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Aljabri R, Al-Saraie S, Alhouti A. Optimizing Biologic Therapy for the Prevention of Post-Operative Recurrence in Crohn's Disease: Current Evidence and Future Perspectives. Biomedicines 2025; 13:1232. [PMID: 40427059 PMCID: PMC12108690 DOI: 10.3390/biomedicines13051232] [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: 03/09/2025] [Revised: 04/05/2025] [Accepted: 04/24/2025] [Indexed: 05/29/2025] Open
Abstract
Crohn's disease (CD) imposes a substantial burden on patients due to its chronic, relapsing nature, often necessitating surgical intervention. However, surgery is not curative, and post-operative recurrence (POR) remains a major clinical challenge, with up to 80% of patients developing endoscopic recurrence within one year if left untreated. The pathophysiology of POR is multifactorial, involving dysregulated immune responses, gut microbiota alterations, and mucosal healing impairment, highlighting the need for targeted therapeutic strategies. This review aims to explore the current landscape of POR management, focusing on biologic therapies and emerging advanced treatments. Conventional management relies on early prophylactic therapy with anti-TNF agents such as infliximab and adalimumab, which have demonstrated efficacy in reducing endoscopic and clinical recurrence. However, newer biologics, including IL-23 inhibitors (risankizumab) and Janus kinase (JAK) inhibitors (upadacitinib), have shown promise in CD management, though their role in POR remains underexplored. The lack of direct clinical evidence for advanced biologics in POR prevention, combined with inter-individual variability in treatment response, underscores the need for further research. Future directions should focus on optimizing therapeutic strategies through personalized medicine, identifying predictive biomarkers, and conducting robust trials to establish the efficacy of novel agents in POR prevention. A tailored, evidence-driven approach is essential to improving long-term outcomes and minimizing disease recurrence in post-operative CD patients.
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Affiliation(s)
- Reem Aljabri
- Division of Gastroenterology, Department of Internal Medicine, Ministry of Health of Kuwait—Farwaniya Hospital, Sabah Al-Nasser 92426, Kuwait; (S.A.-S.); (A.A.)
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Khan I, Holubar SD. Operative Management of Small and Large Bowel Crohn's Disease. Surg Clin North Am 2025; 105:247-276. [PMID: 40015815 DOI: 10.1016/j.suc.2024.09.006] [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
The majority of patients with Crohn's disease, despite an ever-increasing number of advanced therapies, require abdominal surgery during their lifetime. In this review article, the authors provide a comprehensive overview of abdominal surgery for Crohn's disease, with an evidence-based focus on surgery for upper gastrointestinal Crohn's disease, bowel-preserving surgery with strictureplasties, selection of ileocolic anastomotic technique for terminal ileal Crohn's disease, extended resections and proctectomy for Crohn's proctocolitis, intentional ileoanal pouch for Crohn's disease, and several "hot topics" including early surgery for ileocolic Crohn's disease, and surgical approaches that target the mesentery including the Kono-S anastomosis and extended mesenteric excision.
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Affiliation(s)
- Imran Khan
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA.
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3
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Choi B, Cohen D, Schwartzberg DM. Bowel Resection Margins in Crohn's Disease: Do They Matter? Clin Colon Rectal Surg 2025; 38:96-103. [PMID: 39944303 PMCID: PMC11813611 DOI: 10.1055/s-0044-1786376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2025]
Abstract
Many patients with Crohn's disease (CD) will ultimately require surgical intervention for refractory disease despite recognizing that surgery does not cure CD. The initial operation, primarily for ileocolic disease, is focused on resecting the offending pathology and ideally providing a reduced likelihood for subsequent operations and additional bowel loss through surgical techniques. The appropriate margin, macro- vs. microscopic, lays in balance to provide an adequate resection that minimizes bowel loss, compared to an extensive resection which ensures a thorough resection but inherently includes the loss of normal bowel in attempts to reduce recurrent symptomatic disease. Ensuring the appropriately timed operation, performed in optimal conditions, with apt mesenteric resections and an ideal anastomotic configuration are all only part of the equation, as bowel margins play an important role in limiting surgical recurrence and maintaining bowel length. A grossly normal margin assessed by the lack of serositis and the mesenteric "pinch test" can result in an appropriate margin without sacrificing normal bowel in this group of patients who are at risk of further bowel loss from CD recurrence.
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Affiliation(s)
- Beatrix Choi
- Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - David Cohen
- Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - David M. Schwartzberg
- Division of Colorectal Surgery, Inflammatory Bowel Disease Center, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
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Chaouch MA, Mallek W, Ben Jabra S, Jallali M, Zenati H, Ben Hassine H, Ghedira A, Boughanmi F, Touati M, Chaka A, Korbi I, Noomen F. Isoperistaltic versus antiperistaltic side-to-side ileocolic anastomosis in Crohn's disease and right colon adenocarcinoma: Controlled clinical trial. LA TUNISIE MEDICALE 2025; 103:239-249. [PMID: 40096725 PMCID: PMC12034358 DOI: 10.62438/tunismed.v103i2.5460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Accepted: 11/17/2024] [Indexed: 03/19/2025]
Abstract
INTRODUCTION Ileocolonic anastomoses are frequent in colorectal surgeries, but anastomotic leakage remains a serious complication associated with increased morbidity and mortality. The optimal peristaltic orientation for anastomosis is still debated. AIM To evaluate and compare short- and long-term outcomes of isoperistaltic (IA) and antiperistaltic (AA) side-to-side ileocolic anastomoses after right colectomy or ileocecal resection for right-sided adenocarcinoma or Crohn's disease. METHODS A single-center retrospective clinical trial was conducted at Fattouma Bourguiba University Hospital, Monastir, involving patients with right-sided colon cancer or ileocecal Crohn's disease who underwent elective resection with either IA or AA. The primary outcome was anastomotic leakage, while secondary outcomes included postoperative morbidity and long-term results. RESULTS Ninety-four patients, including 55 with right-sided colon cancer and 39 with Crohn's disease, were analyzed between January 2016 and July 2023. Of these, 48 underwent IA, and 46 underwent AA. Both anastomotic techniques exhibited similar leakage rates. Baseline and operative variables were comparable except for male predominance in AA for Crohn's disease and a higher conversion rate in AA. No significant differences were noted regarding pathological variables, operative time, bowel transit recovery, oral tolerance, hospital stay, or postoperative complications. Multivariate analysis revealed that elevated white blood cell count, R2 resection, and mucinous adenocarcinoma were risk factors for anastomotic leakage, while albumin levels and staple line reinforcement were protective factors against postoperative morbidity. CONCLUSION IA and AA demonstrated comparable safety and feasibility, though AA had a higher conversion rate. Further studies are required to optimize AA safety.
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Affiliation(s)
- Mohamed Ali Chaouch
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Ward Mallek
- Faculty of medicine of Monastir, Monastir University Hospital, Monastir, Tunisia
| | - Sadok Ben Jabra
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Maissa Jallali
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Hanene Zenati
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Hiba Ben Hassine
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Abdesslem Ghedira
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Faiez Boughanmi
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Midani Touati
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Amina Chaka
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Ibtissem Korbi
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Faouzi Noomen
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
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Shen B, Ko HM, Kiran R, Church J. Resolution of cuffitis after removal surgical staple from ileal pouch-anal anastomosis. Gastroenterol Rep (Oxf) 2025; 13:goaf002. [PMID: 39840326 PMCID: PMC11745894 DOI: 10.1093/gastro/goaf002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/27/2024] [Accepted: 06/12/2024] [Indexed: 01/23/2025] Open
Affiliation(s)
- Bo Shen
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Center for Inflammatory Bowel Diseases, New York, NY, USA
| | - Huaibin M Ko
- Division of Anatomic Pathology, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, NY, USA
| | - Ravi Kiran
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Center for Inflammatory Bowel Diseases, New York, NY, USA
| | - James Church
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Center for Inflammatory Bowel Diseases, New York, NY, USA
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van der Does de Willebois EML, Bemelman WA, Buskens CJ. Mesenteric sparing or extended resection in primary ileocolic resection for Crohn's disease - Authors' reply. Lancet Gastroenterol Hepatol 2025; 10:16-17. [PMID: 39674214 DOI: 10.1016/s2468-1253(24)00383-2] [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: 11/03/2024] [Accepted: 11/04/2024] [Indexed: 12/16/2024]
Affiliation(s)
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam 1100DD, Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam 1100DD, Netherlands.
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7
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Johnston WR, Hwang R, Mattei P. Risk Factors for Recurrence of Crohn's Disease After Ileocecal Resection and Management Strategies. J Pediatr Surg 2025; 60:161923. [PMID: 39358079 DOI: 10.1016/j.jpedsurg.2024.161923] [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: 08/25/2024] [Accepted: 09/07/2024] [Indexed: 10/04/2024]
Abstract
INTRODUCTION Pediatric patients with ileocecal Crohn's Disease (CD) refractory to medical management frequently require ileocecectomy. However, risk factors for post-operative ileocecal recurrence and appropriate management strategies are poorly defined in the pediatric literature in the biologic era. METHODS We queried our institutional database from 1/1/2012-12/31/2022 for patients aged 1-21 who underwent primary ileocecectomy for CD. We analyzed baseline characteristics, operative details, medical management, recurrence patterns, and management patterns. RESULTS We identified 208 patients who underwent primary ileocecal resection, of which 66 (23%) demonstrated endoscopic recurrence at 2.1 ± 0.5 years and 28 (13%) developed clinical recurrence at 2.5 ± 0.8 years. Recurrence was at the surgical anastomosis in 43 (21%). Before surgery, 138 (66%) were treated with a biologic, of which 25 (18%) were transitioned to a second line biologic pre-operatively. Requiring a separate intervention for perianal or intestinal disease increased the odds of recurrence on multivariable analysis, as did requiring a second line biologic. Of those with endoscopic recurrence, most [62/66 (94%)] were successfully managed with medical optimization alone. Only four (6.7%) required procedural intervention with two being managed with endoscopic balloon dilation and two requiring repeat resection and re-anastomosis. Median follow up was 2.6 years [IQR 1.2-4.5]. CONCLUSION Requiring separate interventions for perianal or intestinal disease and demonstrating disease difficult to medically control may increase the risk of recurrent post-operative ileocecal CD. Such patients should be closely surveilled for endoscopic recurrence and may warrant more aggressive medical regimens. Recurrence can typically be managed medically with few patients requiring procedural intervention. LEVEL OF EVIDENCE III.
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Affiliation(s)
- William R Johnston
- Children's Hospital of Philadelphia, Department of General, Thoracic, and Fetal Surgery, Philadelphia, PA, 19104, USA.
| | - Rosa Hwang
- Children's Hospital of Philadelphia, Department of General, Thoracic, and Fetal Surgery, Philadelphia, PA, 19104, USA
| | - Peter Mattei
- Children's Hospital of Philadelphia, Department of General, Thoracic, and Fetal Surgery, Philadelphia, PA, 19104, USA
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Aras OA, Patel AS, Satchell EK, Serniak NJ, Byrne RM, Cagir B. Comparison of outcomes in small bowel surgery for Crohn's disease: a retrospective NSQIP review. Int J Colorectal Dis 2024; 39:119. [PMID: 39073495 PMCID: PMC11286688 DOI: 10.1007/s00384-024-04661-4] [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] [Accepted: 05/28/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Despite advances in medical therapy, approximately 33% of Crohn's disease (CD) patients will need surgery within 5 years after initial diagnosis. Several surgical approaches to CD have been proposed including small bowel resection, strictureplasty, and combined surgery with resection plus strictureplasty. Here, we utilize the American College of Surgeons (ACS) national surgical quality registry (NSQIP) to perform a comprehensive analysis of 30-day outcomes between these three surgical approaches for CD. METHODS The authors queried the ACS-NSQIP database between 2015 and 2020 for all patients undergoing open or laparoscopic resection of small bowel or strictureplasty for CD using CPT and IC-CM 10. Outcomes of interest included length of stay, discharge disposition, wound complications, 30-day related readmission, and reoperation. RESULTS A total of 2578 patients were identified; 87% of patients underwent small bowel resection, 5% resection with strictureplasty, and 8% strictureplasty alone. Resection plus strictureplasty (combined surgery) was associated with the longest operative time (p = 0.002). Patients undergoing small bowel resection had the longest length of hospital stay (p = 0.030) and the highest incidence of superficial/deep wound infection (44%, p = 0.003) as well as the highest incidence of sepsis (3.5%, p = 0.03). Small bowel resection was found to be associated with higher odds of wound complication compared to combined surgery (OR 2.09, p = 0.024) and strictureplasty (1.9, p = 0.005). CONCLUSION Our study shows that various surgical approaches for CD are associated with comparable outcomes in 30-day related reoperation and readmission, or disposition following surgery between all three surgical approaches. However, small bowel resection displayed higher odds of developing post-operative wound complications.
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Affiliation(s)
- Oguz Az Aras
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA.
- Department of Internal Medicine, TriStar Centennial Medical Center, Nashville, TN, USA.
| | - Apar S Patel
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
- Department of Surgery, Geisinger Health System, Danville, PA, USA
| | - Emma K Satchell
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Nicholas J Serniak
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Raphael M Byrne
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Burt Cagir
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
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Kelm M, Benatzky C, Buck V, Widder A, Schoettker K, Rosenfeldt M, Brand M, Schlegel N, Germer CT, Meining A, Nusrat A, Flemming S. Positive resection margins in Crohn's disease are a relevant risk factor for postoperative disease recurrence. Sci Rep 2024; 14:10823. [PMID: 38734721 PMCID: PMC11088694 DOI: 10.1038/s41598-024-61697-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024] Open
Abstract
Postoperative disease recurrence in Crohn's disease represents a relevant issue despite recent advancements in surgical and medical therapies. Additional criteria are necessary to improve the identification of patients at risk and to enable selective therapeutic approaches. The role of resection margins on disease recurrence remains unclear and general recommendations are lacking. A single-center retrospective analysis was performed including all patients who received ileocecal resection due to Crohn's disease. Resection margins were analyzed by two independent pathologists and defined by histopathological criteria based on previous consensus reports. 158 patients were included for analysis with a median follow up of 35 months. While postoperative morbidity was not affected, positive resection margins resulted in significantly increased rates of severe endoscopic recurrence at 6 months (2.0% versus 15.6%, p = 0.02) and overall (4.2% versus 19.6%, p = 0.001), which resulted in significantly increased numbers of surgical recurrence (0% versus 4.5%, p = 0.04). Additionally, positive margins were identified as independent risk factor for severe endoscopic disease recurrence in a multivariate analysis. Based on that, positive margins represent an independent risk factor for postoperative endoscopic and surgical disease recurrence. Prospective studies are required to determine whether extended resection or postoperative medical prophylaxis is beneficial for patients with positive resection margins.
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Affiliation(s)
- Matthias Kelm
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Clara Benatzky
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Viktoria Buck
- Department of Pathology, University of Würzburg, Würzburg, Germany
| | - Anna Widder
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Katrin Schoettker
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | | | - Markus Brand
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Nicolas Schlegel
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany
| | - Alexander Meining
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Asma Nusrat
- Department of Pathology, University of Michigan Medical School, Ann Arbor, USA
| | - Sven Flemming
- Department for General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberduerrbacher Str., 697080, Würzburg, Germany.
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Spertino M, Gabbiadini R, Dal Buono A, Busacca A, Franchellucci G, Migliorisi G, Repici A, Spinelli A, Bezzio C, Armuzzi A. Management of Post-Operative Crohn's Disease: Knowns and Unknowns. J Clin Med 2024; 13:2300. [PMID: 38673573 PMCID: PMC11051270 DOI: 10.3390/jcm13082300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by relapsing-remission phases. CD often requires surgical intervention during its course, mainly ileo-cecal/ileo-colonic resection. However, surgery in CD is not curative and post-operative recurrence (POR) can happen. The management of CD after surgery presents challenges. Ensuring timely, effective, and safe therapy to prevent POR is essential but difficult, considering that approximately 20-30% of subjects may not experience endoscopic POR and that 40-50% will only exhibit intermediate lesions, which carry a low risk of mid- and long-term clinical and surgical POR. Currently, there are two accepted intervention strategies: early post-operative prophylactic therapy (systematically or based on the patient's risk of recurrence) or starting therapy after confirming endoscopic POR 6-12 months after surgery (endoscopy-driven prophylactic therapy). The risk of overtreatment lies in exposing patients to undesired adverse events, along with the costs associated with medications. Conversely, undertreatment may lead to missed opportunities to prevent bowel damage and the necessity for additional surgery. This article aims to perform a comprehensive review regarding the optimal strategy to reduce the risk of POR in CD patients and the current therapeutic options.
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Affiliation(s)
- Matteo Spertino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Roberto Gabbiadini
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Arianna Dal Buono
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Anita Busacca
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Gianluca Franchellucci
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Giulia Migliorisi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Cristina Bezzio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
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Ullrich SJ, Frischer JS. Surgical management of complicated Crohn's disease. Semin Pediatr Surg 2024; 33:151399. [PMID: 38642531 DOI: 10.1016/j.sempedsurg.2024.151399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2024]
Abstract
Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population - notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.
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Affiliation(s)
- Sarah J Ullrich
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA
| | - Jason S Frischer
- Colorectal Center at Cincinnati Children's Hospital, Divison of Pediatric General & Thoracic Surgery, 3333 Burnet Ave, MLC-2024, Cincinnati, OH 45229, USA.
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12
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Shehada M, McMahon LE. Recurrent Crohn's disease. Semin Pediatr Surg 2024; 33:151403. [PMID: 38593515 DOI: 10.1016/j.sempedsurg.2024.151403] [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: 04/11/2024]
Abstract
Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.
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Affiliation(s)
- Mahmoud Shehada
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Lisa E McMahon
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
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Doğru V, Ashburn JH, Akova U, Sutter AG, Esen E, Gardner EM, da Luz Moreira A, Erkan A, Kirat J, Grieco MJ, Remzi FH. Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study. ANNALS OF SURGERY OPEN 2024; 5:e374. [PMID: 38883936 PMCID: PMC11175959 DOI: 10.1097/as9.0000000000000374] [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: 02/02/2023] [Accepted: 12/08/2023] [Indexed: 06/18/2024] Open
Abstract
Objective Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. Background The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. Methods In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. Results In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. Conclusion The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.
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Affiliation(s)
- Volkan Doğru
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, NC
| | - Umut Akova
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Alton G Sutter
- Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, NC
| | - Eren Esen
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Emily M Gardner
- Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, NC
| | | | - Arman Erkan
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - John Kirat
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Michael J Grieco
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Feza H Remzi
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
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14
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Shepherd NA. Macroscopic pathology and all that: a personal view. J Clin Pathol 2024; 77:157-163. [PMID: 38123351 DOI: 10.1136/jcp-2023-209106] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
I hope that this treatise adds to the excellent reviews by Varma and colleagues, emphasising the importance of accurate macroscopic assessment and report provision. I have especially highlighted the importance of not divorcing the clinical data and the macroscopic analysis from the microscopic assessment as all are required to provide an accurate and cogent overall composition. The review has also identified areas where the evolution of pathological practice has gone a little awry and requires to be modified and/or justified with evidence base. There is also an emphasis on block economy, as there is no doubt that considerable savings can be made if more attention is paid to more judicious block selection. It is also commended that subspecialties other than gastrointestinal pathology introduce reporting quality standards, like lymph node harvest numbers and other important prognostic and management indicators, to improve the quality of macroscopic pathology worldwide to the benefit of our service users and their patients.
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Affiliation(s)
- Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham, Gloucestershire, UK
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15
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Yzet C, Riault C, Brazier F, Grados L, Nguyen-Khac E, Chatelain D, Sabbagh C, Buisson A, Diouf M, Fumery M. Positive margins and plexitis increase the risk of recurrence after ileocecal resection: A systematic review and meta-analysis. Dig Liver Dis 2023; 55:1611-1620. [PMID: 36658042 DOI: 10.1016/j.dld.2022.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/23/2022] [Accepted: 12/23/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION There is debate over the impact of residual microscopic disease after ileocecal resection in Crohn's disease (CD) to predict recurrence. We conducted a meta-analysis to evaluate the impact of positive histological margins and plexitis after ileocecal resection on the risk of postoperative recurrence. METHODS Using a systematic search, we identified. 30 studies evaluating the impact of inflammatory margins on CD recurrence. The primary outcome was the postoperative clinical recurrence and secondary outcomes were surgical, and endoscopic recurrence. We performed random-effects meta-analysis and estimated odds ratio (OR) and 95% CIs. RESULTS Thirty studies were analyzed, seven focused on myenteric plexitis, six on submucosal plexitis and twenty-three on positive margins. Inflammatory margins were associated with a higher rate of clinical and surgical recurrences: respectively 14 studies - OR 2.38; 95% CI, 1.54 - 3.68- I2 = 68.2%, Q test-p = 0.0003 and 8 studies - OR, 1.52; 95% CI, 1.07-2.16 - I2 =0%; Q test-p = 0.43. The presence of myenteric plexitis was associated with a higher rate of clinical recurrence (4 studies- OR, 1.60; 95%CI, 1.12-2.29; I2= 0%, Q-test-p = 0.61), and of endoscopic recurrence (4 studies - OR, 4.25; 95%CI; 2.06-8.76; I2= 0%, Q test-p = 0.97). Submucosal plexitis was not associated with an increased risk of endoscopic recurrence (4 studies - OR, 0.94; 95%CI; 0.58-1.52; I2= 0%, Q test-p = 0.79). CONCLUSION Inflammatory margins and/or plexitis were associated with postoperative recurrence after ileocecal resection for CD. These elements should be taken into account in future algorithm for prevention of postoperative recurrence.
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Affiliation(s)
- Clara Yzet
- Department of gastroenterology, Amiens University hospital, Picardie University, Amiens, France
| | - Clémentine Riault
- Department of gastroenterology, Amiens University hospital, Picardie University, Amiens, France
| | - Franck Brazier
- Department of gastroenterology, Amiens University hospital, Picardie University, Amiens, France
| | - Lucien Grados
- Department of gastroenterology, Amiens University hospital, Picardie University, Amiens, France
| | - Eric Nguyen-Khac
- Department of gastroenterology, Amiens University hospital, Picardie University, Amiens, France
| | | | | | - Anthony Buisson
- Department of gastroenterology, Clermont-Ferrand University hospital, Clermont-Ferrand, France
| | - Momar Diouf
- Department of statistics, Amiens University hospital, Picardie University, Amiens, France
| | - Mathurin Fumery
- Department of gastroenterology, Amiens University hospital, Picardie University, Amiens, France; PériTox Laboratory, Périnatalité & Risques Toxiques, UMR-I 01 INERIS, Picardie Jules Verne University, Amiens, France.
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16
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Rivière P, Bislenghi G, Hammoudi N, Verstockt B, Brown S, Oliveira-Cunha M, Bemelman W, Pellino G, Kotze PG, Ferrante M, Panis Y. Results of the Eighth Scientific Workshop of ECCO: Pathophysiology and Risk Factors of Postoperative Crohn's Disease Recurrence after an Ileocolonic Resection. J Crohns Colitis 2023; 17:1557-1568. [PMID: 37070326 DOI: 10.1093/ecco-jcc/jjad054] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Postoperative recurrence [POR] after an ileocolonic resection with ileocolonic anastomosis is frequently encountered in patients with Crohn's disease. The 8th Scientific Workshop of ECCO reviewed the available evidence on the pathophysiology and risk factors for POR. In this paper, we discuss published data on the role of the microbiome, the mesentery, the immune system and the genetic background. In addition to investigating the causative mechanisms of POR, identification of risk factors is essential to tailor preventive strategies. Potential clinical, surgical and histological risk factors are presented along with their limitations. Emphasis is placed on unanswered research questions, guiding prevention of POR based on individual patient profiles.
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Affiliation(s)
- Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Nassim Hammoudi
- Department of Gastroenteology, Hôpital Saint-Louis, APHP, INSERM U1160, Université Paris Cité, Paris, France
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Steven Brown
- Department of Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Melissa Oliveira-Cunha
- Department of Colorectal Surgery, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, location Meibergdreef, Amsterdam, the Netherlands
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Science, Università Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
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17
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Vieujean S, Kotze PG, Netter P, Germain A, Louis E, Danese S, Peyrin-Biroulet L. Stemming the tide with ileocecal Crohn's disease: when is pharmacotherapy enough? Expert Opin Pharmacother 2023; 24:1595-1607. [PMID: 37401098 DOI: 10.1080/14656566.2023.2232726] [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: 09/13/2022] [Accepted: 06/30/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Crohn's disease (CD) mostly affects the terminal ileum and ileocecal region and up to 80% of patients end up requiring surgery. Previously reserved for complicated or refractory forms, surgery is now considered as an alternative to medical treatment in localized ileocecal disease. AREAS COVERED This review examines factors associated with response to medical treatment and those associated with the need for surgery in ileocecal CD to identify the patients' profile for whom pharmacotherapy might be enough. Factors associated with the recurrence and the postoperative complications are also reviewed to help the clinician identify patients for whom medical therapy might be preferred. EXPERT’S OPINION LIR!C study long-term follow-up data show that 38% of infliximab-treated patients were still treated with infliximab at the end of their follow-up, while 14% had switched to another biologic or had received immunomodulator or corticosteroid and 48% had CD-related surgery. Only the combination with an immunomodulator was associated with a greater likelihood of continuing infliximab. Patients with ileocecal CD for whom pharmacotherapy might be sufficient are probably those with no risk factors for CD-related surgery.In addition, patients with high risk of recurrence or of post-operative complications may benefit more from medical treatment than from surgery.
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Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná, Curitiba, Brazil
| | - Patrick Netter
- Université de Lorraine, CNRS, Laboratoire IMoPa, Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-Les-Nancy, France
| | - Edouard Louis
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, INSERM, NGERE, Nancy, France
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18
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Aggeletopoulou I, Tsounis EP, Mouzaki A, Triantos C. Creeping Fat in Crohn's Disease-Surgical, Histological, and Radiological Approaches. J Pers Med 2023; 13:1029. [PMID: 37511642 PMCID: PMC10381426 DOI: 10.3390/jpm13071029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
During the course of Crohn's disease, the response of mesenteric adipose tissue to the production of inflammatory mediators and bacterial invasion through the intestinal mucosa results in the formation of creeping fat. Creeping fat describes the arresting finger-like projections that surround the inflamed bowel. In this review, the microscopic and macroscopic features of creeping fat and histological evidence for the importance of this tissue are discussed. Moreover, the most recent insights into the radiological assessment of creeping fat in patients with Crohn's disease are reported. Advances in imaging techniques have revolutionized the possibility of visualization and quantification of adipose tissue depots with excellent accuracy. Visceral fat has been significantly correlated with various Crohn's-disease-related outcomes. Despite the difficulties in distinguishing physiologic perienteric fat from creeping fat, the growing interest in fat-wrapping in Crohn's disease has rejuvenated radiologic research. With regard to the noninvasive fat-wrapping assessment, a novel CT enterography-based mesenteric creeping fat index has been developed for the mitigation of the confounding effect of normal retroperitoneal and perienteric adipose tissue. Research on machine learning algorithms and computational radiomics in conjunction with mechanistic studies may be the key for the elucidation of the complex role of creeping fat in Crohn's disease.
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Affiliation(s)
- Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.)
- Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, 26504 Patras, Greece;
| | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.)
| | - Athanasia Mouzaki
- Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, 26504 Patras, Greece;
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.)
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19
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Lee KE, Cantrell S, Shen B, Faye AS. Post-operative prevention and monitoring of Crohn's disease recurrence. Gastroenterol Rep (Oxf) 2022; 10:goac070. [PMID: 36405006 PMCID: PMC9667961 DOI: 10.1093/gastro/goac070] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 10/22/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are relapsing and remitting chronic inflammatory diseases of the gastrointestinal tract. Although surgery for UC can provide a cure, surgery for CD is rarely curative. In the past few decades, research has identified risk factors for postsurgical CD recurrence, enabling patient risk stratification to guide monitoring and prophylactic treatment to prevent CD recurrence. A MEDLINE literature review identified articles regarding post-operative monitoring of CD recurrence after resection surgery. In this review, we discuss the evidence on risk factors for post-operative CD recurrence as well as suggestions on post-operative management.
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Affiliation(s)
- Kate E Lee
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Adam S Faye
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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20
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Maher D, Ting P, Edmundson A, Cuda TJ, Clark DA. Diminishing lengths of subsequent bowel resections in the surgical management of ileal Crohn's disease. ANZ J Surg 2022; 92:2921-2925. [PMID: 36129467 DOI: 10.1111/ans.18047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Crohn's disease is a chronic inflammatory bowel disease that most commonly affects the ileum. As a result, it is associated with a high lifetime risk of one or more surgical resections. The surgical paradigm is to preserve intestinal length. This study aims to assess the length of ileum resected at the index operation and at subsequent ileocolic resections for Crohn's disease. METHODS This is a retrospective study assessing the clinical and pathological data of patients undergoing ileocolic resection for the management of Crohn's disease over the period 01/01/2002 to 31/07/2020 in two metropolitan Australian hospitals. RESULTS One hundred and seventy-six patients were analysed: 130 underwent a single resection; 31 underwent two resections; and 15 underwent three resections. The median age at the first operation was 37.2 years (range 18-69) with 60% of patients female. The median length resected at the first surgery was 17.8 cm (IQR 12.0) for small bowel, and 5.0 cm (IQR 1.0) for large bowel. The length of ileum resected at the first surgery was significantly greater than that of the second (P = 0.0001), without significant differences between the second and third resections (P = 0.49). The time interval from diagnosis to the first surgery had no significant impact on the length of intestine resected at the index ileocolic resection. CONCLUSION In Crohn's disease, the length of ileum removed at first resection is the greatest, with subsequent resection lengths less than the first.
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Affiliation(s)
- Declan Maher
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Pascallina Ting
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Aleksandra Edmundson
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Tahleesa J Cuda
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Medical Imaging Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - David A Clark
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Surgery, St Vincent's Private Hospital Northside, Brisbane, Queensland, Australia
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21
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Sacchetti F, Caprino P, Potenza AE, Pastena D, Presacco S, Sofo L. Early and late outcomes of a series of 255 patients with Crohn's disease who underwent resection: 10 years of experience at a single referral center. Updates Surg 2022; 74:1657-1664. [PMID: 35841530 PMCID: PMC9481492 DOI: 10.1007/s13304-022-01322-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/17/2022] [Indexed: 11/27/2022]
Abstract
Patients with Crohn's disease experience an increased risk of postoperative complications and disease recurrence. The aim of this study was to investigate the role of the risk factors in determining these outcomes and whether preoperative removal of some of these risk factors would optimize the results. We conducted a retrospective study analyzing a consecutive series of 255 patients who underwent surgical resection for Crohn's disease between 2010 and 2020. We considered short- and long-term endpoints, such as postoperative complications categorized according to the Clavien–Dindo classification and the appearance of surgical and endoscopic postoperative recurrence. Univariable and multivariable analyses showed that multiple and extensive localizations increased the incidence of postoperative complications (OR = 2.19; 95% CI 1.05–4.5; p = 0.035 and OR = 1.015; 95% CI 1.003–1.028; p = 0.017 for each cm of resected segment, respectively). Regarding theoretically modifiable factors, preoperative hypoalbuminemia (for each g/L reduction) increased the risk of complications with an OR = 1.1; 95% CI 1.02–1.12; p = 0.003. Preoperative steroid therapy exerted a similar effect, with an OR = 2.6; 95% CI 1.1–5.9; p = 0.018. Modifying these last two risk factors by improving the nutritional status or discontinuing steroid therapy significantly reduced complications. Microscopic positivity of the resection margins was a risk factor for surgical recurrence (OR = 8.7; 95% CI 1.9–40; p = 0.05). Based on the results of the present study, surgeons must examine modifiable risk factors, and careful preoperative tailored management may reduce postoperative complications and disease recurrence.
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Affiliation(s)
- Franco Sacchetti
- Abdominal Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli”-IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Paola Caprino
- Abdominal Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli”-IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Angelo Eugenio Potenza
- Abdominal Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli”-IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Dario Pastena
- Abdominal Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli”-IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | | | - Luigi Sofo
- Abdominal Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli”-IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
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22
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Abstract
Treatment of Crohn's disease (CD) focuses on providing acceptable quality of life for the affected individual by optimizing medical therapy, endoscopic procedures, and surgical intervention. Biologics have changed the medical management of moderate to severe CD. However, despite their introduction, the need for surgical resection in CD has not drastically changed, with two-thirds of the patients still requiring an intestinal resection. Patient outcomes are optimized by focusing on preoperative management and intraoperative technical aspects to maximize bowel preservation. This article reviews some of the important principles of Crohn's surgery to help guide surgeons when approaching this challenging patient population.
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Affiliation(s)
- Valery Vilchez
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA; Center for Regenerative Medicine and Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Center for Immunotherapy, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
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23
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Gklavas A, Tiniakos D, Karandrea D, Karamanolis G, Bamias G, Papaconstantinou I. Specific Neuropeptide Expression in Crohn's Disease Ileocolonic Resection Specimens Is Not Associated with Plexitis at the Ileal Margin or Postoperative Recurrence. J Gastrointest Surg 2022; 26:887-899. [PMID: 34997467 DOI: 10.1007/s11605-021-05215-7] [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: 10/10/2021] [Accepted: 11/24/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Myenteric plexitis is considered a risk factor for postoperative recurrence (POR) in Crohn's disease (CD). The primary purpose of this study was to evaluate the association between neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), and substance P (SP) expression and plexitis at the proximal resection margin. The secondary aim was to identify risk factors for POR. METHODS A retrospective, single-center study on CD patients who underwent ileocolonic resection (ICR) between January 2010 and December 2016 was conducted. The presence and severity of plexitis were evaluated by hematoxylin and eosin stain. Mast cells were highlighted by Giemsa stain. Immunohistochemistry was used to identify T lymphocytes and NPY-, VIP-, and SP-ergic neurons. Neuropeptide expression was quantified using image analysis. RESULTS Seventy-nine patients were included. No association was detected between NPY, VIP, and SP expression and plexitis. Similarly, the number of involved inflammatory cells, T lymphocytes or mast cells was not correlated with neuropeptide expression. Smoking (hazard ratio [HR] 4.07; 95% confidence interval [CI] 2.08-7.94; p < 0.001), moderate (HR 3.68; 95%CI 1.06-12.73; p = 0.040), and severe myenteric plexitis (HR 7.36; 95%CI 1.12-48.30; p = 0.037) were independent risk factors for endoscopic POR, whereas smoking (HR 2.78; 95%CI 1.01-7.67; p = 0.049), severe myenteric plexitis (HR 20.03; 95%CI 1.09-368.28; p = 0.044), and involved ileal margin (HR 3.45; 95%CI 1.33-8.96; p = 0.011) for clinical POR. CONCLUSIONS Smoking, moderate or severe myenteric plexitis, and involved ileal margin negatively affect POR in CD patients undergoing ICR. Submucosal and myenteric plexitis at the proximal resection margin is not related to the expression of specific neuropeptides.
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Affiliation(s)
- Antonios Gklavas
- Second Department of Surgery, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dina Tiniakos
- Department of Pathology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Despoina Karandrea
- Department of Pathology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Karamanolis
- Gastroenterology Unit, Second Department of Surgery, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Giorgos Bamias
- Gastrointestinal Unit, Third Department of Internal Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Papaconstantinou
- Second Department of Surgery, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Can Enteric Fistulae in Patients with Crohn's Disease Occur in Isolation: Findings from 500 Consecutive Operative Cases. J Gastrointest Surg 2022; 26:643-651. [PMID: 34845653 DOI: 10.1007/s11605-021-05199-4] [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: 07/31/2021] [Accepted: 10/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND OR PURPOSE Enteric Crohn's disease (CD) is characterized by transmural inflammation resulting in inflammatory, stricturing, or penetrating phenotypes. However, data regarding the relationship between stricturing and penetrating behavior is lacking. The incidence of penetrating CD in the absence of a stricture is unclear. The aim of this study is to assess if enteric fistulae in adult patients undergoing abdominal surgery for symptomatic CD occur in isolation. METHODS Resection or repair of enteric CD fistulae performed in a quaternary care referral center (2009-2017) was analyzed. Fistulae associated with pelvic or continent pouch, rectal stump, or ano-vagina were excluded. Fistulae were stratified based on origin, tract, target, and relationship to stricture. Strictures were stratified as inflammatory or fibrostenotic. RESULTS Five hundred consecutive operative reports were reviewed. A total of 490 fistulae were evaluated. Two hundred ninety-nine fistulae were in patients undergoing index surgery. Incidence of CD fistulae not associated with stricture was 14.9% in total, but only 8% in the index surgery cohort. The majority of fistulae originated from the ileum (95%). CD fistulae originating from the stomach or duodenum were not identified in the index cohort. Fistulae within an inflammatory stricture were likely to include an intra-abdominal abscess (p < 0.001). Fistulae associated with a fibrostenotic stricture were more likely to originate proximal to the stricture (p < 0.001). The incidence of fistula-associated adenocarcinoma was 0.6%. CONCLUSIONS Symptomatic CD fistulae in the absence of stricture are uncommon. Caution should be exercised when making a diagnosis of CD in the presence of enteric fistulae, but an absence of stricture, particularly in patients with prior abdominal surgery.
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Click B, Merchea A, Colibaseanu DT, Regueiro M, Farraye FA, Stocchi L. Ileocolic Resection for Crohn Disease: The Influence of Different Surgical Techniques on Perioperative Outcomes, Recurrence Rates, and Endoscopic Surveillance. Inflamm Bowel Dis 2022; 28:289-298. [PMID: 33988234 DOI: 10.1093/ibd/izab081] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Indexed: 12/16/2022]
Abstract
Ileocolic resection (ICR) is the most common surgical procedure in Crohn disease (CD). There are many surgical techniques for performing ICRs and subsequent anastomoses. Recurrence of CD after ICR is common, often clinically silent, and thus requires monitoring including periodic use of endoscopy to detect early active disease. There is emerging evidence that surgical approaches may influence CD recurrence. This review explores the various surgical considerations, the data behind each decision, and how these techniques influence subsequent endoscopic surveillance.
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Affiliation(s)
- Benjamin Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, United States
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, United States
| | - Francis A Farraye
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Luca Stocchi
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
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Reynolds IS, Doogan KL, Ryan ÉJ, Hechtl D, Lecot FP, Arya S, Martin ST. Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection. Front Surg 2021; 8:804137. [PMID: 34977147 PMCID: PMC8718441 DOI: 10.3389/fsurg.2021.804137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.
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Affiliation(s)
- Ian S. Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
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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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Zemel M, Solo E, Tulchinsky H. Does microscopic involvement of the surgical margins after ileocecectomy in Crohn's patients predict early recurrence? Int J Colorectal Dis 2021; 36:2427-2435. [PMID: 33928416 DOI: 10.1007/s00384-021-03941-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The primary aim of this study was to determine whether the microscopic presence of Crohn's disease (CD) in the resected specimen margins in patients undergoing ileocecectomy predicts disease recurrence. The secondary aim was to identify other risk factors which can predict recurrence. METHODS All CD patients who underwent ileocecectomy in a single colorectal unit between 2000 and 2015 were retrospectively evaluated. The diagnosis of CD and margin involvement status were retrieved from pathology reports. Recurrence was determined according to medical records or via a telephone questionnaire. Demographic, clinical, and surgical parameters were compared between patients with and without histopathologic evidence of CD in the resected margins. RESULTS A total of 202 CD patients were included, 49 with and 153 without evidence of microscopic involvement in the resected margins. The main demographic characteristics, surgical approach and procedure, and postoperative course, including medical treatment, clinical or endoscopic recurrence, and reoperation rates, were similar for both groups. Patients who were operated laparoscopically (n=58, p 0.016), conversion from laparoscopic to open (n=25, p 0.016), stapled anastomosis (n=150, p 0.004), when stricturoplasty was required (n=12, p 0.046), and those with perianal disease (n=32, p 0.045) had shorter time to recurrence. Male gender had increased hazard ratio (n=106, HR 1.38) for reoperation, but not significantly (p=0.058). CONCLUSIONS The presence of microscopic CD at the resected specimen margins was not associated with the risk of disease recurrence. Other demographic, clinical, and technical features that did correlate with early recurrence were identified. These results support a conservative approach to the extent of resection in CD patients undergoing ileocecectomy. TRIAL REGISTRATION Not relevant.
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Affiliation(s)
- Meir Zemel
- The Colorectal Unit, Surgical Division, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel Aviv, Israel
| | - Elian Solo
- The Colorectal Unit, Surgical Division, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel Aviv, Israel
| | - Hagit Tulchinsky
- The Colorectal Unit, Surgical Division, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel Aviv, Israel.
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Kamel S, Sakr M, Hamed W, Eltabbakh M, Sherief A, Rashad H, Elghamrini Y, Elbaz A. Characterization of Crohn's disease patients in Egypt: Risk factors for postoperative recurrence (A cohort study). Ann Med Surg (Lond) 2021; 69:102781. [PMID: 34527234 PMCID: PMC8430268 DOI: 10.1016/j.amsu.2021.102781] [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: 08/10/2021] [Revised: 08/23/2021] [Accepted: 09/02/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of study to identify the characterizations of Crohn's disease in Egyptian patients and to determine its predictors for postoperative recurrence. METHODS We conducted a retrospective observational cohort study on 15 patients diagnosed as Crohn's disease with surgical interventions. Different characteristics of studied patients were analyzed to determine the risk factors for postoperative recurrence such as age at diagnosis, gender, smoking, main presenting symptom, Montreal classification, perianal disease, laboratory findings and protocol of management including surgical characteristics like age at operation, surgical indication, preoperative medication, surgical approach, and operative findings. RESULTS Nine of the studied patients (60%) suffered from clinical postoperative recurrence with mean duration of 23.5 ± 40.6 months. In comparison the demographic, clinical, operative, and medical treatment data between patients with postoperative recurrence of Crohn's disease and those without recurrence, age at diagnosis (mean age 42.9 years) and age at operation (mean 44.7 years) were found statistically significant in postoperative recurrence group (p-value = 0.001). According to Montreal classification of Crohn's disease, patients >40 years were significantly found in postoperative recurrence group, while patients between 17 and 40 years were significantly found in postoperative non-recurrence group (p-value=0.007) and ileal location of Crohn's disease was found significantly in postoperative recurrent group (p-value=0.044). Postoperative biological therapy significantly decreased the incidence of postoperative recurrence in the current study (p-value= 0.041). CONCLUSIONS Age at diagnosis, age at operation, ileal location of Crohn's disease can significantly predict postoperative recurrence. Also, postoperative biological therapy can significantly decrease the incidence of postoperative recurrence.
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Affiliation(s)
- Shimaa Kamel
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Mohamed Sakr
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Waleed Hamed
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Mohamed Eltabbakh
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Ahmed Sherief
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Heba Rashad
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Yasser Elghamrini
- Department of General Surgery, Ain Shams University, Abbasiya, Cairo, Egypt
| | - Ahmed Elbaz
- Department of Tropical Medicine, Gastroenterology, and Hepatology, Ain Shams University, Abbasiya, Cairo, Egypt
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Riault C, Diouf M, Chatelain D, Yzet C, Turpin J, Brazier F, Dupas JL, Sabbagh C, Nguyen-Khac E, Fumery M. Positive histologic margins is a risk factor of recurrence after ileocaecal resection in Crohn's disease. Clin Res Hepatol Gastroenterol 2021; 45:101569. [PMID: 33199239 DOI: 10.1016/j.clinre.2020.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Surgical resection is not curative in Crohn's disease (CD) and, recurrence after surgery is a common situation. The identification of patients at high risk of recurrence remains disappointing in clinical practice. OBJECTIVE To evaluate the impact of residual microscopic disease on margins on the risk of recurrence after ileocaecal resection in CD. PATIENTS AND METHODS All patients who underwent ileocaecal resection between January 1992 and December 2016 were prospectively identified. Demographic data, clinical, surgical and histological variables were retrospectively collected. Positive histologic margin was assessed prospectively and defined by the presence of acute inflammatory lesions on margins: erosion, ulceration, chorion infiltration by neutrophils, cryptic abscesses or cryptitis. RESULTS One hundred twenty five patients were included, with a median follow-up of 8 years (Interquartile Range (IQR), 4.3-15.2). Half (49.6%, n = 62) were women, and the median age at surgery was 33 years (IQR, 24-42). Fifty-six (44.8%) had positive inflammatory margins. Five years after surgery, respectively 29 (51%) and 23 (34%) patients with positive and negative margins had clinical recurrence (p = 0.034). At the end of the follow-up, respectively 60% (n = 34) and 47% (n = 33) patients had clinical recurrence (p = 0.07). CD-related hospitalizations were observed in respectively 37.5% (n = 21) and 18.8% (n = 13) with positive and negative margins (p = 0.02). Fourteen patients (25%) with positive intestinal margins had surgical recurrence at the end of the follow-up compared to 5 patients (7%) with negative margins (p = 0.04). Multivariate analysis confirmed that positive intestinal margin was independently associated with surgical recurrence (OR, 4.7 (CI95%, 1.4-15.3), p = 0.01). CONCLUSION Positive histologic margin was associated with an increased risk of clinical and surgical recurrence after ileocaecal resection for Crohn's disease.
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Affiliation(s)
- Clementine Riault
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Momar Diouf
- Pathology Unit, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Denis Chatelain
- Department of Biostatistics, University Hospital of Amiens, Amiens, France
| | - Clara Yzet
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Justine Turpin
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Franck Brazier
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Jean-Louis Dupas
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Charles Sabbagh
- Digestive Surgery, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Eric Nguyen-Khac
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Mathurin Fumery
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France.
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Wagner M, Mayer BFB, Bodenstedt S, Kowalewski KF, Nickel F, Speidel S, Fischer L, Kenngott HG, Müller-Stich BP. Comparison of Conventional Methods for Bowel Length Measurement in Laparoscopic Surgery to a Novel Computer-Assisted 3D Measurement System. Obes Surg 2021; 31:4692-4700. [PMID: 34331186 PMCID: PMC8490232 DOI: 10.1007/s11695-021-05620-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 12/05/2022]
Abstract
Purpose Accurate laparoscopic bowel length measurement (LBLM), which is used primarily in metabolic surgery, remains a challenge. This study aims to three conventional methods for LBLM, namely using visual judgment (VJ), instrument markings (IM), or premeasured tape (PT) to a novel computer-assisted 3D measurement system (BMS). Materials and Methods LBLM methods were compared using a 3D laparoscope on bowel phantoms regarding accuracy (relative error in percent, %), time in seconds (s), and number of bowel grasps. Seventy centimeters were measured seven times. As a control, the first, third, fifth, and seventh measurements were performed with VJ. The interventions IM, PT, and BMS were performed following a randomized order as the second, fourth, and sixth measurements. Results In total, 63 people participated. BMS showed better accuracy (2.1±3.7%) compared to VJ (8.7±13.7%, p=0.001), PT (4.3±6.8%, p=0.002), and IM (11±15.3%, p<0.001). Participants performed LBLM in a similar amount of time with BMS (175.7±59.7s) and PT (166.5±63.6s, p=0.35), but VJ (64.0±24.0s, p<0.001) and IM (144.9±55.4s, p=0.002) were faster. Number of bowel grasps as a measure for the risk of bowel lesions was similar for BMS (15.8±3.0) and PT (15.9±4.6, p=0.861), whereas VJ required less (14.1±3.4, p=0.004) and IM required more than BMS (22.2±6.9, p<0.001). Conclusions PT had higher accuracy than VJ and IM, and lower number of bowel grasps than IM. BMS shows great potential for more reliable LBLM. Until BMS is available in clinical routine, PT should be preferred for LBLM. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05620-6.
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Affiliation(s)
- Martin Wagner
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Benjamin F B Mayer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Sebastian Bodenstedt
- Division of Translational Surgical Oncology, National Center for Tumor Diseases, Partner-Site Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Karl-Friedrich Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.,Department of Urology and Urological Surgery, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer, 68167, Mannheim, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Stefanie Speidel
- Division of Translational Surgical Oncology, National Center for Tumor Diseases, Partner-Site Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Lars Fischer
- Department for General and Visceral Surgery, Hospital Mittelbaden, Balger Str. 50, 76532, Baden-Baden, Germany
| | - Hannes G Kenngott
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat-Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Lowenfeld L, Michelassi F. Managing Stricturing Crohn's Disease: Resect? Strictureplasty? Dilate? J Laparoendosc Adv Surg Tech A 2021; 31:881-889. [PMID: 34265212 DOI: 10.1089/lap.2021.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Crohn's disease (CD) is a pan-intestinal disease of the gastrointestinal tract characterized by inflammatory, penetrating, and fibrostenotic phenotypes. Fibrostenotic stricture formation, without inflammatory or penetrating disease, is a common complication in CD, primarily affecting the small intestine and leading to small bowel obstruction. Because there is no medical therapy that prevents or reverses stricturing disease, endoscopic and surgical treatments are the mainstays of treatment, indicated to palliate symptoms and treat the complications. Endoscopic approaches include dilation, stricturotomy, and endoscopic stenting. Surgical options include resection, intestinal bypass, and various strictureplasty techniques. In this article, we will focus on the treatment of stricturing CD: specifically, the considerations important in choosing between different treatment options and technical tips to deal with complicated disease.
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Affiliation(s)
- Lea Lowenfeld
- Division of Colon and Rectal Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Fabrizio Michelassi
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
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Watanabe Y, Murata M, Hirota M, Suzuki R. Whole jejunoileal diverticulosis with recurrent inflammation and perforation: A case report. Int J Surg Case Rep 2021; 84:106020. [PMID: 34119945 PMCID: PMC8196046 DOI: 10.1016/j.ijscr.2021.106020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/22/2021] [Accepted: 05/22/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Jejunoileal diverticulitis is uncommon and poorly understood. We report a case of whole jejunoileal diverticulosis with recurrent inflammation and perforation. Case presentation A 72-year-old man with hemodialysis presented with fever and abdominal pain. The patient had a medical history of twice having jejunoileal diverticulitis. Serum testing indicated a white blood cell count of 15,670/μL and a C-reactive protein level of 10.31 mg/dL. Contrast-enhanced computed tomography showed jejunoileal diverticulosis with the concomitant mesenteric fat opacity and a 60-mm × 45-mm mass lesion containing extraluminal air bubbles. Jejunoileal partial resection was performed. Multiple diverticulosis was recognized over the entire jejunoileum, and the pouches existed along entry points of the bowel vascular supply through the mesentery. Intestinal resection was limited to the intestinal loop associated with complicated diverticulitis with abscess. Macroscopic examination revealed multiple jejunoileal diverticulosis. In the reddened mucosa, the diverticulitis and mesenteric perforation were recognized. Microscopic examination showed protrusion of mucosal and submucosal layers through a defect in the muscular layer with gangrenous inflammation. These findings supported a diagnosis of jejunoileal diverticulitis with perforation and abscess. The patient had no postoperative complications and no recurrence within 6 months. Discussion Treatment for jejunoileal diverticulitis should be individualized for each patient according to their degree of inflammation, recurrence, and the patient's background. Conclusion Extensive diverticulosis over the entire jejunoileum is very rare. In this case, the section of the inflamed diverticulosis can be distinguished and resected to avoid a short-bowel syndrome, which should lead to an uneventful postoperative course.
Jejunoileal diverticulitis is uncommon in clinical practice and poorly understood. Multiple diverticula were recognized over the entire jejunoileum in our case. Treatment for jejunoileal diverticulitis should be individualized for each patient. The section involving only the inflamed diverticulosis should be resected to avoid a short-bowel.
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Affiliation(s)
- Yoshifumi Watanabe
- Department of Surgery, Hoshigaoka Medical Center, 4-8-1 Hoshigaoka, Hirakata, Osaka, Japan.
| | - Masaru Murata
- Department of Surgery, Hoshigaoka Medical Center, 4-8-1 Hoshigaoka, Hirakata, Osaka, Japan.
| | - Masashi Hirota
- Department of Surgery, Hoshigaoka Medical Center, 4-8-1 Hoshigaoka, Hirakata, Osaka, Japan.
| | - Rei Suzuki
- Department of Surgery, Hoshigaoka Medical Center, 4-8-1 Hoshigaoka, Hirakata, Osaka, Japan.
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Tavares de Sousa H, Gullo I, Castelli C, Dias CC, Rieder F, Carneiro F, Magro F. Ileal Crohn's Disease Exhibits Similar Transmural Fibrosis Irrespective of Phenotype. Clin Transl Gastroenterol 2021; 12:e00330. [PMID: 33848279 PMCID: PMC8049162 DOI: 10.14309/ctg.0000000000000330] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/17/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION In Crohn's disease (CD), the assessment of transmural inflammation and fibrosis is of utmost importance. This study aimed to quantify these parameters in CD ileal specimens and correlate them with disease progression. METHODS This is a retrospective unicentric study based on the analysis of archived specimens (n = 103) of primary ileal resection. Data were retrieved from a prospective national inflammatory bowel disease registry. Two pathologists, blinded for CD phenotype and clinical indications for surgery, examined 3 sections per patient and graded inflammation and fibrosis, based on a histopathological score. RESULTS Penetrating (B3, n = 74) CD exhibited significantly higher inflammation in diseased areas, compared with stricturing (B2, n = 29) disease (score 3: 96% vs 76%, P = 0.005 in inflamed areas; 78% vs 55%, P = 0.019 in most affected areas). This was also observed for the comparison of B2 CD with B3 CD with (B3s, n = 54) and without associated stricture (B3o, n = 20): B3s vs B2: 81% vs 55%, P = 0.033 in most affected areas; B3o vs B2: 100% vs 76%, P = 0.006 in inflamed areas; 70% vs 55%, P = 0.039 in most affected areas. We could not show differences in fibrosis scores between the subphenotypes. Postoperative new penetrating events occurred only in B3s (n = 6, 11%, P = 0.043) patients. The changing of biologic therapy after surgery correlated with severe inflammation at the proximal ileal margin (55% changed vs 25% not changed, P = 0.035). DISCUSSION In our cohort, fibrosis scores and fibromuscular changes were comparable, irrespective of CD phenotype. Inflammation severity was the major differentiator between penetrating and stricturing disease.JOURNAL/cltg/04.03/01720094-202104000-00012/inline-graphic1/v/2021-04-13T161901Z/r/image-tiff.
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Affiliation(s)
- Helena Tavares de Sousa
- Gastroenterology Department, Algarve University Hospital Center, Portimão, Portugal
- ABC—Algarve Biomedical Center, University of Algarve, Faro, Portugal
| | - Irene Gullo
- Department of Pathology, São João University Hospital Center and Faculty of Medicine, University of Porto, Porto, Portugal
- Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Porto, Portugal
- Institute of Investigation and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Claudia Castelli
- Section of Pathology, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Fátima Carneiro
- Department of Pathology, São João University Hospital Center and Faculty of Medicine, University of Porto, Porto, Portugal
- Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Porto, Portugal
- Institute of Investigation and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Fernando Magro
- Unit of Pharmacology and Therapeutics, Department of Biomedicine, Faculty of Medicine, University of Porto, Portugal
- Department of Gastroenterology, São João University Hospital Center, Porto, Portugal
- MedInUP, Center for Drug Discovery and Innovative Medicines, Porto, Portugal
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Ozgur I, Kulle CB, Buyuk M, Ormeci A, Akyuz F, Balik E, Bulut T, Keskin M. What are the predictors for recurrence of Crohn's disease after surgery? Medicine (Baltimore) 2021; 100:e25340. [PMID: 33832109 PMCID: PMC8036018 DOI: 10.1097/md.0000000000025340] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
Surgical resection is an unavoidable part of the current treatment options for Crohn's disease (CD), and more than half of patients develop recurrence. The aim of this study was to investigate the predictors for recurrence in the long-term follow-up of CD patients after surgery.Medical records of consecutive CD patients who were operated on between January 2003 and January 2015 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients were recorded. Recurrence was evaluated based on the Crohn's Disease Activity Index or endoscopic findings.The majority of 112 patients were males (n = 64, 57.1%), and 61 (54.4%) of them were active smokers. The median follow-up was 113 (range: 61-197) months. Disease recurrence occurred in 16 (14.3%) patients at a median of 13.5 months. The endoscopic recurrence rate was 8% (n = 9) at 1 year, 12.5% (n = 14) at 5 years, and 13.4% (n = 15) at 10 years. One (0.9%) patient underwent colonoscopic balloon dilatation at 1 year, and 7 (6.3%) patients needed re-resection at a median of 36 months. The age of the patient at the time of diagnosis (P = .033), penetrating disease behavior (P = .011), intra-abdominal abscess (P = 0.040) and, concomitant fistula and intra-abdominal abscess (P = .017) were associated with disease recurrence.Our study results suggest that the patients' age at the time of diagnosis, penetrating disease, intra-abdominal abscess, and concomitant fistula and abscess are the risk factors for CD recurrence after surgery.
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Affiliation(s)
- Ilker Ozgur
- Gastrointestinal Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University
| | - Cemil Burak Kulle
- Department of General Surgery, VKV Koc University Hospital, VKV Koc University Medicine School
| | | | - Asli Ormeci
- Gastroenterohepatology, Department of Internal Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Filiz Akyuz
- Gastroenterohepatology, Department of Internal Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, VKV Koc University Hospital, VKV Koc University Medicine School
| | - Turker Bulut
- Gastrointestinal Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University
| | - Metin Keskin
- Gastrointestinal Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University
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36
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Tandon P, Malhi G, Abdali D, Pogue E, Marshall JK, de Buck van Overstraeten A, Riddell R, Narula N. Active Margins, Plexitis, and Granulomas Increase Postoperative Crohn's Recurrence: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2021; 19:451-462. [PMID: 32801016 DOI: 10.1016/j.cgh.2020.08.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Rates of postoperative Crohn's disease recurrence remain high, although the ability to predict this risk of recurrence remains limited. As such, we aimed to determine the association of histologic features at the time of resection with postoperative recurrence. METHODS Electronic databases were searched through February 2020 for studies that reported risk of clinical, endoscopic, or surgical postoperative recurrence in patients with positive resection margins, plexitis, or granulomas in the index specimen. Pooled risk ratios (RRs) with 95% CIs were calculated for this risk in patients with and without these histologic features. RESULTS Twenty-one studies (2481 patients) assessed positive resection margins, 10 studies (808 patients) assessed plexitis, and 19 studies (1777 patients) assessed granulomas. Positive resection margins increased the risk of clinical (RR, 1.26; 95% CI, 1.06-1.49; I2 = 41%) and surgical (RR, 1.87; 95% CI, 1.14-3.08; I2 = 71%) recurrence, with a trend toward endoscopic recurrence (RR, 1.56; 95% CI, 0.79-3.05; I2 = 85%). Granulomas increased the risk of clinical (RR, 1.31; 95% CI, 1.05-1.64; I2 = 36%) and endoscopic (RR, 1.37; 95% CI, 1.00-1.87; I2 = 49%) recurrence, with a trend toward surgical recurrence (RR, 1.58; 95% CI, 0.89-2.80; I2 = 75%). Plexitis increased the risk of endoscopic recurrence (RR, 1.31; 95% CI, 1.00-1.72; I2 = 20%), with a trend toward clinical recurrence (RR, 1.34; 95% CI, 0.95-1.91; I2 = 46%). CONCLUSIONS Positive resection margins, granulomas, and plexitis are predictive of postoperative Crohn's disease recurrence and should be recorded at the time of index resection.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gurpreet Malhi
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Daniyal Abdali
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Elahn Pogue
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | | | - Robert Riddell
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.
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Hissong E, Yantiss RK. Intraoperative Evaluation of the Gastrointestinal Tract. FROZEN SECTION PATHOLOGY 2021:15-48. [DOI: 10.1007/978-3-030-71308-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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The Role of Inflammation in Crohn's Disease Recurrence after Surgical Treatment. J Immunol Res 2020; 2020:8846982. [PMID: 33426097 PMCID: PMC7781709 DOI: 10.1155/2020/8846982] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Postoperative recurrence after surgery for Crohn's disease (CD) is virtually inevitable, and its mechanism is poorly known. Aim To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives. Methods A systematic literature search on CD POR, followed by a review of the main findings. Results The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation. Conclusions POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.
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Tan ZV, Kosana K, Savarino J, Croft N, Naik S, Kaplan J, Giles E. Histology at diagnostic gastroscopy predicts outcome after intestinal resection in pediatric Crohn's disease. J Gastroenterol Hepatol 2020; 35:2074-2079. [PMID: 32343456 DOI: 10.1111/jgh.15080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 04/15/2020] [Accepted: 04/24/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Pediatric Crohn's disease (CD) has been shown to have a high recurrence rate following surgical resection. Risk factors for postoperative CD recurrence in children are not well known. The aim of this study was to identify factors influencing postoperative recurrence in pediatric CD. METHODS Pediatric CD patients who underwent surgical resection with primary anastomosis with a minimum follow up of 2 years were identified from databases at the Royal London Hospital and Massachusetts General Hospital. Patients were subdivided into a recurrence group defined by clinical, endoscopic, histological, radiological and/or surgical outcomes, and a nonrecurrence group. Patient demographics, initial gastroscopy and colonoscopy findings, Paris classification, and preoperative and postoperative pharmacotherapy were analyzed. RESULTS Ninety-six children who underwent an ileal or ileocolonic resection with primary anastomosis were identified. Fifty-seven children had postoperative recurrence. Recurrence was associated with abnormal initial gastroscopy findings (P = 0.0077), ileocolonic disease location (P = 0.03), and perianal disease involvement (P = 0.04). Patients with abnormal initial gastroscopy had higher rates of relapse (hazard ratio 3.42, 95% confidence interval [CI] [1.86-6.30], P = 0.001). Multivariate analysis demonstrated that abnormal diagnostic gastroscopy histology was a significant independent predictor of postoperative recurrence in this cohort (odds ratio 1.33, 95% CI [1.04-1.70], P = 0.024). The most common histological abnormality was non-Helicobacter gastritis, found in 29/46 (63%). CONCLUSION This dual-center study has shown that the presence of upper gastrointestinal tract inflammation, especially non-Helicobacter gastritis, at the time of diagnosis, is associated with an increased risk of postoperative recurrence in pediatric CD.
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Affiliation(s)
- Zien Vanessa Tan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Kiranmai Kosana
- Department of Paediatric Gastroenterology, Barts Health NHS Trust, London, UK
| | - Jeffrey Savarino
- Division of Pediatric Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Croft
- Department of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Sandhia Naik
- Department of Paediatric Gastroenterology, Barts Health NHS Trust, London, UK
| | - Jess Kaplan
- Division of Pediatric Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Edward Giles
- Department of Pediatrics, Monash University, Centre for Innate Immunity and Infectious Disease, Hudson Institute for Medical Research, Melbourne, Victoria, Australia
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Petagna L, Antonelli A, Ganini C, Bellato V, Campanelli M, Divizia A, Efrati C, Franceschilli M, Guida AM, Ingallinella S, Montagnese F, Sensi B, Siragusa L, Sica GS. Pathophysiology of Crohn's disease inflammation and recurrence. Biol Direct 2020; 15:23. [PMID: 33160400 PMCID: PMC7648997 DOI: 10.1186/s13062-020-00280-5] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 02/07/2023] Open
Abstract
Chron's Disease is a chronic inflammatory intestinal disease, first described at the beginning of the last century. The disease is characterized by the alternation of periods of flares and remissions influenced by a complex pathogenesis in which inflammation plays a key role. Crohn's disease evolution is mediated by a complex alteration of the inflammatory response which is characterized by alterations of the innate immunity of the intestinal mucosa barrier together with a remodeling of the extracellular matrix through the expression of metalloproteins and increased adhesion molecules expression, such as MAcCAM-1. This reshaped microenvironment enhances leucocytes migration in the sites of inflammation, promoting a TH1 response, through the production of cytokines such as IL-12 and TNF-α. IL-12 itself and IL-23 have been targeted for the medical treatment of CD. Giving the limited success of medical therapies, the treatment of the disease is invariably surgical. This review will highlight the role of inflammation in CD and describe the surgical approaches for the prevention of the almost inevitable recurrence.
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Affiliation(s)
- L. Petagna
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - A. Antonelli
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - C. Ganini
- Torvergata Oncoscience Research Centre of Excellence, TOR, Department of Experimental Medicine, University Tor Vergata, Rome, Italy
| | - V. Bellato
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - M. Campanelli
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - A. Divizia
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - C. Efrati
- Ospedale Israelitico, Department of Gastroenterology, Rome, Italy
| | - M. Franceschilli
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - A. M. Guida
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - S. Ingallinella
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - F. Montagnese
- Nuovo Ospedale dei Castelli, Endoscopy Unit, Rome, Italy
| | - B. Sensi
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - L. Siragusa
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - G. S. Sica
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Torvergata Oncoscience Research Centre of Excellence, TOR, Department of Experimental Medicine, University Tor Vergata, Rome, Italy
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Wasmann KATGM, van Amesfoort J, van Montfoort ML, Koens L, Bemelman WA, Buskens CJ. The Predictive Value of Inflammation at Ileocecal Resection Margins for Postoperative Crohn's Recurrence: A Cohort Study. Inflamm Bowel Dis 2020; 26:1691-1699. [PMID: 31879766 DOI: 10.1093/ibd/izz290] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Resections for Crohn's disease should be limited and only resect macroscopically affected bowel. However, recent studies suggest microscopic inflammation at resection margins as a predictor for postoperative recurrence. The clinical impact remains unclear, as non-uniform pathological criteria have been used. The aim of this study was to assess the predictive value of pathological characteristics at ileocecal resection margins for recurrence. METHODS Both resection margins of 106 consecutive patients undergoing ileocecal resection for Crohn's disease between 2002 and 2009 were revised and scored for active inflammation, myenteric plexitis, and granulomas. Pathological findings were correlated to recurrence, defined as recurrent disease activity demonstrated by endoscopy (modified Rutgeerts score ≥i2) requiring upscaling medical treatment, using multivariate analysis. RESULTS Active inflammation was found at the proximal and distal resection margin in 27% and 15% of patients, respectively, myenteric plexitis in 37% and 32%, respectively, and granulomas in 4% and 6%, respectively. In total, 47 out of 106 patients developed recurrence. Only active inflammation at the distal colonic resection margin was an independent significant predictor for recurrence (88% vs 43% vs 51% for distal, proximal, and no involved margins, respectively; P < 0.01). CONCLUSION Active inflammation at the distal colonic resection margin after ileocecal resection identifies a patient group at high risk for postoperative recurrence both at the anastomotic site and the colon because it identifies undiagnosed L3 disease. These patients have a different and more aggressive natural history and require more intense medical treatment. Therefore, pathological evaluation of the distal resection margin should be implemented in daily practice.
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Affiliation(s)
- Karin A T G M Wasmann
- Dept. of surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jojanneke van Amesfoort
- Dept. of surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept. of pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Lianne Koens
- Dept. of pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Dept. of surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christianne J Buskens
- Dept. of surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kono T, Fichera A. Surgical Treatment for Crohn's Disease: A Role of Kono-S Anastomosis in the West. Clin Colon Rectal Surg 2020; 33:335-343. [PMID: 33162837 DOI: 10.1055/s-0040-1714236] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
More than 80% of patients with Crohn's disease (CD) will require surgical intervention during their lifetime, with high rates of anastomotic recurrence and stenosis necessitating repeat surgery. Current data show that pharmacotherapy has not significantly improved the natural history of postoperative clinical and surgical recurrence of CD. In 2003, antimesenteric hand-sewn functional end-to-end (Kono-S) anastomosis was first performed in Japan. This technique has yielded very desirable outcomes in terms of reducing the incidence of anastomotic surgical recurrence. The most recent follow-up of these patients showed that very few had developed surgical recurrence. This new approach is superior to stapled functional end-to-end anastomosis because the stumps are sutured together to create a stabilizing structure (a "supporting column"), serving as a supportive backbone of the anastomosis to help prevent distortion of the anastomotic lumen due to disease recurrence and subsequent clinical symptoms. This technique requires careful mesenteric excision for optimal preservation of the blood supply and innervation. It also results in a very wide anastomotic lumen on the antimesenteric side. The Kono-S technique has shown efficacy in preventing surgical recurrence and the potential to become the new standard of care for intestinal CD.
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Affiliation(s)
- Toru Kono
- Advanced Surgery Center, Department of Surgery, Sapporo Higashi Tokushukai Hospital, Higahi-ku, Sapporo, Hokkaido, Japan
| | - Alessandro Fichera
- Division of Colon and Rectal Surgery, Baylor University Medical Center, Dallas, Texas
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Yamamoto T, Lightner AL, Spinelli A, Kotze PG. Perioperative management of ileocecal Crohn's disease in the current era. Expert Rev Gastroenterol Hepatol 2020; 14:843-855. [PMID: 32729736 DOI: 10.1080/17474124.2020.1802245] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The ileocecal region is most commonly involved in patients with Crohn's disease (CD). AREAS COVERED In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention. EXPERT OPINION Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center & Department of Surgery, Yokkaichi Hazu Medical Center , Yokkaichi, Japan
| | - Amy Lee Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS , Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University , Rozzano, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR) , Curitiba, Brazil
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Argollo M, Kotze PG, Lamonaca L, Gilardi D, Furfaro F, Yamamoto T, Danese S. Prevention of Postoperative Recurrence in CD: Tailoring Treatment to Patient Profile. Curr Drug Targets 2020; 20:1327-1338. [PMID: 30894106 DOI: 10.2174/1389450120666190320110809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is an immune-mediated condition characterized by the transmural inflammation of the gut tissue, associated with progressive bowel damage often leading to surgical intervention. As operative resection of the damaged segment is not curative, a majority of patients undergoing intestinal resections for complicated CD present disease recurrence within 3 years after the intervention. Postoperative recurrence can be defined as endoscopic, clinical, radiological or surgical. Endoscopic recurrence rates within 1 year exceed 60% and the severity, according to the Rutgeerts' score, is associated with worse prognosis and can predict clinical recurrence (in up to 1/3 of the patients). Most importantly, about 50% of patients will undergo a reoperation after 10 years of their first intestinal resection. Therefore, the prevention of postoperative recurrence in CD remains a challenge in clinical practice and should be properly managed. We aim to summarize the most recent data on the definition, risk factors, assessment and treatment of postoperative CD recurrence.
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Affiliation(s)
- Marjorie Argollo
- Department of Gastroenterology, Universidade Federal de São Paulo, São Paulo, Brazil.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Paulo Gustavo Kotze
- IBD outpatient clinics, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Laura Lamonaca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Takayuki Yamamoto
- Department of Surgery and IBD Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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45
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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46
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Kotze PG, Yamamoto T. Microscopic Inflammation at Ileocaecal Resection Margins in Crohn's Disease: Prevent Recurrence or Treat Residual Disease? J Crohns Colitis 2020; 14:872-873. [PMID: 31628470 DOI: 10.1093/ecco-jcc/jjz172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Takayuki Yamamoto
- Department of Surgery, Yokkaichi Hazu Medical Centre, Yokkaichi, Mie, Japan
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47
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Levin A, Risto A, Myrelid P. The changing landscape of surgery for Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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48
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Chen PC, Kono T, Maeda K, Fichera A. Surgical technique for intestinal Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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49
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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Poredska K, Kunovsky L, Marek F, Kala Z, Prochazka V, Dolina J, Zboril V, Kovalcikova P, Pavlik T, Jabandziev P, Pavlovsky Z, Vlazny J, Mitas L. The Influence of Microscopic Inflammation at Resection Margins on Early Postoperative Endoscopic Recurrence After Ileocaecal Resection for Crohn's Disease. J Crohns Colitis 2020; 14:361-368. [PMID: 31501878 DOI: 10.1093/ecco-jcc/jjz153] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The pathogenesis and risk factors for early postoperative endoscopic recurrence of Crohn's disease [CD] remain unclear. Thus, this study aimed to identify whether histological inflammation at the resection margins after an ileocaecal resection influences endoscopic recurrence. METHODS We have prospectively followed up patients with CD who underwent ileocaecal resection at our hospital between January 2012 and January 2018. The specimens were histologically analysed for inflammation at both of the resection margins [ileal and colonic]. We evaluated whether histological results of the resection margins are correlated with endoscopic recurrence of CD based on colonoscopy 6 months after ileocaecal resection. Second, we assessed the influence of known risk factors and preoperative therapy on endoscopic recurrence of CD. RESULTS A total of 107 patients were included in our study. Six months after ileocaecal resection, 23 patients [21.5%] had an endoscopic recurrence of CD. The histological signs of CD at the resection margins were associated with a higher endoscopic recurrence [56.5% versus 4.8%, p < 0.001]. Disease duration from diagnosis to surgery [p = 0.006] and the length of the resected bowel [p = 0.019] were significantly longer in patients with endoscopic recurrence. Smoking was also proved to be a risk factor for endoscopic recurrence [p = 0.028]. CONCLUSIONS Histological inflammation at the resection margins was significantly associated with a higher risk of early postoperative endoscopic recurrence after an ileocaecal resection for CD.
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Affiliation(s)
- Karolina Poredska
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Filip Marek
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdenek Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vladimir Prochazka
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiri Dolina
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vladimir Zboril
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petra Kovalcikova
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Pavlik
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Jabandziev
- Department of Pediatrics, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdenek Pavlovsky
- Department of Pathology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jakub Vlazny
- Department of Pathology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ladislav Mitas
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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