Laparoscopic surgery for complex and recurrent Crohn’s disease

Predicting short-term major postoperative complications in intestinal resection for Crohn's disease: A machine learning-based study

BACKGROUND

Due to the complexity and numerous comorbidities associated with Crohn's disease (CD), the incidence of postoperative complications is high, significantly impacting the recovery and prognosis of patients. Consequently, additional studies are required to precisely predict short-term major complications following intestinal resection (IR), aiding surgical decision-making and optimizing patient care.

AIM

To construct novel models based on machine learning (ML) to predict short-term major postoperative complications in patients with CD following IR.

METHODS

A retrospective analysis was performed on clinical data derived from a patient cohort that underwent IR for CD from January 2017 to December 2022. The study participants were randomly allocated to either a training cohort or a validation cohort. The logistic regression and random forest (RF) were applied to construct models in the training cohort, with model discrimination evaluated using the area under the curves (AUC). The validation cohort assessed the performance of the constructed models.

RESULTS

Out of the 259 patients encompassed in the study, 5.0% encountered major postoperative complications (Clavien-Dindo ≥ III) within 30 d following IR for CD. The AUC for the logistic model was 0.916, significantly lower than the AUC of 0.965 for the RF model. The logistic model incorporated a preoperative CD activity index (CDAI) of ≥ 220, a diminished preoperative serum albumin level, conversion to laparotomy surgery, and an extended operation time. A nomogram for the logistic model was plotted. Except for the surgical approach, the other three variables ranked among the top four important variables in the novel ML model.

CONCLUSION

Both the nomogram and RF exhibited good performance in predicting short-term major postoperative complications in patients with CD, with the RF model showing more superiority. A preoperative CDAI of ≥ 220, a diminished preoperative serum albumin level, and an extended operation time might be the most crucial variables. The findings of this study can assist clinicians in identifying patients at a higher risk for complications and offering personalized perioperative management to enhance patient outcomes.

Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery

INTRODUCTION

Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery.

METHODS

Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively.

RESULTS

There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity.

CONCLUSION

Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Preoperative cross-sectional imaging findings in patients with surgically complex ileocolic Crohn's disease

PURPOSE

The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD).

METHODS

69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared.

RESULTS

60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04).

CONCLUSION

Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.

Post-operative morbidity in Crohn's disease: what is the impact of patient-, disease- and surgery-related factors?

PURPOSE

Over 50% of patients suffering from Crohn's disease (CD) require surgery in their lifetime. Predictors/risk factors of post-operative morbidity and mortality in CD are poorly investigated. We aimed to assess the risk factors of post-operative morbidity/mortality in CD.

METHODS

We performed a retrospective cohort study in which all CD patients operated and followed up at our tertiary Inflammatory Bowel Disease Centre from 2014 to 2019 were enrolled. For each patient, we evaluated patient-dependent, disease-dependent and surgery-dependent variables. All patients underwent small bowel and/or colic resections.

RESULTS

Of the 165 operated patients, forty-two (25.5%) developed post-operative complications (major complication rate = 9.8%) including wound infection (12.1%), respiratory complications (4.8%), prolonged ileum (4.2%), anastomotic leak (3.6%), urinary infections (3%), abdominal abscess (2.4%), anastomotic bleeding (3.6%), abdominal bleeding (1.2%) and obstruction (0.6%). Two subjects (1.2%) required re-operation within 30 days, and one died. A surgery duration < 141 min was predictive of a better post-operative outcome (sensitivity 80.9%, specificity 43.1%, PPV 32.7%, NPV 86.9%). The multivariable analysis showed stricturing/fistulizing behaviour (OR 3.7, 95% CI 1.6-6.4, p = 0.02), need for total parenteral nutrition (OR 4.1, 95% CI 2.4-9.2, p = 0.01), pre-operative bowel cleansing (OR 0.6, 95% CI 0.41-0.83, p = 0.01) and surgery duration < 141 min (OR 0.2, 95% CI 0.08-0.7, p = 0.03) as the only risk factors associated with post-operative morbidities.

CONCLUSIONS

About 25% of CD patients develop post-operative complications. Several patient-related, disease-related and surgery-related factors should be considered risk factors for post-operative morbidity. The recognition of these factors, as well as a multidisciplinary approach to the pre-operative management of CD, could reduce post-operative complications.

Laparoscopy for Crohn's disease: A comprehensive exploration of minimally invasive surgical techniques

BACKGROUND

Along with the unceasing progress of medicine, Crohn's disease (CD), especially complex CD, is no longer a taboo for minimally invasive surgery. However, considering its special disease characteristics, more clinical trials are needed to confirm the safety and feasibility of laparoscopic surgery for CD.

AIM

To investigate the safety and feasibility of laparoscopic enterectomy for CD, assess the advantages of laparoscopy over laparotomy in patients with CD, and discuss comprehensive minimally invasive surgical techniques in complex CD.

METHODS

This study prospectively collected clinical data from patients with CD who underwent enterectomy from January 2017 to January 2020. It was registered in the Chinese clinical trial database with the registration number ChiCTR-INR-16009321. Patients were divided into a laparoscopy group and a traditional laparotomy group according to the surgical method. The baseline characteristics, operation time, intraoperative blood loss, temporary stoma, levels of abdominal adhesion, pathological characteristics, days to flatus and soft diet, postoperative complications, hospitalization time, readmission rate within 30 d, and hospitalization cost were compared between the two groups.

RESULTS

A total of 120 eligible patients were enrolled into the pre-standardized groups, including 100 in the laparoscopy group and 20 in the laparotomy group. Compared with the laparotomy group, the postoperative hospitalization time in the laparoscopy group was shorter (9.1 ± 3.9 d vs 11.0 ± 1.6 d, P < 0.05), the days to flatus were fewer (2.8 ± 0.8 d vs 3.5 ± 0.7 d, P < 0.05), the days to soft diet were fewer (4.2 ± 2.4 d vs 6.2 ± 2.0 d, P < 0.05) and the intraoperative blood loss was less (103.3 ± 80.42 mL vs 169.5 ± 100.42 mL, P < 0.05). There were no statistically significant differences between the two groups in preoperative clinical data, operation time (149.0 ± 43.8 min vs 159.2 ± 40.0 min), stoma rate, levels of abdominal adhesion, total cost of hospitalization, incidence of postoperative complications [8.0% (8/100) vs 15.0% (3/20)], or readmission rate within 30 days [1.0% (1/100) vs 0.00 (0/20)].

CONCLUSION

Compared with laparotomy, laparoscopic enterectomy promotes the recovery of gastrointestinal function, shortens the postoperative hospitalization time, and does not increase the incidence of postoperative complications. Laparoscopic enterectomy combined with varieties of minimally invasive surgical techniques is a safe and acceptable therapeutic method for CD patients with enteric fistulas.

Crohn's Disease Obstructions

Obstruction from stricturing Crohn's disease remains one of the most common reasons for intervention. Acute inflammation is often responsive to medications, but chronic fibrosis is unlikely to respond and will generally go on to require additional treatment. Newer methods, such as endoscopic balloon dilation, are gaining grounds in strictures that are amenable, but with high recurrence and strictures that may not be endoscopically accessible, surgery still plays a key role in the treatment of obstructing Crohn's disease.

IBDDB: a manually curated and text-mining-enhanced database of genes involved in inflammatory bowel disease

To date, research on inflammatory bowel disease (IBD, encompassing Crohn's disease and ulcerative colitis), a chronic complex disorder, has generated a large amount of data scattered across published literature (1 06 333) listed in PubMed on 14 October 2020, and no dedicated database currently exists that catalogues information on genes associated with IBD. We aimed to manually curate 289 genes that are experimentally validated to be linked with IBD and its known phenotypes. Furthermore, we have developed an integrated platform providing information about different aspects of these genes by incorporating several resources and an extensive text-mined knowledgebase. The curated IBD database (IBDDB) allows the selective display of collated 34 subject-specific concepts (listed as columns) exportable through a user-friendly IBDDB portal. The information embedded in concepts was acquired via text-mining of PubMed (manually cleaned and curated), accompanied by data-mining from varied resources. The user can also explore different biomedical entities and their co-occurrence with other entities (about one million) from 11 curated dictionaries in the indexed PubMed records. This functionality permits the user to generate and cross-examine a new hypothesis that is otherwise not easy to comprehend by just reading the published abstracts and papers. Users can download required information using various file formats and can display information in the form of networks. To our knowledge, no curated database of IBD-related genes is available so far. IBDDB is free for academic users and can be accessed at https://www.cbrc.kaust.edu.sa/ibd/.

What is the outcome for patients undergoing more than two ileocolonic resections for recurrent Crohn's disease? A comparative study of 569 consecutive procedures

AIM

To assess the outcome for patients undergoing repeated ileocolonic resection for recurrent Crohn's disease (CD).

METHOD

All patients undergoing ileocolonic resection for terminal ileal CD between 1998 and 2016 in our tertiary care centre were retrospectively reviewed.

RESULTS

Between 1998 and 2016, 569 ileocolonic resections were performed for CD: 403 of these were primary resections (1R, 71%), 107 second resections (2R, 19%) and 59 were third (or more) resections (> 2R, 10%). The laparoscopic approach rate was significantly less in the > 2R group (20/59, 34%) compared with the 2R (71/107, 66%; P = 0.002) and 1R (366/403, 91%) groups. However, conversion to an open approach did not show any difference between the three groups [1R group 46/366 (13%) vs 2R group 14/71 (20%) vs > 2R group 3/20 (15%); 1R vs > 2R P = 0.750; 2R vs > 2R P = 0.633]. Postoperative morbidity was significantly increased in the > 2R (28/59, 52%) group compared with the 1R group (115/403, 29%; P < 0.001) but showed no difference compared with the 2R group (43/107, 40%; P = 0.365). There was no difference between the groups in the incidence of severe postoperative morbidity (Clavien-Dindo ≥ 3) [1R group n = 24 (6%); 2R group n = 6 (6%); > 2R group n = 4, 7%; 1R vs > 2R P = 0.865, 2R vs > 2R P = 0.761].

CONCLUSION

Although the overall morbidity rate was higher, repeated surgery for recurrent CD in patients undergoing three or more ileocolonic resections was not associated with an increased risk of severe postoperative morbidity in our series.