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Maspero M, Hull TL. State of the Art: Pouch Surgery in the 21st Century. Dis Colon Rectum 2024; 67:S1-S10. [PMID: 38441240 DOI: 10.1097/dcr.0000000000003326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations. OBJECTIVE To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration. RESULTS The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications. CONCLUSIONS Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Fu Y, Liu X, Xu J, Zhong T, Jiang J, Fu T, Cao Q, Jiang Z. A Combination of Pathological Features Identifies Crohn's Disease in Surgical Bowel Resection Specimens. Int J Surg Pathol 2024; 32:738-747. [PMID: 37715659 DOI: 10.1177/10668969231195028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
BACKGROUND Diagnosis of Crohn's disease is challenging. This study aims to compare the histological features of Crohn's disease and non-Crohn's disease (other intestinal inflammatory diseases) in surgical specimens to identify a set of histologic features distinguishing Crohn's disease from non-Crohn's disease. METHODS Patients with Crohn's disease (N = 171) and patients with non-Crohn's disease (N = 215) diagnosed between 2010 and 2015 who had surgical bowel resection were identified. The frequency of histological features in surgical resection specimens was compared between these two groups. RESULTS Univariate analysis revealed that transmural inflammation, subserosal lymphoid aggregates, fissures or sinus-like structures, granulomas or granuloma-like nodules, abnormalities of the enteric nervous system, and mucosa structure alterations (muscularis mucosa thickening or mucosal atrophy with pseudopyloric gland metaplasia) were more frequent in Crohn's disease than non-Crohn's disease cases (p < 0.001 for all). Some of the above histologic features were further grouped as chronic inflammatory change which includes granulomas or granuloma-like nodules, lymphoid aggregates in the muscularis propria or subserosa, fissures or sinus-like structures, and architectural abnormality which is defined as the presence of abnormal enteric nervous system and/or mucosa structural alterations (muscularis mucosa thickening or mucosal atrophy with pseudopyloric gland metaplasia). A combination of transmural inflammation, chronic inflammatory change, and architectural abnormality had a sensitivity of 92.4% and a specificity of 97.7% for Crohn's disease. CONCLUSIONS In surgical bowel resection specimens, a combination of transmural inflammation, chronic inflammatory change, and architectural abnormality help diagnose Crohn's disease.
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Affiliation(s)
- Yujuan Fu
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Jiaqi Xu
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tingting Zhong
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junchang Jiang
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianhong Fu
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qian Cao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhinong Jiang
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Shen B, Bruining DH, YunMa H. Radiographic Evaluation of Ileal Pouch Disorders: A Systematic Review. Dis Colon Rectum 2024; 67:S70-S81. [PMID: 38441126 DOI: 10.1097/dcr.0000000000003181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI, contrasted pouchography, and defecography. OBJECTIVES To perform a systematic review of the literature and describe applications of cross-sectional imaging, pouchography, defecography, and ultrasonography. DATA SOURCES PubMed, Google Scholar, and Cochrane database. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2003 and June 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included. MAIN OUTCOME MEASURES Accuracy in characterization of ileal pouch disorders. RESULTS CT is the test of choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). MRI of the pelvis is suitable for the assessment of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn's disease of the pouch. CT enterography and magnetic resonance enterography are useful in assessing intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for evaluating acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series and case reports. CONCLUSIONS Abdominopelvic imaging, along with clinical and endoscopic evaluation, is imperative for accurately assessing structural, inflammatory, functional, and neoplastic disorders. See video from symposium .
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Affiliation(s)
- Bo Shen
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Hong YunMa
- Department of Radiology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
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Husain SG. Improvised Techniques for Enhanced Detection of Crohn's Strictures During Surgery. Dis Colon Rectum 2024; 67:e359. [PMID: 38354048 DOI: 10.1097/dcr.0000000000003150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Affiliation(s)
- Syed G Husain
- Department of Colorectal Surgery, Ohio State University, Columbus, Ohio
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Glenisson M, Bonnard A, Berrebi D, Belarbi N, Viala J, Martinez-Vinson C. Complications and Disease Recurrence After Ileocecal Resection in Pediatric Crohn's Disease: A Retrospective Study. Eur J Pediatr Surg 2024; 34:253-260. [PMID: 36882155 PMCID: PMC11076103 DOI: 10.1055/a-2048-7407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/15/2022] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The aim of this retrospective study was to describe the risk of postoperative recurrence (POR) after ileocecal resection, the occurrence of surgical complications, and identify predictors of these adverse postoperative outcomes in pediatric Crohn's disease (CD). PATIENTS AND METHODS All the children less than 18 years of age with a diagnosis of CD, who underwent primary ileocecal resection for CD between January 2006 and December 2016 in our tertiary center, were considered for inclusion. Factors related to POR were investigated. RESULTS A total of 377 children were followed for CD between 2006 and 2016. During this period, 45 (12%) children needed an ileocecal resection. POR was diagnosed in 16% (n = 7) at 1 year and 35% (n = 15) at the end of the follow-up, with a median follow-up of 2.3 years (Q1-Q3 1.8-3.3). Median duration of the postoperative clinical remission was 1.5 years (range 0.5-2). Multivariate Cox regression analysis identified only young age at diagnosis as a risk factor for POR.In total, 7 of the 43 patients (16%) developed severe postoperative complications, defined as requiring surgical, endoscopic, or radiological intervention. The only risk factor was intraoperative abscess. CONCLUSION Only young age at diagnosis was associated with POR. This information could be useful to develop targeted therapeutic strategies for young CD children. At the end of follow-up with a median follow-up of 2.3 years (Q1-Q3 1.8-3.3), there was no surgical POR: endoscopic dilatation for POR should be considered in order to delay or prevent surgery.
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Affiliation(s)
- M Glenisson
- Department of Pediatric Surgery, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - A Bonnard
- Department of Pediatric Surgery, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - D Berrebi
- Department of Pediatric Pathology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - N Belarbi
- Department of Pediatric Radiology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - J Viala
- Department of Pediatric Gastroenterology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - C Martinez-Vinson
- Department of Pediatric Gastroenterology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
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Nallapaneni P, Picoraro JA. Diagnosis and Treatment of Pouch Disorders in Children: A Systematic Review. Dis Colon Rectum 2024; 67:S115-S124. [PMID: 38422401 DOI: 10.1097/dcr.0000000000003317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous polyposis. OBJECTIVE This systematic review aims to assess the diagnosis and treatment of pouch disorders in pediatric patients who undergo IPAA. DATA SOURCES A literature search was performed using MEDLINE, Google Scholar, and Embase for all publications describing outcomes of pediatric IPAA. STUDY SELECTION Studies between January 1, 2000, and September 7, 2022, published in English were included. Studies were excluded on the basis of title, abstract, and full-length review. INTERVENTIONS IPAA. MAIN OUTCOME MEASURES Pouch disorders described include anastomotic leaks, pouch strictures, pouch failure, pouchitis, cuffitis, and de novo Crohn's disease of the pouch. RESULTS Thirty-three studies were included in this review, all of which were retrospective in nature. The outcomes of 2643 pediatric patients were included in the 33 studies. LIMITATIONS Management is largely informed by clinical practices in adult patients with scant data on treatment efficacy in children. CONCLUSIONS The reported incidence of disorders of the pouch in children varies widely and is likely attributable to differences in definitions and follow-up periods across studies. Pouchitis was the most frequently described outcome. The overall rate of pouch failure in children is relatively low, with de novo Crohn's disease of the pouch being the most significant risk factor. Multicenter prospective studies are needed in the pediatric population to accurately identify risk factors, standardize the assessment of pouch complications, and determine effective treatment strategies. See video from the symposium .
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Affiliation(s)
- Padmini Nallapaneni
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
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Maspero M, Lavryk O, Holubar SD, Lipman JM, Steele SR, Hull T. Third Time's the Charm? Indications and Outcomes for Redo-Redo IPAA. Dis Colon Rectum 2024; 67:805-811. [PMID: 38363195 DOI: 10.1097/dcr.0000000000003165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Up to 20% to 40% cases of redo IPAA procedures will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision. OBJECTIVE To report our institutional experience of second redo IPAA procedures. DESIGN This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redo procedures and those undergoing first redo procedures using propensity score matching to balance the 2 cohorts. SETTINGS Tertiary referral center. PATIENTS Patients who underwent second redo IPAA procedures between 2004 and 2021 were included in this study. INTERVENTIONS Second redo IPAA. MAIN OUTCOME MEASURES Pouch survival and patient-reported outcomes were measured using the Cleveland Global Quality of Life survey. RESULTS Twenty-three patients were included (65% women), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. The final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo procedures in 21 (91%) cases: 20 (87%) patients had both redo IPAAs for septic complications. After a median follow-up of 39 months (interquartile range, 18.5-95.5 months), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of whom 3 never had their stoma closed, and 1 case due to poor function); all patients who experienced pouch failure underwent the second redo procedure due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with a final diagnosis of Crohn's disease versus 82.5% in patients with ulcerative/indeterminate colitis ( p = 0.09). Overall quality-of-life score (0-1) was 0.6 (0.5-0.8). Quality of life and functional outcomes were comparable between first and second redo procedures, except incontinence, which was higher in second redo procedures. LIMITATIONS Single-center retrospective review. CONCLUSIONS A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract . LA TERCERA ES LA VENCIDA INDICACIONES Y RESULTADOS DE LA RERECONFECCION DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL ANTECEDENTES:Hasta un 20-40% de los casos de rehacer anastomosis anal con bolsa ileal (IPAA) resultarán en falla de la bolsa. La posibilidad de ofrecer un segundo procedimiento para mantener la continuidad intestinal sigue siendo una decisión controvertida.OBJETIVO:Reportar nuestra experiencia institucional de una segunda re-confección de la anastomosis anal con bolsa ileal.DISEÑO:Revisión retrospectiva; los resultados informados por los pacientes se compararon entre los pacientes que se sometieron a una segunda re-confeccion con los de los pacientes que se sometieron a una la primera re-confeccion utilizando el puntaje de propensión para equilibrar las dos cohortes.AJUSTES ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes que se sometieron a una segunda re-confeccion de de la anastomosis anal con bolsa ileal entre 2004 y 2021.INTERVENCIONES:Segunda re-confeccion de la anastomosis anal con bolsa ileal.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia de la bolsa, resultados informados por los pacientes medidos mediante la encuesta Cleveland Global Quality of Life.RESULTADOS:Se incluyeron veintitrés pacientes (65% mujeres), 20 (87%) con diagnóstico inicial de colitis ulcerosa y 3 (13%) con colitis indeterminada. El diagnóstico final se cambió a enfermedad de Crohn en ocho (35%) casos. La indicación para el rescate de la bolsa fue la misma para la primera y segunda re-confeccion en 21 (91%) casos: 20 (87%) pacientes tuvieron ambas re-confecciones de la anastomosis anal con bolsa ileal por complicaciones sépticas. Después de una mediana de seguimiento de 39 meses (RIC 18,5 - 95,5), se produjo falla de la bolsa en 8 (30%) casos (7 casos debido a sepsis, de los cuales 3 nunca cerraron el estoma y 1 caso debido a una mala función); todos los pacientes que experimentaron falla de la bolsa se sometieron a una segunda re-confeccion debido a complicaciones sépticas. La supervivencia global de la bolsa a los 3 años fue del 76%: 62,5% en pacientes con diagnóstico final de enfermedad de Crohn, versus 82,5% en colitis ulcerativa/indeterminada ( p = 0,09). La puntuación general de calidad de vida (0 -1) fue 0,6 (0,5 - 0,8). La calidad de vida y los resultados funcionales fueron comparables entre la primera y la segunda re-confeccion, excepto la incontinencia, que fue mayor en la segunda re-confeccion.LIMITACIONES:Revisión retrospectiva de un solo centro.CONCLUSIONES:Se puede ofrecer un segundo procedimiento de rescate de la bolsa con resultados aceptables a pacientes seleccionados con alta motivación para mantener la continuidad intestinal. (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Weigl E, Schwerd T, Lurz E, Häberle B, Koletzko S, Hubertus J. Children with Localized Crohn's Disease Benefit from Early Ileocecal Resection and Perioperative Anti-Tumor Necrosis Factor Therapy. Eur J Pediatr Surg 2024; 34:236-244. [PMID: 36929126 DOI: 10.1055/s-0043-1764320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION In pediatric Crohn's disease ileocecal resection is performed reluctantly as postoperative recurrence is frequent. Anti-tumor necrosis factor (TNF) therapy reduces postoperative recurrence rates but increases the risk for infections. MATERIALS AND METHODS We retrospectively reviewed pediatric Crohn's disease patients who underwent ileocecal resection in our center. We compared disease activity and z-scores for height, weight, and body mass index of patients, who continuously received perioperative anti-TNF therapy (TNF + ), with those who did not (TNF-). RESULTS Of 29 patients (48% females), 13 and 16 were grouped to TNF+ and TNF-, respectively. Patients' characteristics did not differ between groups, except a longer follow-up time in TNF-. We saw significant postoperative improvement but no normalization in z-scores for weight (1.78 vs. 0.77, p < 0.001), body mass index (1.08 vs. 0.22, p < 0.001), and height (0.88 vs. 0.66, p < 0.001). Disease activity improved significantly more in patients receiving anti-TNF therapy (moderate improvement in 83% vs. 31%, p = 0.02). Endoscopic recurrence was more frequent in patients without anti-TNF therapy (80% vs. 20%; p = 0.023), but endoscopic follow-up was incomplete. There was no increase of infections under perioperative anti-TNF therapy (1 patient each; p = 1.000). CONCLUSION In patients with localized Crohn's disease an ileocecal resection leads to short-term postoperative improvement of disease activity, body mass index, weight, and growth. For relevant catch-up growth an earlier intervention is necessary. Continuous perioperative anti-TNF therapy had no increased risk of perioperative infections.
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Affiliation(s)
- Elena Weigl
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Bayern, Germany
| | - Tobias Schwerd
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU Munich, Bayern, Germany
| | - Eberhard Lurz
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU Munich, Bayern, Germany
| | - Beate Häberle
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Bayern, Germany
| | - Sibylle Koletzko
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU Munich, Bayern, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Jochen Hubertus
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Bayern, Germany
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Gupta A, Guisado D, Ricart E, Colombel JF, Cohen L. Haematopoietic stem-cell transplantation in Crohn's disease. Lancet Gastroenterol Hepatol 2024; 9:499-500. [PMID: 38734002 DOI: 10.1016/s2468-1253(24)00055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Akshita Gupta
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-5674, USA
| | - Daniela Guisado
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-5674, USA
| | - Elena Ricart
- Hospital Clinic de Barcelona, Gastroenterology Department, Barcelona, Spain
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-5674, USA
| | - Louis Cohen
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-5674, USA.
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Kelm M, Benatzky C, Buck V, Widder A, Schoettker K, Rosenfeldt M, Brand M, Schlegel N, Germer CT, Meining A, Nusrat A, Flemming S. Positive resection margins in Crohn's disease are a relevant risk factor for postoperative disease recurrence. Sci Rep 2024; 14:10823. [PMID: 38734721 PMCID: PMC11088694 DOI: 10.1038/s41598-024-61697-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024] Open
Abstract
Postoperative disease recurrence in Crohn's disease represents a relevant issue despite recent advancements in surgical and medical therapies. Additional criteria are necessary to improve the identification of patients at risk and to enable selective therapeutic approaches. The role of resection margins on disease recurrence remains unclear and general recommendations are lacking. A single-center retrospective analysis was performed including all patients who received ileocecal resection due to Crohn's disease. Resection margins were analyzed by two independent pathologists and defined by histopathological criteria based on previous consensus reports. 158 patients were included for analysis with a median follow up of 35 months. While postoperative morbidity was not affected, positive resection margins resulted in significantly increased rates of severe endoscopic recurrence at 6 months (2.0% versus 15.6%, p = 0.02) and overall (4.2% versus 19.6%, p = 0.001), which resulted in significantly increased numbers of surgical recurrence (0% versus 4.5%, p = 0.04). Additionally, positive margins were identified as independent risk factor for severe endoscopic disease recurrence in a multivariate analysis. Based on that, positive margins represent an independent risk factor for postoperative endoscopic and surgical disease recurrence. Prospective studies are required to determine whether extended resection or postoperative medical prophylaxis is beneficial for patients with positive resection margins.
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Affiliation(s)
- Matthias Kelm
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Clara Benatzky
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Viktoria Buck
- Department of Pathology, University of Würzburg, Würzburg, Germany
| | - Anna Widder
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Katrin Schoettker
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | | | - Markus Brand
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Nicolas Schlegel
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Alexander Meining
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Asma Nusrat
- Department of Pathology, University of Michigan Medical School, Ann Arbor, USA
| | - Sven Flemming
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany.
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Buldukoglu OC. Factors influencing the outcomes of colonic resections for Crohn's colitis. Int J Colorectal Dis 2024; 39:67. [PMID: 38703191 PMCID: PMC11069470 DOI: 10.1007/s00384-024-04620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Osman Cagin Buldukoglu
- Department of Gastroenterology, Antalya Training and Research Hospital, University of Health Sciences, Varlik mah. Kazim Karabekir cad., 07100, Antalya, Turkey.
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Lahes S, Fischer C, Igna D, Jacob P, Glanemann M. Stapled versus hand-sewn anastomoses after bowel resection in patients with crohn disease. BMC Surg 2024; 24:130. [PMID: 38698365 PMCID: PMC11067230 DOI: 10.1186/s12893-024-02410-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Anastomosis configuration is an essential step in treatment to restore continuity of the gastrointestinal tract following bowel resection in patients with Crohn's disease (CD). However, the association between anastomotic type and surgical outcome remains controversial. This retrospective study aimed to compare early postoperative complications and surgical outcome between stapler and handsewn anastomosis after bowel resection in Crohn's disease. METHODS Between 2001 and 2018, a total of 339 CD patients underwent bowel resection with anastomosis. Patient characteristics, intraoperative data, early postoperative complications, and outcomes were analyzed and compared between two groups of patients. Group 1 consisted of patients with stapler anastomosis and group 2 with handsewn anastomosis. RESULTS No significant difference was found in the incidence of postoperative surgical complications between the stapler and handsewn anastomosis groups (25% versus 24.4%, p = 1.000). Reoperation for complications and postoperative hospital stay were similar between the two groups. CONCLUSION Our analysis showed that there were no differences in anastomotic leak, nor postoperative complications, mortality, reoperation for operative complications, or postoperative hospital stay between the stapler anastomosis and handsewn anastomosis groups.
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Affiliation(s)
- Saleh Lahes
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr- University Bochum, In der Schornau 23-25, Bochum, Germany.
| | - Celine Fischer
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany
| | - Dorian Igna
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany
| | - Peter Jacob
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany
| | - Matthias Glanemann
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany
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13
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Ip CL, Boyapati R, Kalla R. Postoperative small bowel Crohn's disease: how to diagnose, manage and treat. Curr Opin Gastroenterol 2024; 40:209-216. [PMID: 38294891 DOI: 10.1097/mog.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE OF REVIEW Crohn's disease is a relapsing inflammatory condition and disease recurrence after surgery is common. Significant variation in clinical practice remains despite progress in management of postoperative Crohn's disease. In this review, we summarise current management strategies and guidelines, unmet needs, and research progress in this field. RECENT FINDINGS There has been real progress in risk stratifying individuals' postsurgery and tailoring therapies based on their risk; this has been incorporated into current management guidelines in the USA, UK, and Europe. Furthermore, novel noninvasive monitoring tools such as intestinal ultrasound have shown high sensitivity and specificity at detecting disease recurrence and are an attractive point-of-care test. Recent studies are also investigating multiomic biomarkers to prognosticate postoperative Crohn's disease. However, given the heterogeneity within this condition, large multicentre clinical validation across all age groups is needed for clinical translation in the future. SUMMARY Ongoing progress in research and the development of novel prognostic and noninvasive disease monitoring tools offers hope for personalised therapy tailored to individual recurrence risk in postoperative Crohn's disease.
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Affiliation(s)
- Chak Lam Ip
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh UK
| | - Ray Boyapati
- Department of Gastroenterology, Monash Medical Centre, Melbourne, Australia
| | - Rahul Kalla
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh UK
- Gut Research Unit, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
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14
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Hirayama D, Hyodo S, Morita K, Nakase H. Change in systemic steroid use and surgery rate in patients with inflammatory bowel disease: a Japanese real-world database analysis. J Gastroenterol 2024; 59:389-401. [PMID: 38492011 PMCID: PMC11033244 DOI: 10.1007/s00535-024-02086-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/30/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Corticosteroids are recommended only for induction of remission in inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD). This study aimed to evaluate the change in pharmacologic treatment use, particularly systemic corticosteroids, over approximately 30 years, and the impact of biologics on IBD treatment since their appearance in the 2000s. METHODS This retrospective study conducted in Japan used data from the Phoenix cohort database (January 1990 to March 2021). Patients with disease onset at age ≥ 10 years who received treatment for UC or CD between January 1990 and March 2021 were included. Outcome measures were change in IBD treatments used, total cumulative corticosteroid doses, initial corticosteroid dose, duration of corticosteroid treatment, and surgery rate. RESULTS A total of 1066 and 579 patients with UC and CD, respectively, were included. In UC, the rate of corticosteroid use as initial treatment was relatively stable regardless of the year of disease onset; however, in CD, its rate decreased in patients who had disease onset after 2006 (before 2006: 14.3-27.8% vs. after 2006: 6.6-10.5%). Compared with patients with disease onset before biologics became available, cumulative corticosteroid doses in both UC and CD, and the surgery rate in CD only, were lower in those with disease onset after biologics became available. CONCLUSIONS Since biologics became available, corticosteroid use appears to have decreased, with more appropriate use. Furthermore, use of biologics may reduce surgery rates, particularly in patients with CD. UMIN Clinical Trials Registry; UMIN000035384.
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Affiliation(s)
- Daisuke Hirayama
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, S1 W17, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8556, Japan
| | | | - Kazuo Morita
- AbbVie GK, 3-1-21 Shibaura, Minato-Ku, Tokyo, 108-0023, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, S1 W17, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8556, Japan.
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15
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Syed H, Nadeem A, Gardinier D, Weekley K, Ribakow D, Lupe S, Bhat S, Holubar S, Cohen BL. Peri-Operative Optimization of Patients with Crohn's Disease. Curr Gastroenterol Rep 2024; 26:125-136. [PMID: 38421577 PMCID: PMC11081987 DOI: 10.1007/s11894-024-00925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach. RECENT FINDINGS Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.
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Affiliation(s)
- Hareem Syed
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ahmed Nadeem
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - David Gardinier
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kendra Weekley
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Dovid Ribakow
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephen Lupe
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Shubha Bhat
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Benjamin L Cohen
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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16
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Loganathan S, Smyth SL, Mykula R, Soleymani Majd H. The role of the multidisciplinary team in surgical management of intractable tubo-ovarian abscess as a late sequelae of challenging Crohn's disease in the modern era: A case report and review of current literature. Int J Gynaecol Obstet 2024; 165:535-541. [PMID: 37882505 DOI: 10.1002/ijgo.15196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023]
Abstract
Chronic, severe Crohn's disease in a young female patient can result in surgical complexity. The rarity of the presentation of intractable pelvic abscesses within this etiology with additional considerations given to fertility concerns and hence requirement for input from a multi-disciplinary team makes this a vital case in building a consensus for evidence-based surgical management. A 29-year-old nulliparous woman was referred to our tertiary centre for surgical management of Crohn's disease with known tubo-ovarian abscess and abdominoperineal and abdominal wall sinuses. Her previous surgical history included 4 midline laparotomies, subtotal colectomy and proctectomy with stoma formation. The patient underwent egg collection to preserve fertility. This was followed by midline laparotomy and abdominoperineal resection, which involved a retrograde radical modified hysterectomy using the Hudson technique, alongside excision of the perineal sinus, with reconstruction of the perineal defect using an internal pudendal artery perforator gluteal fold flap, and in addition to excision and drainage of the abdominal wall abscess. Involvement was sought from gynecological oncology, colorectal, urology, plastics, stoma, fertility, microbiology, and gastroenterology teams, which enabled successful preservation of end organ function and improvement in patient psychological well-being. This case is a paradigm of surgical challenge, requiring expert gynecological oncology techniques including a retroperitoneal approach, nerve and vessel sparing considerations alongside colorectal and urological procedures. Moreover, we believe that our blueprint for effective multi-disciplinary practice will inform the future management of gynecological surgery. Therefore this report aims to contribute towards the optimum management of the gynecological sequelae of Crohn's disease.
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Affiliation(s)
| | | | - Roman Mykula
- Plastic Surgery, University of Oxford, Oxford, UK
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17
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Steinberg JM, Chowdhury R, Sharma S, Charabaty A. Biologics, small molecule therapies and surgery in small bowel Crohn's disease. Curr Opin Gastroenterol 2024; 40:203-208. [PMID: 38294885 DOI: 10.1097/mog.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE OF REVIEW The terminal ileum and small bowel (SB) are involved in 30-45% of patients with Crohn's disease, while 20% have both small and large bowel involvement. Ileal Crohn's is associated with higher risk of progression to stricturing and penetrating disease 1 , hence it's imperative to utilize effective therapies to induce and maintain clinical and endoscopic remission and prevent intestinal complications. We review the available data of biologics and upadacitinib in small bowel disease, and the emerging data on the role of surgery as first line therapy for isolated Crohn's ileitis. RECENT FINDINGS Most trials assessing drug efficacy do not report efficacy by disease location, and robust data on efficacy of therapies in isolated small bowel Crohn's is sparse. Several studies indicate that small bowel disease is generally less responsive to biologics, and could require higher drug trough levels to achieve endoscopic healing. SUMMARY Current therapies for induction and maintenance of remission in moderate to severe Crohn's disease include several classes of monoclonal antibodies and a Janus Kinase inhibitor, upadacitinib. While small bowel Crohn's disease is generally less responsive to treatment, anti-TNFs are still preferred as first line therapy, and the option of early ileocecal resection in early limited ileal disease is gaining interest.
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Affiliation(s)
- Joshua M Steinberg
- Gastroenterology of the Rockies; University of Colorado School of Medicine; Denver, CO
| | | | - Sowmya Sharma
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aline Charabaty
- Johns Hopkins School of Medicine, Washington, District of Columbia, USA
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18
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Angriman I, Bordignon G, Kotsafti A, Mescoli C, Scarpa M, Ruffolo C, Fassan M, Dei Tos AP, D'Incà R, Savarino EV, Zingone F, Pucciarelli S, Bardini R, Castagliuolo I, Scarpa M. Innate Immunity Activation in Newly Diagnosed Ileocolonic Crohn's Disease: A Cohort Study. Dis Colon Rectum 2024; 67:681-692. [PMID: 38319717 DOI: 10.1097/dcr.0000000000003145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND Recent studies showed that early surgery for Crohn's disease leads to a lower recurrence rate. However, the underlying mechanism is unknown. OBJECTIVE The study aims to analyze the innate immunity microenvironment in ileal mucosa according to the duration of Crohn's disease. DESIGN A prospective cohort study. SETTINGS Tertiary referral center for IBD surgery. PATIENTS A total of 88 consecutive patients with Crohn's disease undergoing ileocolonic resection were prospectively enrolled. Mucosal samples were obtained from both healthy and inflamed ileum. Data from a public data set were analyzed as an external validation cohort. MAIN OUTCOME MEASURES Neutrophil infiltration was evaluated by histological asessment and macrophage subpopulation was assessed by immunohistochemistry. Expressions of TLR2 , TLR4 , TLR5 , DEFB1 , DEFB4A , DEFB103 , DEFA5 , and DEFA6 were quantified by real-time quantitative polymerase chain reaction. Concentrations of BDNF, CCL-11, ICAM-1, IL-1A, IL-1β, IL-1RN, IL-12p40, IL-12p70, IL-15, IL-17A, IL-23A, MMP-3, CCL-3, KITLG, and VEGFA were determined with an immunometric assay. RESULTS Neutrophil infiltration is inversely correlated with disease duration. DEFB4A mRNA expression tended to be higher in late-stage Crohn's disease ( p = 0.07). A higher number of macrophages expressed CD163 at low intensity in late-stage Crohn's disease ( p = 0.04). The concentration of IL-15 ( p = 0.02) and IL-23A ( p = 0.05) was higher in healthy ileal mucosa of early-stage patients. In the external cohort, expressions of DEFB1 ( p = 0.03), DEFB4A ( p = 0.01), IL-2 ( p = 0.04), and IL-3 ( p = 0.03) increased in patients with late-stage Crohn's disease. LIMITATIONS A relatively small number of patients, especially in the newly diagnosed group. CONCLUSIONS In newly diagnosed Crohn's disease, high levels of IL-15 and IL-23 in healthy mucosa suggest that innate immunity is the starter of acute inflammation. Moreover, M2 macrophages increase in the healthy mucosa of patients with late-stage Crohn's disease, suggesting that reparative and profibrotic processes are predominant in the long term, and in this phase, anti-inflammatory therapy may be less efficient. See Video Abstract . ACTIVACIN DE LA INMUNIDAD INNATA EN LA RECIENTEMENTE DIAGNOSTICADA ENFERMEDAD DE CROHN ILEOCLICA UN ESTUDIO DE COHORTE ANTECEDENTES:Estudios recientes demostraron que la cirugía temprana para la enfermedad de Crohn (EC) conduce a una menor tasa de recurrencia. Sin embargo, se desconoce el mecanismo subyacente.OBJETIVO:El estudio tiene como objetivo analizar el microambiente de la inmunidad innata en la mucosa ileal según la duración de la EC.DISEÑO:Un estudio de cohorte prospectivo.AJUSTES:Centro terciario de referencia para cirugía de EII.PACIENTES:Fueron registrados de manera prospectiva y consecutiva 88 pacientes con EC sometidos a resección ileocolónica. Se obtuvieron muestras de mucosa ileal, tanto del íleon sano como del íleon inflamado. Los datos se analizaron como una cohorte de validación externa.PRINCIPALES MEDIDAS DE RESULTADO:Fueron evaluados la infiltración de neutrófilos por histología y la subpoblación de macrófagos por inmunohistoquímica. La expresión de TLR2, TLR4, TLR5, DEFB1, DEFB4A, DEFB103, DEFA5 y DEFA6 fueron cuantificados mediante qPCR en tiempo real. Las concentraciones de BDNF, CCL-11, ICAM-1, IL-1A, IL-1B, IL-1RN, IL-12 p40, IL-12 p70, IL-15, IL-17A, IL-23A, MMP-3, CCL-3, KITLG, VEGFA se determinaron con ensayo inmunométrico.RESULTADOS:La infiltración de neutrófilos se correlaciona inversamente con la duración de la enfermedad. La expresión del ARNm de DEFB4A mostro una tendencia a ser mayor en la EC en etapa tardía ( p = 0,07). Un mayor número de macrófagos expresaron CD163 a baja intensidad en la etapa tardía ( p = 0,04). La concentración de IL15 ( p = 0,02) e IL23A ( p = 0,05) fue mayor en la mucosa ileal sana de pacientes en estadio temprano. En la cohorte externa, la expresión de DEFB1 ( p = 0,03) y DEFB4A ( p = 0,01), IL2 ( p = 0,04) e IL3 ( p = 0,03) aumentó en pacientes en etapa tardía.LIMITACIONES:Un número relativamente pequeño de pacientes, especialmente en el grupo recién diagnosticado.CONCLUSIONES:En la EC recién diagnosticada, los altos niveles de IL-15 e IL-23 en la mucosa sana sugieren que la inmunidad innata es el promotor de la inflamación aguda. Además, los macrófagos M2 aumentan en la mucosa sana de pacientes con EC en etapa tardía, lo que sugiere que los procesos reparadores y profibróticos son predominantes a largo plazo y en esta fase, la terapia antiinflamatoria puede ser menos eficiente. (Traducción-Dr. Osvaldo Gauto ).
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Affiliation(s)
- Imerio Angriman
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
| | | | - Andromachi Kotsafti
- Laboratory of Advanced Translational Research, Veneto Institute of Oncology IOV, IRCCS, Padua, Italy
| | - Claudia Mescoli
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Melania Scarpa
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Cesare Ruffolo
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
| | - Matteo Fassan
- Laboratory of Advanced Translational Research, Veneto Institute of Oncology IOV, IRCCS, Padua, Italy
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Angelo Paolo Dei Tos
- Pathology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Renata D'Incà
- Gastroenterology Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | | | - Fabiana Zingone
- Gastroenterology Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | | | - Romeo Bardini
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
| | - Ignazio Castagliuolo
- Microbiology Unit, Department of Molecular Medicine (DMM), University of Padova, Padua, Italy
| | - Marco Scarpa
- General Surgery Unit 3, Azienda Ospedaliera di Padova, Padua, Italy
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Avellaneda N, Maroli A, Tottrup A, Buskens C, Kotze PG, Pellino G, Dige A, Haase AM, Haanappel A, Giorgi L, Carvello M, Maruyama BY, Christensen P, Spinelli A. Short and long-term outcomes of surgery for inflammatory (uncomplicated) ileocecal Crohn's disease: Multicentric retrospective analysis of 211 patients. Dig Liver Dis 2024; 56:730-736. [PMID: 38044224 DOI: 10.1016/j.dld.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Surgical management for patients with inflammatory ileocecal Crohn's disease (CD) could be a reasonable alternative to second-line medical treatment. AIM To assess short and long-term outcomes of patients operated on for inflammatory, ileocecal Crohn's disease. METHODS A retrospective analysis of patients intervened at four referral hospitals during 2012-2021 was performed. RESULTS 211 patients were included. 43% of patients underwent surgery more than 5 years after diagnosis, and 49% had been exposed to at least one biologic agent preoperatively. 89% were operated by laparoscopy, with 1.6% conversion rate. The median length of the resected bowel was 25 cm (7-92) and three patients (1.43%) received a stoma. Median follow-up was 36 (17-70) months. The endoscopic recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 56%, 52%, 45%, 38%, and 33%, respectively. The clinical recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 83%, 79%, 76%, 74%, and 74%, respectively. In multivariate analysis, previous biological treatment (HR=2.01; p = 0.001) was associated with a higher risk of overall recurrence. CONCLUSION Surgery in patients with primary inflammatory ileocecal CD is associated with good postoperative outcomes, low postoperative morbidity with reasonable recurrence rates.
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Affiliation(s)
- Nicolas Avellaneda
- Department of Surgery, Aarhus University Hospital, Denmark; General Surgery Department, CEMIC, Buenos Aires, Argentina.
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
| | - Anders Tottrup
- Department of Surgery, Aarhus University Hospital, Denmark
| | - Christianne Buskens
- Colorectal Surgery Department, Amsterdam Medical Hospitals, Amsterdam, the Netherlands
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Brazil
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Anders Dige
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anouck Haanappel
- Colorectal Surgery Department, Amsterdam Medical Hospitals, Amsterdam, the Netherlands
| | - Lorenzo Giorgi
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy
| | - Michelle Carvello
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
| | | | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS - Humanitas Research Hospital, Milano, Italy; Department of Biomedical science, Humanitas University, Milan, Italy
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20
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Kolho KL, Nikkonen A, Merras-Salmio L, Molander P. The need for surgery in pediatric patients with inflammatory bowel disease treated with biologicals. Int J Colorectal Dis 2024; 39:58. [PMID: 38661931 PMCID: PMC11045629 DOI: 10.1007/s00384-024-04634-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Inflammatory bowel disease (IBD) in childhood often presents with a more extensive and more aggressive disease course than adult-onset disease. We aimed to evaluate if biological treatment started in childhood decreases the need for intestinal surgery over time. METHODS This was a retrospective, single-center, cohort study. All pediatric patients with IBD initiated to biological therapy at the Children's Hospital, were included in the study and followed up to the first surgical procedure or re-operation in their adulthood or until 31.12.2021 when ≥ 18 of age. Data were collected from the pediatric registry of IBD patients with biologicals and medical charts. RESULTS A total of 207 pediatric IBD patients were identified [150 with Crohn´s disease (CD), 31 with ulcerative colitis (UC), 26 with IBD unclassified (IBDU)] of which 32.9% (n = 68; CD 49, UC 13, IBDU 6) underwent intestinal surgery. At the end of a median follow-up of 9.0 years (range 2.0-25.9), patients reached a median age of 21.4 years (range 18-36). Patients who had intestinal surgery in childhood were more likely to have IBD-related surgery also in early adulthood. The duration of the disease at induction of the first biological treatment emerged as the only risk factor, with a longer duration in the surgical group than in patients with no surgery. CONCLUSION Despite initiation of biological treatment, the risk of intestinal surgery remains high in pediatric IBD patients and often the need for surgery emerges after the transition to adult IBD clinics.
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Affiliation(s)
- Kaija-Leena Kolho
- Children's Hospital, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland.
| | - Anne Nikkonen
- Children's Hospital, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland
| | - Laura Merras-Salmio
- Children's Hospital, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland
| | - Pauliina Molander
- Abdominal Center, Gastroenterology, Helsinki University Hospital HUS and Helsinki University, Helsinki, Finland
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21
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Alibert L, Betton L, Falcoz A, Manceau G, Benoist S, Zerbib P, Podevin J, Maggiori L, Brouquet A, Tyrode G, Vuitton L, Vernerey D, Lefevre JH, Lakkis Z. Does Kono-S Anastomosis Reduce Recurrence in Crohn's Disease Compared with Conventional Ileocolonic Anastomosis? A Nationwide Propensity Score-matched Study from GETAID Chirurgie Group [KoCoRICCO Study]. J Crohns Colitis 2024; 18:525-532. [PMID: 37850342 DOI: 10.1093/ecco-jcc/jjad176] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND AND AIMS Postoperative recurrence is a major concern in Crohn's disease. The Kono-S anastomosis has been described to reduce the rate of recurrence. However, the level of evidence for its effectiveness remains low. The KoCoRICCO study aimed to compare outcomes between Kono-S anastomosis and conventional anastomosis in two nationwide, prospective cohorts. METHODS Adult patients with Crohn's disease, who underwent ileocolonic resection with Kono-S anastomosis, were prospectively included in seven referral centres between 2020 and 2022. Patients with conventional side-to-side anastomosis were enrolled from a previously published cohort. A propensity score analysis was performed to compare recurrence at first endoscopy in a matched 1:2 ratio population. RESULTS A total of 433 patients with ileocolonic anastomosis were enrolled, of whom 155 had a Kono-S anastomosis. Before matching, both groups were unbalanced for preoperative, intraoperative, and postoperative characteristics. After matching patients with available endoscopic follow-up, endoscopic recurrence ≥i2 was found in 47.5% of the Kono-S group and 44.3% of the conventional side-to-side group [p = 0.6745]. CONCLUSIONS The KoCoRICCO study suggests that Kono-S anastomosis does not reduce the risk of endoscopic recurrence in Crohn's disease compared with conventional side-to-side anastomosis. Further research with a longer follow-up is necessary to determine whether there is a potential benefit on surgical recurrence.
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Affiliation(s)
- Line Alibert
- University Hospital of Besançon, Department of Digestive Surgery, Besançon, France
| | - Louis Betton
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Antoine Falcoz
- University Hospital of Besançon, Methodology and Quality of Life Unit in Oncology, Besançon, France
- Établissement Français du Sang Bourgogne Franche-Comté, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Gilles Manceau
- European Georges Pompidou Hospital, Department of Digestive and Oncologic Surgery, Paris, France
| | - Stéphane Benoist
- Bicêtre Hospital, Department of Digestive Surgery and Surgical Oncology, Le Kremlin Bicêtre, France
| | - Philippe Zerbib
- Lille University Hospital, Department of Digestive Surgery and Transplantation, Lille, France
| | - Juliette Podevin
- University Hospital of Nantes, Digestive and Endocrine Surgery Clinic, Nantes, France
| | - Léon Maggiori
- St Louis Hospital, Department of General- Endocrine and Digestive Surgery, Paris, France
| | - Antoine Brouquet
- Bicêtre Hospital, Department of Digestive Surgery and Surgical Oncology, Le Kremlin Bicêtre, France
| | - Gaëlle Tyrode
- University Hospital of Besançon, Department of Gastroenterology, Besançon, France
| | - Lucine Vuitton
- University Hospital of Besançon, Department of Gastroenterology, Besançon, France
| | - Dewi Vernerey
- University Hospital of Besançon, Methodology and Quality of Life Unit in Oncology, Besançon, France
| | - Jérémie H Lefevre
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Zaher Lakkis
- University Hospital of Besançon, Department of Digestive Surgery, Besançon, France
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22
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Hernández-Rocha C, Walshe M, Birch S, Sabic K, Korie U, Chasteau C, Miladinova VM, Sabol WB, Mengesha E, Hanna M, Pozdnyakova V, Datta L, Kohen R, Milgrom R, Stempak JM, Bitton A, Brant SR, Rioux JD, McGovern DPB, Duerr RH, Cho JH, Schumm PL, Silverberg MS, Lazarev M. Clinical Predictors of Early and Late Endoscopic Recurrence Following Ileocolonic Resection in Crohn's Disease. J Crohns Colitis 2024; 18:615-627. [PMID: 37976264 PMCID: PMC11037109 DOI: 10.1093/ecco-jcc/jjad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND AIMS Multiple factors are suggested to place Crohn's disease patients at risk of recurrence after ileocolic resection with conflicting associations. We aimed to identify clinical predictors of recurrence at first [early] and further [late] postoperative colonoscopy. METHODS Crohn's disease patients undergoing ileocolic resection were prospectively recruited at six North American centres. Clinical data were collected and endoscopic recurrence was defined as Rutgeerts score ≥i2. A multivariable model was fitted to analyse variables independently associated with recurrence. RESULTS A total of 365 patients undergoing 674 postoperative colonoscopies were included with a median age of 32 years, 189 [51.8%] were male, and 37 [10.1%] were non-Whites. Postoperatively, 133 [36.4%] used anti-tumour necrosis factor [anti-TNF] and 30 [8.2%] were smokers. At first colonoscopy, 109 [29.9%] had recurrence. Male gender (odds ratio [OR] = 1.95, 95% confidence interval [CI] 1.12-3.40), non-White ethnicity [OR = 2.48, 95% CI 1.09-5.63], longer interval between surgery and colonoscopy [OR = 1.09, 95% CI 1.002-1.18], and postoperative smoking [OR = 2.78, 95% CI 1.16-6.67] were associated with recurrence, while prophylactic anti-TNF reduced the risk [OR = 0.28, 95% CI 0.14-0.55]. Postoperative anti-TNF prophylaxis had a protective effect on anti-TNF experienced patients but not on anti-TNF naïve patients. Among patients without recurrence at first colonoscopy, Rutgeerts score i1 was associated with subsequent recurrence [OR = 4.43, 95% CI 1.73-11.35]. CONCLUSIONS We identified independent clinical predictors of early and late Crohn's disease postoperative endoscopic recurrence. Clinical factors traditionally used for risk stratification failed to predict recurrence and need to be revised.
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Affiliation(s)
- Cristian Hernández-Rocha
- Zane Cohen Centre for Digestive Diseases, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Margaret Walshe
- Zane Cohen Centre for Digestive Diseases, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Sondra Birch
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Ksenija Sabic
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ujunwa Korie
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Colleen Chasteau
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vessela M Miladinova
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - William B Sabol
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emebet Mengesha
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Mary Hanna
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Valeriya Pozdnyakova
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Lisa Datta
- Department of Gastroenterology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Rita Kohen
- Inflammatory Bowel Disease Centre, Division of Gastroenterology, McGill University Health Centre, Montréal, Quebec, Canada
| | - Raquel Milgrom
- Zane Cohen Centre for Digestive Diseases, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Joanne M Stempak
- Zane Cohen Centre for Digestive Diseases, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Alain Bitton
- Inflammatory Bowel Disease Centre, Division of Gastroenterology, McGill University Health Centre, Montréal, Quebec, Canada
| | - Steven R Brant
- Crohn’s and Colitis Center of New Jersey, Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John D Rioux
- Research Centre, Montreal Heart Institute, Montréal, Quebec, Canada
| | - Dermot P B McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Richard H Duerr
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Judy H Cho
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Phil L Schumm
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Mark Lazarev
- Department of Gastroenterology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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23
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McKenna NP, Bews KA, Mirande MD, Abarca Rendon FM, Ofshteyn A, Peponis T, Shawki SF, Kelley SR, Mathis KL. Surgical management of duodenal crohn's disease. Langenbecks Arch Surg 2024; 409:132. [PMID: 38639899 DOI: 10.1007/s00423-024-03324-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Operative options for duodenal Crohn's disease include bypass, stricturoplasty, or resection. What factors are associated with operation selection and whether differences exist in outcomes is unknown. METHODS Patients with duodenal Crohn's disease requiring operative intervention across a multi-state health system were identified. Patient and operative characteristics, short-term surgical outcomes, and the need for future endoscopic or surgical management of duodenal Crohn's disease were analyzed. RESULTS 40 patients underwent bypass (n = 26), stricturoplasty (n = 8), or resection (n = 6). Median age of diagnosis of Crohn's disease was 23.5 years, and over half of the patients had undergone prior surgery for CD. Operation type varied by the most proximal extent of duodenal involvement. Patients with proximal duodenal CD underwent bypass operations more commonly than those with mid- or distal duodenal disease (p = 0.03). Patients who underwent duodenal stricturoplasty more often required concomitant operations for other sites of small bowel or colonic CD (63%) compared to those who underwent bypass (39%) or resection (33%). No patients required subsequent surgery for duodenal CD at a median follow-up of 2.8 years, but two patients required endoscopic dilation (n = 1 after stricturoplasty, n = 1 after resection). CONCLUSION Patients who require surgery for duodenal Crohn's disease appear to have an aggressive Crohn's disease phenotype, represented by a younger age of diagnosis and a high rate of prior resection for Crohn's disease. Choice of operation varied by proximal extent of duodenal Crohn's disease.
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Affiliation(s)
- Nicholas P McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA.
| | - Katherine A Bews
- The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Asya Ofshteyn
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA
| | - Thomas Peponis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA
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24
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Ferreira SDC, Aprile LRO, Parra RS, Feitosa MR, de Castro PPM, Perdoná GDCDS, Feres O, da Rocha JJR, Troncon LEDA. Factors associated with surgical resection in patients with Crohn's disease: long-term evaluation. Acta Cir Bras 2024; 39:e391924. [PMID: 38629651 PMCID: PMC11020661 DOI: 10.1590/acb391924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/05/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE To evaluate patient characteristics and factors associated with surgical resection in patients with Crohn's disease (CD). METHODS An analysis was performed on data from 295 patients with CD in follow-up from 2001 to 2018. Medical record data comprised age, gender, location, behavior and duration of the CD, smoking, and extraintestinal manifestation. Patients were divided into two groups according to the presence or absence of surgical resection. RESULTS Out of the 295 patients with CD, 155 underwent surgical resection (53.2% male, mean age: 43.88 ± 14.35 years). The main indications for surgery were stenosis (44.5%), clinical intractability (15.5%), and intra-abdominal fistulas (15.5%). Smoking (p < 0.001), longer CD duration (p < 0.0001), ileo-colonic location (p = 0.003), stenosing behavior (p < 0.0001), and fistulizing behavior (p < 0.0001) were significantly associated with surgical resection. Initial use of biological was significantly more frequent in the group of patients without surgical resection (p < 0.001). CONCLUSIONS Patients with CD still frequently need surgical treatment. Smoking (current or past), longer disease time, stenosing and fistulizing behavior, and ileo-colonic localization in CD patients were associated with a higher risk of surgery. Awareness about factors associated with unfavorable outcome allows such patients to be treated more appropriately.
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Affiliation(s)
- Sandro da Costa Ferreira
- Universidade de São Paulo – Medical School – Department of Medicine – Ribeirão Preto (SP), Brazil
| | | | - Rogério Serafim Parra
- Universidade de São Paulo – Medical School – Department of Surgery and Anatomy – Ribeirão Preto (SP), Brazil
| | - Marley Ribeiro Feitosa
- Universidade de São Paulo – Medical School – Department of Surgery and Anatomy – Ribeirão Preto (SP), Brazil
| | | | | | - Omar Feres
- Universidade de São Paulo – Medical School – Department of Surgery and Anatomy – Ribeirão Preto (SP), Brazil
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25
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Martinelli M, Miele E, Staiano A. Surgical Complications Need to Be Carefully Excluded Before Ruling Out a Diagnosis of De Novo Crohn's Disease. Inflamm Bowel Dis 2024; 30:690. [PMID: 38401568 DOI: 10.1093/ibd/izae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Affiliation(s)
- Massimo Martinelli
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II" Naples, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II" Naples, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II" Naples, Italy
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26
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de Jong D, Reijntjes M, Buskens C, Hompes R, D'Haens G, Bemelman W, Duijvestein M. Response to "De Novo Crohn's Disease in Children With Ulcerative Colitis Undergoing Ileal Pouch Anal Anastomosis: A Multicenter, Retrospective Study From the Pediatric IBD Porto Group of the ESPGHAN". Inflamm Bowel Dis 2024; 30:691-692. [PMID: 38387614 DOI: 10.1093/ibd/izae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Djuna de Jong
- Department of Gastroenterology and Hepatology, Amsterdam UMC, the Netherlands
| | | | | | - Roel Hompes
- Department of Surgery, Amsterdam UMC, the Netherlands
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, the Netherlands
| | | | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, the Netherlands
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27
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Djalal A, Wong SY, Colombel JF, Ungaro R, Kayal M. Problem with Hookups: Perianal Fistula After Ileal Pouch-Anal Anastomosis. Dig Dis Sci 2024; 69:1102-1104. [PMID: 38446307 DOI: 10.1007/s10620-024-08344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Arafa Djalal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Serre-Yu Wong
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Ungaro
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Ullrich SJ, Frischer JS. Surgical management of complicated Crohn's disease. Semin Pediatr Surg 2024; 33:151399. [PMID: 38642531 DOI: 10.1016/j.sempedsurg.2024.151399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2024]
Abstract
Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population - notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.
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Affiliation(s)
- Sarah J Ullrich
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA
| | - Jason S Frischer
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA.
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29
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Shah RS, Bachour S, Joseph A, Xiao H, Lyu R, Syed H, Li T, Pothula S, Vinaithirthan V, Ali AH, Contreras S, Hu JH, Barnes EL, Axelrad JE, Holubar SD, Regueiro M, Cohen BL, Click BH. Real-World Surgical and Endoscopic Recurrence Based on Risk Profiles and Prophylaxis Utilization in Postoperative Crohn's Disease. Clin Gastroenterol Hepatol 2024; 22:847-857.e12. [PMID: 37879523 DOI: 10.1016/j.cgh.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 09/30/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND & AIMS Preoperative risk stratification may help guide prophylactic biologic utilization for the prevention of postoperative Crohn's disease (CD) recurrence; however, there are limited data exploring and validating proposed clinical risk factors. We aimed to explore the preoperative clinical risk profiles, quantify individual risk factors, and assess the impact of biologic prophylaxis on postoperative recurrence risk in a real-world cohort. METHODS In this multicenter retrospective analysis, patients with CD who underwent ileocolonic resection (ICR) from 2009 to 2020 were identified. High-risk (active smoking, ≥2 prior surgeries, penetrating disease, and/or perianal disease) and low-risk (nonsmokers and age >50 y) features were used to stratify patients. We assessed the risk of endoscopic (Rutgeert score, ≥i2b) and surgical recurrence by risk strata and biologic prophylaxis (≤90 days postoperatively) with logistic and time-to-event analyses. RESULTS A total of 1404 adult CD patients who underwent ICR were included. Of the high-risk factors, 2 or more ICRs (odds ratio [OR], 1.71; 95% CI, 1.13-2.57), active smoking (OR, 1.73; 95% CI, 1.17-2.53), penetrating disease (OR, 1.41; 95% CI, 1.02-1.94), and history of perianal disease alone (OR, 1.99; 95% CI, 1.42-2.79) were associated with surgical but not endoscopic recurrence. Surgical recurrence was lower in high-risk patients receiving prophylaxis vs not (10.2% vs 16.7%; P = .02), and endoscopic recurrence was lower in those receiving prophylaxis irrespective of risk strata (high-risk, 28.1% vs 37.4%; P = .03; and low-risk, 21.1% vs 38.3%; P = .002). CONCLUSIONS Clinical risk factors accurately illustrate patients at risk for surgical recurrence, but have limited utility in predicting endoscopic recurrence. Biologic prophylaxis may be of benefit irrespective of risk stratification and future studies should assess this.
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Affiliation(s)
- Ravi S Shah
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Salam Bachour
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Huijun Xiao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Terry Li
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Shravya Pothula
- Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Adel Hajj Ali
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sussel Contreras
- Department of Gastroenterology and Hepatology, New York University, New York, New York
| | - Jessica H Hu
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Jordan E Axelrad
- Department of Gastroenterology and Hepatology, New York University, New York, New York
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin H Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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30
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Bačić B, Hrgović Z, Cerovac A, Barčot O, Sabljić J, Dumančić S, Markoski B, Leskur M. Extraperitoneal Cesarean Section after two Medial Laparotomies, Anus Prater, and Surgical Treatment of the Rectovaginal Fistula in a Patient with Crohn's Disease: A Case Report. Z Geburtshilfe Neonatol 2024; 228:192-195. [PMID: 38056597 DOI: 10.1055/a-2200-9504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
The aim of this case report is to show the advantages of the extraperitoneal cesarean section (ECS) approach in a pregnant patient with multiple previous abdominal transperitoneal colon surgeries and Crohn's disease. A pregnant nulliparous woman with Crohn's disease was admitted for delivery. After delivery, a large rupture and lesion of the rectum was observed. Suturing of the vagina, rectum and sphincter was performed by an abdominal surgeon. Because of a very large and irregularly shaped rectum rupture, the patient underwent infraumbilical medial laparotomy and sigmoidostomy. After 18 months, the patient started to experience vaginal discharge and Y-shaped rectovaginal fistula was confirmed. Surgical reconstruction was performed. The patient's second pregnancy began one year later. At 38 weeks of pregnancy, elective extraperitoneal cesarean section was performed. A healthy newborn was delivered. Follow-up showed full and fast recovery after the ECS. In cases of pregnant women who have had multiple colon surgeries, gynecology surgeons can choose to perform an ECS to avoid transperitoneal entrance into the abdomen. ECS avoids lysis of postoperative adhesions after repetitive gastrointestinal surgeries, the formation of new adhesions by lysis of the old adhesions, and most importantly, the possibility of colon or small intestine lesions during lysis of dense or firm adhesions.
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Affiliation(s)
- Boris Bačić
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center Split, Croatia
- University of Split, Medical School, Croatia
| | - Zlatko Hrgović
- Frauenklinik, J.W. Goethe Universität Frankfurt, Frankfurt am Main, Germany
| | - Anis Cerovac
- Department of Gynaecology and Obstetrics, General Hospital Tešanj, Tešanj, Bosnia and Herzegovina
- Department of Anatomy, School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Ognjen Barčot
- Department of Surgery, Clinical Hospital Center Split, Split, Croatia
| | - Jelena Sabljić
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center Split, Croatia
- University of Split, Medical School, Croatia
| | - Stipe Dumančić
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center Split, Croatia
- University of Split, Medical School, Croatia
| | - Blagoja Markoski
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center Split, Croatia
- University of Split, Medical School, Croatia
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Smalbroek BP, Poelmann FB, Smits AB. A new surgical technique: robotic intracorporeal Kono-S anastomosis in Crohn's - a safety and feasibility case series on short-term outcomes. Colorectal Dis 2024; 26:702-708. [PMID: 38369963 DOI: 10.1111/codi.16914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/10/2023] [Accepted: 01/12/2024] [Indexed: 02/20/2024]
Abstract
AIM The Kono-S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra-/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot-assisted intracorporeal Kono-S anastomosis. METHOD This is a prospective single-centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot-assisted intracorporeal Kono-S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow-up for postoperative complications was 30 days. RESULTS Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22-51 years] and the median BMI was 25 kg/m2 (IQR 19-28 kg/m2). Intracorporeal Kono-S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144-176 min) and the median length of stay was 3 days (IQR 1-5 days). No conversions or 30-day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days. CONCLUSION Performance of intracorporeal robot-assisted Kono-S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population-based cohort.
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Affiliation(s)
- Bo P Smalbroek
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Floris B Poelmann
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
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Pandya RP, Ganesan V, Rodriguez AN, Magruder ML, Wong CHJ, Choueka J, Razi AE. Crohn's disease is associated with higher rates of implant-related complications following primary total knee arthroplasty. Eur J Orthop Surg Traumatol 2024; 34:1357-1362. [PMID: 38150021 DOI: 10.1007/s00590-023-03794-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/16/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION In Western countries, there has been a rise in the prevalence of Crohn's Disease (CD) and primary total knee arthroplasty (TKA). This study delves deeper into the effects of CD on TKA patients by examining (1) the length of in-hospital stay (LOS); (2) the rates of readmission; (3) complications related to implants; and (4) the costs associated with care. METHODS A retrospective analysis using the PearlDiver database was conducted, encompassing the time frame between January 1st, 2005 and March 31st, 2014, focusing on patients who underwent TKA and were either diagnosed with CD or not. Patients with CD were paired with control subjects at a 1:5 ratio based on age, gender, and medical comorbidities. The analysis comprised a total of 96,229 patients (CD = 16,039; non-CD = 80,190). RESULTS Patients with CD had a notably longer hospital stay (3 v. 2 days, p < 0.0001) and faced significantly higher rates of 90-day readmissions and complications (19.80% v. 14.91%, OR: 1.40, p < 0.0001; 6.88% v. 4.88%, OR: 1.43, p < 0.0001 respectively). Additionally, CD patients incurred greater expenses on the surgery day ($18,365.98 v. $16,192.00) and within 90 days post-surgery ($21,337.46 v. $19,101.42). CONCLUSION This study demonstrates longer in-hospital LOS, higher rates of readmissions, implant-related complications, and costs of care among CD patients following primary TKA.
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Affiliation(s)
- Radha P Pandya
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA
- State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Vanathi Ganesan
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA
- State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA.
| | - Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA
| | - Che Hang Jason Wong
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA
| | - Jack Choueka
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA
| | - Afshin E Razi
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49Th St., Brooklyn, NY, 11219, USA
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Holubar SD, Lavryk O, Steele SR. Bowel preserving surgery for stricturing jejunoileal Crohn's disease, part 1: Heineke-Mikulicz strictureplasty, a step-by-step video vignette. Colorectal Dis 2024; 26:822-824. [PMID: 38331585 DOI: 10.1111/codi.16911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olga Lavryk
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Carter M, Lim IIP. Surgical management of pediatric Crohn's disease. Semin Pediatr Surg 2024; 33:151401. [PMID: 38615423 DOI: 10.1016/j.sempedsurg.2024.151401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Management of pediatric-onset Crohn's disease uniquely necessitates consideration of growth, pubertal development, psychosocial function and an increased risk for multiple future surgical interventions. Both medical and surgical management are rapidly advancing; therefore, it is increasingly important to define the role of surgery and the breadth of surgical options available for this complex patient population. Particularly, the introduction of biologics has altered the disease course; however, the ultimate need for surgical intervention has remained unchanged. This review defines and evaluates the surgical techniques available for management of the most common phenotypes of pediatric-onset Crohn's disease as well as identifies critical perioperative considerations for optimizing post-surgical outcomes.
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Affiliation(s)
- Michela Carter
- Department of Surgery, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Irene Isabel P Lim
- Department of Pediatric Surgery, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States.
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Duan M, Cao L, Lu M, Zhang T, Ji Q, Guo X, Guo Z, Wu Q, Liu Y, Gong J, Zhu W, Li Y. Prophylactic Intra-abdominal Drainage is Associated With Lower Postoperative Complications in Patients With Crohn's Disease: A Randomized Controlled Trial. Surg Innov 2024; 31:157-166. [PMID: 38339842 DOI: 10.1177/15533506241232598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Prophylactic intraoperative drains have been shown not superior for patients underwent intestinal surgery. However, for patients with Crohn's disease (CD), this needs further exploration. METHODS In this pilot study, CD patients were randomly assigned to drain (n = 50) and no-drain (n = 50) groups. The primary endpoint was the rate of postoperative prolonged ileus (PPOI). The secondary endpoints were postoperative abdominal ascites, postoperative systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) levels. RESULTS The incidences of PPOI and postoperative abdominal ascites were significantly lower in the drain group (12% vs 44%; 0% vs 24%, both P < .05). Postoperative SIRS incidence and CRP levels were significantly increased in the no-drain group [36% vs 10%; 54.9 vs 34.3 mg/L, both P < .05]. In multivariate analysis, prophylactic drainage was the independent protective factor for PPOI and postoperative LOS. CONCLUSIONS Prophylactic drainage may be associated with improved clinical outcomes in CD patients.
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Affiliation(s)
- Ming Duan
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Mengjie Lu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qing Ji
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Xian Guo
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qiong Wu
- Department of Scientific Research and Training, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Yuxiu Liu
- Data and Statistics Division, Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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McKenna NP, Bews KA, Behm KT, Mathis KL, Cima RR, Habermann EB. Timing and Location of Venous Thromboembolisms After Surgery for Inflammatory Bowel Disease. J Surg Res 2024; 296:563-570. [PMID: 38340490 DOI: 10.1016/j.jss.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/04/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Patients with inflammatory bowel disease are reported to be at elevated risk for postoperative venous thromboembolism (VTE). The rate and location of these VTE complications is unclear. METHODS Patients with ulcerative colitis (UC) or Crohn's disease (CD) undergoing intestinal operations between January 2006 and March 2021 were identified from the medical record at a single institution. The overall incidence of VTEs and their anatomic location were determined to 90 days postoperatively. RESULTS In 2716 operations in patients with UC, VTE prevalence was 1.95% at 1-30 days, 0.74% at 31-60 days, and 0.48% at 90 days (P < 0.0001). Seventy two percent of VTEs within the first 30 days were in the portomesenteric system, and this remained the location for the majority of VTE events at 31-60 and 61-90 days postoperatively. In the first 30 days, proctectomies had the highest incidence of VTEs (2.5%) in patients with UC. In 2921 operations in patients with CD, VTE prevalence was 1.43%, 0.55%, and 0.41% at 1-30 days, 31-60 days, and 61-90 days, respectively (P < 0.0001). Portomesenteric VTEs accounted for 31% of all VTEs within 30 days postoperatively. In the first 30 days, total abdominal colectomies had the highest incidence of VTEs (2.5%) in patients with CD. CONCLUSIONS The majority of VTEs within 90 days of surgery for UC and Crohn's are diagnosed within the first 30 days. The risk of a VTE varies by the extent of the operation performed, with portomesenteric VTE representing a substantial proportion of events.
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Affiliation(s)
- Nicholas P McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Katherine A Bews
- The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Ge X, Liu H, Wu Y, Liu W, Qi W, Ye L, Cao Q, Lian H, Bai R, Zhou W. Parenteral n-3 polyunsaturated fatty acids supplementation improves postoperative recovery for patients with Crohn's disease after bowel resection: a randomized, unblinded controlled clinical trial. Am J Clin Nutr 2024; 119:1027-1035. [PMID: 38569774 DOI: 10.1016/j.ajcnut.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The postoperative inflammatory response is associated with postoperative recovery in surgery. n-3 (ω-3) polyunsaturated fatty acids have been reported to lower inflammation. The postoperative role of parenteral n-3 polyunsaturated fatty acids supplementation on outcomes in Crohn's disease after bowel resection is unclear. OBJECTIVES We aimed to investigate the effects of postoperative parenteral n-3 polyunsaturated fatty acids supplementation in Crohn's disease. METHODS A prospective randomized, unblinded controlled clinical trial was conducted for patients with Crohn's disease who underwent bowel resection between May 2019 and February 2022. Postoperative complications, complete blood count, serum biochemical values, and cytokine concentrations were compared in patients with and without parenteral n-3 polyunsaturated fatty acids supplementation for 5 d postoperatively. RESULTS There were 268 patients randomly assigned in the analysis, with 134 in the control group (a mix of long-chain and medium-chain fats at 1.0 g/kg/d) and 134 in the treatment group (long-chain, medium-chain, and n-3 polyunsaturated fats at 1.2 g/kg/d). Twenty-six did not complete the allocated treatment, and 8 patients were lost to follow-up. The intention-to-treat analysis and the per-protocol analysis showed that there were a significant reduction in overall complication rates (22.4% compared with 49.3%; P < 0.001 and 21.8% compared with 38.2%; P = 0.006) and postoperative stay (8.8 ± 4.5 d compared with 11.2 ± 6.8 d; P = 0.001 and 8.7 ± 4.0 d compared with 11.5 ± 7.3 d; P < 0.001) in patients with parenteral n-3 polyunsaturated fatty acids supplementation compared with patients in the control group. In the secondary outcomes, the mean ± standard deviation of interleukin (IL)-6 (17.11 ± 2.14 pg/mL compared with 30.50 ± 5.14 pg/mL; P = 0.014), IL-1β (2.01 ± 0.05 pg/mL compared with 2.24 ± 0.09 pg/mL; P = 0.019), tumor necrosis factor-α (2.09 ± 0.06 pg/mL compared with 2.29 ± 0.06 pg/mL; P = 0.029), and C-reactive protein concentrations (51.3 ± 4.2 mg/L compared with 64.4 ± 5.3 mg/L; P = 0.050) on postoperative day 5 in the treatment group were much lower than those in the control group. CONCLUSIONS Parenteral n-3 polyunsaturated fatty acids supplementation promotes postoperative recovery in patients with Crohn's disease following bowel resection, with fewer complications and reduced inflammatory cytokines. This trial was registered at clinicaltrials.gov as NCT03901937 at https://classic. CLINICALTRIALS gov/ct2/show/NCT03901937?term=NCT03901937&cond=Crohn+Disease&draw=2&rank=1.
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Affiliation(s)
- Xiaolong Ge
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huaying Liu
- Department of Medicine, Guangxi Medical College, Nanning, China
| | - Yan Wu
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wei Liu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Weilin Qi
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Linna Ye
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qian Cao
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haifeng Lian
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China.
| | - Rongpan Bai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Wei Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Callado GY, de Almeida Leite RM, Araujo SEA, Barchi LC, Seddiq W, Correa IP, Junior UR, Ricciardi R. Bowel preparation for elective colectomy in Crohn's disease: results from a global cohort study using the NSQIP database. Colorectal Dis 2024; 26:709-715. [PMID: 38385895 DOI: 10.1111/codi.16918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
AIM The role of bowel preparation before colectomy in Crohn's disease patients remains controversial. This retrospective analysis of a prospective cohort study aimed to investigate the clinical outcomes associated with mechanical and antibiotic colon preparation in patients diagnosed with Crohn's disease undergoing elective colectomy. METHOD Data were collected from the American College of Surgeons National Surgical Quality Improvement Program participant user files from 2016 to 2021. A total of 6244 patients with Crohn's disease who underwent elective colectomy were included. The patients were categorized into two groups: those who received combined colon preparation (mechanical and antibiotic) and those who did not receive any form of bowel preparation. The primary outcomes assessed were the rate of anastomotic leak and the occurrence of deep organ infection. Secondary outcomes included all-cause short-term mortality, clinical-related morbidity, ostomy creation, unplanned reoperation, operative time, hospital length of stay and ileus. RESULTS Combined colon preparation was associated with significantly reduced risks of anastomotic leak (relative risk 0.73, 95% CI 0.56-0.95, P = 0.021) and deep organ infection (relative risk 0.68, 95% CI 0.56-0.83, P < 0.001). Additionally, patients who underwent colon preparation had lower rates of ostomy creation, shorter hospital stays and a decreased incidence of ileus. However, there was no significant difference in all-cause short-term mortality or the need for unplanned reoperation between the two groups. CONCLUSION This study shows that mechanical and antibiotic colon preparation may have clinical benefits for patients with Crohn's disease undergoing elective colectomy.
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Affiliation(s)
- Gustavo Yano Callado
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo City, São Paulo, Brazil
| | - Rodrigo Moisés de Almeida Leite
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo City, São Paulo, Brazil
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sergio Eduardo Alonso Araujo
- Staff Colorectal Surgeon and Medical Director, Oncology Division, Hospital Israelita Albert Einstein, São Paulo City, São Paulo, Brazil
| | | | - Waleed Seddiq
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ulysses Ribeiro Junior
- Gastrointestinal Surgery, Faculdade de Medicina da Universidade de São Paulo, São Paulo City, São Paulo, Brazil
| | - Rocco Ricciardi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lee Y, Anvari S, Padoan A, McKechnie T, Park L, Doumouras AG, Eskicioglu C, Hong D. Financial toxicity among patients undergoing resectional surgery for inflammatory bowel disease in the United States. Colorectal Dis 2024; 26:692-701. [PMID: 38353528 DOI: 10.1111/codi.16903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/11/2023] [Accepted: 01/21/2024] [Indexed: 05/02/2024]
Abstract
AIM Financial toxicity describes the financial burden and distress that patients experience due to medical treatment. Financial toxicity has yet to be characterized among patients with inflammatory bowel disease (IBD) undergoing surgical management of their disease. This study investigated the risk of financial toxicity associated with undergoing surgery for IBD. METHODS This study used a retrospective analysis using the National Inpatient Sample from 2015 to 2019. Adult patients who underwent IBD-related surgery were identified using the International Classification of Diseases (10th Revision) diagnostic and procedure codes and stratified into privately insured and uninsured groups. The primary outcome was risk of financial toxicity, defined as hospital admission charges that constituted 40% or more of patient's post-subsistence income. Secondary outcomes included total hospital admission cost and predictors of financial toxicity. RESULTS The analytical cohort consisted of 6412 privately insured and 3694 uninsured patients. Overall median hospital charges were $21 628 (interquartile range $14 758-$35 386). Risk of financial toxicity was 86.5% among uninsured patients and 0% among insured patients. Predictors of financial toxicity included emergency admission, being in the lowest residential income quartile and having ulcerative colitis (compared to Crohn's disease). Additional predictors were being of Black race or male sex. CONCLUSION Financial toxicity is a serious consequence of IBD-related surgery among uninsured patients. Given the pervasive nature of this consequence, future steps to support uninsured patients receiving surgery, in particular emergency surgery, related to their IBD are needed to protect this group from financial risk.
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Affiliation(s)
- Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Sama Anvari
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adelia Padoan
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lily Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Kodia K, Huerta CT, Alnajar A, Collins S, Ribieras A, Horner LP, Paluvoi N. Outcomes Among Malnourished Patients With Crohn's Disease Undergoing Elective Ileocecectomy: A Nationwide Analysis. Am Surg 2024; 90:739-747. [PMID: 37902098 DOI: 10.1177/00031348231209866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Crohn's patients' nutritional status can be suboptimal given disease pathophysiology; the effect of a malnourished state prior to elective surgery on post-operative outcomes remains to be more clearly elucidated. This study aims to characterize the effect of malnutrition on post-operative outcomes and readmission patterns for Crohn's patients undergoing elective ileocecectomy using a nationally representative cohort. METHODS The colectomy-targeted National Surgical Quality Improvement Program Database (2016-2020) was used to identify patients with Crohn's disease without systemic complications who underwent elective ileocecectomy; emergency surgeries were excluded. Malnourished status was defined as pre-operative hypoalbuminemia <3.5 g/dL, weight loss >10% in 6 months, or body mass index <18.5 kg/m2 prior to surgery. RESULTS Of 1464 patients (56% female) who met inclusion criteria, 1137 (78%) were well-nourished and 327 (22%) were malnourished. Post-operatively, malnourished patients had more organ space surgical site infections (SSI) (9% vs 4% nourished groups, P < .001) and more bleeding events requiring transfusion (9% vs 3% nourished, P < .001). 30-day unplanned readmission was higher in the malnourished group (14% vs 9% nourished, P = .032). Index admission length of stay was significantly longer in the malnourished group (4 days [3-7 days] vs the nourished cohort: 4 days [3-5 days], P < .001). DISCUSSION Poor nutritional status is associated with organ space infections and bleeding as well as longer hospitalizations and more readmissions in Crohn's patients undergoing elective ileocecectomy. A detailed nutritional risk profile and nutritional optimization is important prior to elective surgery.
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Affiliation(s)
- Karishma Kodia
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Carlos T Huerta
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Ahmed Alnajar
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Shane Collins
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Antoine Ribieras
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Lance P Horner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Nivedh Paluvoi
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
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41
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Sanger CB. Targeted mesenteric approaches to ileocolic Crohn's disease: A promising operative approach. Am J Surg 2024; 230:14-15. [PMID: 38104022 DOI: 10.1016/j.amjsurg.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Cristina B Sanger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; William S. Middleton Memorial Veteran's Hospital, Madison, WI, USA.
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Holubar SD, Lipman J, Steele SR, Uchino T, Lincango EP, Liska D, Ban K, Rosen D, Sommovilla J, Gorgun E, Kessler H, Valente M, Hull T. Safety & feasibility of targeted mesenteric approaches with Kono-S anastomosis and extended mesenteric excision in ileocolic resection and anastomosis in Crohn's disease. Am J Surg 2024; 230:16-20. [PMID: 37914660 DOI: 10.1016/j.amjsurg.2023.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The mesentery has recently been implicated in the pathophysiology of Crohn's disease (CD), and several techniques have been developed to target the mesentery to reduce its influence on recurrence. We aimed to describe short-term safety and feasibility after these approaches. METHODS This is a comparative, retrospective, single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection from 2015 to 2022 with Kono-S anastomosis (KSA), extended mesenteric excision (EME) only, or both: mesenteric excision and exclusion (MEE). RESULTS 186 patients underwent KSA (n = 74), EME (n = 66), or MEE (n = 46). The groups had comparable baseline characteristics. The MEE group operative time was longer (median: 187 vs. KSA 170, EME 152 min, p < 0.01). Postoperatively, the groups had similar lengths of stay (median 4 days), readmissions (9.1 %), major postoperative complications (6.5 %), and anastomotic leaks (1.1 %). CONCLUSION Targeting the mesentery with novel surgical approaches for ileocolic Crohn's disease was safe and feasible for short-term follow-up.
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Affiliation(s)
- Stefan D Holubar
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Jeremy Lipman
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tairin Uchino
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eddy P Lincango
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kristen Ban
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Rosen
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Sommovilla
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Valente
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy Hull
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, OH, USA
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Ciccocioppo R, Gaspar L. Haematopoietic stem-cell transplantation for patients with Crohn's disease: primum non nocere. Lancet Gastroenterol Hepatol 2024; 9:278-279. [PMID: 38340760 DOI: 10.1016/s2468-1253(24)00004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, Policlinico Giovanni Battista Rossi, University of Verona, Verona 37134, Italy.
| | - Ludovit Gaspar
- Faculty of Health Sciences, University of Ss Cyril and Methodius in Trnava, Trnava, Slovakia
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44
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Gosse J, Simonelli V, Dessily M. Adenocarcinoma arising from a chronic perianal fistula in a Crohn's disease patient: case report and review of the literature. Acta Chir Belg 2024; 124:143-146. [PMID: 37668063 DOI: 10.1080/00015458.2023.2205722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/18/2023] [Indexed: 09/06/2023]
Abstract
Crohn's disease patients frequently develop perianal fistulas during their life. They are also at higher risk to develop cancers. Rarely, those cancers appear within a prior chronic fistula. The main types are adenocarcinoma mostly mucinous and squamous cell carcinoma. They are generally discovered at an advanced stage with a poor prognosis because symptoms are generally the same as those of the fistula itself. Regular follow-up of chronic fistulas is then important for an early diagnosis as well as histological analysis of the fistula during surgery. There is no consensus on the ideal treatment but abdominoperineal resection is the corner stone with or without neo or adjuvant chemo-radiotherapy. This paper presents a rare case of mucinous adenocarcinoma in a chronic perianal fistula in a Crohn's disease female and provides a review of the literature.
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Affiliation(s)
| | | | - Michael Dessily
- Department of Digestive Surgery, CHU Tivoli, La Louvière, Belgium
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Abstract
Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.
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Affiliation(s)
- Mahmoud Shehada
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Lisa E McMahon
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
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46
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Liu W, Zhou W, Zhang Y, Ge X, Qi W, Lin T, Cao Q, Cao L. Strictureplasty may lead to increased preference in the surgical management of Crohn's disease: a case-matched study. Tech Coloproctol 2024; 28:40. [PMID: 38507096 DOI: 10.1007/s10151-024-02915-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/05/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Resection and strictureplasty are the two surgical modalities used in the management of Crohn's disease (CD). The objective of this study was to compare morbidity and clinical recurrence between patients who underwent strictureplasty and patients who underwent resection. METHODS Patients with CD who underwent strictureplasty between January 2012 and December 2022 were enrolled. The patients were well matched with patients who underwent resection without strictureplasty. Patient- and disease-specific characteristics, postoperative morbidity, and clinical recurrence were also analyzed. RESULTS A total of 118 patients who underwent a total of 192 strictureplasties were well matched to 118 patients who underwent resection. The strictureplasty group exhibited significantly less blood loss (30 ml versus 50 ml, p < 0.001) and stoma creation (2.5% versus 16.9%, p < 0.001). No significant difference was found regarding postoperative complications or length of postoperative stay. At the end of the follow-up, the overall rate of clinical recurrence was 39.4%, and no difference was observed between the two groups. Postoperative prophylactic use of biologics (odds ratio = 0.2, p < 0.001) was the only protective factor against recurrence. CONCLUSION Strictureplasty does not increase the risk of complications or recurrence compared with resection. It represents a viable alternative to resection in selected patients, and as such, it should have a broader scope of indications and greater acceptance among surgeons.
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Affiliation(s)
- W Liu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - W Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China.
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China.
| | - Y Zhang
- School of Medicine, Shantou University, Shantou, 515063, Guangdong Province, China
| | - X Ge
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - W Qi
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - T Lin
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Q Cao
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - L Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China.
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Yang L, Zhang Y, Yao B, Wu Q, Peng L, Yuan L. Timing of first abdominal operation in Crohn's disease based on a diagnostic model. Sci Rep 2024; 14:6099. [PMID: 38480778 PMCID: PMC10937665 DOI: 10.1038/s41598-024-55221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Lichao Yang
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Yawei Zhang
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Baojia Yao
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Qiang Wu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Liangxin Peng
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Lianwen Yuan
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.
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Kappenberger AS, Schardey J, Wirth U, Kühn F, Werner J, Zimmermann P. Clinical outcomes and perioperative morbidity and mortality following segmental resections of the colon for Crohn's colitis. Int J Colorectal Dis 2024; 39:36. [PMID: 38456914 PMCID: PMC10923963 DOI: 10.1007/s00384-024-04596-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory bowel disease of a multifactorial pathogenesis. Recently numerous genetic variants linked to an aggressive phenotype were identified, leading to a progress in therapeutic options, resulting in a decreased necessity for surgery. Nevertheless, surgery is often inevitable. The aim of the study was to evaluate possible risk factors for postoperative complications and disease recurrence specifically after colonic resections for CD. PATIENTS AND METHODS A total of 241 patients who underwent colonic and ileocaecal resections for CD at our instiution between 2008 and 2018 were included. All data was extracted from clinical charts. RESULTS Major complications occurred in 23.8% of all patients. Patients after colonic resections showed a significantly higher rate of major postoperative complications compared to patients after ICR (p = < 0.0001). The most common complications after colonic resections were postoperative bleeding (22.2%), the need for revision surgery (27.4%) and ICU (17.2%) or hospital readmission (15%). As risk factors for the latter, we identified time interval between admission and surgery (p = 0.015) and the duration of the surgery (p = 0.001). Isolated distal resections had a higher risk for revision surgery and a secondary stoma (p = 0.019). Within the total study population, previous bowel resections (p = 0.037) were identified as independent risk factors for major perioperative complications. CONCLUSION The results indicate that both a complex surgical site and a complex surgical procedure lead to a higher perioperative morbidity in colonic resections for Crohn's colitis.
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Affiliation(s)
- Alina-Sophie Kappenberger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany.
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Dotlacil V, Lerchova T, Lengalova M, Kucerova B, Schwarz J, Hradsky O, Rygl M, Skaba R. Kono-S anastomosis in Crohn's disease: initial experience in pediatric patients. Pediatr Surg Int 2024; 40:67. [PMID: 38438752 DOI: 10.1007/s00383-024-05648-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications. METHODS We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification. RESULTS Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months. CONCLUSION According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.
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Affiliation(s)
- Vojtech Dotlacil
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic.
| | - Tereza Lerchova
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | | | - Barbora Kucerova
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
| | - Jan Schwarz
- Department of Paediatrics, Faculty of Medicine in Pilsen, Faculty Hospital, Charles University in Prague, Pilsen, Czech Republic
| | - Ondrej Hradsky
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Michal Rygl
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
| | - Richard Skaba
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
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50
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Mourad FH, Maalouf RG, Aoun R, Gustavo Kotze P, Hashash JG. Are the New Biologics Effective in the Management of Postoperative Crohn's Disease? Inflamm Bowel Dis 2024; 30:459-469. [PMID: 36879404 DOI: 10.1093/ibd/izad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND Despite the growing therapeutic armamentarium, at least half of the patients with Crohn's disease will require surgery during their lifetime. Current evidence for the prevention and treatment of postoperative Crohn's disease supports the use of anti-tumor necrosis factor agents with limited data about the use of the newer biologics, vedolizumab and ustekinumab. METHODS We performed a systematic review of available data to determine the efficacy of the newer biologics in the management of postoperative Crohn's disease. We included noncomparative and comparative studies. The main outcomes of interest were clinical and endoscopic postoperative recurrence rates. RESULTS The search strategy identified 1231 citations, with 32 eligible for review. Several studies showed that the postoperative Crohn's disease recurrence rates with the use of the newer biologics were comparable to previously published results with the use of anti-tumor necrosis factor agents, while other studies failed to show their efficacy. It is important to note that the studies were heterogeneous and included a relatively small sample size, making it difficult to draw a definite conclusion about the efficacy of the newer biologics in the management of postoperative Crohn's disease. CONCLUSION The newer biologics do play a role in the management of postoperative Crohn's disease. After our review, we proposed an updated algorithm on the role of newer biologics in the approach to patients with postoperative Crohn's disease. Yet, until we have better-designed studies, their definite positioning remains to be determined.
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Affiliation(s)
- Fadi H Mourad
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
| | - Rami G Maalouf
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
| | - Roni Aoun
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
| | | | - Jana G Hashash
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
- Division of Gastroenterology and Hepatology, Mayo Clinic, Florida, USA
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