Determinants for postoperative complications after laparoscopic intestinal resection for Crohn's disease

Influencing factors and preventive measures of infectious complications after intestinal resection for Crohn's disease

The incidence of Crohn's disease (CD) has increased in recent years, with most patients requiring intestinal resection. Complications after intestinal resection for CD can lead to poor prognosis and recurrence, among which infectious complications are the most common. This study aimed to investigate the common risk factors, including medications, preoperative nutritional status, surgery-related factors, microorganisms, lesion location and type, and so forth, causing infectious complications after intestinal resection for CD, and to propose corresponding preventive measures. The findings provided guidance for identifying susceptibility factors and the early intervention and prevention of infectious complications after intestinal resection for CD in clinical practice.

Prehabilitation prior to intestinal resection in Crohn's disease patients: An opinion review

Patients with Crohn's disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Current Use of EEN in Pre-Operative Optimisation in Crohn's Disease

Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.

Complications after intestinal resection in Crohn's disease: laparoscopic versus conventional approach

Background significant advances in medical therapy for Crohn's disease (CD) occurred in the last 12 years, mainly due to the introduction of anti-TNF therapy. Laparoscopic colorectal surgery represented the most important advance on surgical treatment in the management of CD, as it also had developed in the treatment of other conditions. There is a tendency for lower complication rates after laparoscopic bowel resections as compared to open surgery. The aim of this study was to analyze and compare the complication rates after bowel resections for CD between the two approaches in a Brazilian case series.

Methods this was a retrospective longitudinal study, including CD patients submitted to bowel resections from a single Brazilian Inflammatory Bowel Diseases (IBD) referral center, treated between January 2008 and June 2012 with laparoscopic approach (LA) or conventional approach (CA).

Variables analyzed age at surgery, gender, Montreal classification, smoking, concomitant medication, type of surgery, surgical approach, presence and type of complication up to 30 days after the procedures. Readmission and reoperation rates, as well as mortality, were also analyzed. Patients were allocated in two groups regarding the type of procedure (LA or CA), and complication rates and characteristics were compared. Statistical analysis was performed with Mann-Whitney test (quantitative variables) and chi-square test (qualitative variables), with p < 0.05 considered significant.

Results a total of 46 patients (25 men) were included (16 submitted to LA), with mean age of 38.1 (± 12.7) years. The groups were considered homogeneous according to age, gender, CD location, perianal disease and concomitant medications. There were more patients with fistulizing CD on the CA group (p = 0.029). The most common procedure performed was ileocolic resection on both groups (56.7% of the CA and 75% of the LA patients – p = 0.566). Overall, total complications (surgical and medical, including minor and major issues) occurred in 60% (18/30) of the CA group and 12.5% (2/16) of the LA group (p = 0.002). Wound infection was the most frequent complication (10/30 on CA and 1/16 on the LA groups). There were 3 deaths in the CA group. Specific analysis of each complication did not demonstrate any difference between the groups regarding abdominal sepsis, urinary tract infections, pneumonia, readmission, reoperations and deaths (p = 0.074).

Conclusions there was a higher complication rate in patients operated with CA as compared to LA. This was probably due to patient selection for the laparoscopic approach, with severe cases, mostly due to fistulizing abdominal CD, being operated mainly by open surgery. LA tends to be the recommended approach in most cases of non-complicated CD.

A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease

PURPOSE

The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection.

METHOD

The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures.

RESULTS

The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates.

CONCLUSION

Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.

Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease

BACKGROUND AND AIM

Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research.

METHODS

A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified.

RESULTS

An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed.

CONCLUSION

EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.

Biological Treatment and the Potential Risk of Adverse Postoperative Outcome in Patients With Inflammatory Bowel Disease: An Open-Source Expert Panel Review of the Current Literature and Future Perspectives

Background

There is widespread concern that treatment with biologic agents may be associated with suboptimal postoperative outcome after surgery for inflammatory bowel diseases (IBD).

Aim

We aimed to search and analyze the literature regarding the potential association of biologic treatment on adverse postoperative outcome in patients with IBD. We used the subject as a case in point for surgical research. The aim was not to conduct a new systematic review.

Method

This is an updated narrative review written in a collaborative method by authors invited through Twitter via the following hashtags (#OpenSourceResearch and #SoMe4Surgery). The manuscript was presented as slides on Twitter to allow discussion of each section of the paper sequentially. A Google document was created, which was shared across social media, and comments and edits were verified by the primary author to ensure accuracy and consistency.

Results

Forty-one collaborators responded to the invitation, and a total of 106 studies were identified that investigated the potential association of preoperative biological treatment on postoperative outcome in patients with IBD. Most of these studies were retrospective observational cohorts: 3 were prospective, 4 experimental, and 3 population-based studies. These studies were previously analyzed in 10 systematic/narrative reviews and 14 meta-analyses. Type of biologic agents, dose, drug concentration, antidrug antibodies, interval between last dose, and types of surgery varied widely among the studies. Adjustment for confounders and bias control ranged from good to very poor. Only 10 studies reported postoperative outcome according to Clavien–Dindo classification.

Conclusion

Although a large number of studies investigated the potential effect of biological treatment on postoperative outcomes, many reported divergent results. There is a need for randomized controlled trials. Future studies should focus on the avoiding the weakness of prior studies we identified. Seeking collaborators and sharing information via Twitter was integral to widening the contributors/authors and peer review for this article and was an effective method of collaboration.

Predictive parameters of early postoperative complications in Crohn's disease: Single team experience

BACKGROUND/AIMS

Most of the patients with Crohn's disease (CD) may require at least one surgical procedure over their lifetime. However, these patients tend to have a high incidence of postoperative complications. The aim of this retrospective study was to investigate the predictive parameters of postoperative complications in CD.

MATERIALS AND METHODS

All consecutive patients with CD between March 2001 and March 2016 who underwent bowel resection were included to this study. Postoperative complications were divided as; major complications including anastomotic leakage, ostomy complications, acute mechanical intestinal obstruction and hemorrhage, and minor complications including wound infection.

RESULTS

A total of 147 patients (74 females, 73 males) with a mean age of 36±11.9 years met the inclusion criteria. Behaviors of CD were stricturing in 90 (62%), fistulizing in 45 (30%) and inflammatory in 12 (8%) patients. Minimally invasive approach was applied in 35% (n=51) of the patients. Twentysix (17%) patients had early (≤30 days) postoperative surgical complications including anastomotic leak (n=10), intra-abdominal bleeding (n=2), complications related to ostomy (n=2), acute mechanical intestinal obstruction (n=1) and wound infection (n=11). Only fistulizing disease behavior was associated with early postoperative complications (p=0.014).

CONCLUSION

This study suggests that postoperative complications are still more common in fistulizing CD. Surgical approach did not affect the complication rate. The decision should be individualized according to the prominent risk factors and surgeons' preference.

Surgery for Intestinal Crohn's Disease: Results of a multidisciplinary approach

OBJECTIVES

Crohn's disease is a chronic inflammatory bowel disease that requires lifelong multidisciplinary management. Seventy percent of patients affected by Crohn's disease will require at least one surgical procedure over their lifetime. The aim of this retrospective study was to present our series of patients suffering from Crohn's disease who were scheduled for surgery by a multidisciplinary team.

MATERIAL AND METHODS

The data were retrieved from a review of 950 patients with Crohn's disease treated at our institution between March 2000 and March 2016. Only patients with intestinal Crohn's disease were included into the study. A multidisciplinary team assessed the decision to perform surgery.

RESULTS

There were 203 patients who underwent surgery included in this study. One hundred and sixty-six were intestinal and 37 were perianal Crohn's disease. The mean age was 36±11.5 (range, 12-75) years. Ninety-two were stricturing, 45 were fistulizing, and 12 were inflammatory. The most commonly affected site was the ileocecal region (n=109, 65.7%), and the most common surgical procedure was the ileocecal resection (n=109, 65.6%). Laparoscopic approach was the procedure of choice in 56 (33.7%) patients. Of the patients enrolled, the most common early (<30 days) complications observed were the wound infection as the first (n=11) and anastomotic leak as the second (n=10). The mortality rate was 2.4% (n=4).

CONCLUSION

Multidisciplinary approach to Crohn's disease may decrease the surgical complications and recurrence rates leading to a better treatment.

Visceral fat area measured with computed tomography does not predict postoperative course in Crohn´s disease patients

The role of visceral fat measured by computer tomography is yet not well defined in patients with Crohn's disease. Therefore, the present study was designed to assess the impact of visceral fat area on postoperative short-term outcome and surgical characteristics. We analyzed 95 patients, who underwent intestinal resection for symptomatic Crohn's disease at an academic tertiary referral center between 2003 and 2008. Visceral fat area was measured on preoperative computed tomography scans. Postoperative morbidity was graded according to the Clavien-Dindo classification. Visceral fat area was correlated with baseline characteristics, disease phenotype and 30-day morbidity. Body mass index and age were significantly associated with a higher visceral fat area (p = 0.001). Overall 19 (20.0%) postoperative complications were observed, of whom 7 (7.4%) patients required surgical re-intervention. No significant difference was found with regard to visceral fat area between patients with an uneventful and eventful postoperative course (no complications: median visceral fat area 52.0 cm² SD 59.7, complications: 41.3 cm² SD 42.8; p = 0.465). In contrast to current literature, we cannot support the role of visceral fat area for predicting postoperative course in Crohn's disease. In addition, no correlation of the visceral fat area and disease behavior was detected.

The Presence of Postoperative Infectious Complications is Associated with the Risk of Early Postoperative Clinical Recurrence of Crohn's Disease

BACKGROUND

The purpose of the study was to identify risk factors for early clinical and surgical recurrence in Crohn's disease (CD) patients who underwent intestinal resection.

METHOD

This was a retrospective study. Consecutive patients who underwent intestinal resection with a primary anastomosis from January 2011-December 2014 were enrolled. Gender, age at surgery, clinical phenotypes of CD, serum albumin and C-reactive protein level the day before surgery, smoking status at surgery, anastomosis technique, number of anastomoses, details of postoperative complications, the postoperative prophylactic treatment were assessed to figure out risk factors for postoperative clinical and surgical recurrence within 1 year after the initial resection by univariate and then multivariate analysis.

RESULTS

Two hundred and thirty-seven patients were analyzed. The risk of early postoperative clinical recurrence was 2.99 times higher in patients suffered postoperative infectious complications [odds ratio (OR) 2.99; 95% CIs, 1.42-6.32; p = 0.004], while never-smoking was found to be a protective factor for early clinical recurrence (OR 0.326; 95% CIs, 0.18-0.59; p < 0.0001). For surgical recurrence within 1 year after resection, the presence of postoperative intra-abdominal septic complications might be a risk factor (OR 6.77; 95% CIs, 1.61-28.5; p = 0.009). Smoker at surgery was also a risk factor for early surgical recurrence (OR 5.41; 95% CIs, 1.36-21.5; p = 0.017).

CONCLUSION

The presence of postoperative infectious complications was identified as a possible risk factor for early postoperative clinical recurrence after resection in CD patients.

Minimal-invasive approach for penetrating Crohn's disease is not associated with increased complications

Background

Laparoscopic surgery for penetrating Crohn’s disease (CD) still remains highly conflicting due to a lack of sufficient data. Therefore, the following large study was designed to compare postoperative outcomes after minimal-invasive resections for penetrating and non-penetrating CD.

Methods

Consecutive patients, who underwent laparoscopic intestinal resection for symptomatic CD at a tertiary academic referral center, were included. Patients were divided according to perioperative findings in penetrating and non-penetrating type of disease. All clinical data were obtained from an institutional database and analyzed retrospectively.

Results

Of 234 patients enrolled, 101 patients [females: n = 54 (53.5 %)] were operated on for non-penetrating CD and 133 patients [females: n = 50 (37.6 %)] for penetrating CD. Fistulas (p < 0.001), inflammatory mass (p < 0.001) and abscess formation (p < 0.001) were observed more frequently in the perforating group. Ileocolic resections were performed predominantly in both groups [perforating CD: n = 110 (82.7 %), non-perforating CD: n = 82 (81.2 %)], with more complex resections (>1 intestinal resection) found in perforating CD (p < 0.001). Conversion rates did not differ significantly. Notably, 30-day postoperative morbidity was comparable for both groups [perforating CD: n = 20 (15 %), non-perforating CD: n = 19 (18.8 %), p = 0.44]. Postoperative complication rates graded according to the Clavien–Dindo classification showed no difference too (p = 0.49).

Conclusion

Laparoscopic surgery can be conducted safely in selected patients with penetrating CD without increasing the risk of postoperative complications. This finding needs to be implemented in future guidelines.

Post-operative recurrence in Crohn's disease. Critical analysis of potential risk factors. An update

INTRODUCTION

Crohn's disease is associated with high rates of postoperative recurrence. At 10 years after surgery a high percentage of patients suffer recurrence (as many as 75% and above) and many of these (up to 45%) require re-intervention. The aim of the study was to identify, amongst the various "potential predictive factors", those which today should be considered "real risk factors" for postoperative recurrence.

METHODS

A review of literature of the last 30 years was carried out. A medical literature search was conducted using Medline, Embase, Ovid Journals, Science Direct, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Potential risk factors related to the patient, disease, type of surgery and pharmacological treatment were analyzed.

RESULTS

According to most Authors predictive factors, in addition to smoke, are also represented by an extent of disease superior to 100 cm and by absence of postoperative pharmacological treatment. Moreover, according to "the second European evidence-based Consensus on the diagnosis and the management of Crohn's disease: Special situations", localization of disease in the colon, penetrative behavior of disease, extensive small bowel resection and prior intestinal surgery should also be considered predictive factors.

CONCLUSIONS

The high incidence of postoperative recurrence in Crohn's disease mandates a strict follow up (clinical, laboratory and instrumental monitoring). Identifying patients with increased risk would enable physicians to plan a surveillance program and to implement a rational therapeutic prophylaxis.

Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease

BACKGROUND

Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear.

METHODS

An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013.

RESULTS

Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028).

CONCLUSION

Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.

Laparoscopy improves clinical outcome of gastrointestinal fistula caused by Crohn's disease

BACKGROUND

Benefits of laparoscopic surgery in the management of gastrointestinal fistula caused by Crohn disease need to be fully elucidated. We conducted this retrospective study to investigate the safety and feasibility and emphasize the advantages of laparoscopy compared with that of laparotomy for patients with gastrointestinal fistula caused by Crohn disease.

MATERIALS AND METHODS

A total of 1213 patients with gastrointestinal fistula in our center were screened, and 318 qualified patients were enrolled and divided into laparoscopy (n = 122) and laparotomy (n = 196) groups. Postoperative complications, length of hospital stay, systemic stress responses to surgery, postoperative mortality, and economic burden were collected and compared.

RESULTS

A total of 125 laparoscopic interventions were performed with a conversion rate of 20.0%. Fifteen versus 84 postoperative complications were obtained in laparoscopy and laparotomy groups, respectively (P = 0.0033). Total hospitalization was 22.7 d and 38.0 d in laparoscopy and laparotomy groups, respectively (P < 0.0001). Postoperative hospitalization was 10.9 d and 24.8 d in two groups, respectively (P < 0.0001). Elevation curve of serum C-reactive protein and procalcitonin in response to laparoscopy was significantly lower than that to laparotomy. Reduced postoperative mortality (P = 0.0292) and postoperative cost (P = 0.0292) were observed in laparoscopy instead of laparotomy group.

CONCLUSIONS

Laparoscopic approach is safe and feasible and could improve clinical outcome in gastrointestinal fistula patients with Crohn disease.

CONSORT: Different End-Points of Preoperative Nutrition and Outcome of Bowel Resection of Crohn Disease: A Randomized Clinical Trial

Nutritional therapy cannot only improve nutritional status but also reduce bowel inflammation in Crohn disease (CD). The benefits of preoperative nutritional therapy on outcomes of surgery for CD have been demonstrated. However, the ideal end-points of preoperative nutrition in CD remain elusive. We conducted this study to figure out whether improvement of malnutrition or reduction of inflammation is the better end-point of preoperative nutrition for CD. This was a prospective, randomized study. All patients enrolled received preoperative nutrition with different end-points (improvement of malnutrition, IOM, or reduction of inflammation, ROI). The end-points were defined using serum albumin and body weight gain, and serum C-reactive protein (CRP), respectively. Postoperative complications, rate of fecal diversion, and postoperative recurrence of the disease were compared. A total of 108 patients were randomized and 91 patients (44 in IOM group and 47 in ROI group) completed this study. It took 25.57 ± 11.68 days to achieve ROI and 45.29 ± 18.47 days for IOM (P = 0.0023). After nutritional therapy, serum CRP, CDAI, and serum albumin in both groups improved significantly. But patients in the IOM group had a higher albumin level and body weight gain compared with ROI group (P = 0.0026, P < 0.0001). When comparing postoperative complications, rate of fecal diversion, and postoperative recurrence, no significant differences were noted. Compared with IOM, ROI as the end-point of preoperative nutrition had the same benefits on operative outcomes in CD patients undergoing resection, but could be achieved in a shorter time (NCT01540942).

Skeletal muscle percentage: a protective factor for postoperative morbidity in Crohn's disease patients with severe malnutrition

BACKGROUND

There are no appropriate variables for predicting postoperative morbidity in Crohn's disease (CD) patients with severe malnutrition. We examined a retrospective cohort to clarify these.

MATERIALS AND METHODS

Between 2005 and 2013, 138 CD patients with severe malnutrition underwent elective intestinal resection after preoperative management, consisting of nutritional support, abscess drainage, intravenous antibiotics, steroids tapering, and infliximab weaning, as appropriate. The severity of postoperative morbidity (within the first 30 days) was examined according to the Clavien-Dindo classification system.

RESULTS

After a median duration of 26 days of preoperative management, Crohn's disease activity index (CDAI) and C-reactive protein (CRP) significantly decreased, and body mass index (BMI), skeletal muscle percentage (SMP), body fat percentage (BFP), albumin, prealbumin, and hemoglobin significantly increased (P < 0.001). Postoperative overall morbidities occurred in 28 (20.3%) patients including 15 (10.8%) major complications (Clavien-Dindo classification ≥ III). In the multivariate logistic regression analysis, preoperative CRP (P = 0.044, OR 1.156, 95% CI 1.004-1.331) was a significantly independent risk factor for overall complications, and preoperative SMP (P = 0.002, OR 0.487, 95% CI 0.307-0.772) and BFP (P = 0.036, OR 0.691, 95% CI 0.490-0.996) were significantly independent protective factors. Notably, only preoperative SMP (P = 0.002, OR 0.588, 95% CI 0.422-0.820) was a significantly independent protective factor for major complications, and our threshold of SMP was 24.3% (P < 0.001, sensitivity 83.7%, specificity 95.9%).

CONCLUSIONS

Preoperative SMP is a protective factor for postoperative overall and major complications in CD patients with severe malnutrition and deserves further study.

Value of clinical and laboratory inflammation factors in the postoperative period after laparoscopic urogynecological surgery

BACKGROUND/AIMS

Leukocytes and C-reactive protein (CRP) levels are often used to detect infections. The aim of this study was to evaluate the diagnostic and screening validity of leukocytes and CRP levels as well as body temperature >38° C to predict infections after laparoscopic sacrocolpopexy.

METHODS

The study included 287 patients suffering from genital prolapse higher than POP-Q I. In addition to the sacrocolpopexy, a laparoscopic supracervical hysterectomy was performed in cases of preexisting uterus (n = 171). Leukocytes and CRP levels were analyzed preoperatively and 4 days after surgery. Early and late onset of infections was documented.

RESULTS

Urinary tract infection was identified as the most frequent early postoperative complication (11.4%). Early wound infections were found in 2.8% of the patients (8/287). Late onset of infections was found in 1% of patients (3/287). Areas under ROC curves were low for both leukocytes (0.52, 95% CI: 0.37-0.66) and CRP levels (0.60, 95% CI: 0.44-0.77).

CONCLUSION

Our findings question the benefit of routine determination of leukocytes and CRP levels 4 days after surgery. The sensitivity and specificity of leukocytes and CRP levels are probably more significant after normalization of the initial tissue response (days 8-10).

Repeat intestinal resections increase the risk of recurrence of Crohn's disease

BACKGROUND

Which factors predict recurrence in patients with Crohn's disease in the era of immunosuppressive medications is still under debate.

OBJECTIVE

The current study was conducted to assess long-term outcome after ileocolic resection for Crohn's disease and to define predictive factors for surgical relapse.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted in a tertiary referral center.

PATIENTS

A consecutive cohort of patients (n = 203) with Crohn's disease who underwent ileocolic resection between 1997 and 2006 were analyzed. The mean follow-up time was 8.4 (±2.4) years.

MAIN OUTCOME MEASURES

The cumulative probability for repeated intestinal resection for recurrent Crohn's disease was described by Kaplan-Meier curves. Predictors of surgical recurrence were analyzed by univariate tests.

RESULTS

One hundred five patients (51.7%) were exposed to azathioprine/6-mercaptopurine, and 28 patients (13.8%) were exposed to tumor necrosis factor-α blockers after operation. During the follow-up period, 32 patients (15.8%) were reoperated on for disease recurrence. At 5 and 10 years after index surgery, 95.5% and 81.3% of the patients had reoperation-free survival. Previous resections for Crohn's disease (HR, 2.981; 95% CI, 1.411-6.29; p = 0.003) and urgent indication for surgery (HR, 2.729; 95% CI, 1.047-7.116; p = 0.03) were significant risk factors for reoperation. In addition, patients with postoperative complications following ileocolonic resection were more likely to require reoperation (HR, 1.712; 95% CI, 041-2.817; p = 0.03). In a multiple Cox regression model, previous intestinal resection for Crohn's disease remained significant (p = 0.0114) with a HR of 2.654 (95% CI, 1.246-5.654).

LIMITATIONS

The limitation is the retrospective design of the study, with its potential selection bias.

CONCLUSION

In the present analysis, previous intestinal resection for Crohn's disease was found to be an independent risk factor for surgical recurrence. Consequently, shorter surveillance intervals in this group of patients should be considered.