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Erozkan K, Costedio MM, DeRoss AL. Operative Management of Inflammatory Bowel Disease in Children. Surg Clin North Am 2025; 105:329-356. [PMID: 40015820 DOI: 10.1016/j.suc.2024.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
Inflammatory bowel disease (IBD) encompasses a spectrum of chronic, idiopathic, and progressive inflammatory conditions of the gastrointestinal tract, with Crohn's disease and ulcerative colitis comprising the majority. Both conditions have distinct pathophysiological and clinical characteristics but share common immune-mediated mechanisms. Specific facets of IBD and its management in the pediatric population differ from adult parallels. This article explores the surgical treatments of pediatric IBD, focusing on indications for surgery and perioperative considerations.
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Affiliation(s)
- Kamil Erozkan
- Colorectal Division, Department of General Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Meagan M Costedio
- Division of Colorectal Surgery, Department of General Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Anthony L DeRoss
- Cleveland Clinic Children's, Section of Pediatric Surgery, 9500 Euclid Avenue, R3, Cleveland, OH 44195, USA.
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Joseph A, Bachour SP, Shah R, El Halabi J, Syed H, Lyu R, Cohen B, Rieder F, Achkar JP, Philpott J, Qazi T, Hull T, Lipman J, Wexner S, Holubar SD, Regueiro M, Click B. Postoperative Crohn's Disease Recurrence Risk and Optimal Biologic Timing After Temporary Diversion Following Ileocolic Resection. Inflamm Bowel Dis 2025; 31:686-695. [PMID: 38842693 DOI: 10.1093/ibd/izae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Indexed: 06/07/2024]
Abstract
BACKGROUND Postoperative recurrence of Crohn's disease (CD) is common. While most patients undergo resection with undiverted anastomosis (UA), some individuals also have creation of an intended temporary diversion (ITD) with an ileostomy followed by ostomy takedown (OT) due to increased risk of anastomotic complications. We assessed the association of diversion with subsequent CD recurrence risk and the influence of biologic prophylaxis timing to prevent recurrence in this population. METHODS This was a retrospective cohort study of CD patients who underwent ileocolic resection between 2009 and 2020 at a large quaternary health system. Patients were grouped by continuity status after index resection (primary anastomosis or ITD). The outcomes of the study were radiographic, endoscopic, and surgical recurrence as well as composite recurrence postoperatively (after OT in the ITD group). Propensity score-weighted matching was performed based on risk factors for diversion and recurrence. Multivariable regression and a Cox proportional hazards model adjusting for recurrence risk factors were used to assess association with outcomes. Subgroup analysis in the ITD group was performed to assess the impact of biologic timing relative to OT (no biologic, biologic before OT, after OT) on composite recurrence. RESULTS A total of 793 CD patients were included (mean age 38 years, body mass index 23.7 kg/m2, 52% female, 23% active smoker, 50% penetrating disease). Primary anastomosis was performed in 67.5% (n = 535) and ITD in 32.5% (n = 258; 79% loop, 21% end) of patients. Diverted patients were more likely to have been males and to have had penetrating and perianal disease, prior biologic use, lower body mass index, and lower preoperative hemoglobin and albumin (all P < .01). After a median follow-up of 44 months, postoperative recurrence was identified in 83.3% patients (radiographic 40.4%, endoscopic 39.5%, surgical 13.3%). After propensity score matching and adjusting for recurrence risk factors, no significant differences were seen between continuity groups in radiographic (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 0.91-1.91) or endoscopic recurrence (aHR, 1.196; 95% CI, 0.84-1.73), but an increased risk of surgical recurrence was noted in the ITD group (aHR, 1.61; 95% CI, 1.02-2.54). Most (56.1%) ITD patients started biologic prophylaxis after OT, 11.4% before OT, and 32.4% had no postoperative biologic prophylaxis. Biologic prophylaxis in ITD was associated with younger age (P < .001), perianal disease (P = .04), and prior biologic use (P < .001) but not in recurrence (P = .12). Despite higher rates of objective disease activity identified before OT, biologic exposure before OT was not associated with a significant reduction in composite post-OT recurrence compared with starting a biologic after OT (52% vs 70.7%; P = 0.09). CONCLUSIONS Diversion of an ileocolic resection is not consistently associated with a risk of postoperative recurrence and should be performed when clinically appropriate. Patients requiring diversion at time of ileocolic resection are at high risk for recurrence, and biologic initiation prior to stoma reversal may be considered.
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Affiliation(s)
- Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Salam P Bachour
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ravi Shah
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Jessica El Halabi
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Cohen
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Florian Rieder
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Jean-Paul Achkar
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Jessica Philpott
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Taha Qazi
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel Regueiro
- Division of Gastroenterology and Hepatology, Cleveland Clinic, OH, USA
| | - Benjamin Click
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
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Wang FT, Lin Y, Gao RY, Wu XC, Wu TQ, Jiao YR, Li JY, Yin L, Chen CQ. Machine learning for temporary stoma after intestinal resection in surgical decision-making of Crohn's disease. BMC Gastroenterol 2025; 25:117. [PMID: 40000985 PMCID: PMC11863836 DOI: 10.1186/s12876-025-03668-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/05/2025] [Indexed: 02/27/2025] Open
Abstract
BACKGROUND Crohn's disease (CD) often necessitates surgical intervention, with temporary stoma creation after intestinal resection (IR) being a crucial decision. This study aimed to construct novel models based on machine learning (ML) to predict temporary stoma formation after IR for CD. METHODS Patient data who underwent IR for CD at our center between July 2017 and March 2023 were collected for inclusion in this retrospective study. Eligible CD patients were randomly divided into training and validation cohorts. Feature selection was executed using the least absolute shrinkage and selection operator. We employed three ML algorithms including traditional logistic regression, novel random forest and XG-Boost to create prediction models. The area under the curve (AUC), accuracy, sensitivity, specificity, precision, recall, and F1 score were used to evaluate these models. SHapley Additive exPlanation (SHAP) approach was used to assess feature importance. RESULTS A total of 252 patients with CD were included in the study, 150 of whom underwent temporary stoma creation after IR. Eight independent predictors emerged as the most valuable features. An AUC between 0.886 and 0.998 was noted among the three ML algorithms. The random forest (RF) algorithms demonstrated the most optimal performance (0.998 in the training cohort and 0.780 in the validation cohort). By employing the SHAP method, we identified the variables that contributed to the model and their correlation with temporary stoma formation after IR for CD. CONCLUSIONS The proposed RF model showed a good predictive ability for identifying patients at high risk for temporary stoma formation after IR for CD, which can assist in surgical decision-making in CD management, provide personalized guidance for temporary stoma formation, and improve patient outcomes.
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Affiliation(s)
- Fang-Tao Wang
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, 200090, China
| | - Ren-Yuan Gao
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xiao-Cai Wu
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Tian-Qi Wu
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yi-Ran Jiao
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Ji-Yuan Li
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Lu Yin
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Chun-Qiu Chen
- Department of Abdominal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Holubar SD, Keller J, Cooper L. When Patients With IBD Require an Ostomy: Evidence-Based Answers to 10 Common Clinical Questions in IBD Surgery. Am J Gastroenterol 2025; 120:268-271. [PMID: 39887123 DOI: 10.14309/ajg.0000000000002914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 06/17/2024] [Indexed: 02/01/2025]
Affiliation(s)
- Stefan D Holubar
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Liu WH, Xiong M, Chen GQ, Long Z, Xu C, Zhu L, Wu JS. Laparoscopic intracorporeal anastomosis vs open anastomosis for ileostomy reversal in Crohn's disease: A single center retrospective study. World J Gastrointest Surg 2025; 17:98269. [PMID: 39872758 PMCID: PMC11757179 DOI: 10.4240/wjgs.v17.i1.98269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 10/24/2024] [Accepted: 11/12/2024] [Indexed: 12/27/2024] Open
Abstract
BACKGROUND There is an increased maturation of laparoscopic intracorporeal anastomosis techniques. However, research on its application for small bowel stoma reversal in patients with Crohn's disease (CD) is limited. Therefore, in this study, we compared the perioperative outcomes between laparoscopic intracorporeal ileostomy reversal (LIIR) and open ileostomy reversal (OIR). AIM To compare the safety, feasibility, bowel function recovery, and short- and long-term LIIR and OIR outcomes in patients with CD. METHODS This study included patients who underwent ileal reversal for CD between January 2021 and January 2023 at our institution. The baseline data, postoperative recovery, and complication indicators were retrospectively analyzed. Logistic regression analysis was conducted to explore factors that significantly influenced the development of enteral nutrition intolerance-related symptoms. RESULTS Notably, 15 of the 45 patients in this study underwent OIR, and the remaining 30 received LIIR. Notably, no statistically significant differences were found between the two groups regarding clinical baseline characteristics, operation time, intraoperative hemorrhage, anastomotic site, enterolysis range, first postoperative flatus, postoperative complications, reoperation rate, or incidence of postoperative enteral nutrition intolerance. Compared with the OIR group, the LIIR group had a shorter postoperative hospital stay (P = 0.045), lower incidence of enteral nutrition intolerance symptoms (P = 0.019), and earlier postoperative total enteral nutrition initiation (P = 0.033); however, it incurred higher total hospital costs (P = 0.038). Furthermore, multivariate logistic regression analysis revealed that the duration of surgery and anastomotic technique were independent risk factors for postoperative symptoms of enteral nutrition intolerance (P < 0.05). CONCLUSION Laparoscopic intracorporeal anastomosis for ileostomy reversal is safe and feasible. Patients who underwent this technique demonstrated improved tolerance to postoperative enteral nutrition and quicker resumption of total enteral nutrition.
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Affiliation(s)
- Wei-Hang Liu
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
| | - Mao Xiong
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
| | - Guo-Qing Chen
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
| | - Zhui Long
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
| | - Chao Xu
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
| | - Li Zhu
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
| | - Jing-Song Wu
- Department of General Surgery, Chongqing General Hospital, Chongqing 401120, China
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Yang Y, Zhu F, Li S, Yu Z, Xu Y, Xu Y, Gong J. Impact of biologics on stoma creation and reversal in Crohn's disease: a retrospective analysis from 2007 to 2021. Tech Coloproctol 2025; 29:43. [PMID: 39775956 DOI: 10.1007/s10151-024-03085-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 11/26/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND Trends of stoma creation at index surgery for Crohn's disease (CD) in the biologics era has not been thoroughly investigated. This study aimed to assess the impact of increasing biologics use on stoma rates at index surgery of CD, as well as identifying risk factors for the creation and nonreversal of CD-related stoma. METHODS In this single-center retrospective analysis, consecutive CD patients who underwent index bowel surgery from 2007 to 2021 were reviewed. The rates of diverting stoma formation and reversal were compared across different time periods, delineated by January 2019, as biologics [anti-tumor necrosis factor (anti-TNF)] were included in national health insurance coverage in China. Logistic regression models and Cox proportional hazards models were utilized to assess factors influencing stoma creation and its reversal, respectively. RESULTS Among 1022 CD patients, 27.9% received a diverting stoma during index surgery. Despite increasing preoperative use of biologics, the incidence of stoma creation remained statistically unchanged pre- and post-2019 (29.5% versus 25.2%; P = 0.14). Factors contributing to stoma creation included colonic and perianal involvement, penetrating CD, poorer preoperative conditions, and preoperative steroid usage, but not preoperative biologics. Among diverted patients, 68.8% underwent successful bowel restoration, with the reversal rate significantly increasing from 63.0% before 2019 to 80.2% after 2019 (P < 0.01). Patients with postoperative use of immunomodulators and biologics were more likely to have the stoma closed, with a reversal rate of 90.0% for those receiving biologics compared with 64.0% for those not. CONCLUSIONS Increasing prevalence of biologics did not alter the stoma rates in CD patients. Additionally, postoperative biologics were independently associated with a higher probability of stoma reversal.
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Affiliation(s)
- Y Yang
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China
| | - F Zhu
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China
| | - S Li
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China
| | - Z Yu
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China
| | - Y Xu
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China
| | - Y Xu
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China
| | - J Gong
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, No. 305 East Zhongshan Rd, Nanjing, 210002, People's Republic of China.
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Sassun R, Larson DW, Bews KA, Kelley SR, Mathis KL, Habermann EB, McKenna NP. When Is Diversion Indicated After Right-Sided Colon Resections? J Surg Res 2024; 303:361-370. [PMID: 39413697 DOI: 10.1016/j.jss.2024.09.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 07/29/2024] [Accepted: 09/13/2024] [Indexed: 10/18/2024]
Abstract
INTRODUCTION Ileocolonic anastomoses have a low anastomotic leak (AL) risk, resulting in infrequent diverting loop ileostomy use. Identifying patients who warrant diverting loop ileostomy with right-sided resection is challenging due to this low incidence of AL. Therefore, a multicenter database was used to develop an AL risk score to help inform when diversion should be strongly considered after right-sided resections. MATERIALS AND METHODS Patients undergoing elective right-sided resections within the 2012-2020 American College of Surgeons National Surgical Quality Improvement Program-targeted colectomy participant user files were identified. Multivariable logistic regression identified AL risk factors that were then converted to point values to develop an AL risk score. The developed AL risk score was then assessed for visual correspondence and analyzed for internal validity. RESULTS 42,176 patients underwent right-sided resection without diversion, and the incidence of AL was 2.4%. The risk calculator exhibited excellent calibration and fair discrimination. Strong visual correspondence was observed for predicted and actual AL rates within the 95% confidence interval for nine of ten risk score deciles. CONCLUSIONS An internally validated AL risk score for elective ileocolic resections was developed. Most patients had scores that categorized them at a low risk of AL. The diversion after elective right-sided resections should be reserved for extreme cases.
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Affiliation(s)
- Richard Sassun
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- 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
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- 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
| | - Nicholas P McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.
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Kane WJ, Kuron M, Gooding JL, Hoang SC, Friel CM, Jin R, Turrentine FE, Hedrick TL. Have outcomes following colectomy in the United States improved over time? Am J Surg 2024; 237:115808. [PMID: 38944622 DOI: 10.1016/j.amjsurg.2024.115808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/12/2024] [Accepted: 06/23/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND There has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale. METHODS American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses. RESULTS 261,301 patients, 135,876 (52 %) female, with a median age of 62 (IQR 53-72) were included. Across all years, MIS partial colectomy was the most common procedure (37 %), followed by MIS low anterior resection (27 %), open partial colectomy (24 %), and open low anterior resection (12 %). MIS increased from 59 % in 2012-2014 to 66 % in 2018-2020 (p < 0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4-7) in 2012-2014 to 4 days (IQR 3-6) in 2018-2020 (p < 0.001). Superficial surgical site infections decreased from 5.5 % in 2012-2014 to 2.9 % in 2018-2020 (p < 0.001). Deep surgical site infections similarly decreased from 1.1 % to 0.4 % between these periods (p < 0.001). Pulmonary embolism also decreased from 0.6 % to 0.5 % between periods (p = 0.02). 30-day mortality was unchanged at 1.7 % between 2012-2014 and 2018-2020 (p = 0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 % decrease in postoperative length of stay (p < 0.001). CONCLUSIONS Between 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally.
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Affiliation(s)
- William J Kane
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | | | - Jordan L Gooding
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Sook C Hoang
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Charles M Friel
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Ruyun Jin
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | | | - Traci L Hedrick
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Sun Z, Cao L, Chen Y, Song T, Guo Z, Zhu W, Li Y. The impact of delayed closure of ileostomy on postoperative complications in patients with Crohn's disease: a case-matched study. Updates Surg 2024; 76:1339-1345. [PMID: 38238543 DOI: 10.1007/s13304-023-01722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/29/2023] [Indexed: 08/24/2024]
Abstract
Ileostomy creation is a common procedure to mitigate postoperative complications in Crohn's disease (CD) patients. However, the optimal timing for ileostomy closure remains controversial. This study aims to investigate whether delayed ileostomy closure (> 6 months post formation) affects postoperative complications compared to early closure (≤ 6 months post formation). Consecutive CD patients who underwent ileostomy reversal at a tertiary care center between January 1, 2013, and December 1, 2021, were included. The study compared patients who underwent early ileostomy closure to matched patients undergoing delayed ileostomy closure. The 90-day postoperative complications were compared between the two groups. The study included 352 eligible patients for ileostomy reversion. Our data showed that patients undergoing delayed ileostomy closure had higher incidence of ileostomy-related infectious complications (12% vs. 4%, p = 0.008), a longer postoperative hospital stay (10 days with an IQR of 7-12 days versus 8 days with an IQR of 7-11 days, p = 0.024), and increased rate of ileus (28% versus 15%, p = 0.003). There were 256 patients included after 1:1 propensity score matching. The results revealed no significant differences in postoperative hospital stay, infectious or non-infectious complications except for a statistically significant increase in the incidence of ileus in the delayed closure group (p = 0.01). Patients undergoing delayed ileostomy closure has similar outcomes to early closure in terms of postoperative complications, except for a higher incidence of ileus.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Lei Cao
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Yusheng Chen
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Tianrun Song
- Department of General Surgery, Jinling Clinical School of Medicine (Eastern Theater General Hospital), Nanjing Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Zhen Guo
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Weiming Zhu
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China.
| | - Yi Li
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China.
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Wiesler B, Hirt L, Guenin MO, Steinemann DC, von Flüe M, Müller-Stich B, Glass T, von Strauss Und Torney M. Stoma associated complications after diverting loop ileostomy, end ileostomy or split stoma formation after right sided colectomy-a retrospective cohort study (StoComSplit Analysis). Tech Coloproctol 2024; 28:68. [PMID: 38866942 PMCID: PMC11169016 DOI: 10.1007/s10151-024-02945-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 05/15/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND For high-risk patients receiving right-sided colectomy, stoma formation is a safety strategy. Options are anastomosis with loop ileostomy, end ileostomy, or split stoma. The aim is to compare the outcome of these three options. METHODS This retrospective cohort study included all patients who underwent right sided colectomy and stoma formation between January 2008 and December 2021 at two tertial referral centers in Switzerland. The primary outcome was the stoma associated complication rate within one year. RESULTS A total of 116 patients were included. A total of 20 patients (17%) underwent primary anastomosis with loop ileostomy (PA group), 29 (25%) received an end ileostomy (ES group) and 67 (58%) received a split stoma (SS group). Stoma associated complication rate was 43% (n = 21) in PA and in ES group and 50% (n = 34) in SS group (n.s.). A total of 30% (n = 6) of patients in PA group needed reoperations, whereas 59% (n = 17) in ES and 58% (n = 39) in SS group had reoperations (P = 0.07). Wound infections occurred in 15% (n = 3) in PA, in 10% (n = 3) in ES, and in 30% (n = 20) in SS group (P = 0.08). A total of 13 patients (65%) in PA, 7 (24%) in ES, and 29 (43%) in SS group achieved stoma closure (P = 0.02). A total of 5 patients (38%) in PA group, 2 (15%) in ES, and 22 patients (67%) in SS group had a stoma-associated rehospitalization (P < 0.01). CONCLUSION Primary anastomosis and loop ileostomy may be an option for selected patients. Patients with end ileostomies have fewer stoma-related readmissions than those with a split stoma, but they have a lower rate of stoma closure. CLINICAL TRIAL REGISTRATION Trial not registered.
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Affiliation(s)
- B Wiesler
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Switzerland, Basel, Switzerland
| | - L Hirt
- University of Basel, Basel, Switzerland
| | - M-O Guenin
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Switzerland, Basel, Switzerland
| | - D C Steinemann
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Switzerland, Basel, Switzerland
| | - M von Flüe
- ChirurgieZentrum Zentralschweiz, Lucerne, Switzerland
| | - B Müller-Stich
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Switzerland, Basel, Switzerland
| | - T Glass
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
| | - M von Strauss Und Torney
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Switzerland, Basel, Switzerland.
- St. Clara Research Ltd, St. Clara Hospital, Basel, Switzerland.
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11
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Sun Z, Cao L, Guo Z, Zhou Y, Zhu W, Li Y. A nomogram to predict stoma creation in elective surgical resection for penetrating Crohn's disease. ANZ J Surg 2024; 94:923-930. [PMID: 38290990 DOI: 10.1111/ans.18872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/14/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUNDS The decision to perform a stoma during surgical resection of penetrating Crohn's disease (CD) is a critical consideration. The objective of this study was to identify factors that influence stoma creation and develop a predictive nomogram model to assist surgeons in making optimal surgical decisions. METHODS A retrospective study was conducted at a tertiary center from December 1, 2012, to December 1, 2021, involving consecutive patients with penetrating CD who underwent elective surgical resection. The LASSO regression method was used to select preoperative predictors, and a nomogram was constructed using multivariate logistic regression. The performance of the nomogram was validated in an internal cohort by assessing its discrimination, calibration, and clinical usefulness. RESULTS The study included 405 cases in the training group and 135 cases in the validation group. Nine risk factors for stoma formation were identified, including disease location, fistula resulted from previous anastomosis, absence of preoperative exclusive enteral nutrition support, albumin levels below 35 g/L, C-reactive protein levels above 10 mg/L, hemoglobin levels below 100 g/L, perianal disease, internal fistula, and surgical approach. These risk factors were selected using the LASSO regression method, and a nomogram was developed based on them. The area under the curve and the coefficient of determination (R2) of the nomogram were 0.821 and 0.394, respectively. And the nomogram demonstrated good performance in the validation cohort. CONCLUSIONS The nomogram exhibited good predictive ability for stoma formation during elective surgical resection for penetrating CD, which can assist surgeons in making informed clinical decisions.
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Affiliation(s)
- Zhenya Sun
- 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
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yan Zhou
- 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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12
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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] [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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13
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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] [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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14
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Avellaneda N, Rodrigues Coy CS, Sarubbi Fillmann H, Saad-Hossne R, Muñoz JP, García-Duperly R, Bellolio F, Rotholtz N, Rossi G, Marquez V JR, Cillo M, Lacerda-Filho A, Carrie A, Yuki Maruyama B, Sarubbi Fillmann L, Silvino Craveiro MM, Ferro E, Londoño-Schimmer E, Iglesias A, Bras Harriott C, Campana JP, Londoño Estrada D, Balachandran R, Kotze PG. Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicentric Latin American experience. Cir Esp 2023; 101:824-832. [PMID: 37244420 DOI: 10.1016/j.cireng.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures. MATERIALS AND METHODS We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo > II), the "postoperative complication" (POC) group; and those who did not, the "no postoperative complication" (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC. RESULTS In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs. 17.83; P = .026), who presented more preoperative anemia (33.33 vs. 17.48%; P = .009), required more urgent care (37.25 vs. 22.38; P = .023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs. 143.86 min; P = .005), more intraoperative complications (17.65 vs. 4.55%; P < .001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications. CONCLUSION This study shows that risk factors for complications after primary ileocecal resections for Crohn's disease in Latin America are similar to those reported elsewhere. Future efforts in the region should be aimed at improving these outcomes by controlling some of the identified factors.
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Affiliation(s)
- Nicolás Avellaneda
- General Surgery Department, Hospital Universitario CEMIC, Argentina; Colorectal Surgery Department, Aarhus University Hospital, Denmark.
| | | | | | | | | | | | - Felipe Bellolio
- Coloproctology Unit, Digestive Surgery Department, Pontíficia Universidad Católica de Chile, Chile
| | - Nicolás Rotholtz
- Colorectal Surgery Service, General Surgery Department, Hospital Aleman de Buenos Aires, Argentina
| | - Gustavo Rossi
- Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Mariano Cillo
- Colorectal Surgery Department, Hospital Británico de Buenos Aires, Argentina
| | | | - Augusto Carrie
- General Surgery Department, Hospital Universitario CEMIC, Argentina
| | - Beatriz Yuki Maruyama
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | | | | | - Ezequiel Ferro
- Colorectal Surgery Department, Nueva Proctología, Argentina
| | | | - Andrés Iglesias
- Coloproctology Unit, Digestive Surgery Department, Pontíficia Universidad Católica de Chile, Chile
| | - Camila Bras Harriott
- Colorectal Surgery Service, General Surgery Department, Hospital Aleman de Buenos Aires, Argentina
| | - Juan Pablo Campana
- Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
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15
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Sun Z, Song T, Guo Z, Cao L, Zhu W, Li Y. Biologic use is not associated with postoperative complications in patients with Crohn's disease undergoing stoma reversion. ANZ J Surg 2023; 93:2921-2927. [PMID: 38041216 DOI: 10.1111/ans.18790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Stoma creation is a common procedure in patients with Crohn's disease (CD), and early prophylaxis with biologics is recommended for high-risk patients. However, the effect of biologic exposure on morbidity after stoma closure remains unknown. Therefore, this study aimed to investigate the impact of biologic use on the occurrence of complications in CD patients following stoma closure. METHODS Consecutive patients diagnosed with CD who underwent ileostomy reversal at a tertiary care centre between 1 January 2013 and 1 December 2021, were included in the study. The primary outcome was the occurrence of 90-day postoperative complications. RESULTS The study included 347 eligible patients who underwent ileostomy reversal. There was no significant difference in terms of infectious complications, overall complications or length of postoperative stay between the biologic and non-biologic groups. Multivariate logistic regression analysis identified several predictors of postoperative morbidity, including preoperative haemoglobin levels below 100 g/L, CRP levels above 10 mg/L, anastomotic site, ileostomy-related infectious complications and albumin levels below 35 g/L. CONCLUSIONS This study demonstrated that the use of biologics is not associated with adverse outcomes. However, such as high CRP levels, ileostomy-related infectious complications, hypoproteinemia, and hemoglobinemia, should be optimized prior to surgery to reduce postoperative morbidities.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Tianrun Song
- Department of General Surgery, Jinling Clinical School of Medicine (Eastern Theater General Hospital), Nanjing Medical University, Nanjing, China
| | - Zhen Guo
- 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
| | - 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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16
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Yang S, Prien C, Jia X, Hull T, Liska D, Steele SR, Lightner AL, Valente M, Holubar SD. Redo Ileocolic Resection Is Not an Independent Risk Factor for Anastomotic Leak in Recurrent Crohn's Disease. Dis Colon Rectum 2023; 66:1373-1382. [PMID: 36649183 DOI: 10.1097/dcr.0000000000002675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Redo ileocolic resection for recurrent Crohn's disease is associated with increased technical complexity and higher complication rates compared to primary resection. Literature concerning redo surgery for recurrent Crohn's disease is scarce and it is controversial whether a redo is a risk factor for postoperative anastomotic leak. OBJECTIVE This study aimed to hypothesized that redo ileocolic resection for Crohn's disease is an independent risk factor for anastomotic leak. DESIGN Retrospective, case-control study from 1994 to 2019 with multivariate analysis and propensity score weighting. SETTING Quaternary, IBD-referral center. PATIENTS Adult patients aged >18 years were included in the study. INTERVENTIONS Primary or redo ileocolic resection with an anastomosis, with or without diverting ileostomy. MAIN OUTCOME MEASURES Thirty-day anastomotic leak rate. RESULTS A total of 991 patients (56% primary and 44% redo ileocolic resections) were included. Patients who underwent redo resection were significantly older with more comorbidities, fewer medications, and less fistulizing disease compared to the primary group. On univariate analysis, patients who underwent redo resection had more overall complications (50.5% vs 36.2%, p < 0.001), and the cumulative number of prior ileocolic resections was significantly associated with increased risk for overall morbidity ( p < 0.001). There were 31 (3%) anastomotic leaks; leak rates did not differ between groups ( p = 0.60). Multivariable analysis indicated that extensive adhesiolysis ( p < 0.001), ileostomy omission ( p = 0.009), and intraoperative abscess/fistula ( p = 0.02) were independently associated with leaks but not redo resection ( p = 0.27). Patients with 0, 1, 2, or 3 of these risk factors had observed leak rates of 1.1%, 1.3%, 6.0%, and 11.6.% ( p = 0.03), respectively. LIMITATIONS The limitations of this study were selection bias, referral bias, and single quaternary center. CONCLUSIONS Compared to primary procedures, redo ileocolic resection for recurrent Crohn's disease is associated with increased overall morbidity but not anastomotic leak. See Video Abstract at http://links.lww.com/DCR/C132 . LA RESECCIN ILEOCLICA REHECHA NO ES UN FACTOR DE RIESGO INDEPENDIENTE DE FUGA ANASTOMTICA EN LA ENFERMEDAD DE CROHN RECURRENTE ANTECEDENTES:La resección ileocólica para la enfermedad de Crohn recurrente se asocia con una mayor complejidad técnica y mayores tasas de complicaciones en comparación con la resección primaria. La literatura sobre la reintervención quirúrgica para la enfermedad de Crohn recurrente es escasa y es controvertido si una redo es un factor de riesgo para la fuga anastomótica posoperatoria.OBJETIVO:Tenemos la hipótesis de que rehacer la resección ileocólica para la enfermedad de Crohn es un factor de riesgo independiente para la fuga anastomótica.DISEÑO:Estudio retrospectivo de casos y controles de 1994 a 2019 con análisis multivariado y ponderación de puntuación de propensión.AJUSTE:Centro de referencia de enfermedad inflamatoria intestinal de cuarto nivel.PACIENTES:Pacientes adultos >18 años.INTERVENCIONES:Resección ileocólica primaria o rehecha con una anastomosis, con o sin derivación de ileostomía.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de fuga anastomótica a los 30 días.RESULTADOS:Se incluyeron un total de 991 pacientes (56% resecciones primarias y 44% resecciones ileocólicas rehechas). Los pacientes de reintervención eran significativamente mayores con más comorbilidades, menos medicamentos y menos enfermedad fistulizante en comparación con el grupo primario. En el análisis univariado, los pacientes reoperados tuvieron más complicaciones generales (50,5% frente a 36,2%, p < 0,001) y el número acumulado de resecciones ileocólicas previas se asoció significativamente con un mayor riesgo de morbilidad general ( p < 0,001). Hubo 31 (3%) fugas anastomóticas; las tasas de fuga no difirieron entre los grupos ( p = 0,6). El análisis multivariado indicó que la adhesiolisis extensa ( p < 0,001), la omisión de ileostomía ( p = 0,009) y el absceso/fístula intraoperatorios ( p = 0,02) se asociaron de forma independiente con fugas, pero no con nueva resección ( p = 0,27). Los pacientes con 0, 1, 2 o 3 de estos factores de riesgo observaron tasas de fuga del 1,1%, 1,3%, 6,0% y 11,6% ( p = 0,03), respectivamente.LIMITACIONES:Sesgo de selección, Sesgo de referencia, un centro de cuarto nivelCONCLUSIÓN:En comparación con los procedimientos primarios, la resección ileocólica para la enfermedad de Crohn recurrente se asocia con una mayor morbilidad general, pero no con una fuga anastomótica. Consulte Video Resumen en http://links.lww.com/DCR/C132 . (Traducción-Dr. Mauricio Santamaria ).
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Affiliation(s)
- Songsoo Yang
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | | | - Xue Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael Valente
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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17
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Ocaña J, Pastor P, Timoteo A, Diez‐Alonso MM, de la Portilla F, Cagigas C, Labalde‐Martínez M, Espin E, Dujovne P, Nieto M, González M, Sanz R, Pascual M, Aguirre‐Allende I, Cervera J, Jiménez‐Carneros V, Guadalajara H, García‐Granero A, Fernández‐Cebrián JM, Die‐Trill J. Risk factors for anastomotic leakage and postoperative outcomes after total and subtotal colectomy: A nationwide retrospective cohort study (RIALTCOT Study Collaborative Group). Colorectal Dis 2023; 25:420-430. [DOI: 10.1111/codi.16384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/03/2022] [Indexed: 02/05/2025]
Abstract
AbstractAimAnastomotic leakage (AL) following ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with a high morbidity. The identification of potential risk factors for AL could change operative planning and reduce further complications. This study assesses the rate, potential risk factors and management of AL after total colectomy (TC) and subtotal colectomy (STC).MethodsA nationwide, multicentre, retrospective cohort study involved 26 Spanish referral centres. It included TC and STC with IRA or ISA patients between January 2013 and December 2020. Clinical data, primary surgery and complications were collected. Univariate and multivariate analysis to identify risk factors for AL were performed. Management of Grade B–C AL and permanent stoma rate was assessed according to revisional surgeries.ResultsThe study included 1074 patients, 433 ISA group (40.3%) and 641 IRA group (59.7%). The overall incidence of AL was 14.3% with no differences between IRA and ISA (14.2% and 14.5% respectively), P = 0.871. Male sex, ASA score and lower total preoperative proteins were identified as independent risk factors for global and Grade B–C AL. Diverting ileostomy did not protect against AL (P = 0.084). Clavien–Dindo ≥IIIA complication was found in 251 patients (23.3%). Stoma reversal was not possible in 85 patients (8.1%), being more frequent after anastomosis excision and terminal ileostomy in AL Grade C.ConclusionTotal colectomy and STC with IRA or ISA are high‐risk procedures with an increased AL rate. Male sex, ASA score and lower preoperative protein level were associated with global AL and AL Grade B and C. A lower permanent stoma rate could be obtained when diverting ileostomy is performed in revision surgery.
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Affiliation(s)
- Juan Ocaña
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
| | - Paula Pastor
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
| | - Ander Timoteo
- Division of Coloproctology Hospital Universitario Doctor Josep Trueta Gerona Spain
| | | | | | - Carmen Cagigas
- Division of Coloproctology Hospital Universitario Marqués de Valdecilla Santander Spain
| | | | - Eloy Espin
- Department of Colorectal Surgery, Hospital Universitari Vall d'Hebron Universitat Autonoma de Barcelona Barcelona Spain
| | - Paula Dujovne
- Division of Coloproctology Hospital Universitario Gregorio Marañón Madrid Spain
| | - Marta Nieto
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario La Fe Valencia Spain
| | - Manuel González
- Division of Coloproctology Complejo Hospitalario Universitario A Coruña A Coruña Spain
| | - Rodrigo Sanz
- Division of Coloproctology Hospital Universitario Clínico San Carlos Madrid Spain
| | - Marta Pascual
- Division of Coloproctology Hospital Del Mar Barcelona Spain
| | | | - Jorge Cervera
- Division of Coloproctology Hospital Universitario de Cruces Barakaldo Spain
| | | | - Hector Guadalajara
- Division of Coloproctology Hospital Universitario Fundación Jiménez Díaz Madrid Spain
| | | | - José María Fernández‐Cebrián
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
| | - Javier Die‐Trill
- Division of Coloproctology, Department of General and Digestive Surgery Hospital Universitario Ramón y Cajal Madrid Spain
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18
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Abstract
A number of factors should be considered when performing an intestinal anastomosis in the setting of surgery for Crohn's disease. Preoperative risk factors, such as malnutrition, abdominal sepsis, and immunosuppressive medications, may increase the risk of postoperative anastomotic complications and alter surgical decision-making. The anatomical configuration and technique of constructing the anastomosis may have an impact on postoperative function and risk of recurrence, particularly in the setting of ileocolic resection, where the Kono-S anastomosis has gained popularity in recent years. There may be circumstances in which it may be more appropriate to perform an ostomy either without an anastomosis or to temporarily divert an anastomosis when the risk of anastomotic complications is felt to be high. In the setting of total abdominal colectomy or proctocolectomy for Crohn's colitis, restorative procedures may appropriate in lieu of a permanent stoma in certain scenarios.
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Affiliation(s)
- Brian R. Kann
- Department of Colon & Rectal Surgery, Ochsner Health, New Orleans, Louisiana,Address for correspondence Brian R. Kann, MD, FACS, FASCRS Department of Colon & Rectal Surgery, Ochsner Health1514 Jefferson Highway, New Orleans, LA 70121
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19
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Freund MR, Emile SH, Horesh N, Garoufalia Z, Gefen R, Perets M, Wexner SD. Redo ileocolic resection for recurrent Crohn's disease: A review and meta-analysis of surgical outcomes. Surgery 2022; 172:1614-1621. [PMID: 36270822 DOI: 10.1016/j.surg.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/09/2022] [Accepted: 09/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Recurrence of postoperative Crohn's disease neccesitating repeat ileocolic resection is a common problem. The aim of this meta-analysis was to present the collective evidence on the surgical outcomes of this procedure. METHODS PubMed, Scopus, and Google Scholar were searched for eligible studies that reported the surgical outcomes of redo ileocolic resection for Crohn's disease. The primary outcomes were overall and major complication rates. The secondary outcome was anastomotic leak and conversion rate. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies - of Interventions tool. RESULTS This meta-analysis included 12 studies comprising 1,203 patients (50% men). The weighted mean rate of overall complications was 31.8% (95% confidence interval, 25-38.6) and rate of major complications was 8% (95% confidence interval, 5.7-10.2). The weighted mean rate of conversion was 20.9%, and the weighted mean rate of anastomotic leak was 3% (95% confidence interval, 1.8%-4.3%; inconsistency = 0). Male sex (slope coefficient = 0.0001; P = .01), American Society of Anesthesiologists score >3 (slope coefficient = 0.001; P = .04), smoking (slope coefficient = 0.0001; P = .008), preoperative use of steroid therapy (slope coefficient = 0.0001; P = .009), open approach (slope coefficient = 0.0001; P = .005), and having ≥2 previous resections (slope coefficient = 0.0001; P = .02) were significant risk factors for major complications. CONCLUSION Although redo ileocolic resection for patients with recurrent Crohn disease has a relatively high overall complication rate, a majority of these complications are minor and anastomotic leak rate is relatively low. Further prospective multicenter trials are warranted to confirm the conclusions of this meta-analysis.
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Affiliation(s)
- Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | - Michal Perets
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Bachour SP, Shah RS, Rieder F, Qazi T, Achkar JP, Philpott J, Lashner B, Holubar SD, Lightner AL, Barnes EL, Axelrad J, Regueiro M, Click B, Cohen BL. Intra-abdominal septic complications after ileocolic resection increases risk for endoscopic and surgical postoperative Crohn's disease recurrence. J Crohns Colitis 2022; 16:1696-1705. [PMID: 35705188 PMCID: PMC9924045 DOI: 10.1093/ecco-jcc/jjac078] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Postoperative recurrence [POR] of Crohn's disease following ileocolonic resection is common. The impact of immediate postoperative intra-abdominal septic complications [IASC] on endoscopic and surgical recurrence has not been elucidated. AIMS To evaluate if IASC is associated with an increased risk for endoscopic and surgical POR. METHODS This was a retrospective study of adult Crohn's disease patients undergoing ileocolonic resection with primary anastomosis between 2009 and 2020. IASC was defined as anastomotic leak or intra-abdominal abscess within 90 days of the date of surgery. Multivariable logistic and Cox proportional hazard modelling were performed to assess the impact of IASC on endoscopic POR [modified Rutgeerts' score ≥ i2b] at index postoperative ileocolonoscopy and long-term surgical recurrence. RESULTS In 535 Crohn's disease patients [median age 35 years, 22.1% active smokers, 35.7% one or more prior resection] had an ileocolonic resection with primary anastomosis. A minority of patients [N = 47; 8.8%] developed postoperative IASC. In total, 422 [78.9%] patients had one or more postoperative ileocolonoscopies, of whom 163 [38.6%] developed endoscopic POR. After adjusting for other risk factors for postoperative recurrence, postoperative IASC was associated with significantly greater odds (adjusted odds ratio [aOR]: 2.45 [1.23-4.97]; p = 0.01) and decreased time (adjusted hazards ratio [aHR]: 1.60 [1.04-2.45]; p = 0.03] to endoscopic POR. Furthermore, IASC was associated with increased risk (aOR: 2.3 [1.04-4.87] p = 0.03) and decreased survival-free time [aHR: 2.53 [1.31-4.87]; p = 0.006] for surgical recurrence. CONCLUSION IASC is associated with an increased risk for endoscopic and surgical POR of Crohn's disease. Preoperative optimization to prevent IASC, in addition to postoperative biological prophylaxis, may help reduce the risk for endoscopic and surgical POR.
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Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Ravi S Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Stefan D Holubar
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, OH, USA
| | - Amy L Lightner
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, OH, USA
| | - Edward L Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology, New York, NY, USA
| | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Benjamin Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Benjamin L Cohen
- Correspondence: Benjamin L. Cohen, MD, MAS, Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, 9500 Euclid Ave., A30, Cleveland, OH, 44195, USA.
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Myrelid P, Soop M, George BD. Surgical Planning in Penetrating Abdominal Crohn's Disease. Front Surg 2022; 9:867830. [PMID: 35592128 PMCID: PMC9110798 DOI: 10.3389/fsurg.2022.867830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.
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Affiliation(s)
- Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mattias Soop
- Department of Surgery, Ersta Hospital, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
| | - Bruce D. George
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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22
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Has the Removing of the Mesentery during Ileo-Colic Resection an Impact on Post-Operative Complications and Recurrence in Crohn’s Disease? Results from the Resection of the Mesentery Study (Remedy). J Clin Med 2022; 11:jcm11071961. [PMID: 35407568 PMCID: PMC8999639 DOI: 10.3390/jcm11071961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023] Open
Abstract
Some evidence suggests a reduction in clinical and surgical recurrence after mesenteric resection in Crohn’s Disease (CD). The aim of the REsection of the MEsentery StuDY (Remedy) was to assess whether mesenteric removal during surgery for ileocolic CD has an impact in terms of postoperative complications, endoscopic and ultrasonographic recurrences, and long-term surgical recurrence. Among the 326 patients undergoing primary resection between 2009 and 2019 in two referral centers, in 204 (62%) the mesentery was resected (Group A) and in 122 (38%) it was retained (Group B). Median follow-up was 4.7 ± 3 years. Groups were similar in the peri-operative course. Endoscopic and ultrasonographic recurrences were 44.6% and 40.4% in Group A, and 46.7% and 41.2% in Group B, respectively, without statistically significant differences. The five-year time-to-event estimates, compared with the Log-rank test, were 3% and 4% for normal or thickened mesentery (p = 0.6), 2.8% and 4% for resection or sparing of the mesentery (p = 0.6), and 1.7% and 5.4% in patients treated with biological or immunosuppressants versus other adjuvant therapy (p = 0.02). In Cox’s model, perforating behavior was a risk factor, and biological or immunosuppressant adjuvant therapy protective for surgical recurrence. The resection of the mesentery does not seem to reduce endoscopic and ultrasonographic recurrences, and the five-year recurrence rate.
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23
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Freund MR, Kent I, Horesh N, Smith T, Wexner SD. Redo ileocolic resection in Crohn's disease - does time passed since previous surgery matter? Colorectal Dis 2022; 24:484-490. [PMID: 34958523 DOI: 10.1111/codi.16035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/15/2021] [Accepted: 12/20/2021] [Indexed: 12/13/2022]
Abstract
AIM Surgical resection for Crohn's disease (CD) remains noncurative, therefore recurrence is a significant problem. Although numerous factors affecting surgical outcomes in redo ileocolic resection have been previously described, no study has considered the relation between the interval of time from initial ileocolic resection to the redo procedure and its effect on surgical outcomes. The aim of this study was to explore this relationship. METHOD A retrospective review of all adult patients undergoing redo ileocolic resection for CD between 2011 to 2020 was conducted. Patients were divided into two groups based on time from initial ileocolic resection. Patients operated within 10 years of their initial surgery (≤10 years) were assigned to the early group, while patients operated >10 years after initial surgery were allocated to the late group. Primary outcome was the 30-day postoperative major complication rate. RESULTS Fifty-eight patients underwent redo ileocolic resection, 24 in the early group and 34 in the late group. Apart from older median age in the late group (56 vs. 46.5 years, p = 0.026), the groups were similar for patient factors, disease site and behaviour, use of immune-suppressing medication and procedural factors. Significant differences in 30-day postoperative morbidity included longer length of stay (6 vs. 5 days, p = 0.035), a higher major complication rate (23.5% vs. 4.1%, p = 0.04) and higher readmission rate (26.4% vs. 4.1%, p = 0.035) in the late group. The overall complication rate remained nonsignificant (37.5% vs. 61.8%, p = 0.1). CONCLUSIONS Redo ileocolic resection, when performed >10 years from the initial ileocolic resection, may be associated with increased morbidity, specifically higher rates of major postoperative complications, a longer length of stay and more readmissions.
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Affiliation(s)
- Michael R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Ilan Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nir Horesh
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Timothy Smith
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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24
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Abdalla S, Abd El Aziz MA, Calini G, Saeed H, Merchea A, Shawki S, Behm KT, Larson DW. Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort. Surgery 2022; 172:522-529. [PMID: 35337682 DOI: 10.1016/j.surg.2022.01.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease. METHODS A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group). RESULTS Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188). CONCLUSION Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.
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Affiliation(s)
- Solafah Abdalla
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Giacomo Calini
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL
| | - Sherief Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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25
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Mittelstädt A, von Loeffelholz T, Weber K, Denz A, Krautz C, Grützmann R, Weber GF, Brunner M. Influence of interrupted versus continuous suture technique on intestinal anastomotic leakage rate in patients with Crohn's disease - a propensity score matched analysis. Int J Colorectal Dis 2022; 37:2245-2253. [PMID: 36216902 PMCID: PMC9560923 DOI: 10.1007/s00384-022-04252-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Intestinal anastomosis is a crucial step in most intestinal resections, as anastomotic leakage is often associated with severe consequences for affected patients. There are especially two different techniques for hand-sewn intestinal anastomosis: the interrupted suture technique (IST) and the continuous suture technique (CST). This study investigated whether one of these two suture techniques is associated with a lower rate of anastomotic leakage. METHODS A retrospective review of 332 patients with Crohn's disease who received at least one hand-sewn colonic anastomosis at our institution from 2010 to 2020 was performed. Using propensity score matching 183 patients with IST were compared to 96 patients with CST in regard to the impact of the anastomotic technique on patient outcomes. RESULTS Overall anastomotic leakage rate was 5%. Leakage rate did not differ between the suture technique groups (IST: 6% vs. CST: 3%, p = 0.393). Multivariate analysis revealed the ASA score as only independent risk factor for anastomotic leakage (OR 5.3 (95% CI = 1.2-23.2), p = 0.026). Suture technique also showed no significant influence on morbidity and the re-surgery rate in multivariate analysis. CONCLUSION Our data suggest that the chosen suture technique (interrupted vs. continuous) has no influence on postoperative outcome, especially on anastomotic leakage rate. This finding should be confirmed by a randomized controlled trial.
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Affiliation(s)
- Anke Mittelstädt
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Tobias von Loeffelholz
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Klaus Weber
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Axel Denz
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Christian Krautz
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Robert Grützmann
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Georg F. Weber
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Maximilian Brunner
- grid.5330.50000 0001 2107 3311Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
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26
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Ferrari L, Fichera A. Operative indications and options in intestinal Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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27
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Ellis CT, Maykel JA. Defining Anastomotic Leak and the Clinical Relevance of Leaks. Clin Colon Rectal Surg 2021; 34:359-365. [PMID: 34853555 DOI: 10.1055/s-0041-1735265] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.
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Affiliation(s)
- Clayton Tyler Ellis
- Division of Colorectal Surgery, Hiram C. Polk, Jr., MD, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Worcester, Massachusetts
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28
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Freund MR, Kent I, Agarwal S, Wexner SD. Use of indocyanine green fluorescence guidance in redo ileocolic resection for Crohn's disease. Colorectal Dis 2021; 23:3190-3195. [PMID: 34741391 DOI: 10.1111/codi.15980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/26/2021] [Accepted: 10/31/2021] [Indexed: 12/13/2022]
Abstract
AIM Redo ileocolic resection in patients with Crohn's disease (CD) is associated with significant technical challenges that may be associated with high complication rates. The aim of this study was to evaluate the feasibility of near-infrared fluorescence angiography with indocyanine green (ICG), often used to evaluate blood supply to the anastomosis in CD patients undergoing repeat ileocolic resection. METHOD This study was a retrospective analysis of patients who underwent redo ileocolic resection using ICG bowel perfusion assessment between 2015 and 2021. Patients were matched and compared on a 1:2 basis with a control group undergoing the same procedure without perfusion assessment. RESULTS Twelve patients underwent redo ileocolic resection with ICG perfusion assessment (ICG group). These were compared with 24 patients who underwent the procedure without ICG (control group). Both groups were similar in demographics and operative characteristics including median operating time (255 vs. 255.5 min, p = 0.39) and conversion rate (22% vs. 36.8%, p = 0.68). Median estimated blood loss was significantly higher in the ICG group [150 (50-400) vs. 100 ml (20-125)]. Successful ICG perfusion assessment was seen in all patients in the ICG group and did not change management in any case. Overall postoperative complication rates were comparable between the groups (58.3% vs. 54.1%, p = 0.72). No anastomotic leaks occurred in the ICG group compared with one (1/24, 4.2%) in the control group (p = 0.99). CONCLUSION Fluorescence ICG perfusion assessment is feasible and safe in redo ileocolic resection in patients with CD. Larger studies are needed to evaluate whether this technique should be routinely used in these complex surgical interventions.
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Affiliation(s)
- Michael R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Ilan Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Samir Agarwal
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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29
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Zhang Z, He X, Hu J, Zheng Z, Chen Y, Tang J, Li S, Ke J, Lian L, Lan P, Wu X. Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease. Surgery 2021; 171:1486-1493. [PMID: 34863524 DOI: 10.1016/j.surg.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease. METHODS A retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach. RESULTS A total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) CONCLUSION: Split stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.
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Affiliation(s)
- Zongjin Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zheyu Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongle Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian Tang
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Senmao Li
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiaojian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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30
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Wan J, Yuan XQ, Wu TQ, Yang MQ, Wu XC, Gao RY, Yin L, Chen CQ. Laparoscopic vs open surgery in ileostomy reversal in Crohn’s disease: A retrospective study. World J Gastrointest Surg 2021; 13:1414-1422. [PMID: 34950430 PMCID: PMC8649567 DOI: 10.4240/wjgs.v13.i11.1414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/23/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although minimally invasive surgery is becoming more commonly applied for ileostomy reversal (IR), there have been relatively few studies of IR for patients with Crohn's disease (CD). It is therefore important to evaluate the potential benefits and risks of laparoscopy for patients with CD.
AIM To compare the safety, feasibility, and short-term and long-term outcomes of laparoscopic IR (LIR) vs open IR (OIR) for the treatment of CD.
METHODS The baseline characteristics, operative data, and short-term (30-d) and long-term outcomes of patients with CD who underwent LIR and OIR at our institution between January 2017 and January 2020 were retrieved from an electronic database and retrospectively reviewed.
RESULTS Of the 60 patients enrolled in this study, LIR was performed for 48 and OIR for 12. There were no statistically significant differences in baseline characteristics, operation time, intraoperative blood loss, days to flatus and soft diet, postoperative complications, hospitalization time, readmission rate within 30 d, length of hospitalization, hospitalization costs, or reoperation rate after IR between the two groups. However, patients in the LIR group more frequently required lysis of adhesions as compared to those in the OIR group (87.5% vs 41.7%, respectively, P < 0.05). Notably, following exclusion of patients who underwent enterectomy plus IR, OIR was more advantageous in terms of postoperative recovery of gastrointestinal function and hospitalization costs.
CONCLUSION The safety and feasibility of LIR for the treatment of CD are comparable to those of OIR with no increase in intraoperative or postoperative complications.
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Affiliation(s)
- Jian Wan
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Xiao-Qi Yuan
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Tian-Qi Wu
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Mu-Qing Yang
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Xiao-Cai Wu
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Ren-Yuan Gao
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Lu Yin
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
| | - Chun-Qiu Chen
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai 200092, China
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31
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State-of-the-art surgery for Crohn's disease: Part I-small intestine/ileal disease. Langenbecks Arch Surg 2021; 407:885-895. [PMID: 34738167 DOI: 10.1007/s00423-021-02324-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/13/2022]
Abstract
The management of Crohn's disease has evolved significantly over the past 20 years. The arrival of biologic therapies has altered not only the management and outcomes but also rates for refractory disease requiring surgery. New surgical techniques have paralleled these medical advances, and this article will provide an overview of these new modalities as well as their outcomes. This is the first of a three-part series and will focus on terminal ileal and ileocolic disease.
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32
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Sampietro GM, Colombo F, Frontali A, Baldi C, Conti L, Dilillo D, Penagini F, Nebuloni M, D'Addio F, Fiorina P, Maconi G, Corsi F, Zuccotti G, Ardizzone S, Foschi D. Strictureplasties performed by laparoscopic approach for complicated Crohn's disease. A prospective, observational, cohort study. Dig Liver Dis 2021; 53:1286-1293. [PMID: 33627296 DOI: 10.1016/j.dld.2021.01.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopy is considered the best surgical approach for Crohn's Disease (CD), and strictureplasty a reliable alternative to intestinal resection. Nevertheless, their association has never been evaluated. AIM To investigate feasibility and safety of conventional (SP) and non-conventional (NCSP) strictureplasties, using laparoscopy, for complicated CD. METHODS Starting January 2008, a prospective cohort study was performed, in consecutive, unselected patients, undergoing primary surgery for CD (Group-A). The residential database (CD-CARD) was used for the retrospective extraction of control patients (Group-B). Univariate and multi-variate analysis of pre-operative characteristics, intra-operative findings, morbidity, and intra-abdominal septic complications (IASCs) was performed. RESULTS Between January 2008 and December 2019, 331 patients received 162 SPs, 138 NCSPs, and 373 resections (Group-A). From the CD-CARD, 227 control patients received 159 SPs, 117 NCSPs, and 271 resections (Group-B) (ns). Preoperatively, Group-A presented batter nutritional status and received more biological therapies, Group-B more steroids. Group-A presented less abdominal abscesses, planned ostomies, minor complications, shorter operating time and hospitalization than Group-B, but similar major complications, IASCs and anastomotic leaks. IASCs were related to older age, elevated inflammatory indices, and preoperative treatment with high-risk drugs. CONCLUSIONS SP and NCSP are feasible by laparoscopy, with low morbidity rate, confirming the advantages of both minimally invasive and conservative surgery.
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Affiliation(s)
- Gianluca M Sampietro
- Division of General and HPB Surgery, ASST Rhodense - Rho, Corso Europa, 250, 20017 - Rho, Milan, Italy.
| | - Francesco Colombo
- Division of General Surgery, ASST Fatebenefratelli - Sacco, Milan, Italy
| | - Alice Frontali
- Division of General Surgery, ASST Fatebenefratelli - Sacco, Milan, Italy; Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Assistance Publique - Hôpiteau de Paris (AP-HP), Beaujon Hospital, University Denis Diderot, Paris, France
| | - Caterina Baldi
- Division of General and HPB Surgery, ASST Rhodense - Rho, Corso Europa, 250, 20017 - Rho, Milan, Italy
| | - Lorenzo Conti
- Division of General Surgery, ASST Fatebenefratelli - Sacco, Milan, Italy
| | - Dario Dilillo
- Children's University Hospital, ASST Fatebenefratelli - Sacco, Milan, Italy
| | - Francesca Penagini
- Children's University Hospital, ASST Fatebenefratelli - Sacco, Milan, Italy
| | - Manuela Nebuloni
- Division of Pathology, ASST Fatebenefratelli - Sacco, Milan, Italy; Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy
| | - Francesca D'Addio
- Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy; International Center for T1D, Pediatric Clinical Research Center Fondazione Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy
| | - Paolo Fiorina
- Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy; Division of Endocrinology, ASST Fatebenefratelli - Sacco, Milan, Italy; Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; International Center for T1D, Pediatric Clinical Research Center Fondazione Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy
| | - Giovanni Maconi
- Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy; Division of Gastroenterology, ASST Fatebenefratelli - Sacco, Milan, Italy
| | - Fabio Corsi
- Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy; Breast Unit, Surgery Department, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Gianvincenzo Zuccotti
- Children's University Hospital, ASST Fatebenefratelli - Sacco, Milan, Italy; Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy; International Center for T1D, Pediatric Clinical Research Center Fondazione Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy
| | - Sandro Ardizzone
- Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy; Division of Gastroenterology, ASST Fatebenefratelli - Sacco, Milan, Italy
| | - Diego Foschi
- Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy
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33
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El-Hussuna A, Karer MLM, Uldall Nielsen NN, Mujukian A, Fleshner PR, Iesalnieks I, Horesh N, Kopylov U, Jacoby H, Al-Qaisi HM, Colombo F, Sampietro GM, Marino MV, Ellebæk M, Steenholdt C, Sørensen N, Celentano V, Ladwa N, Warusavitarne J, Pellino G, Zeb A, Di Candido F, Hurtado-Pardo L, Frasson M, Kunovsky L, Yalcinkaya A, Tatar OC, Alonso S, Pera M, Granero AG, Rodríguez CA, Minaya A, Spinelli A, Qvist N. Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease. BJS Open 2021; 5:6369776. [PMID: 34518869 PMCID: PMC8438259 DOI: 10.1093/bjsopen/zrab075] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD. METHODS A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes. RESULTS The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042). CONCLUSION Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.
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Affiliation(s)
- A El-Hussuna
- Department of Clinical Medicin, Aalborg University, Aalborg, Denmark
| | - M L M Karer
- Department of Clinical Medicin, Aalborg University, Aalborg, Denmark
| | | | - A Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - P R Fleshner
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - I Iesalnieks
- Department of Surgery, Städtisches Klinikum München Bogenhausen, Munich, Germany
| | - N Horesh
- Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of gastroentrology, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel
| | - U Kopylov
- Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of gastroentrology, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel
| | - H Jacoby
- Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of gastroentrology, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel
| | - H M Al-Qaisi
- Department of Surgery, Aalborg University Hospital, Denmark
| | - F Colombo
- Division of General and HPB Surgery, Luigi Sacco Hospital, Milan, Italy
| | - G M Sampietro
- Department of Surgery, Università degli Studi di Milano, Milan, Italy
| | - M V Marino
- Department of Surgery, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - M Ellebæk
- Research Unit for Surgery and IBD-Care, Odense University Hospital, Odense, Denmark
| | - C Steenholdt
- Department of Gastroentrology, Herlev University Hospital, Herlev, Denmark
| | - N Sørensen
- Department of Surgery, Aalborg University Hospital, Denmark
| | - V Celentano
- Department of Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - N Ladwa
- Department of Surgery, St Mark's and Northwick Park Hospital, UK
| | - J Warusavitarne
- Department of Surgery, St Mark's and Northwick Park Hospital, UK
| | - G Pellino
- Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Zeb
- Department of Surgery, Hvidovre Hospital, Denmark
| | - F Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Centre IRCCS, Humanitas University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - L Hurtado-Pardo
- Department of Surgery, University Hospital La Fe, University of Valencia, Spain
| | - M Frasson
- Department of Surgery, University Hospital La Fe, University of Valencia, Spain
| | - L Kunovsky
- Department of Surgery, University Hospital Brno, Brno, Czech Republic.,Department of Gastroenterology and Internal Medicine, University Hospital Brno, Brno, Czech Republic
| | - A Yalcinkaya
- Department of Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - O C Tatar
- Department of Surgery, Kocaeli University School of Medicine, Turkey
| | - S Alonso
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - M Pera
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - A G Granero
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Mallorca, Spain
| | - C A Rodríguez
- Department of Surgery, Universidad Francisco de Vitoria, Madrid, Spain.,Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - A Minaya
- Department of Surgery, Universidad Francisco de Vitoria, Madrid, Spain.,Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Centre IRCCS, Humanitas University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - N Qvist
- Department of Clinical Medicin, Aalborg University, Aalborg, Denmark.,Department of surgery, Sheba Medical Centre, Ramat Gan Israel and Sackler Medical School, Tel Aviv University, Israel.,Department of Surgery, Aalborg University Hospital, Denmark.,Research Unit for Surgery and IBD-Care, Odense University Hospital, Odense, Denmark.,Department of Surgery, St Mark's and Northwick Park Hospital, UK.,Department of Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey.,Department of Surgery, Universidad Francisco de Vitoria, Madrid, Spain.,Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
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34
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Adamina M, Feakins R, Iacucci M, Spinelli A, Cannatelli R, D'Hoore A, Driessen A, Katsanos K, Mookhoek A, Myrelid P, Pellino G, Peros G, Tontini GE, Tripathi M, Yanai H, Svrcek M. ECCO Topical Review Optimising Reporting in Surgery, Endoscopy, and Histopathology. J Crohns Colitis 2021; 15:1089-1105. [PMID: 33428711 DOI: 10.1093/ecco-jcc/jjab011] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Diagnosis and management of inflammatory bowel diseases [IBD] requires a lifelong multidisciplinary approach. The quality of medical reporting is crucial in this context. The present topical review addresses the need for optimised reporting in endoscopy, surgery, and histopathology. METHODS A consensus expert panel consisting of gastroenterologists, surgeons, and pathologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. The following topics were covered: in endoscopy: [i] general IBD endoscopy; [ii] disease activity and surveillance; [iii] endoscopy treatment in IBD; in surgery: [iv] medical history with surgical relevance, surgical indication, and strategy; [v] operative approach; [vi] intraoperative disease description; [vii] operative steps; in pathology: [viii] macroscopic assessment and interpretation of resection specimens; [ix] IBD histology, including biopsies, surgical resections, and neoplasia; [x] IBD histology conclusion and report. Statements were developed using a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥ 80% of participants agreed on a recommendation. RESULTS Thirty practice positions established a standard terminology for optimal reporting in endoscopy, surgery, and histopathology. Assessment of disease activity, surveillance recommendations, advice to surgeons for operative indication and strategies, including margins and extent of resection, and diagnostic criteria of IBD, as well as guidance for the interpretation of dysplasia and cancer, were handled. A standardised report including a core set of items to include in each specialty report, was defined. CONCLUSIONS Interdisciplinary high-quality care requires thorough and standardised reporting across specialties. This topical review offers an actionable framework and practice recommendations to optimise reporting in endoscopy, surgery, and histopathology.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Roger Feakins
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham, UK.,Division of Gastroenterology, University Hospitals Birmingham NHS Trust, UK
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano,Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Rosanna Cannatelli
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK.,Gastroenterology Unit, Spedali Civili di Brescia, Brescia, Italy
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Ann Driessen
- Department of Pathology, University Hospital Antwerp, University Antwerp, Edegem, Belgium
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy.,Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Georgios Peros
- Department of Surgery, Cantonal Hospital of Winterthur, Winterthur, Switerland; Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Henit Yanai
- Division of Gastroenterology, IBD Center, Rabin Medical Center, Petah Tikva, Israel
| | - Magali Svrcek
- Department of Pathology, Sorbonne Université, AP-HP, Saint-Antoine hospital, Paris, France
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35
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Aksan A, Farrag K, Blumenstein I, Schröder O, Dignass AU, Stein J. Chronic intestinal failure and short bowel syndrome in Crohn’s disease. World J Gastroenterol 2021; 27:3440-3465. [PMID: 34239262 PMCID: PMC8240052 DOI: 10.3748/wjg.v27.i24.3440] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/24/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.
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Affiliation(s)
- Aysegül Aksan
- Institute of Nutritional Sciences, Justus-Liebig-Universität, Giessen 35392, Germany
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
| | - Karima Farrag
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
| | - Irina Blumenstein
- Department of Gastroenterology, Hepatology and Clinical Nutrition, First Medical Clinic, JW Goethe University Hospital, Frankfurt am Main 60529, Germany
| | - Oliver Schröder
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
| | - Axel U Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt am Main 60431, Germany
| | - Jürgen Stein
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
- Institute of Pharmaceutical Chemistry, JW Goethe University, 60438 Frankfurt am Main, Germany
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36
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Higashijima J, Kono T, Shimada M, Kashihara H, Takasu C, Nishi M, Tokunaga T, Sugitani A, Yoshikawa K. Intestinal hypoperfusion in patients with Crohn's disease revealed by intraoperative indocyanine green fluorescence imaging. Ann Med Surg (Lond) 2021; 66:102402. [PMID: 34136203 PMCID: PMC8176290 DOI: 10.1016/j.amsu.2021.102402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022] Open
Abstract
Background Anastomotic leakage has been reported as an independent risk factor for surgical recurrence at the anastomotic site in patients with Crohn's disease. An inadequate blood supply may contribute to this leakage. Real-time indocyanine green angiography has been useful for confirming vascular perfusion of the intestines. The aim of this study was to evaluate the use of intraoperative indocyanine green angiography to detect vascular perfusion of the intestines during ileocaecal resection in patients with Crohn's disease and colon cancer. Materials and methods We retrospectively evaluated the medical records of 26 consecutive patients with colon cancer arising in the caecum or ascending colon and 3 consecutive patients with Crohn's disease without a history of disease-related surgery. The patients in the 2 cohorts had undergone ileocaecal resection at Tokushima University Hospital between January 2018 and January 2021. After ileocaecal resection, blood flow was evaluated in ileal (oral) and colon (anal) stapled stumps by indocyanine green fluorescence angiography. The fluorescence time was defined as the time from indocyanine green injection and flush of the injection route to the point when the stump showed the strongest fluorescent signal in the monitor. Results The fluorescence time for the ileal and colon stumps in patients with Crohn's disease was 43.3 ± 8.8 s each and was significantly longer than the fluorescence time in the patients with colon cancer (29.4 ± 6.5 s and 29.6 ± 6.8 s, respectively) (P < 0.05). Conclusion Intraoperative indocyanine green fluorescence imaging is safe and reproducible for assessing intestinal perfusion prior to anastomosis in patients with colon cancer and Crohn's disease.
Low blood supply increases leakage and surgical recurrence in Crohn's disease. Indocyanine green angiography is useful for evaluating the intestinal blood supply. Blood supply at anastomotic sites was lower in Crohn's disease than colon cancer.
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Affiliation(s)
- Jun Higashijima
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
| | - Toru Kono
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan.,Advanced Surgery Center, Sapporo Higashi Tokushukai Hospital, 3-1, N-33, E-14, Higashi-ku, Sapporo, Hokkaido, 0650033, Japan.,Center for Clinical and Biomedical Research, Sapporo Higashi Tokushukai Hospital, 3-1, N-33, E-14, Higahi-ku, Sapporo, Hokkaido, 0650033, Japan
| | - Mitsuo Shimada
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
| | - Hideya Kashihara
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
| | - Chie Takasu
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
| | - Masaaki Nishi
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
| | - Takuya Tokunaga
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
| | - Ayumu Sugitani
- Center for Clinical and Biomedical Research, Sapporo Higashi Tokushukai Hospital, 3-1, N-33, E-14, Higahi-ku, Sapporo, Hokkaido, 0650033, Japan
| | - Kozo Yoshikawa
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Kuramoto 3-18-15, Tokushima, 770-8503, Japan
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37
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Celentano V, Pellino G, Spinelli A, Selvaggi F, Celentano V, Pellino G, Rottoli M, Poggioli G, Sica G, Giglio MC, Campanelli M, Coco C, Rizzo G, Sionne F, Colombo F, Sampietro G, Lamperti G, Foschi D, Ficari F, Vacca L, Cricchio M, Giudici F, Selvaggi L, Sciaudone G, Peltrini R, Manfreda A, Bucci L, Galleano R, Ghazouani O, Zorcolo L, Deidda S, Restivo A, Braini A, Di Candido F, Sacchi M, Carvello M, Martorana S, Bordignon G, Angriman I, Variola A, Di Ruscio M, Barugola G, Geccherle A, Tropeano FP, Luglio G, Tanzanu M, Sasia D, Migliore M, Giuffrida MC, Marrano E, Moretto G, Impellizzeri H, Gallo G, Vescio G, Sammarco G, Terrosu G, Calini G, Bondurri A, Maffioli A, Zaffaroni G, Resegotti A, Mistrangelo M, Allaix ME, Botti F, Prati M, Boni L, Perotti S, Mineccia M, Giuliani A, Romano L, Graziano GMP, Pugliese L, Pietrabissa A, Delaini G, Spinelli A, Selvaggi F. Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: a multicentre study. Updates Surg 2021; 73:149-156. [PMID: 33409848 DOI: 10.1007/s13304-020-00918-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/26/2020] [Indexed: 12/15/2022]
Abstract
A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD.
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Affiliation(s)
- Valerio Celentano
- Portsmouth Hospitals NHS Trust, Portsmouth, UK. .,University of Portsmouth, Portsmouth, UK. .,Department of Surgery and Cancer, Imperial College, London, UK.
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Science, Universita' degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Science, Universita' degli Studi della Campania Luigi Vanvitelli, Naples, Italy
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Shah RS, Bachour S, Jia X, Holubar SD, Hull TL, Achkar JP, Philpott J, Qazi T, Rieder F, Cohen BL, Regueiro MD, Lightner AL, Click BH. Hypoalbuminaemia, Not Biologic Exposure, Is Associated with Postoperative Complications in Crohn's Disease Patients Undergoing Ileocolic Resection. J Crohns Colitis 2021; 15:1142-1151. [PMID: 33388775 PMCID: PMC8427722 DOI: 10.1093/ecco-jcc/jjaa268] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on the postoperative outcomes in Crohn's disease patients exposed to preoperative ustekinumab or vedolizumab. We hypothesised that preoperative biologic use in Crohn's disease is not associated with postoperative complications after ileocolic resection. METHODS Crohn's disease patients who underwent ileocolic resection over 2009-2019 were identified at a large regional health system. Preoperative biologic use within 12 weeks of surgery was categorised as no biologic, anti-tumour necrosis factor, vedolizumab, or ustekinumab. The primary endpoint was 90-day intra-abdominal septic complication. Risk factors included preoperative medical therapies, demographics, disease characteristics, laboratory values, and surgical approach. Regression models assessed the association of biologic use with intra-abdominal septic complication. RESULTS A total of 815 Crohn's disease patients who underwent an ileocolic resection were included [62% no biologic, 31.4% anti-tumour necrosis factor, 3.9% vedolizumab, 2.6% ustekinumab]. Primary anastomosis was performed in 85.9% of patients [side-to-side 48.8%, end-to-side 26%, end-to-end 25%] in primarily a stapled [77.2%] manner. Minimally invasive approach was used in 41.4%. The 90-day postoperative intra-abdominal sepsis rate of 810 patients was 12%, abscess rate was 9.6%, and anastomotic leak rate was 3.2%. Multivariable regression modelling controlling for confounding variables demonstrated that preoperative biologic use with anti-tumour necrosis factor [p = 0.21], vedolizumab [p = 0.17], or ustekinumab [p = 0.52] was not significantly associated with intra-abdominal septic complication. Preoperative albumin < 3.5 g/dl was independently associated with intra-abdominal septic complication (odds ratio [OR] 1.76 [1.03, 3.01]). CONCLUSIONS In Crohn's disease patients undergoing ileocolic resection, preoperative biologics are not associated with 90-day postoperative intra-abdominal septic complication. Preoperative biologic exposure should not delay necessary surgery.
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Affiliation(s)
- Ravi S Shah
- Department of Internal Medicine, Cleveland Clinic, OH, USA,Corresponding author: Benjamin H. Click, MD, 9500 Euclid Avenue, A-30, Cleveland, OH 44195, USA. Tel: 216-444-1711; fax: 216-445-3889;
| | - Salam Bachour
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Xue Jia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica Philpott
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel D Regueiro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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Abstract
A 27-year-old man with fistulizing terminal ileal Crohn's disease with an ileosigmoid fistula progressed through medical management and required an abdominal operation at an outside hospital. He underwent an ileocolic resection and a debridement with oversewing of his mesenteric sigmoid fistula with a diverting loop ileostomy. After a normal colonoscopy, his stoma was reversed; however, 2 weeks later he presented to the hospital with pelvic sepsis. A CT scan with oral, intravenous, and rectal contrast demonstrated a persistent sigmoid fistula with associated abscess. After treatment with antibiotics and percutaneous drainage, the patient underwent a segmental sigmoid resection to repair the mesenteric fistula and a diverting loop ileostomy. The ileostomy has been reversed and the patient's Crohn's disease is in remission.
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Singh A, Koenen B, Kirby DF. Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients. Inflamm Bowel Dis 2020; 26:1155-1165. [PMID: 31626698 DOI: 10.1093/ibd/izz246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Indexed: 12/14/2022]
Abstract
Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.
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Affiliation(s)
- Amandeep Singh
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Koenen
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Mohan HM, Coffey JC. Surgical treatment of intestinal stricture in inflammatory bowel disease. J Dig Dis 2020; 21:355-359. [PMID: 32410340 DOI: 10.1111/1751-2980.12880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short-segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing-remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre- and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario.
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Affiliation(s)
- Helen M Mohan
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - John C Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,University of Limerick Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity, Limerick, Ireland
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Yoon YS, Stocchi L, Holubar S, Aiello A, Shawki S, Gorgun E, Steele SR, Delaney CP, Hull T. When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn’s disease? Surg Endosc 2020; 35:2543-2557. [PMID: 32468260 DOI: 10.1007/s00464-020-07670-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/21/2020] [Indexed: 12/14/2022]
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Soop M, Khan H, Nixon E, Teubner A, Abraham A, Carlson G, Lal S. Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre. J Crohns Colitis 2020; 14:1558-1564. [PMID: 32215559 PMCID: PMC7648168 DOI: 10.1093/ecco-jcc/jjaa060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported. METHODS Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records. RESULTS A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2. CONCLUSIONS IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.
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Affiliation(s)
- Mattias Soop
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK,Corresponding author: Mattias Soop, MD PhD, Department of Surgery, Ersta Hospital, Box 4619, SE 116 91 Stockholm, Sweden. Tel.: +4867146100;
| | - Haroon Khan
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Emma Nixon
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Antje Teubner
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Arun Abraham
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Gordon Carlson
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Simon Lal
- Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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