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Celentano V, Pellino G, Rottoli M, Poggioli G, Sica G, Giglio MC, Campanelli M, Coco C, Rizzo G, Sionne F, Colombo F, Sampietro G, Lamperti G, Foschi D, Ficari F, Vacca L, Cricchio M, Giudici F, Selvaggi L, Sciaudone G, Peltrini R, Manfreda A, Bucci L, Galleano R, Ghazouani O, Zorcolo L, Deidda S, Restivo A, Braini A, Di Candido F, Sacchi M, Carvello M, Martorana S, Bordignon G, Angriman I, Variola A, Barugola G, Di Ruscio M, Tanzanu M, Geccherle A, Tropeano FP, Luglio G, Sasia D, Migliore M, Giuffrida MC, Marrano E, Moretto G, Impellizzeri H, Gallo G, Vescio G, Sammarco G, Terrosu G, Calini G, Bondurri A, Maffioli A, Zaffaroni G, Resegotti A, Mistrangelo M, Allaix ME, Botti F, Prati M, Boni L, Perotti S, Mineccia M, Giuliani A, Romano L, Graziano GMP, Pugliese L, Pietrabissa A, Delaini GG, Spinelli A, Selvaggi F. Surgical treatment of colonic Crohn's disease: a national snapshot study. Langenbecks Arch Surg 2021; 406:1165-1172. [PMID: 33263140 PMCID: PMC8208904 DOI: 10.1007/s00423-020-02038-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023]
Abstract
AIM The different surgical options for patients with colonic Crohn's disease (CD) include segmental colectomy, subtotal colectomy or proctocolectomy with end ileostomy. We present a national, multicentre study, promoted by the Italian Society of Colorectal Surgery with the aim to collect benchmark data and national variations on multidisciplinary management and postoperative outcomes of patients undergoing surgery for colonic CD. METHODS All adult patients having elective surgery for colonic CD from June 2018 to May 2019 were eligible for participation in this retrospective study. The primary outcome measure was postoperative morbidity within 30 days of surgery. RESULTS One hundred twenty-two patients were included: 55 subtotal colectomy, 30 segmental colectomy, 25 proctectomy and 12 proctocolectomy. Eighty-six patients (70.4%) were discussed at the inflammatory bowel disease (IBD) multidisciplinary team meeting (MDT) prior to surgery. This ranged from 76.6% for segmental colectomy to 60% for subtotal colectomy, 66.6% for proctocolectomy and 48% for proctectomy. The proportion of patients counselled by a stoma nurse preoperatively was 50%. Laparoscopy was associated with reduced postoperative morbidity (p = 0.017) and shorter length of hospital stay (p < 0.001), whilst pre-operative anti-TNF was associated with Dindo-Clavien ≥ 3 complications (p = 0.023) and longer in-hospital stay (p = 0.007). The main procedure performed (segmental colectomy, subtotal colectomy, proctocolectomy or proctectomy) was not associated with postoperative morbidity (p = 0.626). CONCLUSIONS Surgery for colonic CD has a high rate of postoperative complications. Almost a third of the patients were not preoperatively discussed at the IBD MDT, whilst the use of minimally invasive surgery for surgical treatment of colonic CD ranges from 40 to 66%.
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Postoperative outcomes following inguinal hernia repair in inflammatory bowel disease patients compared to matched controls. Eur J Gastroenterol Hepatol 2021; 33:522-526. [PMID: 32956182 DOI: 10.1097/meg.0000000000001936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To assess surgical outcome in inflammatory bowel disease (IBD) patients who underwent inguinal hernia repair and to asses possible risk factors. METHODS A retrospective analysis of a prospective database including all IBD patients treated in a large tertiary center between 2008 and 2019 was conducted. IBD patients who underwent inguinal hernia surgery were matched using a propensity match scoring based on demographic and perioperative characteristics. Clinical operative data were extracted from medical records and analyzed. RESULTS Overall, out of 5467 IBD patients treated in our institute, 26 patients (0.47%) underwent inguinal hernia repair. Seventy-six matched patients with similar characteristics were compared to the IBD group. Postoperative complications were found to be more common in the IBD group (30.7% vs 11.8%; P = 0.03) compared to controls. We found no significant differences in length of stay (3.38 vs 2.83 days; P = 0.21) and hernia recurrence rate (7.6% vs 9.2%; P = 1). Within the IBD group, multivariate analysis failed to demonstrate any possible risk factor for postoperative complications, including gender [-1.53 to 2.81 95% confidence interval (CI), P = 0.52], age (-0.34 to 1.15 95% CI, P = 0.25), BMI (-0.041 to 0.019 95% CI, P = 0.43), American Society of Anesthesiologists score (-0.15 to 0.54 95% CI, P = 0.24) or medications (-0.25 to 0.28 95% CI, P = 0.88). In addition, out of various operative factors, including operation urgency, surgical approach and surgery duration, only the latter was found to be correlated with postoperative complications (0.013-0.035 95% CI, P < 0.001). CONCLUSION IBD Patients undergoing abdominal wall hernia surgery are prone to more postoperative complications.
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Yamamoto T, Lightner AL, Spinelli A, Kotze PG. Perioperative management of ileocecal Crohn's disease in the current era. Expert Rev Gastroenterol Hepatol 2020; 14:843-855. [PMID: 32729736 DOI: 10.1080/17474124.2020.1802245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The ileocecal region is most commonly involved in patients with Crohn's disease (CD). AREAS COVERED In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention. EXPERT OPINION Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center & Department of Surgery, Yokkaichi Hazu Medical Center , Yokkaichi, Japan
| | - Amy Lee Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS , Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University , Rozzano, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR) , Curitiba, Brazil
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Yamamoto T, Nakahigashi M, Shimoyama T, Umegae S. Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study. Colorectal Dis 2020; 22:554-561. [PMID: 31782874 DOI: 10.1111/codi.14922] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
AIM Currently, the notion that preoperative optimization with enteral nutrition (EN) reduces the incidence of complication after surgery in Crohn's disease (CD) patients is being debated. This case-matched study was to evaluate the impact of preoperative EN on surgical outcomes in patients with CD. METHOD Twenty-four patients received EN therapy with an elemental diet (1800-2400 kcal/day) for at least 2 weeks before the planned surgery (EN group). A further 24 patients who underwent surgery without receiving preoperative EN or parenteral nutrition formed a control group based on four matched criteria: age (≤/>40 years), the use of preoperative medications (corticosteroids/azathioprine/biologics), disease behaviour (inflammatory/stricturing/penetrating) and main surgical procedure (ileal resection/ileocolonic resection/colectomy). The incidence of complications observed within 30 days after surgery was compared between the two groups. Septic complications were defined as anastomotic leak, intra-abdominal abscess, entero-cutaneous fistula or wound infection. RESULTS In the EN group, the median serum albumin level significantly increased, while C-reactive protein (CRP) significantly decreased during the preoperative EN (albumin, from 3.0 mg/dl to 3.1 mg/dl, P = 0.04; CRP, from 3.05 mg/dl to 2.52 mg/dl, P = 0.02). The incidence of postoperative septic complications was significantly lower in the EN group compared with the control group (4% vs 25%, P = 0.04). The occurrence rate of overall complications was lower in the EN group (21% vs 29%, P = 0.51), but not statistically significant. CONCLUSION In patients with CD, preoperative optimization with EN reduced the overall rate of postoperative complications and significantly decreased postoperative septic complications.
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Affiliation(s)
- T Yamamoto
- Department of Surgery and Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - M Nakahigashi
- Faculty of Health Sciences, Suzuka University of Medical Science, Suzuka, Japan
| | - T Shimoyama
- Department of Surgery and Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - S Umegae
- Department of Surgery and Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
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Lee MJ, Brown SR. Digesting research on preoperative nutrition in Crohn's disease. Colorectal Dis 2020; 22:588. [PMID: 31971314 DOI: 10.1111/codi.14979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023]
Affiliation(s)
- M J Lee
- Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - S R Brown
- Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Helmink BA, Roland CL, Kiernan CM, Wargo JA. Toxicity of Immune Checkpoint Inhibitors: Considerations for the Surgeon. Ann Surg Oncol 2020; 27:1533-1545. [PMID: 31965370 DOI: 10.1245/s10434-019-08183-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of immunotherapeutic agents, specifically immune checkpoint inhibitors (ICIs) for solid malignancies, is rapidly rising, and many new agents and treatment combinations are in development. However, ICIs have a unique side-effect profile of immune-related adverse events (irAEs) compared with chemotherapeutic agents or targeted therapies. METHODS In this report the diverse spectrum of irAEs is highlighted using two patients with metastatic melanoma undergoing treatment with ICIs. We supplement these case reports with a brief literature review of the data regarding the safety of surgical intervention in patients taking irAEs. RESULTS The report describes the basic approach to the detection and management of irAEs, notes important perioperative considerations, and discusses the safety of surgical intervention for these patients. CONCLUSIONS Overall, these irAEs represent a diverse group of pathologies with variable timing and sometimes subtle presentation requiring careful monitoring and heightened clinical suspicion for potential toxicity by all providers, including surgeons.
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Affiliation(s)
- Beth A Helmink
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Colleen M Kiernan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jennifer A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA. .,Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Yamamoto T, Kotze PG. Letter: should we delay surgery, or stop anti-TNF therapy prior to elective surgical procedures in Crohn's disease patients receiving anti-TNF agents? Aliment Pharmacol Ther 2019; 50:969-970. [PMID: 31591777 DOI: 10.1111/apt.15450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Takayuki Yamamoto
- Department of Surgery, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
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