Timing of surgery in Crohn’s disease: A key issue in the management

A Comparison of Clinical Outcomes of Colectomies for Pediatric and Adult Patients With Inflammatory Bowel Disease

Background: Crohn's disease (CD) and ulcerative colitis (UC) are prevalent in adult and pediatric populations, but their differences are not well studied using national data. We compared the clinical outcomes of these patients using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases.Methods: Colectomy cases for CD and UC, the 2 major forms of inflammatory bowel disease (IBD), were compared between adult and pediatric patients using the 2017-2019 ACS NSQIP databases. Various clinical factors were analyzed, with postoperative complications being the primary outcome of interest.Results: We identified 542 pediatric and 5174 adult CD patients and 360 pediatric and 1292 adult UC patients. Adults with CD or UC were more likely to be on steroids preoperatively (CD: 60.15% vs 24.54%; UC: 65.63% vs 51.39%). Children with IBD were more likely to have preoperative transfusions (CD: 1.48% vs .33%; UC: 8.33% vs .62%), systemic inflammatory response syndrome (CD: 3.51% vs .93%; UC: 12.78% vs 3.10%), or sepsis (CD: 1.85% vs .66%; UC: 1.39% vs .31%). Unplanned reoperations were more common among pediatric patients in both disease states compared to adults (CD: 6.27% vs 4.10%; UC: 11.11% vs 4.26%), with P-values for all factors described as ≤.02. Multivariate logistic regression found pediatric age to be associated with higher odds of needing a reoperation among UC patients but not CD patients.Conclusion: Pediatric patients were sicker at the time of surgery, and those with either disease were more likely to require a reoperation within 30 days.

Optimal Management of Refractory Crohn's Disease: Current Landscape and Future Direction

Refractory Crohn's disease, defined as ongoing inflammation despite the trial of multiple advanced therapies, impacts a number of individuals with Crohn's disease, and leads to significant burden in quality of life and cost. Interventions such as early implementation of advanced therapies, optimization of current therapies prior to switching to an alternative, as well as understanding the overlapping pathophysiology between immune-mediated disorders, however, can help shift the current landscape and reduce the number of patients with refractory disease. As such, in this review we summarize the key takeaways of the latest research in the management of moderate-to-severe Crohn's disease, focusing on maximization of our currently available medications, while also exploring topics such as combination advanced therapies. We also describe evidence for emerging and alternative therapeutic modalities, including fecal microbiota transplant, exclusive enteral feeding, hyperbaric oxygen, stem cell therapy, bone marrow transplant, and posaconazole, with a focus on both the potential impact and specific indications for each.

Timing of first abdominal operation in Crohn's disease based on a diagnostic model

This study aims to develop a clinical diagnostic model for assessing the need for initial abdominal surgery in patients diagnosed with Crohn's disease (CD) and create a nomogram to facilitate clinical decision-making. A total of 164 surgical CD patients and 230 control CD patients were included in this retrospective analysis. Least Absolute Shrinkage and Selection Operator (Lasso) regression and binomial logistic regression were employed to select clinical variables. The 394 CD patients were randomly allocated to a training set and a validation set in a 7:3 ratio. The filtered variables were used to establish a diagnostic model and nomogram in the training set, subsequently validated in the testing set. Decision Curve Analysis (DCA) and clinical impact curve were constructed to validate the clinical applicability of the model. Binomial logistic regression analysis identified seven clinical variables with a p-value less than 0.01, including Biomarker (B), Waist-to-Height Ratio (WHtR), Intestinal obstruction, Albumin (ALB), Crohn's Disease Activity Index (CDAI), Myocardial Flow Index (MFI), and C-reactive protein (CRP). These variables were utilized to establish the diagnostic model. Calibration curves showed good alignment, with a C-index of 0.996 in the training set and 0.990 in the testing set. DCA and clinical impact curve demonstrated that the diagnostic model had good clinical efficiency and could provide clinical benefits. A validated diagnostic model for determining the timing of the first abdominal operation in CD patients was established and evaluated, showing high discriminative ability, calibration, and clinical efficiency. It can be utilized by clinicians to assess the optimal timing for transitioning CD patients from medical treatment to surgical intervention, providing valuable references for individualized treatment decisions for CD patients.

Preoperative Magnetic Resonance Enterography to Predict Pathological Specimen Length in Crohn's Disease

BACKGROUND

The European Crohn's and Colitis Organization guidelines have highlighted the importance of the preoperative evaluation of the affected segment length in patients with ileocolic Crohn's disease to determine the best surgical approach.

OBJECTIVE

This study aimed to evaluate the accuracy of preoperative magnetic resonance enterography in assessing the length of the affected segment in patients with ileocolic Crohn's disease.

DESIGN

This observational study was conducted with a prospectively maintained database and retrospective analysis.

SETTINGS

This study was conducted in a tertiary center.

PATIENTS

This study included consecutive patients undergoing ileocolic resection for Crohn's disease between August 2014 and June 2020. All patients underwent a preoperative magnetic resonance enterography.

MAIN OUTCOME MEASURES

The correlation between the length measured on magnetic resonance enterography and pathological examination was evaluated.

RESULTS

A total of 96 patients were included. The median time between magnetic resonance enterography and surgery was 65.5 (3-331) days. The length of the affected segment on magnetic resonance enterography was correlated with the length assessed on pathological evaluation ( R = 0.48, p < 0.001). No correlation was found between the 2 measurements when imaging was performed >6 months before surgery ( R = 0.14, p = 0.62). The presence of an abscess underestimated the length affected by Crohn's disease on imaging compared to pathology, whereas the presence of a fistula was associated with magnetic resonance enterography overestimation of the length of the affected segment.

LIMITATIONS

Limitations included single-center study and retrospective analysis.

CONCLUSION

In Crohn's disease, preoperative magnetic resonance enterography is a highly reliable tool for predicting the length of the affected segment compared to pathology examination in the absence of an abscess or fistula. See Video Abstract at http://links.lww.com/DCR/C26 .

ENTEROGRAFA POR RESONANCIA MAGNTICA PREOPERATORIA PARA PREDECIR LA LONGITUD DE MUESTRAS PATOLGICAS EN LA ENFERMEDAD DE CROHN

ANTECEDENTES:Las guías de la Organización Europea de Crohn y Colitis han resaltado la importancia de la evaluación preoperatoria de la longitud del segmento afectado para determinar el mejor abordaje quirúrgico.OBJETIVO:Evaluamos la precisión de la enterografía por resonancia magnética preoperatoria para evaluar la longitud del segmento afectado en pacientes con enfermedad de Crohn ileocólica.DISEÑO:Realizamos un estudio observacional con una base de datos mantenida prospectivamente y un análisis retrospectivo.CONFIGURACIÓN:Este estudio se realizó en un centro terciario.PACIENTES:Se incluyeron pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre Agosto de 2014 y Junio de 2020. A todos los pacientes se les realizó una enterografía por resonancia magnética preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluó la correlación entre la longitud medida en la enterografía por resonancia magnética y el examen patológico.RESULTADOS:Se incluyeron un total de 96 pacientes. El tiempo mediano entre la enterografía por resonancia magnética y la cirugía fue de 65,5 (3-331) días. La longitud del segmento afectado en la enterografía por resonancia magnética se correlacionó con la longitud evaluada en la evaluación patológica ( R = 0,48, p < 0,001). No hubo correlación entre las 2 mediciones cuando las imágenes se realizaron más de 6 meses antes de la cirugía ( R = 0,14, p = 0,62). La presencia de un absceso subestimó la longitud afectada por la enfermedad de Crohn en las imágenes en comparación con la patología, mientras que la presencia de una fístula se asoció con una sobrestimación de la longitud del segmento afectado por enterografía por resonancia magnética.LIMITACIONES:Las limitaciones incluyeron un estudio de un solo centro y un análisis retrospectivo.CONCLUSIÓNES:En la enfermedad de Crohn, la enterografía por resonancia magnética preoperatoria es una herramienta altamente confiable para predecir la longitud del segmento afectado en comparación con el examen de patología, en ausencia de absceso o fístula. Consulte el Video Resumen en http://links.lww.com/DCR/C26 . (Traducción-Dr. Yesenia Rojas-Khalil ).

Role of perioperative nutritional status and enteral nutrition in predicting and preventing post-operative complications in patients with Crohn's disease

Background

Perioperative immune-nutritional status is correlated with post-operative outcomes. This study aimed to evaluate whether pre-operative nutritional status could predict post-operative complications in patients with Crohn's disease (CD) and whether pre-operative enteral nutrition (EN) can prevent post-operative complications.

Methods

This retrospective cohort study analyzed the electronic health records of 173 patients diagnosed with CD in Ruijin Hospital, Shanghai, China, between August 2015 and May 2021: 122 patients had pre-operative nutritional support while 51 patients underwent surgery without pre-operative nutritional support. The pre-operative nutritional status, disease activity index, disease-related data, frequency of multiple surgery, operative data, and post-operative characters in each group were compared to determine whether the nutritional support and status could significantly affect post-operative outcome. One-to-one propensity score matching (PSM) was performed to limit demographic inequalities between the two groups.

Results

After PSM, no statistically significant differences were found in pre-operative patient basic characteristics between the two groups of 47 patients (98 patients in all) included in this study. Overall, 21 patients developed 26 post-operative complications. In terms of pre-operative nutritional status, the level of serum albumin (ALB), pre-albumin (pre-ALB), and hemoglobin (Hb) in the nutrition group were statistically higher than that in the control group. We also observed a statistically significant decrease in post-operative complications, need for emergency surgery, and staged operations, while the rate of laparoscopic surgery was higher in the nutrition group compared to the non-nutritional group. Post-operative complications were related to pre-operative nutritional condition, which indicated that EN may improve the nutritional status and reduced the rate of post-operative complications.

Conclusion

Pre-operative nutritional status is correlated with post-operative outcomes while EN plays a positive role in preventing the post-operative complications. EN is useful for improving the pre-operative nutritional status and reducing the post-operative adverse events for CD patients undergoing surgery.

Surgery for Crohn’s disease: upfront or last resort?

Crohn’s disease (CD) can involve the entire gastrointestinal tract from the mouth to the anus and can lead to a constellation of symptoms. With the advancement of effective medical treatments for CD, a tendency has emerged to consider surgical treatment as a last resort. This potentially has the disadvantage of delaying surgery and if it fails might leave patients sicker, less well nourished, and with more severe complications. As with most non-malignant diseases, the choice of surgery vs medical treatment is a patient’s personal preference under the guidance of the treating physician, except in extreme situations where surgery might be the only option. In this article, we will discuss the available evidence regarding the optimal timing of surgery in CD, focusing on whether early surgery can bring benefits in terms of disease control, symptom relief, and quality of life.

Biomechanical Properties of Strictures in Crohn’s Disease: Can Dynamic Contrast-Enhanced Ultrasonography and Magnetic Resonance Enterography Predict Stiffness?

Strictures and abdominal pain often complicate Crohn’s disease (CD). The primary aim was to explore whether parameters obtained by preoperative contrast-enhanced (CE) ultrasonography (US) and dynamic CE MR Enterography (DCE-MRE) of strictures associates with biomechanical properties. CD patients undergoing elective small intestinal surgery were preoperatively examined with DCE-MRE and CEUS. The excised intestine was distended utilizing a pressure bag. Luminal and outer bowel wall cross-sectional areas were measured with US. The circumferential stricture stiffness (Young’s modulus E) was computed. Stiffness was associated with the initial slope of enhancement on DCE-MRE (ρ = 0.63, p = 0.007), reflecting active disease, but lacked association with CEUS parameters. For structural imaging parameters, inflammation and stricture stiffness were associated with prestenotic dilatation on US (τ_b = 0.43, p = 0.02) but not with MRE (τ_b = 0.01, p = 1.0). Strictures identified by US were stiffer, 16.8 (14.0–20.1) kPa, than those graded as no or uncertain strictures, 12.6 (10.5–15.1) kPa, p = 0.02. MRE global score (activity) was associated with E (ρ = 0.55, p = 0.018). Elastography did not correlate with circumferential stiffness. We conclude that increasing activity defined by the initial slope of enhancement on DCE-MRE and MRE global score were associated with stricture stiffness. Prestenotic dilatation on US could be a potential biomarker of CD small intestinal stricture stiffness.

Small and Large Intestine (II): Inflammatory Bowel Disease, Short Bowel Syndrome, and Malignant Tumors of the Digestive Tract

The small intestine is key in the digestion and absorption of macro and micronutrients. The large intestine is essential for the absorption of water, to allow adequate defecation, and to harbor intestinal microbiota, for which their nutritional role is as important as it is unknown. This article will describe the causes and consequences of malnutrition in patients with inflammatory bowel diseases, the importance of screening and replacement of micronutrient deficits, and the main indications for enteral and parenteral nutrition in these patients. We will also discuss the causes of short bowel syndrome, a complex entity due to anatomical or functional loss of part of the small bowel, which can cause insufficient absorption of liquid, electrolytes, and nutrients and lead to complex management. Finally, we will review the causes, consequences, and management of malnutrition in patients with malignant and benign digestive tumors, including neuroendocrine tumors (present not only in the intestine but also in the pancreas).

Risk factors for postoperative complications in Crohn disease: analysis of 173 patients

Background and objectives Surgery for Crohn disease has a wide range of factors that are being studied as possible risk factors for postoperative complications. The later are a major problem in those patients and are associated with longer hospital stays and increased mortality and morbidity. Despite the debate regarding the influence of patients’ characteristics, preoperative and operative details, the risk factors are not fully identified. The debate has been focused on the new medical therapy and the time of surgery. Our goal was to help identify and confirm risk factors for postoperative complications.

Materials and methods A retrospective cohort study including all patients operated due to Crohn disease in São João Hospital Center from 2010 to 2015. We analyzed patient, preoperative and surgical characteristics. For postoperative complications data only those occurring within 30 days were included.

Results Neither age at diagnosis or previous corticotherapy/anti-TNF/ustekinumab was significantly associated with an increased risk in postoperative complications. Only age at surgery >40 years (Montreal Classification A1 + A2 vs. A3; OR = 4.12; p < 0.05) and the group others (occlusion vs. others [combination of intestinal perforation, mesenteric ischemia and postoperative complications] vs. fistula/abscess as indication for surgery; OR = 4.12; p < 0.05) remained as independent risk factors after multivariable regression analysis.

Conclusions We described clear associations between age at surgery >40 years and the group others (intestinal perforation, mesenteric ischemia and postoperative complications) and overall postoperative complications in Crohn disease. These results may suggest that surgery does not need to be delayed and, in some cases, should be anticipated.

Experiences with the Kono-S anastomosis in Crohn's disease of the terminal ileum-a cohort study

Purpose

The most frequent long-term complication after ileocecal resection in Crohn’s disease is anastomotic recurrence and subsequent stenosis. Recurrence typically begins at the site of the anastomosis, raising the question of whether the surgical technique of the anastomosis could affect recurrence rates. Kono-S anastomosis is a hand-sewn antimesenteric functional end-to-end anastomosis that offers a wide lumen that is well accessible for endoscopic dilatation. The purpose of our study is to review the rate of postoperative complications almost 2 years after the introduction of this technique.

Materials and methods

This is a prospective single-center cohort study of all consecutive patients with Crohn’s disease undergoing ileocecal resection. Patients’ characteristics as well as specific data for the surgical procedure and short-term outcome were evaluated.

Results

Thirty patients were operated for Crohn’s disease of the terminal ileum (n = 24) or anastomotic recurrence (n = 6). Postoperative complications with a Clavien-Dindo Score ≥ IIIb were observed in three patients. One patient showed a hemorrhage and underwent surgical hemostasis. Two patients developed anastomotic leakage; in both cases, ileostomy was created after resection of the anastomosis. The median hospital stay was 9 days (IQR 7–12). A comparison with a historic group of conventionally operated patients of our hospital revealed no differences in short-term results except for the duration of surgery.

Conclusion

The Kono-S anastomosis is associated with acceptable short-term results, complications, and recurrence rates comparable with the established anastomotic techniques. Longer operation times are observed, but the few published studies concerning long-term recurrence are promising.

Abdominal Emergencies in Inflammatory Bowel Disease

Although improved medical therapies have been associated with decreased rates of emergent intestinal resection for inflammatory bowel disease, prompt diagnosis and management remain of utmost importance to ensure appropriate patient care with reduced morbidity and mortality. Emergent indications for surgery include toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage. Given this broad spectrum of emergent presentations, a multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care.

Preliminary study of short- and long-term outcome and quality of life after minimally invasive surgery for Crohn's disease: Comparison between single incision, robotic-assisted and conventional laparoscopy

Background

The feasibility of minimally invasive approach for Crohn's disease (CD) is still controversial. However, several meta-analysis and retrospective studies demonstrated the safety and benefits of laparoscopy for CD patients. Laparoscopic surgery can also be considered for complex disease and recurrent disease. The aim of this study was to investigate retrospectively the effect of three minimally invasive techniques on short- and long-term post-operative outcome.

Patients and Methods

We analysed CD patients underwent minimally invasive surgery in the Digestive Surgery Unit at Careggi University Hospital (from January 2012 to March 2017). Short-term outcome was evaluated with Clavien-Dindo classification and visual analogue scale for post-operative pain. Long-term outcome was evaluated through four questionnaires: Short Form Health Survey (SF-36), Gastrointestinal Quality Of Life Index (GIQLI), Body Image Questionnaire (BIQ) and Hospital Experience Questionnaire (HEQ).

Results

There were 89 patients: 63 conventional laparoscopy, 16 single-incision laparoscopic surgery and 10 robotic-assisted laparoscopy (RALS). Serum albumin <30 g/L (P = 0.031) resulted to be a risk factor for post-operative complications. HEQ had a better result for RALS (P = 0.019), while no differences resulted for SF-36, BIQ and GIQLI.

Conclusions

Minimally invasive technique for CD is feasible, even for complicated and recurrent disease. Our study demonstrated low rates of post-operative complications. However, it is a preliminary study with a small sample size. Further studies should be performed to assess the best surgical technique.

Kidney transplantation in patients with inflammatory bowel diseases (IBD): analysis of transplantation outcome and IBD activity

Inflammatory bowel diseases (IBD) is a systemic disorder with possible renal involvement, yet data regarding the outcome of kidney transplantation (KT) in those patients, and IBD course post KT, are scarce. In this retrospective analysis, we studied the outcome of 12 IBD kidney recipients (seven Crohn's disease, five ulcerative colitis; primary kidney disease was IgA nephropathy in five, polycystic disease in four), compared to two control groups: matched controls and a cohort of recipients with similar kidney disease. During a follow-up period of 60.1 (11.0-76.6) months (median, interquartile range), estimated 5-year survival was 80.8 vs. 96.8%, with and without IBD, respectively (P = 0.001). Risk of death with a functioning graft was higher with IBD (HR = 1.441, P = 0.048), and with increased age (HR = 1.109, P = 0.05). Late rehospitalization rate was higher in IBD [incidence rate ratio = 1.168, P = 0.030], as well as rate of hospitalization related to infection [1.42, P = 0.037]. All patients that were in remission before KT, remission was maintained. Patients that were transplanted with mild or moderate disease remained stable or improved with Infliximab or Adalimumab treatment. In conclusion, IBD is associated with an increased risk of mortality, hospitalization because of infection and late rehospitalization after KT. Clinical course of IBD is stable after KT.

[The Kono-S anastomosis in surgery for Crohn's disease : First results of a new functional end-to-end anastomotic technique after intestinal resection in patients with Crohn's disease in Germany]

BACKGROUND

Recurrent disease at the anastomotic site after bowel resection represents a major problem in patients with Crohn's disease. In 2011, a new anastomotic technique (Kono-S anastomosis) was published, which as a functional end-to-end anastomosis creating a wide anastomotic diameter aimed to reduce the rate of recurrence after surgery.

AIM

To evaluate the Kono-S anastomosis with respect to early and late postoperative complications and recurrence rate after surgical intestinal resection in patients with Crohn's disease at a university center.

PATIENTS AND METHODS

All patients with Crohn's disease who underwent Kono-S anastomoses between June 2015 and December 2016 at the Department of Surgery, University Medical Centre Mannheim, were included in the study. After obtaining informed consent, patient data regarding surgery and hospital stay were recorded in a prospective database. Follow-up was carried out by structured telephone interviews including disease progression, medication and surveillance. Statistical analysis was performed using the Graph Pad Prism 7 software. Ethics board approval was obtained from the Medical Ethics Commission II of the Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany (No. 2017-575N-MA).

RESULTS

A total of 53 patients (32 female and 21 male) were included in this study. The median procedural time was 157 min. The median follow-up was 12 months (range 4-23 months). Of the patients 3 developed early postoperative complications with a Clavien-Dindo score ≥ III and 25 patients with or without symptoms were controlled by endoscopy and/or magnetic resonance imaging (MRI) and no anastomotic recurrence was detected. No endoscopic interventions were necessary and 16 patients were symptom-free with no further specific therapy or controls.

DISCUSSION

The Kono-S anastomosis is a safe anastomotic method with low morbidity. In the early follow-up recurrence rates of Crohn's disease at the anastomotic site were low. In the literature a reoperation rate of 5 % per year is given for patients with Crohn's disease after intestinal resection, so that in the long-term observation a valid statement on recurrence rate is possible. A potential advantage of the morphological end-to-end configuration of the Kono-S anastomosis is the better endoscopic dilatation compared to a side-to-side anastomosis.

CONCLUSION

The Kono-S anastomotic technique has a low morbidity. In the early follow-up observational period no recurrence occurred in the anastomosis area in this series. Long-term data must clarify whether this technique is advantageous with respect to this aspect in the long run.

Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review

PURPOSE

Surgical management of inflammatory bowel disease (IBD) is a challenging task. The aim of preoperative optimization (PO) is to decrease the risk of complications and reduce the length of postoperative stay. The aim of this study was to review and grade the available evidence, attain clear recommendations, and point out potential future research.

METHODS

Studies were identified from electronic databases (PubMed, Embase, and Cochrane Library) and scanning reference lists in relevant papers. English-written studies examining PO in adult patients with IBD were included. Eight PO factors were investigated.

RESULTS

Management of IBD is a multidisciplinary task. Steroid withdrawal is recommended while steroid stress dose is not recommended. Thiopurines appear to be safe, but it may be prudent to plan the procedure remotely from the last dose of an anti-TNF agent. Nutritional risk screening is recommended to unveil and correct any malnutrition. Thrombosis prophylaxis prior to surgery is well supported by evidence while extended 4-week prophylaxis needs further research. Percutaneous ultrasound or CT-guided drainage for intra-abdominal abscesses is recommended, but it is unclear for how long supplementary antibiotics (ABs) should be used. Oral AB 24 h prior to open surgery might improve outcome if given as complementary to IV perioperative AB. Mechanical bowel preparation is not supported by evidence. Comorbidities must be treated accordingly prior to surgical intervention. Smoking cessation can be beneficial for wound healing.

CONCLUSION

Multimodel PO intervention in IBD patients is recommended.

Kono-S Anastomosis for Crohn's Disease: Report of 2 Cases

Crohn disease (CD) is a chronic inflammatory bowel disease that affects the entire gastrointestinal tract. The standard treatment for CD is medication to control the inflammation and relieve the symptoms. CD patients often require surgery at some point in their life for complications, treatment resistance, and side effects of medication. However, postoperative recurrences are common. To reduce anastomotic troubles, several types of anastomosis were investigated. Kono-S anastomosis, an antimesenteric, functional, end-to-end handsewn anastomosis, was introduced in order to prevent the restenosis caused by recurrence of CD in 2010. Kono-S anastomosis is expected lower susceptibility to mechanical distortions due to the stability provided by the “supporting column.” We herein report 2 cases of CD performed with a Kono-S anastomosis. The importance of these cases is that Kono-S anastomosis is useful for preventing restenosis caused by recurrence. The first patient was a 26-year-old man who suffered from CD for 9 years. Computed tomography (CT) showed inflammation and stenosis at the ileocecum, a fistula between the terminal ileum and sigmoid colon, and an intraperitoneal abscess. We performed an ileocecal resection and a Kono-S anastomosis. The second patient was a 25-year-old woman who suffered from CD for 8 years. CT showed inflammation and stenosis at the ileocecum, and a retroperitoneal abscess. We performed an ileocecal resection and Kono-S anastomosis. Both patients showed no recurrence after surgery. Kono-S anastomosis may be effective for preventing recurrence at anastomotic sites in CD patients.

Completion Proctectomy for Crohn's Colitis: Lessons Learned

Surgical management of Crohn's disease is reserved for patients refractory to medical therapy and those who develop complications alleviated by surgery. Surgical resection may be the most efficient way to restore health in patients with stricturing and or fistulizing disease of the terminal ileum / small bowel. However, decision-making in patients with Crohn's colitis is more difficult. The merits of segmental resection versus subtotal/total colectomy versus total proctocolectomy with end ileostomy are affected by a myriad of factors, including extent of colon involvement, the patient's age, and the patient's degree of desire to avoid an ileostomy. In patients undergoing a total proctocolectomy for Crohn's colitis, the anal canal should be removed. The following case highlights the potential difficulty that may arise when the anal canal is left in situ.

The role of imaging in the preoperative assessment of children with inflammatory colitis

BACKGROUND

Accurate diagnosis of Crohn's disease or ulcerative colitis is essential for surgical planning. This study compared the accuracy, safety, and utility of small bowel follow-through (SBFT) and magnetic resonance enterography (MRE) for detecting small bowel (SB) involvement preoperatively.

METHODS

A retrospective review of children who underwent colectomy for inflammatory bowel disease (2000-2014) was performed. Preoperative SBFT and MRE were independently reviewed by two radiologists blinded to clinical data. Gold standard for diagnosis was surgical pathology.

RESULTS

68 patients (36 female) were included. 45 patients had SBFT prior to colectomy, 17 patients had MRE, and 6 both. Interrater reliability for radiologic interpretation was 90% (SBFT) and 91% (MRE). Mean study durations were 190min (SBFT) and 59min (MRE). Median effective dose for SBFT was 1.5mSv, while MRE involved no ionizing radiation. Specificities for diagnosing SB involvement were 87.5% (SBFT) and 94% (MRE). 54 patients underwent subtotal colectomy and ileostomy, 12 restorative proctocolectomy, and 2 colectomy with ileorectal anastomosis. Preoperative imaging correlated with surgical pathology in 83% (SBFT) and 90% (MRE).

CONCLUSION

MRE is at least as effective as SBFT for assessing SB disease in children with colitis prior to colectomy. MRE requires less time and does not expose children to ionizing radiation. Retrospective Case Series, Level 4 Evidence.

Surgery in Pediatric Crohn's Disease: Indications, Timing and Post-Operative Management

Pediatric onset Crohn's disease (CD) tends to have complicated behavior (stricture or penetration) than elderly onset CD at diagnosis. Considering the longer duration of the disease in pediatric patients, the accumulative chance of surgical treatment is higher than in adult onset CD patients. Possible operative indications include perianal CD, intestinal stricture or obstruction, abdominal abscess or fistula, intestinal hemorrhage, neoplastic changes and medically untreatable inflammation. Growth retardation is an operative indication only for pediatric patients. Surgery can affect a patient's clinical course, especially for pediatric CD patient who are growing physically and mentally, so the decision should be made by careful consideration of several factors. The complex and diverse clinical conditions hinder development of a systemized treatment algorithm. Therefore, timing of surgery in pediatric CD patients should be determined with individualized approach by an experienced and well organized multidisciplinary inflammatory bowel disease team. Best long-term outcomes will require proactive post-operative monitoring and therapeutic modifications according to the conditions.

Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel diseases are common in Europe, with prevalences as high as 1 in 198 persons (ulcerative colitis) and 1 in 310 persons (Crohn's disease).

METHODS

This review is based on pertinent articles retrieved by a search in PubMed and in German and European guidelines and Cochrane reviews of controlled trials.

RESULTS

Typically, the main clinical features of inflammatory bowel diseases are diarrhea, abdominal pain, and, in the case of ulcerative colitis, peranal bleeding. These diseases are due to a complex immunological disturbance with both genetic and environmental causes. A defective mucosal barrier against commensal bowel flora plays a major role in their pathogenesis. The diagnosis is based on laboratory testing, ultrasonography, imaging studies, and, above all, gastrointestinal endoscopy. Most patients with Crohn's disease respond to budesonide or systemic steroids; aminosalicylates are less effective. Refractory exacerbations may be treated with antibodies against tumor necrosis factor (TNF) or, more recently, antibodies against integrin, a protein of the cell membrane. In ulcerative colitis, aminosalicylates are given first; if necessary, steroids or antibodies against TNF-α or integrin are added. Maintenance therapy to prevent further relapses often involves immunosuppression with thiopurines and/or antibodies. Once all conservative treatment options have been exhausted, surgery may be necessary.

CONCLUSION

The treatment of chronic inflammatory bowel diseases requires individually designed therapeutic strategies and the close interdisciplinary collaboration of internists and surgeons.

The effect of pre-operative optimization on post-operative outcome in Crohn's disease resections

BACKGROUND

The timing of surgical intervention in Crohn's disease (CD) may depend on pre-operative optimization (PO) which includes different interventions to decrease the risk for unfavourable post-operative outcome. The objective of this study was to investigate the effect of multi-model PO on the post-operative outcome in CD.

METHOD

This is a multicentre retrospective cohort study. The primary outcome was 30-day post-operative complications. Secondary outcomes were intra-abdominal septic complications, surgical site infection (SSI), re-operation, length of post-operative stay in a hospital and re-admission. PO included nutritional support, discontinuation of medications, pre-operative antibiotic course and thrombosis prophylaxis.

RESULTS

Two hundred and thirty-seven CD elective bowel resections were included. Mean age was 39.9 years SD 14.25, 144 (60.8 %) were female and 129 (54.4 %) had one or more types of medical treatment pre-operatively. Seventy-seven patients (32.5 %) optimized by at least nutritional support or change in pre-operative medications. PO patients were more likely to have penetrating disease phenotype (p = 0.034), lower albumin (p = 0.015) and haemoglobin (p = 0.021) compared to the non-optimized. Multivariate analyses showed that treatment with anti-TNF alpha agents OR 2.058 CI [1.043-4.4.064] and low haemoglobin OR 0.741 CI [0.572-0.0.961] increased the risk of overall post-operative complications. Co-morbidity increased the risk of SSI OR 2.567 CI [1.182-5.576] while low haemoglobin was a risk factor for re-admission OR 0.613 CI [0.405-0.926]. Low pre-operative albumin correlated with longer stay in hospital.

CONCLUSIONS

PO did not change post-operative outcome most likely due to selection bias. Anti-TNF alpha agents, low haemoglobin, low albumin and co-morbidity were associated with unfavourable outcome.

Outcome of Surgery for Coloduodenal Fistula in Crohn's Disease

BACKGROUND

This study was conducted to report the short- and long-term outcomes of surgery for coloduodenal fistula in Crohn's disease and explore the effect of preoperative optimization on surgical outcome.

METHODS

This is a retrospective review of 34 patients with coloduodenal fistula complicating Crohn's disease between Jan 2008 and May 2015. Demographic information, preoperative management, and intraoperative and postoperative outcome data were collected.

RESULTS

Primary duodenal repair was carried out in 33 patients (13 with duodenal defect >3 cm), and bypass surgery was performed in one patient with duodenal stenosis. Patients undergoing preoperative optimization (n = 25) had decreased postoperative major (24.0 vs. 87.5 %, P = 0.005) and intra-abdominal septic (20.0 vs. 75.0 %, P = 0.008) complications compared to patients with emergent/semi-emergent surgery (n = 8). No duodenal stenosis occurred on a median follow-up of 22.5 months. Patients with duodenum-ileocolic anastomosis fistula had longer postoperative stay (14.0 vs. 10.0 days, P = 0.032) and increased possibility of refistulization of the duodenum on follow-up (30.0 vs. 0 %, P = 0.031) compared with those with spontaneous duodenum-colonic fistula.

CONCLUSION

Primary duodenal repair can be safely performed in coloduodenal fistula in Crohn's disease provided there was no duodenal stenosis, even for large duodenal defects. Preoperative optimization is associated with reduced postoperative complications. Patients with duodenum-ileocolic anastomosis fistula are more likely to have duodenum fistula recurrence compared to those with spontaneous duodenum-colonic fistula.

Trends in the Surgical Management of Crohn's Disease

INTRODUCTION

Although medical management of Crohn's disease has changed in recent years, it is unclear whether surgical management has altered. We examined rate changes of surgical interventions, stoma constructions, and subset of ileostomy and colostomy constructions.

MATERIALS AND METHODS

We reviewed the Nationwide Inpatient Sample database from 1988 to 2011. We examined the number of Crohn's-related operations and stoma constructions, including ileostomies and colostomies; a multivariable logistic regression model was developed.

RESULTS

A total of 355,239 Crohn's-related operations were analyzed. Operations increased from 13,955 in 1988 to 17,577 in 2011, p < 0.001. Stoma construction increased from 2493 to 4283, p < 0.001. The subset of ileostomies increased from 1201 to 3169, p < 0.001 while colostomies decreased from 1351 to 1201, p = 0.05. Operation percentages resulting in stoma construction increased from 18 to 24 %, p < 0.001. Weight loss (OR 2.25, 95 % CI 1.88, 2.69) and presence of perianal fistulizing disease (OR 2.91, 95 % CI 2.31, 3.67) were most predictive for requiring stoma construction.

CONCLUSIONS

Crohn's-related surgical interventions and stoma constructions have increased. The largest predictors for stoma construction are weight loss and perianal fistulizing disease. As a result, nutrition should be optimized and the early involvement of a multidisciplinary team should be considered.

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

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

Outcomes of initial medical compared with surgical strategies in the management of intra-abdominal abscesses in patients with Crohn's disease: a meta-analysis

BACKGROUND

Several studies have also evaluated the efficacy of initial medical management compared with initial surgical management strategies with regard to abscess resolution with variable results.

OBJECTIVE

The aim of this study is to evaluate the efficacy of initial medical management compared with surgical management of Crohn's disease (CD)-related intra-abdominal abscesses.

DATA SOURCES

A comprehensive search of multiple databases (MEDLINE/PubMed, Cochrane databases, CINAHL, Scopus, and Google Scholar) was performed in August 2014.

STUDY SELECTION

All studies on adults comparing initial surgical versus medical approaches to treat CD-related abscesses were included.

MAIN OUTCOMES MEASURED

The durability of abscess resolution and rate of stoma creation between the groups undergoing initial surgical versus medical approaches were compared.

RESULTS

The pooled analysis of the nine studies including a total 603 patients showed an overall rate of abscess resolution were 56.6% in the medical group compared with 80.7% in the surgical group. There was over three-fold higher chance of achieving abscess resolution when an initial surgical strategy was used at the time of abscess diagnosis compared with the medical strategy (odds ratio 3.44, 95% confidence interval: 1.80, 6.58, P<0.001). The number needed to treat using the initial surgical approach to prevent a recurrent abscess was four patients.

LIMITATIONS

All included studies were retrospective case series with potential clinical confounders not fully accounted in the analysis.

CONCLUSION

Initial surgical management appears to be superior to medical management in patients with CD-related intra-abdominal abscesses. Though all the included studies in this meta-analysis were retrospective, this meta-analysis is likely the strongest level of evidence with regard to the management of CD-related abscesses, given that a randomized-control trial may not be feasible given the low rate of abscess development in CD.

Novel antimesenteric functional end-to-end handsewn (Kono-S) anastomoses for Crohn's disease: a report of surgical procedure and short-term outcomes

INTRODUCTION

Anastomotic surgical recurrence after bowel resection is a major problem in patients with Crohn's disease. The aim of this prospective observational study was to evaluate the efficacy of a novel technique for restoring bowel continuity after resection involving either the small or the large intestine.

METHODS

The first case was instructed by Dr. Kono at Fujita Health University. The involved bowel segment was divided transversely with a linear stapler. The edges of two stapled lines are then connected to create a supporting column, which prevented surgical recurrence from anastomotic distortion due to mesenteric longitudinal ulcers. Thereafter, an antimesenteric longitudinal enterotomy was performed on each side to create a large-sized handsewn end-to-end anastomosis.

RESULTS

Thirty consecutive patients underwent Kono-S anastomoses from December 2009 to August 2013. Neither anastomotic leakage nor surgical recurrence was observed during a median follow-up period of 35 months. Endoscopic surveillance was performed in 18 cases (69.2%) undergoing ileo-colonic or ileo-rectal anastomosis with an average Rutgeert's score of 0.78 (0-3) at a mean of 14.5 months postoperatively.

CONCLUSION

The Kono-S anastomosis for Crohn's disease has been a safe and feasible technique. Long-term outcomes are required to confirm its advantage in preventing surgical recurrence at the anastomosis.

The respective role of medical and surgical therapy for enterovesical fistula in Crohn's disease

GOALS AND BACKGROUND

There are very few reports available on the role of medical and surgical therapy for enterovesical fistula (EVF) in Crohn's disease (CD). The goal of this study was to investigate the respective role of medical and surgical therapy.

MATERIALS AND METHODS

Thirty-seven patients with EVF in CD, who were consecutively admitted to our institution between 2004 and 2011, underwent initial medical treatment. Medical records were abstracted from our prospective CD database. We performed a univariate analysis of risk factors for surgery.

RESULTS

The origin of EVF was ileal (ileovesical fistula, 78.4%) and sigmoidal (sigmoidovesical and ileosigmoidovesical fistula, 21.6%). After medical therapy (antibiotics, azathioprine, steroids, infliximab, or a combination), 13/37 (35.1%) patients achieved long-term remission over a mean period of 4.7 years and avoided surgery. Surgery was performed in 24/37 (64.9%) patients presenting with intractable disease. Univariate analysis showed that the significant risk factors for surgery included sigmoid-originated EVF (P=0.019) and concurrent CD complications (P=0.001), such as small bowel obstruction, abscess formation, enterocutaneous fistula, enteroenteric fistula, and persistent ureteral obstruction or urinary tract infection.

CONCLUSIONS

For patients with ileovesical fistula alone, medical therapy is the first choice. For patients with ileovesical fistula accompanied by other CD complications, surgical intervention will most likely be needed. Patients with sigmoidovesical or ileosigmoidovesical fistula are more likely to require surgery than an uncomplicated ileovesical fistula.

Successful management of a colo-duodenal fistula in a patient with Crohn's disease using a double lumen gastro-jejunostomy tube

A 41-year-old woman was admitted with upper abdominal pain, vomiting and fever. Abdominal CT scan showed a colo-duodenal fistula with inflammatory thickening of the transverse colon. The patient's general health was poor because of hypoalbuminemia and coagulopathy. Endoscopy showed a fistula at the lower duodenal angle and the stomach was filled with refluxed stool. Ileostomy and percutaneous endoscopic gastrostomy were performed at that time and a double lumen gastro-jejunostomy inserted through the gastrostomy to allow both gastric drainage and distal enteral feeding. Nutrition support was gradually converted from parenteral to enteral feeding. Colonoscopy showed stenosis of the transverse colon with a colo-colonic fistula near the stenosis. Two months later, right hemi-colectomy and closure of the colo-duodenal fistula were performed. The resected specimen showed stenosis and a fistula in the transverse colon due to Crohn's disease. The colo-colonic fistula was present and the colo-duodenal fistula had almost closed due to fibrosis. The postoperative course was uneventful and the patient was discharged after administration of infliximab. Use of a double lumen gastro-jejunostomy tube was effective in improving the patient's general condition. This therapeutic strategy allowed the safe conduct of major resection in a high-risk patient.

Comparative Outcomes of Trocar Puncture With Sump Drain, Percutaneous Drainage, and Surgical Drainage in the Management of Intra-abdominal Abscesses in Crohn’s Disease

Background. Intra-abdominal abscess is a common complication in Crohn’s disease (CD). Traditional percutaneous catheter drainage (PCD) and surgical intervention could not obtain satisfactory results in some cases. We herein demonstrate a novel management option and compare it with traditional strategies. Methods. A total of 77 patients were retrospectively collected into 3 groups. Postoperative complication, postoperative recurrence of abscess, subsequent surgery, ultimate stoma creation rate, and survival rate were analyzed. Results. Patients were divided into the trocar group (n = 21), PCD group (n = 25), and surgery group (n = 31). The incidences of postoperative complication as well as the incidence of recurrent abscess were lowest in trocar group, and ultimate stoma creation rate was highest in the surgery group. Subsequent surgery after initial intervention and survival rate during the follow-up period were similar among the 3 groups. Conclusions. Trocar puncture with sump drain had lower incidence of postoperative complication, postoperative recurrence of abscess, and ultimate stoma creation compared with conventional PCD and surgical interventions. This novel technique might be an optimal option in the management of intra-abdominal abscesses in CD.

Surgery for Crohn's disease and anti-TNF agents: the changing scenario

Surgery has been a mainstay of therapy for Crohn's disease for a long time, essentially as a consequence of the fairly modest efficacy of traditional medications such as immunomodulators, antibiotics and 5-ASA, especially in severe cases. However, in the past decade and half, the advent of anti-TNF agents has greatly changed the medical approach to this disease and may modify its general management as well. Here, we have reviewed the current literature on incidence of surgery, timing of surgery and postoperative recurrence of Crohn's disease before and after the advent of anti-TNF agents. In addition, we have reviewed the risk of perioperative complications in patients on anti-TNF agents before surgery. The data show that the use of these medications is changing or expecting to change shortly a number of surgical aspects of Crohn's disease management.

Accuracy of imaging for predicting operative approach in Crohn's disease

Background

The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease.

Methods

Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings.

Results

Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE.

Conclusion

Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach.

Emergency and elective surgery for small bowel Crohn's disease

Advancements in the medical treatment of Crohn's disease have reduced the need for surgery. The indications for surgery include the failure of medical management, especially the persistence or worsening of symptoms in spite of proper treatment and complications of the disease process. These complications include intestinal obstruction, intestinal perforation with fistula formation or abscess, free perforation, gastrointestinal bleeding, urologic complications, cancer, and perianal disease. In these cases, operative therapy should be directed to the specific indication for surgery, resecting only the segment of bowel involved in the complicating process while preserving as much bowel length as possible in order to prevent short-bowel syndrome. Laparoscopic surgery has been gaining acceptance as an alternative surgical approach for properly selected patients with Crohn's disease. In conclusion, identifying the need for surgery and determining the timing of operation are the cornerstones to successful surgical management of patients with Crohn's disease.

Management of abdominal and pelvic abscess in Crohn's disease

Patients with Crohn's disease may develop an abdominal or pelvic abscess during the course of their illness. This process results from transmural inflammation and penetration of the bowel wall, which in turn leads to a contained perforation and subsequent abscess formation. Management of patients with Crohn's related intra-abdominal and pelvic abscesses is challenging and requires the expertise of multiple specialties working in concert. Treatment usually consists of percutaneous abscess drainage (PAD) under guidance of computed tomography in addition to antibiotics. PAD allows for drainage of infection and avoidance of a two-stage surgical procedure in most cases. It is unclear if PAD can be considered a definitive treatment without the need for future surgery. The use of immune suppressive agents such as anti-tumor necrosis factor-α in this setting may be hazardous and their appropriate use is controversial. This article discusses the management of spontaneous abdominal and pelvic abscesses in Crohn's disease.

Surgical resection in Crohn's disease: is immunosuppressive medication associated with higher postoperative infection rates?

AIM

The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn's disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

METHOD

With IRB approval, the records of all patients with CD who underwent abdominal surgery between 2001 and 2008 were reviewed for comorbidity, preoperative medication, type of surgery, stoma construction and postoperative complications. Patients were divided into three categories according to the preoperative medication within 90 days of surgery as follows: infliximab (IFX), other drugs including steroids and/or immunosuppressive agents (OD) and no drugs (ND).

RESULTS

Two hundred and twenty-five patients were identified. Preoperative comorbidity, surgical indication and type of surgery were not significantly different among the three groups. Ileocolic resection was the most common procedure [50.8%, IFX group; 61.2%, OD group; 41.3%, ND group (P = 0.09)]. Other procedures included total colectomy (16%), protectomy (15%) and others (18%). Laparoscopic surgery was performed in 47.7%, 45.9% and 29.3% of patients in the IFX, OD and ND groups, respectively (P = 0.04). There were no differences in postoperative rates of infection [pneumonia (P = 0.14), wound infection (P = 0.35), abscess (P = 0.34) or anastomotic leakage (P = 0.44)]. Reoperation was needed in 3.0%, 8.2% and 2.6% of patients in the IFX, OD and ND groups, respectively. Multiple logistic regression found no relationship between infliximab use and infection.

CONCLUSION

There was no difference in the rate of postoperative complications among the groups of patients undergoing surgery for CD pretreated with IFX or other immunosuppressive drugs.

Crohn's disease: Multimodality Imaging of Surgical Indications, Operative Procedures, and Complications

Surgical management is considered for specific indications in Crohn's disease and a wide variety of surgeries is performed. The purpose of this pictorial essay is to depict manifestations of Crohn's disease that indicates surgery, various surgical procedures that are performed, and the complications arising from these surgical procedures. Surgical indications including obstruction due to strictures or adhesions, fistulae and abscesses, and surgeries for these conditions, such as, ileocecectomy, stricturoplasty, small bowel resection, fecal diversion, segmental colectomy, and lysis of adhesions and their complications will be discussed and their imaging will also be illustrated.

A new antimesenteric functional end-to-end handsewn anastomosis: surgical prevention of anastomotic recurrence in Crohn's disease

BACKGROUND

Recurrence of Crohn's disease usually occurs at anastomotic sites.

OBJECTIVE

A new anastomosis technique (Kono-S anastomosis) designed to minimize anastomotic restenosis was compared with conventional anastomoses.

DESIGN AND SETTINGS

The Kono-S anastomosis technique was first used for Crohn's disease in 2003 at the Asahikawa Medical University Hospital. The resection is accomplished by transecting the bowel with a linear cutter so that the mesentery side is located in the center of the stump. Both stumps are sutured to create a supporting column to maintain the diameter and dimension of the anastomosis. Longitudinal enterotomies are made at the antimesenteric sides of the 2 segments of intestine. The side-to-side antimesenteric anastomosis is then performed in transverse fashion. The medical records and follow-up details of all patients undergoing this procedure were reviewed.

PATIENTS

: From 2003 to 2009, 69 patients with Crohn's disease who underwent Kono-S anastomosis (group S) were compared with 73 historical patients with Crohn's disease who underwent conventional anastomosis (group C) from 1993 to 2003.

MAIN OUTCOME MEASURES

A Kaplan-Meier analysis of the follow-up data on surgical recurrence at the anastomosis was performed. The endoscopic recurrence score at the anastomosis was calculated.

RESULTS

The median endoscopic recurrence score in group S was significantly lower than that in group C (2.6 vs 3.4; P = .008). The Kaplan-Meier analysis showed a lesser probability of anastomotic surgical recurrence in the S group at 5 years (0% vs 15%; P = .0013). The absence of postoperative infliximab did not affect the restenosis rate in group S.

LIMITATIONS

This study was limited by its historical retrospective nature.

CONCLUSION

The Kono-S anastomosis appears to be effective in preventing anastomotic surgical recurrence in Crohn's disease.

Surgical strategies for Crohn's disease

Crohn's disease (CD) is a chronic relapsing inflammatory disease of the intestine that may affect the entire digestive tract and present with various types of manifestations, including obstruction, internal or external fistula, abdominal abscess, bleeding, and perforation. Currently, neither medical therapy nor surgery can cure this chronic disease. Optimum management of CD patients requires an interactive partnership among gastroenterologist, surgeon and patient. It is estimated that approximately 80% of CD patients will require surgery at some point during their lifetime. This article reviews the surgical management strategies for CD, including indications for surgery and choice of procedures.

Decision-making in ileocecal Crohn's disease management: surgery versus pharmacotherapy

Ileocecal Crohn's disease (CD) can be treated medically as well as surgically. Both treatment modalities have been improved markedly in the last two decades, making CD more manageable. However, multidisciplinary research, addressing issues such as timing of surgery or medical treatment versus surgery, is scarce. Particularly in limited ileocecal CD, ileocolic resection might be a good alternative to long-term medical therapy. This review discusses the evidence on medical and surgical treatment options for ileocecal CD. It provides an aid in decision-making by discussing a treatment algorithm that can be used until further evidence on treatment is available.

Laparoscopic surgery for inflammatory bowel disease: does weight matter?

BACKGROUND

Recent studies have shown improved outcomes after laparoscopic colorectal surgery compared with laparotomy for surgery for both benign and malignant colorectal diseases, including inflammatory bowel disease (IBD). This study was designed to evaluate the results of laparoscopic colorectal resections in normal weight patients compared with overweight and obese patients with IBD.

METHODS

A retrospective analysis of a prospectively acquired institutional review board-approved surgical database was performed. All consecutive patients with IBD who underwent laparoscopy from January 1, 2000 to April 30, 2008 were reviewed. BMI, age, gender, comorbidities, ASA classification, and surgical- and disease-related variables, including 60-day postoperative complications, were reviewed. Chi-square, Mann-Whitney U test, and Student's t test were used for statistical analysis.

RESULTS

A total of 261 patients with IBD underwent laparoscopy: 48 were excluded and 213 were analyzed. Group I comprised 127 normal-weight patients (body mass index (BMI), 18.5-24.9 kg/m(2)), and group II included 67 overweight patients (BMI, 25-29.9 kg/m(2)) and 19 obese patients (BMI >or= 30 kg/m(2)). Crohn's disease was diagnosed in 86 (67.7%) patients in group I and 52 (60.4%) in group II. Procedures performed included ileocolic resection in 56% of patients in each group. Total colectomy with or without proctectomy was undertaken in 39.4% in group I and 40.7% in group II. The conversion rate was 18% for group I and 22.09% for group II (p > 0.005; not significant). The most common reason for conversion was failure to progress due to adhesions or phlegmon. There were no differences in major postoperative complication rates (wound infection, abscess, anastomotic leakage, or small-bowel obstruction) or mean hospital stay (6.7, 6.8, respectively), and there was no mortality.

CONCLUSIONS

Patients with IBD who were overweight or obese and who underwent laparoscopic bowel resection had no significant differences in the rates of conversion, major postoperative complications, or length of stay when comparing to patients with normal BMI. Therefore, the benefits of laparoscopic bowel resection should not be denied to overweight or obese patients based strictly on their BMI.