France.,Laboratory of Biomechanics and Applications UMRT24, Marseille, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France.,Laboratory of Biomechanics and Applications UMRT24, Marseille, France
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Abstract
Surgery for IBD is in constant evolution; it does not appear that the introduction of biologicals has had a major effect on the chance of a patient being operated on or not. Pouch surgery had its heydays in the 80s and 90s and has since then become less frequent, but the number of patients undergoing surgery still seem about the same from one year to the other. Likewise, there is no substantial evidence that surgery for Crohn's disease is diminishing. There have been fears that patients on biological treatment have an increased risk of postoperative complications. The issue is not completely settled but it is likely that patients on biological treatment who come to surgery are those who do not benefit from biologicals. Thus, they are compromised in that they have an ongoing inflammation, are in bad nutritional state, and might have several other known risk factors for a complicated postoperative course. These factors and perhaps not the biologicals per se is what surgeons should consider. During the recent years, we have seen several new developments in IBD surgery; the ileorectal anastomosis is being used for ulcerative colitis and laparoscopic surgery usually resulting in a shorter hospital stay, less pain, and better cosmetics. We have also seen the introduction of robotic surgery, single incision minimal invasive surgery, transanal minimal invasive surgery, and other approaches to minimize surgical trauma. Time will show which of these innovations patients will benefit from.
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Affiliation(s)
- Tom Øresland
- Clinic for Surgical Sciences, Univ of Oslo, Akerhus University Hospital , Lorenskog , Norway
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Stapled side-to-side anastomosis might be better than handsewn end-to-end anastomosis in ileocolic resection for Crohn's disease: a meta-analysis. Dig Dis Sci 2014; 59:1544-51. [PMID: 24500450 DOI: 10.1007/s10620-014-3039-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 01/16/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ileocolic anastomosis is an essential step in the treatment to restore continuity of the gastrointestinal tract following ileocolic resection in patients with Crohn's disease (CD). However, the association between anastomotic type and surgical outcome is controversial. AIMS The aim of this meta-analysis is to compare surgical outcomes between stapled side-to-side anastomosis (SSSA) and handsewn end-to-end anastomosis (HEEA) after ileocolic resection in patients with CD. METHODS Studies comparing SSSA with HEEA after ileocolic resection in patients with CD were identified in PubMed and EMBASE. Outcomes such as complication, recurrence, and re-operation were evaluated. Eight studies (three randomized controlled trials, one prospective non-randomized trial, and four non-randomized retrospective trials) comparing SSSA (396 cases) and HEEA (425 cases) were included. RESULTS As compared with HEEA, SSSA was superior in terms of overall postoperative complications [odds ratio (OR), 0.54; 95 % confidence interval (CI) 0.32-0.93], anastomotic leak (OR 0.45; 95 % CI 0.20-1.00), recurrence (OR 0.20; 95 % CI 0.07-0.55), and re-operation for recurrence (OR 0.18; 95 % CI 0.07-0.45). Postoperative hospital stay, mortality, and complications other than anastomotic leak were comparable. CONCLUSION Based on the results of our meta-analysis, SSSA would appear to be the preferred procedure after ileocolic resection for CD, with reduced overall postoperative complications, especially anastomotic leak, and a decreased recurrence and re-operation rate.
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Runström B, Hallböök O, Nyström PO, Sjödahl R, Olaison G. Outcome of 132 Consecutive Reconstructive Operations for Intestinal Fistula—Staged Operation Without Primary Anastomosis Improved Outcome in Retrospective Analysis. Scand J Surg 2013; 102:152-7. [DOI: 10.1177/1457496913490452] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: To study factors that influenced healing and survival after attempted closure of enterocutaneous fistula. Material and Methods: Retrospective analysis of prospective data concerning 101 patients operated on 132 instances for 110 enterocutaneous fistulae at two hospitals. Results: In all, 96 (87%) of the 110 fistulae healed and 92 (91%) patients survived. A total of 9 patients with unhealed fistula died. Multivariate analysis revealed jaundice as an independent factor for both death and failed closure and operation without anastomosis as an independent positive factor for healing. Failure rate was lower after an operation with stoma without anastomosis (6 of 43, 14%) than after an operation with anastomosis (30 of 89, 34%) p = 0.0213. Of the 36 instances with unhealed fistula, 13 (36%) could be ascribed to inadvertent bowel lesions at the reconstructive operation. In addition, univariate analysis revealed that patients with previous multiple laparotomies or with multiple operations for enterocutaneous fistula healed less likely and had higher mortality. A low serum albumin, high white blood cell count, high C-reactive protein concentration, high fistula output, total parenteral nutrition, and operation for recurrent fistula were associated with death together with long operation time and operative bleeding, both indicators of surgical complexity. Over time, staged surgery avoiding anastomosis increased from 27% to 57%. Mortality decreased from 12% to 6%, and healing increased from 73% to 94%. Conclusions: Chronic inflammation, malnutrition, and liver failure causing an impaired healing capacity are important reasons for failure. Staged operation without primary anastomosis may allow the patient to reverse this condition and improve outcome. The high surgical complexity is a negative factor that requires careful planning of the operation.
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Affiliation(s)
- B. Runström
- Department of Surgery, Falun County Hospital, Falun, Sweden
| | - O. Hallböök
- Department of Surgery, Linköping University Hospital, Linköping and Faculty of Health Sciences, University of Linköping, Sweden
| | - PO. Nyström
- Department of Gastrointestinal Surgery, Karolinska University Hospital, Huddinge and Department of Clinical Sciences, Intervention and Technology, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - R. Sjödahl
- Department of Surgery, Linköping University Hospital, Linköping and Faculty of Health Sciences, University of Linköping, Sweden
| | - G. Olaison
- Department of Surgery, Holbaek Hospital, Holbaek and Faculty of Health Sciences, University of Copenhagen, Denmark
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Yamamoto T. Delayed anastomosis after ileocolonic resection in high-risk Crohn's disease patients. Colorectal Dis 2013; 15:500-1. [PMID: 22958730 DOI: 10.1111/codi.12016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 08/29/2012] [Indexed: 01/01/2023]
Affiliation(s)
- T. Yamamoto
- Inflammatory Bowel Disease Centre; Yokkaichi Social Insurance Hospital; 10-8 Hazuyamacho; Yokkaichi; Mie 510-0016; JapanU2028
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