Indications for and results of operation in inflammatory bowel disease

Biologic treatment or immunomodulation is not associated with postoperative anastomotic complications in abdominal surgery for Crohn's disease

OBJECTIVES

There are concerns that biologic treatments or immunomodulation may negatively influence anastomotic healing. This study investigates the relationship between these treatments and anastomotic complications after surgery for Crohn's disease.

PATIENTS AND METHODS

Retrospective study on 417 operations for Crohn's disease performed at four Danish hospitals in 2000-2007. Thirty-two patients were preoperatively treated with biologics and 166 were on immunomodulation. In total, 154 were treated with corticosteroids of which 66 had prednisolone 20 mg or more.

RESULTS

Anastomotic complications occurred at 13% of the operations. There were no difference in patients on biologic treatment (9% vs. 12% (p = 0.581)) or in patients on immunomodulation (10% vs. 14% (p = 0.263)). Patients on 20 mg prednisolone or more had more anastomotic complications (20% vs. 11% (p = 0.04)). Anastomotic complications were more frequent after a colo-colic anastomosis than after an entero-enteric or entero-colic (33% vs. 12% (p = 0.013)). Patients with anastomotic complications were older (40 years vs. 35 years (p = 0.014)), had longer disease duration (7.5 years vs. 4 years (p = 0.04)), longer operation time (155 min vs. 115 min (p = 0.018)) and more operative bleeding (200 ml vs. 130 ml (p = 0.029)). Multivariate analysis revealed preoperative treatment with prednisolone 20 mg or more, operation time and a colo-colic anastomosis as negative predictors of anastomotic complications.

CONCLUSIONS

Preoperative biologic treatment or immunomodulation had no influence on anastomotic complications. The study confirms previous findings of corticosteroids and a colo-colic anastomosis as negative predictors and also that surgical complexity, as expressed by bleeding and operation time, may contribute to anastomotic complications.

Thiopurine therapy is associated with postoperative intra-abdominal septic complications in abdominal surgery for Crohn's disease

PURPOSE

Thiopurines are important as maintenance therapy in Crohn's disease, but there have been concerns whether thiopurines increase the risk for anastomotic complications. The present study was performed to assess whether thiopurines alone, or together with other possible risk factors, are associated with postoperative intra-abdominal septic complications after abdominal surgery for Crohn's disease.

METHODS

Prospectively registered data regarding perioperative factors were collected at a single tertiary referral center from 1989 to 2002. Data from 343 consecutive abdominal operations on patients with Crohn's disease were entered into a multivariate analysis to evaluate risk factors for intra-abdominal septic complications. All operations involved either anastomoses, strictureplasties, or both; no operations, however, involved proximal diversion.

RESULTS

Intra-abdominal septic complications occurred in 26 of 343 operations (8%). Thiopurine therapy was associated with an increased risk of intra-abdominal septic complications (16% with therapy; 6% without therapy; P = 0.044). Together with established risk factors such as preoperative intra-abdominal sepsis (18% with sepsis; 6% without sepsis; P = 0.024) and colo-colonic anastomosis (16% with such anastomosis; 6% with other types of anastomosis; P = 0.031), thiopurine therapy was associated with intra-abdominal septic complications in 24% if any 2 or all 3 risk factors were present compared with 13% if any 1 factor was present, and only 4% in patients if none of these factors were present (P < 0.0001).

CONCLUSIONS

Thiopurine therapy is associated with postoperative intra-abdominal septic complications. The risk for intra-abdominal septic complications was related to the number of identified risk factors. This increased risk should be taken into consideration when planning surgery for Crohn's disease.

Risks of intestinal anastomoses in Crohn's disease

Six hundred fifty-eight intestinal anastomoses in 429 operations for Crohn's disease were studied prospectively during an 8-year period to detect variables connected with perioperative morbidity. Postoperative complications occurred in 9.7% of the patients, 4% had to be reoperated on, and the overall mortality rate was 0.5%. In multivariate analysis by stepwise logistic regression, the only variable significantly (p = 0.03) associated with overall rate of complications was long-term corticosteroid therapy. Serious complications were more common in cases of intra-abdominal abscesses (p = 0.01) and preoperative steroid medication (p = 0.03). The combination of both of these risk factors increased the rate of reoperations from 0.6% (no steroids, no abscess) to 16% (steroids and abscess). No significant association with postoperative complications could be found for age, sex, duration of disease, previous operations, nutritional status, emergency surgery, extent of disease, type, number, and localization of anastomoses, presence of proximal ileo-/colostomy, or histologically inflamed margins of resection.

Synchronous bowel anastomoses

A retrospective review of patients who underwent double bowel resections and synchronous anastomoses without ileostomy or colostomy was undertaken. The study goal was to determine whether there was an increased incidence of complications attributable to the presence of a second anastomosis. A total of 66 patients who met the criteria were identified and divided into two groups. Group A consisted of 30 patients who had had two colonic resections and two colonic anastomoses. In Group B were 36 patients who had undergone separate colonic and small-bowel resections with two subsequent anastomoses. The indications for primary resection were: 1) adenocarcinoma, 54 percent; 2) Crohn's disease, 26 percent; 3) diverticulitis, 11 percent; 4) "other" indications, 9 percent. The indications for the second resection were: 1) metastatic adenocarcinoma, 30 percent; 2) Crohn's disease, 26 percent; 3) synchronous bowel lesions, 18 percent; 4) adhesions and enterotomies, 14 percent; 5) "other" indications, 12 percent. Overall, there were four major complications (6 percent), and 11 minor complications (17 percent). The sole anastomotic leak occurred in a patient who had undergone a double colonic resection (3%). The other major complications were one death, one ureteral complication that required reoperation, and one early small-bowel obstruction. Minor complications included two wound infections (3 percent), three seromas (5 percent), three prolonged ileus (5 percent), and three urinary infections (5 percent). These results are comparable to the best results reported for patients undergoing single colonic anastomoses. The conclusion is that it is safe to perform synchronous anastomoses without diversion provided the following conditions are present: well-prepared bowel with minimal fecal soilage, an adequate blood supply, technically good anastomoses, and lack of tension on the suture lines.